“Low back pain is the worldwide leading cause of years lived with disability, with an estimated point prevalence of 9.4% and a lifetime prevalence of up to 39%”
If three people are sitting together, the odds are that one of those three had back pain, has back pain or will have back pain. That kind of sucks, unless your the one of the people without pain.
Point prevalence means that any one point in time about 10% of the population will have back pain. There are about 320 million-ish adults in the US. This means that about 30 million adults have back pain at any one point in time.
It’s a great time to be a PT, if we can educate the public that we are well trained and capable of treating back pain.
For patients reading this, not all PTs are equal and just like with a surgical procedure, you’d probably get a couple of opinions before making a decision on YOUR Guy or Gal (after you gain trust in the person all of a sudden they become YOURS). I get it! Some people call me their guy, but I’d like for more people to call me their guy.
***tangent: patients are paying more for healthcare. This could be in the form of a higher deductible, copay, coinsurance or straight cash based. As a patient, you should be looking around for the person that gives you the best value for your dollar. If you ever have questions regarding your treatment, feel free to message me and ask me questions in a free conversation. I have a long commute daily and love having these conversations, which have become a weekly occurrence. You can find me Here
“The presence of centralization is associated with good prognosis in patients with low back pain…recent studies have shown that directional preference and centralization, when I matched with adequate MDT treatment, result in better patient outcomes and then treatment with general range of motion exercises￼”
Centralization?🤔 I wonder what that is?
If you’re new to this page, you can go back and read my old posts on centralization here
Just know that centralization has been called the trump card to helping patients with back pain…it’s that powerful that it darn near always wins for the patient.
“The level of MDT training should also be considered, as it may impact interventions and risk-adjusted functional outcomes.”
Studies have been Published questioning the reliability of using MDT. I believe that these studies need to be looked at in depth because this particular study shows that those not certified in the method may not be the most reliable in noting a particular “syndrome” in the patient’s presentation. The level of training appears to play a role in the therapist’s ability to assess a Patient.
“only trails in which of therapists were MDT trained were included. To be considered MDT trained, therapist were required to have participated in at least one course offered by the McKenzie institute international focused on applying MDT to patients with LBP”
Based on the above research links, just using therapists that have taken courses in MDT decreases the likelihood that a reliable classification took place, therefore reducing the likelihood that the patient was treated according to the proper principle and finally leads me to believe that I was wasting my time in reading the remainder of the article….I digress. I read it anyways to hear what’s being talked about regarding MDT, both good and bad.
“review were’s screen 354 abstracts and selected 51 articles for fall text review. After review, 17 articles were retained for the meta-analysis; however, of these 17 studies, four did not provide sufficient data to be included in the statistical analyses”
This is part of the problem that I have with systematic reviews and meta analyses. So much of the research gets discarded and not used in the actual article, that we then start to see researcher bias based on the question asked and how the researchers go about obtaining information. Think of it, only 5% of the actual information that they found on their initial screen actually makes it to the cutting room floor.
“MDT versus manual therapy plus exercise: there was moderate evidence of a significant difference in pain after the intervention, with results favoring MDT…There was moderate evidence of no significant difference in disability after the intervention period between MDT and manual therapy plus exercise.”
I think this is 👌. Understanding that MDT is the assessment first and treatment second one must also understand the components of MDT. MDT incorporates manual therapy, exercises, postures and positions. This means that there is something specific to the way that manual therapy and exercises are prescribed in MDT that has a greater affect on pain that just manual therapy and exercise together.
No effect on disability or function over a time period is also not surprising for me. It’s well known amongst those of us that use this method that returning a patient to function is not well taught in MDT, as there are many other courses and methods that speak to this. MDT follows a certain paradigm, with returning to function as part of the paradigm, but because it varies widely from patient to patient, it is best learned from other resources.
“this study found that MDT plus first – line care resulted in significant, but small, improvement in pain intensity compared to first – line care only.”
This is significant! But small. For anyone going to an ED for back pain, they are in significant pain. I’ve spent part of my career working in an ED for this exact population. In the time I worked in the ED, only one patient was unable to find a position, movement or posture that provided relief. This is significant because these patients were able to receive the right care through an outpatient means instead of being admitted to the hospital for “non-specific low back pain”.
These patients didn’t receive the rapid MRI, which in some cases may actually make the patient worse over time. These patients didn’t have a hefty hospital bill and these patients were able to recover in their natural environment thereby reducing the risk of infectious disease acquired in the hospital.
This is significant!
“One study included in the review, despite lacking data for analysis, compared MDT to education and found no significant between – group differences for changes in disability.”
This is not too shocking for me. If the pain is acute (started recently), we know that many with back pain will get some relief over time. Education is powerful in and of itself and a large part of MDT is education based.
If both utilize education as the base for acute pain, then the outcomes may not be much different. No shock here!
“There was moderate evidence of a significant difference in pain after the intervention period, with the results favoring MDT. ”
MDT is a patient response system. This means that after every movement, position or posture the therapist is asking the patient if it reduced symptoms. If the answer is yes, then the PT will typically issue this for a home program. 🙄
It’s no wonder that the system is pretty good at reducing pain in a specific classification; the therapist is giving exercises that have been shown to reduce pain/symptoms.
“Two studies included in the review, which lacked sufficient data to be included in the meta-analysis comparing MDT to modalities, found significant between-group differences for changes in pain, favoring MDT.”
Again, comparing an active intervention (patient takes part in the intervention) to passive interventions (treatment is done to the patient) is expected to lead to an outcome favoring the active intervention. There are multiple reasons for this, but one may simply be interactions with another individual during the session.
“Three studies compared the effects of MDT to combined manual therapy plus exercise in participants with chronic LBP…There was moderate evidence of no significant difference in pain after the intervention period between interventions…There was high quality evidence of no significant difference in disability after the intervention period between interventions.”
Again, this is not too difficult. As a treatment strategy MDT is literally manual therapy plus exercise. It’s comparing two similar interventions, with similar results.
“One study had 2 comparison intervention groups consisting of either MDT exercise in the opposite direction as the directional preference or midrange lumbar/stretching exercises. Only this latter group was included as the comparison to MDT in the current analysis.”
This is the part of the analysis that I don’t quite understand. Why bother 🤷♂️ comparing the interventions if one of the treatment groups is removed?
This article is cited frequently by PTs trained in MDT and you can read my analysis of the article Here
Removing one of the groups, specifically the opposite directional preference group, greatly changes how that article impacts the reader.
“There was high quality evidence of a significant difference in disability after the intervention period, with the results favoring MDT.”
Even with removing the group of patients that had a high dropout rate and poorer outcomes, the article still favored MDT over “evidence based” interventions.
“Also, MDT does not explicitly account for pain systems theory, specifically differentiating between pain that is central or peripheral in origin, and for a wider spectrum of psychological factors that could be present in patients with chronic low back pain. ”
This is a good point and those that are well versed in the system would state that there are other classification systems out there that would include this pain system. If you are interested in these systems, I highly encourage readers to take a course by Annie O’Connor, author of A World or Hurt.
You can learn more about Annie by following this Link
Thanks for reading.
Since my last post, I’ve gone through a major job change. I can now be found at PCJ
What would it take to convince you as a patient to give a PT with an MDT certification a chance?
What would it take to convince you as a PT to take an MDT course?
Link to article