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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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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

Misleading Information 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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ILLION

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OLLARS

Use Comparisons

(big numbers are hard to envision)

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Use Local Comparisons (in my back yard)

#S%^'""'S%f'"g%

#S%^'""'S%f'"g%

Use Local Comparisons (in my back yard)

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!

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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.

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Old approach Average cost $2,100-$2,200 The initial meeting might not happen for up to a month, and then there is no set procedure for treatment

New approach Average cost $900-$1,000 Immediately see Physical Therapist Initiate evidence based conservative program

Physical therapy

Patients with complicated back pain are sent for

additional treatment Initial meeting

with doctors

Patient might

see a specialist Patient might undergo diagnostics, such as MRI

Patient follows up with doctors

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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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_W3WW%% _NWW3WW%% _G7WWW3WW%% _G7NWW3WW%% _V7WWW3WW%% _V7NWW3WW%% _b7WWW3WW%% Other LBP Related Costs Prescription Meds

Inpatient Non-Surgical Procedures Surgical/Injection Procedures

Imaging Procedures

Total Costs: $3148 $5884

Early PT Delayed PT

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What’

s Next

I get my back into my living

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

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Manipulate

Hold-Relax

Mobilize

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What tests matter?

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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

240 Patients with LBP

SMT & Placebo

Placebo SMT & Placebo

Placebo SMT & Diclofenac SMT &

Diclofenac

R

SMT Group Placebo Group

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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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Why PT?

BORN TO MOVE

A Quiet Tribe, Healthcare Disrupters, and the Greatest Profession Musculoskeletal Care Has Never Seen

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