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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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Use Local Comparisons (in my back yard)
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#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!
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
Prescriptio
n
Meds
Inpatient N
on-Surgical
Procedures
Surgical/Injectio
n
Procedures Im
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
10/29/11
11
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?