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Lets focus on just one pain condition for a moment…

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Total costs of prescription opioid abuse were estimated at $55.7 Billion in 2007. -Pain Med, 2011

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Jarvik et al, 2003

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Spine 2011;36:320–331 Spine 2011;36:320–331

Age, BMI, diagnoses, education, surgical fusion approach, sex, marital status, the number of lumbar levels with degenerative changes, and the number of vocational sessions were not significant predictors of RTW.

In summary, lumbar fusion may not be an effective operation in workers’ compensation patients with the diagnoses of disc degeneration, disc herniation, and/or radiculopathy. This procedure is offered to improve pain and function, yet objective outcomes showed increased permanent disability, poor RTW status, and higher doses of opioids.

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Efficacy for fusion in relieving back pain is extremely suspect.

Only one trial has shown an advantage for surgery compared with routine nonsurgical care and three trials showing no advantage compared with structured rehabilitation.

Benefit with fusion was roughly the same in all four trials.

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In 2004, spine fusion procedures totaled $16.9 Billion. -Ann Intern Med, 2008

10/29/11

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Mislea

ding

Inform

ation

Spine Surgery Industry

There is one thing stronger than all the armies in the world, and that is an idea whose time has come. -Victor Hugo

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Use Comparisons (big numbers are hard to envision)

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Use Local Comparisons (in my back yard)

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For every 2 miles you drive up I-25 the rate of spine surgery increases by 1%.

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Source: Dartmouth Atlas of Healthcare

Pose Unlikely Questions (or “really???”)

Take Numbers & Make Them Personal

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•! Risk Death •! Spend $60-80K •! Worse odds of success than not having surgery

•! Not Die •! Spend $1-2K •!As good or better odds of success than having surgery

Take Numbers & Make Them Personal

Empower your patients with simple questions…

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Among patients receiving orthopaedic surgery care the likelihood of having spinal surgery increases by

34% if the orthopods own the MRI!

Sugar Daddy

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2011;41(11):838-846

We should reiterate to the patient that the image of a disc lesion of some sort represents a “picture” of a single moment in time and that we have no compelling evidence that this indicates or indicts them to a prolonged course of impairment of disability.

2011;41(11):838-846

PROVIDE EXAMPLES

2011;41(11):838-846

Patients require frequent reassurance that there is no serious damage or disease and that the overall prognosis is good—for example, a consistent positive message informing the patient that, regardless of the imaging findings, the vast majority of low back pain resolves fairly quickly, the risk of chronic LBP is very low, and, therefore, the odds for recovery are good.

"0<%9-,6:%.?%HD><%-Di<>83%Old approachAverage cost $2,100-$2,200

The initial meeting might nothappen for up to a month,and then there is no setprocedure for treatment

New approachAverage cost $900-$1,000

Immediately see Physical TherapistInitiate evidence basedconservative program

Physical therapy

Patients with complicatedback pain are sent foradditional treatment

Initial meetingwith doctors

Patient mightsee a specialist Patient might undergo

diagnostics, such as MRI

Patient followsup with doctors

Fuhrmans V. A Novel Plan Helps Hospital Wean Itself Off Pricey Tests. WSJ. 2007:1/12.

2011;41(11):838-846

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SETTING Data extracted from Mercer HealthOnline® a database of members of employee-sponsored health plans.

PATIENTS 32,070 patients with a new primary care consultation for LBP from November 1, 2007 - January 31, 2009.

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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 physical therapy utilizers, and was associated with decreased risk of advanced imaging, additional physician visits, lumbar surgery, lumbar injections, and opioid use as compared with delayed physical therapy.

•! Total medical costs for LBP were $2736.23 lower for patients receiving early physical therapy.

•! The content of physical therapy was associated with subsequent healthcare utilization and costs, but not as strongly as the timing of physical therapy.

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Other LBP

Related Costs

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n

Meds

Inpatient N

on-Surgical

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Surgical/Injectio

n

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aging

Procedures

Total Costs: $3148 $5884

Early PT Delayed PT

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10/29/11

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What’s

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I don’t need to fight, to prove I’m right

201%=.%M<%=.%M0D/%M<%=.B%Manipulate

Hold-Relax

Mobilize

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We were lacking a recognized body of knowledge.

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What tests matter? 201%"0,8%"<H06,h;<B%

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In the study by Childs and colleagues, spinal manipulation seemed to offer a “slam dunk” effect if patients met certain criteria. -Deyo, Ann Int Med, 2004

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Pre-test Probability of Dramatic Success with Manipulation

45% 2 factors present: •!Recent onset (<16 days) •!No symptoms below knee

91%

Post-test Probability of Dramatic Success

with Manipulation +LR = 12.6

BMC Musculoskeletal

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240 Patients with LBP

SMT & Placebo

Placebo SMT & Placebo

Placebo SMT & Diclofenac

SMT & Diclofenac

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Does the Australian Tool Kit no longer include manipulation?

Cleland et al., Spine 2009

The results of the current study support the hypothesis that the CPR is generalizable to thrust manipulation techniques, but not to non-thrust manipulation techniques. Manual Therapy (2009) 531–538

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Neurophysiological

Supraspinal Mech

Spinal Cord Mech

Peripheral Nervous System

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September 19, 1881 Why PT?

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Why PT? BORN TO MOVE A Quiet Tribe, Healthcare Disrupters, and the Greatest Profession Musculoskeletal Care Has Never Seen

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