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10/29/11!"# %"&'%()* '!!%*.%2 %@.A%/.%/0 %%2,6 -,55%?. %!.5;9.68B%!"# %&'()*" ,'-% . )/0(1203).0)4",03%&)/-%3'()!'%3!",-./01%23%451667% "7% 0*%",-./01%23%451667% "7% 0*%*,896:;,80 % .? 88. %*,896:;,80 % .? 88. %!/.C%/0 % D,6%%!/.C%/0 %(D 6 88%% )E %%FG%HD;8 %.?%D ;5/%% ,8DI,5,/1%,6%/0 %J!) )E %%G%,6%K%C .C5 %5,L %M,/0%H0 .6,H%CD,6!NOP%"#! %%! &'%()!* ,!* &!-*."/0-!".!.,-'.,/(!1 0/!0/!(*,!% )(!2, .!1
10/29/11ONP%.?%C .C5 %-DA %D Q;8/- 6/8%/.%/0 , %5,? 8/15 %I HD;8 %.?%/0 , %CD,67%%KNP%"#!1 3,/()!40(*! C 88,.6!.,1".(,&!(* (!(*,2!4,.,!0/!1*2)0- %!1 0/5!!6 /2!* &!*, & -*,)7!8 -9!1 0/7! /&!:"0/(!1 0/5!Lets focus on just one pain condition for a moment LD5 6H %.?%%R&S# ER%! E )@% )E )% )GTP%U D,67%VWWNX2
10/29/11)%/./D5%.?%YY%-,55,.6%C 8H ,C9.68%M % ,8C 68 %?. %IDHA%CD,6%,6%/0 %J3!3)3%,6%/0 %1 D %VWWW3%Fills 2 StadiumsTotal costs of prescription opioid abuse wereestimated at 55.7 Billion in 2007. -Pain Med, 2011" D ,9.6D5% !)E*!%Z%R#[\V8%OW7WWW%]%VWW7WW%;8 8%D66;D551%*" )55)-'%6)70,)8% %. ).0)60&.0, 9)0:& ;)&(%3%& ;) 1, ,#;)'36)-, &,%-203) 6%&%3 ))70,)@.M% DHA% D,6)%3) ?@)A' )) K% ,55,.6%!C,6D5%4;8,.6!Jarvik et al, 2003; !1 3,/()!40(*! ?@!4,.,!. /&"A0B,&!("!.,-,0 ,!. &0"C. 1*)!".!6DE!!O*,!C" %!"#!)10/ %!#')0"/!)'.C,.2!0)!("!)( 80%0B,! !),CA,/(!"#!(*,!)10/,!(* (!* )!A 'B 3 6! /&!,%0A0/ (,!A"3"/! (!(* (!),CA,/(5!O*0)!)( 80%0B 3"/!40%%!%6 '((#! ;H %/0 %CD,6!(* (!0)! ))"-0 (,&!40(*! ,.(,8. %!A" #'/-3"/!".!) 3)# -3"/!K'.C,.2L!!!!KP%?. %(SE%%%%%%%%%%VP%?. %[\ D1%M")()!1,.!N10)"&,!!!(SE%a% Vb W%%%%[\ D1%a% VWNT%3
10/29/11Spine 2011;36:320–331 ! )%H.0. /%.?%OVN%?;8,.6%HD8 8%L 8;8%OVN%H.6/ .583% ! !; :,HD5%HD8 8%0D %D%G%,6%Y%H0D6H %.?%D% C D/%8; : 17%D%G%,6%b%H0D6H %.?%D%H.-C5,HD9.67%D6 %b%,6%Y%H0D6H %.?%6 L %M. A,6:%D:D,63c%% ! "0 %M %D58.%-. % D/08%,6%/0 %8C,6D5%?;8,.6%: .;C3!Spine 2011;36:320–331Age, BMI, diagnoses, education, surgical fusion approach,sex, marital status, the number of lumbar levels withdegenerative changes, and the number of vocationalsessions were not significant predictors of RTW.In summary, lumbar fusion may not be an effective operationin workers’ compensation patients with the diagnoses of discdegeneration, disc herniation, and/or radiculopathy. Thisprocedure is offered to improve pain and function, yetobjective outcomes showed increased permanentdisability, poor RTW status, and higher doses of opioids.K5P5!60.B 5!O*,!K10/,!Q"'./ %!FF!RG FFS!TUVWTUU!Efficacy for fusion inrelieving back pain isextremely suspect.Only one trial has shown anadvantage for surgerycompared with routinenonsurgical care and threetrials showing no advantagecompared with structuredrehabilitation.Benefit with fusion wasroughly the same in all fourtrials.K10/ %H#')0"/)!."),!82!OOP%%OXY! /&!OPY!0/-., ),&!82!"/%2!F;Z!K10/ %H#')0"/!-")()![ bY7WWW% C&(16%3 )-,07 %03'()7 ) In 2004, spine fusion procedures totaled 16.9 Billion.-Ann Intern Med, 20084
here is one thing stronger than all thearmies in the world, and that is an ideawhose time has come.-Victor HugoUse Comparisons(big numbers are hard to envision)G ! BILLION DOLLARSF !@;-ID %4;8,.6%F\!FT!J3!3%4. ,:6%), %FG!F !RD6H %S 8 D H0%U D8/7%@;6:7% .8/ D/ X% !\!T!G! !Use Local Comparisons (in my back yard)J 2)SS) "'*%) *%J '[ @)E ) @'%d)SE)"E# %E %! E '%!JSe'Sf%S)"'!%Use Local Comparisons (in my back yard)#S% '""'S%f'"g%5
10/29/11Use Local Comparisons (in my back yard)#S% '""'S%f'"g%For every 2 miles you drive up I-25 the rate ofspine surgery increases by 1%.Pose Unlikely Questions (or “really?”)20D/%,8%/0 %FG%C ,H/. %.?%M0 /0 %1.;%M,55%1.;%0DL %5.M%IDHA%8; : 1%,6%/0 %J!)B%Y5!!6DE!"#!X,./0 (,&!]0)-!?5!!@ 0/!K, ,.0(2! ! "- 3"/!M5!! "))!"#!K(.,/C(*! /&!D, , ,)!]5!!a01!M"&,!Source: Dartmouth Atlas of HealthcareTake Numbers & Make Them PersonalTake Numbers & Make Them Personal ,()!1'(!(*0)! /"(*,.!4 2b! ! Risk Death ! Spend 60-80K ! Worse odds of successthan not having surgery ! Not Die ! Spend 1-2K !As good or better odds ofsuccess than havingsurgeryEmpower your patients with simplequestions 20D/%80.;5 %E%D8A%-1% .H/. B%Among patients receiving orthopaedic surgery carethe likelihood of having spinal surgery increases by34% if the orthopods own the MRI!Sugar Daddy6
10/29/11#6 %-. %h; 89.6%?. %1.; %CD9 6/8%/.%D8A%/0 , %8C,6 %8; : .63%*.%1.;%.M6%/0 %(SE%(DH0,6 B%2011;41(11):838-8462011;41(11):838-846PROVIDE EXAMPLESWe should reiterate to the patient that the image of adisc lesion of some sort represents a “picture” of asingle moment in time and that we have no compellingevidence that this indicates or indicts them to aprolonged course of impairment of disability."0 %9-,6:%.?%HD %-Di 83%2011;41(11):838-846Patients require frequent reassurance that there is no seriousdamage or disease and that the overall prognosis is good—forexample, a consistent positive message informing the patientthat, regardless of the imaging findings, the vast majority of lowback pain resolves fairly quickly, the risk of chronic LBP is verylow, and, therefore, the odds for recovery are good.Old approachAverage cost 2,100- 2,2002011;41(11):838-846New approachAverage cost 900- 1,000The initial meeting might nothappen for up to a month,and then there is no setprocedure for treatmentImmediately see Physical TherapistInitiate evidence basedconservative programPhysical therapyPatients with complicatedback pain are sent foradditional treatmentInitial meetingwith doctorsPatient followsup with doctorsPatient mightsee a specialistPatient might undergodiagnostics, such as MRIFuhrmans V. A Novel Plan Helps Hospital Wean Itself Off Pricey Tests. WSJ. 2007:1/12.7
10/29/11 ,-D 1%HD % ? D5%.?%CD9 6/8%M,/0%D%6 M%H.68;5/D9.6%?. %@ %/.%C018,HD5%/0 DC1j%%*" )% -'&.)07)." )2 %3 )'36)&03. 3.)07)&', )03)71.1, )" '(."&', )12(%D'203)'36)&0 . E%%%%%%\%4 ,/k7%R0,5 87%2D,66 7%45166%%UE6%S L, MX%! ,-D 1%HD % ? D5%.?%CD9 6/8%M,/0%D%6 M%H.68;5/D9.6%?. %5.M%IDHA%CD,6%/.%C018,HD5%/0 DC1j%/0 %,-CDH/%.?%/0 %9-,6:%D6 %H.6/ 6/%.?%HD %.6%?;/; %0 D5/0HD %;95,kD9.6%D6 %H.8/83\%4 ,/k7%R0,5 87%2D,66 7%45166%%UE6%S L, MX%!SETTINGData extracted from Mercer HealthOnline a database ofmembers of employee-sponsored health plans.PATIENTS32,070 patients with a new primary care consultation forLBP from November 1, 2007 - January 31, 2009. ,-D 1%HD % ? D5%.?%CD9 6/8%M,/0%D%6 M%H.68;5/D9.6%?. %5.M%IDHA%CD,6%/.%C018,HD5%/0 DC1j%/0 %,-CDH/%.?%/0 %9-,6:%D6 %H.6/ 6/%.?%HD %.6%?;/; %0 D5/0HD %;95,kD9.6%D6 %H.8/83\%4 ,/k7%R0,5 87%2D,66 7%45166%%UE6%S L, MX%! ,-D 1%HD % ? D5%.?%CD9 6/8%M,/0%D%6 M%H.68;5/D9.6%?. %5.M%IDHA%CD,6%/.%C018,HD5%/0 DC1j%/0 %,-CDH/%.?%/0 %9-,6:%D6 %H.6/ 6/%.?%HD %.6%?;/; %0 D5/0HD %;95,kD9.6%D6 %H.8/83%%%%%%%%%\%4 ,/k7%R0,5 87%2D,66 7%45166%%UE6%S L, MX%!RESULTS ! Physical therapy was utilized within 90 days in just 7% of patients. ! Early PT (within 14 days of primary care) occurred with 53% of physicaltherapy utilizers, and was associated with decreased risk of advancedimaging, additional physician visits, lumbar surgery, lumbar injections, andopioid use as compared with delayed physical therapy. ! Total medical costs for LBP were 2736.23 lower for patients receiving earlyphysical therapy. ! The content of physical therapy was associated with subsequent healthcareutilization and costs, but not as strongly as the timing of physical therapy.b7WWW3WW%%Total Costs: 3148 5884V7NWW3WW%%V7WWW3WW%%#6 %-. %h; 89.6%?. %1.; %CD9 6/8%/.%D8A%/ 55%/0 , %C018,H,D63%E%M,55%I %:.,6:%/.%8 %-1%C018,HD5%/0 DC,8/3%G7NWW3WW%%G7WWW3WW%%NWW3WW%%W3WW%%gin esag urIm cedoPrntioecnj sl/I ureca edirg ocSu PralInpicrgSun- esNo durtn ceieat Prontioipcr ses MedrPP sLB ster CothO atedlReEarly PTDelayed PT8
10/29/11I get my back into my living’sthaWI don’t need to fight, to prove I’m righttxNe201% .%M % .%M0D/%M % .B%obzeiliMManipulateHol@ 3,/(!c -(".)!O*,. 10)(!c -(".)!d-RelaxWe were lacking a recognized body of knowledge.D,C0"/ %!c -(".)!9
10/29/11What tests matter?201%"0,8%" H06,h; B%S 8;5/8%%#8M 8/ 1%*,8DI,5,/1%E6 l%U#*EX%ODI ! YNP%CD9 6/8%,-C .L % D-D9HD551%D6 %M %%%%%%%%%%%%%%%%%%%%%%%%H5D88,m %D8%!;HH 88% ! #IQ H9L j%".%LD5, D/ %D%H5,6,HD5%C ,H9.6% ;5 %/.%, 69?1%,6 ,L, ;D58%M,/0%@ %-.8/%5,A 51%/.%I 6 m/%? .-%8C,6D5%-D6,C;5D9.63% ! !/; 1%* 8,:6j%%)% D6 .-,k %H5,6,HD5%/ ,D53%dD5, D9.6%.?%/0 %S;5 %BMC Musculoskeletal2 factors present:45% !Recent onset ( 16 days)91% !No symptoms below kneeIn the study by Childs and colleagues, spinal manipulation seemed to offer a“slam dunk” effect if patients met certain criteria.-Deyo, Ann Int Med, 2004Pre-test Probability ofDramatic Successwith Manipulation LR 12.6Post-test Probabilityof Dramatic Successwith Manipulation10
10/29/11D,)'%()!240 Patients withLBPRSMT &PlaceboSMT &DiclofenacSMT GroupPlacebo SMT& PlaceboPlacebo SMT& DiclofenacPlacebo GroupDoes the Australian Tool Kit nolonger include manipulation?Cleland et al., Spine 2009@ 3,/(!.,-".&)!., , %,&!(* (!A")(!UTOPX%)'8:,-()!.,-,0 ,&!5.M%L 5.H,/1%(,-*/0d',)!40(*! !)A %%!UNPX%1."1".3"/! %)"!.,-,0 0/C!0,:0%L 5.H,/1%(*.')(!(,-*/0d',)5%The results of the current study support the hypothesis that the CPR isgeneralizable to thrust manipulation techniques, but not to non-thrustmanipulation techniques.Manual Therapy (2009) 531–538*,'3 % 3.) &"'3%&'() 2 1(1 ).0)." )2 1 )&'1 )')&"'%3)07)3 1,0-"# %0(0 %&'() F &. E)g,/%D,6n/%Q;8/%/0 %Q.,6/8B%11
10/29/116,-* /0- %!!K3A'%')!6,-* /0- %!!K3A'%')!O0))',!O0))',!I,'."A')-'% .!D,)1"/),)! ,C0 D5% L.;8%%!18/ -%!C,6D5%R. %X21" %C,)0 !],-., ),!K1 )A!!E/-., ),!De6!],-., ),!K1 )A!!E/-., ),!De6!E/ AA (".2!6,&0 (".)!NeurophysiologicalI"/!K1,-0f-!D,)1"/),)! D,6%'lC , 6H %USD96:X% D,6\S 5D/ %% D,6%R, H;,/ 1% D,6%(. ;5D/. 1%R, H;,/ 1%N/&"-.0/,!D,)1"/),)!Y'("/"A0-!D,)1"/),)!6,-* /0- %!!K3A'%')!O0))',!PeripheralNervousSystemSpinal CordMechSupraspinalMechI,'."A')-'% .!D,)1"/),)! ,C0 D5% L.;8%%!18/ -%!C,6D5%R. %X21" %C,)0 !],-., ),!K1 )A!!E/-., ),!De6!E/ AA (".2!6,&0 (".)!September 19, 1881Why PT? ! b#".!" ,.!; !2, .)!Q"),1*! 0)(,.!* &!(. ,%,&!(*,!4".%&!1%, &0/C!40(*!1*2)0-0 /)!("!)(,.0%0B,!(*,0.!* /&)! /&!0/)(.'A,/()5! ! ].5!KA0(*!O"4/),/&!12
10/29/11BORN TO MOVEA Quiet Tribe, Healthcare Disrupters,and the Greatest ProfessionMusculoskeletal Care Has Never SeenWhy PT?.)%, " !0)G '6 ) )% ',) ",11. )A 7) '*" 0IH)13
Physical therapy was utilized within 90 days in just 7% of patients. ! Early PT (within 14 days of primary care) occurred with 53% of physical therapy utilizers, and was associated with decreased risk of advanced imaging, additional physician visits, lumbar surgery, lumbar injections, and opioid use as
