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Transcript of Ron Donelson, MD, MS SelfCare First, LLC Directional Preference: Classification through Mechanical...
Ron Donelson, MD, MSSelfCare First, LLC
Directional Preference:Classification through
Mechanical Assessment
Matched DirectionalExercises +
Postures, Remains better
Matched DirectionalExercises +
Postures, Remains better
Trunk StabilizationTrunk Stabilization
Patient Specific Functional Reactivation
Patient Specific Functional Reactivation
NN
Functional Optimization: Quota
based exercise
Functional Optimization: Quota
based exercise
NN
YY
NN
YY
Red Flags?Red
Flags?
YY
Enter
Enter
Motor Control RestorationMotor Control Restoration
YY
NN
Independent Management
Surgical/Interventional Appropriate Candidate?Surgical/Interventional Appropriate Candidate?
YY
NN
NN
Adjunct Treatments
PRN
Active Rest, Activity
Modification CBT, FRP,
Manual Therapy
Classification through Mechanical Assessment
and Diagnosis
What I’ll cover:Context: Four challenges with our spine care dilemma. Where do we need to go?
Directional preference: How it’s determined; Reliability and validity evidence; Why is it first in the algorithm?
How does it impact the remaining algorithm and future research?
Mafi et al (2013) – National Ambulatory and Hospital Medical
Care Survey: An acceleration of the development of chronic pain, work disability, more opioid prescriptions and narcotic addiction, use of injections and surgery, and guideline-discordant care.
“U.S. Spine Care System ina State of Continuing Decline”
(BackLetter, Oct 2013)
Context: Our Dilemma#1
Mafi J, McCarthy E, Davis R, BE L. Worsening trends in the managementand treatment of back pain. JAMA Intern Med. 2013
A huge effort has been invested to improve RCT design and the Levels of Evidence research construct:
1. Systematic reviews typically conclude: “insufficient evidence”, “more research must be done”
2. Many treatments persist with little supportive evidence
3. Spine care costs keep increasing with no evidence of better outcomes
WHY?
Every process is perfectly designedto get the results it gets.
Paul Batalden
Insanity: doing the same thing overand over again and expecting
different results.Albert Einstein.
“There is so much variability in making a diagnosis that this initial step routinely introduces inaccuracies which are then
further confounded with each succeeding step in care.”
Quebec Task Force Report:
Spitzer, et al: Scientific approach to the assessment and management of activity-related spinal disorders (The Quebec Task Force). Spine, 1987. 12(7S): p. S16-21.
Context: A Fundamental Shortcoming#2
The diagnosis “is the fundamental source of error….. Faced with
uncertainty, physicians become inventive.”
Spitzer, et al: Scientific approach to the assessment and management of activity-related spinal disorders (The Quebec Task Force). Spine, 1987. 12(7S): p. S16-21.
Quebec Task Force Report:
#2Context: A Basic Clinical Shortcoming
ConventionalClinical
Examination
Red FlagsTumor
InfectionFracture
HNP’s w/Neuro Deficit
All Others!(Non-specific)
MuscleHNP
Inflammation
LigamentSI Joint
Subluxation
Facet Spondys
Internal Disc
“Black Box” Classification
“Diagnostic Triage”
“The fundamental source of error.”
QTF Report
85%Clinical Guidelines?
Intuitive Empirical Precision medicine
Context: A Glimpse at the Solution
• Intuitive: highly trained professionals solve med. problems through intuitive experimentation (“Experience-Based Medicine”)
• Empirical: data amassed to show certain ways of treating patients on average (“Evidence-B medicine”)
• Precision: diseases diagnosed precisely; standardized, predictably effective treatment that addresses the cause, not the symptom(Diagnosis-Based medicine”)
#3
Convent’lClinicalExam
Red flags
HNP
Non-SpecificLBP
Our most precise anatomic diagnosis….
But how precise is it?There is no standardized
predictably-effective treatment.
How precise are our diagnoses now?
85%
Our dilemma
85% - no diagnosis
10% - anatomic diagnosis, but it’s imprecise
Need a paradigm shift!
RCTsGuidelines
Levels of Evidence
Yet spine careis in decline!
The best treatment for
NS-symptom?
Two surveys of international LBP researchers:
#1 LBP research priority:
Identifying and validatingLBP subgroups
Borkan, et al: A report from the second international forum for primary care research on low back pain: reexamining priorities. Spine. 1998 Costa, et al: Are we making progress? Spine, 2012
#4
T-O Link
D-T Link
A-D Link
A-D-T-O Research Model for Validating Subgroups
Assessment
Diagnosis
Treatment
OutcomeSubgroup RCTs: Which is the best treatment?Prospective subgrp cohorts: Does subgroup-specific treatment improve outcomes? Reliability studies: ∙ test findings ∙ subgroup classification
Kevin Spratt, AAOS 2003
RCTs that target NS-LBPare “doomed”.
To validate diagnostic subgroups that enhance individualized care……
Matched DirectionalExercises +
Postures, Remains better
Matched DirectionalExercises +
Postures, Remains better
Trunk StabilizationTrunk Stabilization
Patient Specific Functional Reactivation
Patient Specific Functional Reactivation
NN
Functional Optimization: Quota
based exercise
Functional Optimization: Quota
based exercise
NN
YY
NN
YY
Red Flags?Red
Flags?
YY
Enter
Enter
Motor Control RestorationMotor Control Restoration
YY
NN
Independent Management
Surgical/Interventional Appropriate Candidate?Surgical/Interventional Appropriate Candidate?
YY
NN
NN
Adjunct Treatments
PRN
Active Rest, Activity
Modification CBT, FRP,
Manual Therapy
Classification through
Mechanical Assessment
and Diagnosis
MDT - a dynamic mechanical test-drive:patients perform standardized end-range spine bendingand loading tests to see how the symptoms respond.
Reproducible response patterns characterize & classify the underlying problem into mechanical subgroups:
• most have subgroup-specific mechanical treatments• others have objective indications for other diagnostics
How would your car mechanic evaluate your car?A history A test-drive
Mechanical Diagnosis & Therapy (MDT):
Key: perform movements repeatedly and to end-range.
Directional Preference Reduce Centralize Abolish
MDT
Directional Vulnerability Produce Increase Peripheralize
Monitor Pain Response Relatedto Directional Loading StrategiesMonitor Pain Response Related
to Directional Loading Strategies
Insight: persistence / recurrences
Single direction
“Rapidly Reversible LBP”
Lateral
2
Flexion3
Extension
1
Prevalence of dir. pref. & centralization:
Donelson(Spine 1990) 84-89 %Sufka (JOSPT, 1998) 60-83 %Werneke (Spine, 1999) 77 %Karas (Phys. Ther. 1997) 73 %Donelson(Spine 1991, ISSLS 1991) 58 %Delitto (Phys. Ther. 1993) 61 %Erhard (Phys. Ther. 1995) 55 %Kopp (CORR, 1986) 52 %Long (Spine, 1995) 43 %Donelson (Spine ,1997) 49 %Laslett (Spine Jrnl, 2005) 32 %
Acute
Chronic
How common is dir. pref.: a reducible derangement?
Acute, ChronicAxial pain, SciaticaDegenerative disc
Pseudo-claudicationSpondys
• Rapid recovery from current episode• Decreased recurrences (50-70% first yr)
– not well-documented in the literature….yet– Where recurrence prevention is rewarded:
payers’ claims data of 5,000 patients shows that re-utilization of services after MDT care: <10%
• Immense cost savings
What is the Treatment for a Dir. Pref?
Matching Directional Exercises, Posture, Education
The underlying pain-generator is:
1. mechanical
2. reversible (mechanically, directional, & lasting)
3. likely something displaced (a “derangement”)
DP and centralization:clues that help make a diagnosis
A derangement:a “patho-mechanical” diagnosis
2 types are identified by mechanical testing:– Reducible: a directional preference that centralizes
the pain and restores full motion – Irreducible: no centralization or dir. pref.;
every direction of testing increases or peripheralizes the pain
Patho-Anatomic vs. Patho-Mechanical Diagnosis?
Patho-Anatomic Diagnosis:
1. disc herniation: MRI can’t differentiate betw a painful and non-painful finding.
2. even if it is: a. only 10% of LBP population; b. “imprecise”: doesn’t identify a standardized, effective treatment.
Patho-Anatomic Diagnosis (reducible derangement):Reliable dx: a. 70-89% of population; b. the treatment is standardized and predictably-effective.
The Use of Lumbar Extension in the Evaluation and Treatment of Patients with Acute Herniated Nucleus
Pulposus: A Preliminary Report
Anatomic AND mechanical diagnosis:
Kopp, Alexander, et.al. CORR 202:211-8, 1986
Trial of Extension
67 pts. w/ sciatica + neural deficits
33 (48%) irreversible
32 under-went surgery
2-5 day: all 34 pain-free; no surgery
Extension: 3-4 sessions/day
34 (52%) reversible
Same anatomic dx: 52% reducible, 48% irreducible der’tsIf fully tested, 10-15% more had a dir. pref.
Pt. Type Resolved Improved No Chge Worse
Duration Acute (13%) 90% 10% 0% 0%
Subacute (32%) 44.5% 52% 3.5% 0%
Chronic (55%) 32% 59% 9% 0%
Location LBP-only (47%) 51% 49% 0% 0%
Thigh (18%) 42% 50% 8% 0%
Leg/Foot (17%) 42% 50% 8% 0%
NeuroLoss (17%) 33% 50% 17% 0%
Treating Dir. Pref. (N = 72) with 2 weeks of matching exercises
Donelson R, Long A, Spratt K, Fung: Influence of DP on two clinical dichotomies: acute versus chronic pain and axial low back pain versus sciatica. PM&R, 2012
A-D D-T T-O Construct
Reliability Predictive Validity RCTs Disc ModelSpratt – 90 Kopp – 86 Karas - 97 Schenk - 03 Kopp – 86
Kilby – 90 Williams – 91 Donelson – 97 Fritz - 03 Donelson – 90
Spratt – 93 Donelson – 90 Snook – 98 Long – 04 Alexander – 92
Riddle - 94 Donelson – 91 Sufka – 98 Brennan – 06 Spratt – 93
Wilson – 99 Delitto - 93 Werneke - 99 Browder - 07 Donelson – 97
Fritz - 00 Spratt – 93 Werneke – 01 Kilpikoski - 09 Snook – 98
Razmjou – 00 Erhard - 94 Larson - 02 Petersen - 10 Derby – 00
Werneke – 01 Long – 95 Oliver - 10 Guzy - 11 Laslett – 05
Kilpikoski - 02 Scannell - 09
Clare - 04 8 Alexander - 12
Fritz - 06
11
168
10
Reducible Derangement (DP/Cent’n) Literature
9: Formal MDT training:Kappa = 0.9, 0.823, 0.7
% agreement: 88-100%2: Little MDT training: Kappa = .2 to .4
A-D D-T T-O Construct
Reliability Predictive Validity RCTs Disc ModelSpratt – 90 Kopp – 86 Karas - 97 Schenk - 03 Kopp – 86
Kilby – 90 Williams – 91 Donelson – 97 Fritz - 03 Donelson – 90
Spratt – 93 Donelson – 90 Snook – 98 Long – 04 Alexander – 92
Riddle - 94 Donelson – 91 Sufka – 98 Brennan – 06 Spratt – 93
Wilson – 99 Delitto - 93 Werneke - 99 Browder - 07 Donelson – 97
Fritz - 00 Spratt – 93 Werneke – 01 Kilpikoski - 09 Snook – 98
Razmjou – 00 Erhard - 94 Larson - 02 Petersen - 10 Derby – 00
Werneke – 01 Long – 95 Oliver - 10 Guzy - 11 Laslett – 05
Kilpikoski - 02 Scannell - 09
Clare - 04 8 Alexander - 12
Fritz - 06
11
168
10
Reducible Derangement (DP/Cent’n) Literature
Outcomes improve >7X if exercise dir. matches DP.
50% of disc surgeries avoidedAcute, chronic, axial, sciatica: rapid recoveries in 2 weeks
Outcome Prediction(D-T Link)
DP and Centralization are better than:
A-D D-T T-O Construct
Reliability Predictive Validity RCTs Disc ModelSpratt – 90 Kopp – 86 Karas - 97 Schenk - 03 Kopp – 86
Kilby – 90 Williams – 91 Donelson – 97 Fritz - 03 Donelson – 90
Spratt – 93 Donelson – 90 Snook – 98 Long – 04 Alexander – 92
Riddle - 94 Donelson – 91 Sufka – 98 Brennan – 06 Spratt – 93
Wilson – 99 Delitto - 93 Werneke - 99 Browder - 07 Donelson – 97
Fritz - 00 Spratt – 93 Werneke – 01 Kilpikoski - 09 Snook – 98
Razmjou – 00 Erhard - 94 Larson - 02 Petersen - 10 Derby – 00
Werneke – 01 Long – 95 Oliver - 10 Guzy - 11 Laslett – 05
Kilpikoski - 02 Scannell - 09
Clare - 04 8 Alexander - 12
Fritz - 06
11
168
10
Reducible Derangement (DP/Cent’n) Literature
Author
MatchingDirectional
Exercises vs. Alt.Treatments
Prev (%)
FollowUp
Subjects (N)
Pain
Function
Disability
Meds
Depression
Withdrew
/ Wors
e (%)
Brennan Manipulation 1 yr 123 +
Brennan Stabilization 1 yr 123 +
Browdr Stabilization 6 mon 48 + +
Kilpkski Manual Ther. 89 6 mon. 119 * * +
Kilpkski Advice-Only 89 6 mon. 119 + + +
Schenk Jt. Mobilztn Disch 31 + +
Long Opp. Dir’n Ex. 74 2 wks 230 + + + + 33/15
Long “Guidln-Based” 74 2 wks 230 + + + + 34/15
Petersen Manipulation 6 mon. 350 + + +
RCTs of the Directional Preference subgroup
After TESIs, MDT exam repeated
69 non-centralizers
van Helvoirt H, et. al. Transforaminal epidural steroid injections followed by Mechanical Diagnosis and Therapy to prevent surgery for lumbar disc herniation. Pain Medicine. 2014.
16% 16%
22%
46%@ 1-year: 62%
remained excellent w/o surgery
??
16%46%11%73%Non-Centralizers
underwent TESIs.
Why is Dir. Pref. Determination the First Stopin this Decision-Making Algorithm?
Strong evidence across the entire ADTO modelHigh prevalence of dir. pref. across all durations and
all LBP presentationsTreatment is highly consistent with current guidelines:
activity/movement, self-care educ’n, re-assuranceSafety: no known risk or reported complicationsMeets Christensen’s ‘precise diagnosis” definition.No question or controversy on Exer. Com.
Consequences of Starting WithDir. Pref. Determination
• The DP subgroup, successfully treated and very large, leave a much smaller subset to move to next decision point.
• Prior RCTs of NS-LBP: the DP subgroup was not excluded, so many with a dir. pref. are randomized and treated with a non-directional approach.
• Future research: should follow the ADTO model and existing subgroup evidence. First: identify/exclude those with a dir. pref.
If operating on the wrong leg is considered a “medical error”,
John Wennberg, MDDartmouth Atlas
what do we call operating on (injecting) someone who doesn’t need it?