I see patterns

I see patterns, quick flashback to the Sixth Sense.

 

“Nonspecific LBP accounts for the great majority of cases of LBP and is defined as LBP for which there is no identifiable cause (e.g, injury or disease). As a result, treatment recommendations commonly involve a one-size-fits-all approach.”

This is reality. When someone has back pain, it is a guess and a poor one at that as to what is the cause of the back pain. Herniated discs? Sure. Arthritis? Sure, why not. Spinal stenosis? Must be. Cancer? Naw, this one we could rule in or out with imaging. The sinister (read really bad) stuff can be picked up through imaging and is assumed to be the cause of pain. What else is out there? Lumbago…WTF is this about? My favorite is back pain. For real, this is how it works. The patient goes to the doctor with a complaint of back pain and after the end of the session, the doctor says…You have back pain. Here’s your script for back pain. See me in a few weeks.

The problem when we can’t identify different causes of back pain, then all back pain is treated via a “shake and bake” or cookie cutter approach. Is Suzy’s back pain the same as Johnny’s, probably not since the symptoms aren’t even in the same location, but it is still coming from the back so it must be treated the same way. There’s a reason that we as the industry of healthcare have failed in treating back pain…we can’t even define it.

 

“The current treatment classification system (ie, a small group [5%-10%] of patients with identified specific pathology versus the large group [90% -95%] with nonspecific LBP) is clearly not working well.”

Have you seen the numbers?! Not working well is an understatement. Here are some scary stats. The 5-10% that physicians can diagnose are those sinister (read really bad) problems.

“Subgrouping patients in LBP does not need to be complex or difficult”

Everyone subgroups patients. Tony Delitto has stated in an article (It’s late and I don’t want to go find it so trust me…I’m a professional) that everyone classifies patients, but the classifcation system may be very rudimentary. For instance, if someone comes in with a history of back pain and has failed at therapy elsewhere, we would say that this person may fail again. This is a way of classifying, albeit not a good one, but one way. There are methods of classifying back pain (don’t see this as diagnosing) based on signs and symptoms and response to movement or other interventions. This is a slightly more sophisticated way. There are methods that have withstood the rigor of research and demonstrate moderate reliability in the assessment of back pain.

 

“A good example in the LBP field is the STarT Back trial that used a simple prognostic tool (9 questions only) to match patients to treatment packages appropriate for them.”

I was fortunate enough to hear Nadine Foster, one of the authors of the original study, speak at a spine conference in 2013. The questionnaire can help clinicians, especially the primary care coordinator (Physician Assistant, Primary care physician, orthopedist, Advance Nurse Practitioner) determine if the patient may improve without treatment or if PT could be beneficial. The final category that a patient could be classified into is the inclusion of physical therapy with the addition of a psychosocial approach to pain.

 

“Clinicians are usually favorable to the idea of individualized treatments for nonspecific LBP.”

If all back pain were created equal, then I’d be in favor for all treatments being equal. When a patient comes in looking crooked with 9/10 pain, then that patient should not receive the same treatment as someone that has 1/10 pain and is looking to return to sports. Different presentations call for different solutions. There is an excellent book out there for patients and insurance companies called: Rapidly Reversible Low Back Pain by an orthopedic surgeon. He follows the thought and ideas of Robin McKenzie.

“Put simply, if there is a subgroup that does well, it must be balanced by a subgroup that does poorly.”

This research is out there, but because it doesn’t meet the stringent standards of most research studies, it is frowned upon. The problem with the study is that the authors of the study aren’t blinded to the treatments and patient classification. This means that the authors could be biased in one way or another. Aside from this, the study is a legitimate study assessing varying treatment for low back pain. There was one group that did very well and one group that did poorly. One group was in the middle of the two, but leaned more towards poor than well. Check out the study from Audrey Long

“Two aspects of human nature that could explain this situation (treatment effect) are that we tend to see patterns where none exist (patternicity) and that we presume we have more control over events than we truly do (illusion of control).”

This is great stuff. I actually printed off the articles so that I could read them later. I’d love to believe that this isn’t me…but wouldn’t everyone. I’d love to believe that I actually see dead people…I mean patterns and no, not the patterns that people create when they see a shadow and believe it’s a ghost. It does intrigue me though to learn more about pattern recognition.

“…we must conclude that in general, the current research initiatives and achievement in this field are far from optimal and not yet ready to be implemented in clinical practice.”

I wish I could agree with this, but then we are treating all patients the same. If we can’t give individualized instruction to each patient, then it doesn’t matter who the patient sees for their problem. It doesn’t matter that one person’s back pain started 2 years ago and hasn’t subsided or that another’s started this week and is expected to improve with time. Both patient’s would get the same treatment approach if we can’t classify.

 

 

Author: Dr. Vince Gutierrez, PT, cert. MDT

After having dedicated 8 years to growing my knowledge regarding the profession of physical therapy, it seems only fitting that I join the social media world in order to spread a little of the knowledge that I have gained over the years. This by no means is meant to act in place of a one-one medical consultation, but only to supplement your baseline knowledge in which to choose a practitioner for your problem. Having completed a Master of Physical Therapy degree, the MDT (Mechanical Diagnosis and Therapy) certification and currently finishing a post-graduate doctorate degree, I have spent the previous 12 years in some sort of post-baccalalaureate study. Hopefully the reader finds the information insightful and uses the information in order to make more informed healthcare decisions. MISSION STATEMENT: My personal mission statement is as follows: As a professional, I will provide a thorough assessment of your clinical presentation and symptoms in order to determine both the provocative and relieving positions and movements. The assessment process and ensuing treatment will be based on current and relevant evidence. Furthermore, I will educate the patients regarding their symptoms and their likelihood of improving with either skilled therapy, an independent exercise program, spontaneous recovery or if the patient should be referred to a separate specialist to possibly provide a more rapid resolution of symptoms. Respecting the patient’s limited resources is important and I will provide an accurate overview of the prognosis within 7 visits, again based on current research. My goal is to empower the patient in order to take charge of both the symptomatic resolution and return to full function with as little dependence on the therapist as possible. Personally, I strive to be an example for family and friends. My goal is to demonstrate that success is not a byproduct of situations, but a series of choices and actions. I will mentor those, in any way possible, that are having difficulty with the choices and actions for success. I will continue to honor my family’s “blue-collar” roots by working to excel at my chosen career and life situations. I choose to be a leader of example, and not words, all the while reducing negativity in my life. I began working towards the professional aspect of the mission statement while still in physical therapy school. By choosing an internship that emphasized patient care and empowering the patient, instead of the internship that was either closest to home or where I knew that I would have the easiest road to graduation, I took the first step towards learning how to utilize the evidence to teach patients how to reduce their symptoms. I continued this process by completing Mechanical Diagnosis and Therapy courses A-D and passing the credentialing exam. I will continue to pursue my clinical education through CEU’s on MDT and my goal is to obtain the status of Diplomat of MDT. Returning back to school for the t-DPT was a major decision for me, as resources (i.e. time and money) are limited. My choice was between saving money for the Dip MDT course (about 15,000 dollars) and continuing on with the Fellowship of American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) (about 5,000 dollars), as these courses are paired through the MDT curriculum or returning to school to work towards a Doctorate of Physical Therapy degree. I initially planned on saving for the Dip MDT and FAAOMPT, but life changes forced me to re-evaluate my situation. The decision then changed to return for the tDPT, as my employer paid for a portion of the DPT program. My goal for applying to and finishing the Dip MDT and FAAOMPT is 10 years. This is how long I anticipate that it will take to finish paying student loans and save for both programs, based on the current rate of payment. I don’t know if I will ever accomplish what I set forth in the mission statement, but I do know that it will be a forever struggle to maintain this standard that I set for myself.

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