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modified STarT Back Tool

“For example, individuals at a low risk of persistent disabled problems can be reassured and discouraged from receiving unnecessary treatments and investigations, while those at high risk can matched to treatment which combines physical and psychological approaches”

For those of you that haven’t read my previous posts on the Start Back Screening Tool, then this first post may not make sense. It is recommended to read those posts before reading this post.

In short, some patients improve without treatment, with simple advice to stay active.

“In addition, an implementation study testing risk stratification for patients with low back pain in routine general practice demonstrated significant improvements in physical function and time off work, sickness certification rates and reductions in healthcare costs compared to usual non-stratified care.”

Who knew? 🤷‍♂️

If we start classifying patients, we tend to get better results.

This should be a no-brained. Two different patients with similar pains may respond completely different to treatments. We need to be able to determine which type of intervention/or lack of intervention is best paired with each type of patient.

Until we get better at understanding the patient and both the patient’s response to movement and belief systems, we will continue to fail a percentage of these patients when they come into the clinic. Some patients will improve regardless of the intervention/treatment.

“GPs are not alone in wanting information about patients’ likely prognosis over time, as >80% of musculoskeletal patients also want prognostic information from their GO, although less than a third actually receive this information”

The fact that almost 1/3 of patients receive information from their physician is surprising to me. With shortened face time with physicians and the incentive to refer within the system in which the GPs operate, I’m surprised that there is enough time to spend educating even 1/3 of patients.

We know that patients want information. What is bothersome to me is that some practitioners, throughout healthcare as a whole, give patients flippant answers without substance. These patients then hang on to that information and allow it to dictate how they live or avoid living life.

To tell a patient with osteoporosis that they will fracture their spine when flexing can produce fear of a movement and greatly impact the patients quality of life. Giving the patient statistics about fracturing, not just with bending but also with staying neutral, allows the patient to have a more active role in decision-making.

The last thing we want to do is to label a patient, or cause a patient to label themself, as having “big bones”, slipped discs, degenerative spines, or as many of my patients say “Uncle Arthur”.

“The distribution of primary pain regions was reported by clinicians as: lower limb 31.1%, Back 28.7%, upper limb 23.5%, neck 11.8%, and multisite pain 4.8%”

The modified STarT Back tool is a version explores more options than back pain only.

“…a modified STarT Back Tool is similarly predictive of 6-month physical health across different musculoskeletal pain regions.”

This type of prognostic data is important for healthcare providers to obtain in order to build a long-term plan for patients beyond simply 3 times per week for 6 weeks of therapy.

What happens to patients after this six weeks?

If we have not educated and empowered the patient, they will become a patient again.

“This implies that the existing STarT Back Tool score cut-point (4 or more out of 9) used to allocate patients with low back pain to the medium-risk/high-risk subgroups cannot simply became applied to patients with other musculoskeletal pain presentations or in different clinical services”

This is pretty self-explanatory. We can’t use a back tool to help us make decisions about a knee pain, neck pain, headache, etc.

“It is found that regardless of body region of pain, higher modified STarT Back Tool scores were associated with higher levels of kinesiophobia, catastrophising, fear avoidance, anxiety and depressive symptoms.”

Kinesiophobia is fear of movement. Catastrophising is making a bigger deal out of a situation than it actually is. Fear avoidance is actively avoiding an activity for fear of making oneself worse.

None of these descriptors are good, but you know what…we work with them in physical therapy.

Let me say this differently…a good physical therapist will work on these issues, but not all address these issues.

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Go to Physical Therapy to be Physical…think again

“affecting 60% to 80% of individuals during their lifetime”

This statistic gets thrown around so much that all PTs should know this without thinking about it.

LBP is such a common occurrence that many non-healthcare professionals are giving advice about how to fix it.

I was at a fundraiser recently and I heard people talking about back pain as part of the conversations had between laypeople. This is how prevalent that it has become, discussions of back pain have made their way into everyday conversation. Everyone and their mother has a remedy for it.

I heard about cutting out sugars, rolling on tennis balls and soaking in Epsom salt. It wasn’t until someone in the group turned to me (they had a previous knowledge of the website) that people stopped giving advice and started asking for information.

The public wants information. On that note, if you’ve found any information from this website helpful…please share it so others can learn.

“total annual direct healthcare costs in the United States incurred by patients with LBP were estimated at $90 billion in 1998, 60% higher than individuals without LBP.”

🤔

Sounds like we can start to create a change in total costs if we could just be better at treating this issue.

Back pain is top 5 reasons a person seeks out a healthcare provider.

We are spending so much money on this problem…you’d think we’d be making a dent in the number of people with back pain, and the expenses incurred for this ailment.

Nope!

Reading the rest of this post will start to shed light on why our system, as a whole, has a lot of sucky (scientific term 👍) parts.

“Recent reports suggest that the use of physical therapy for patients with LBP is increasing.”

This makes so many people tho I that our profession (as a PT) is booming. Yes, there is a bigger pool of patients daily, but insurance payments have been decreasing for decades.

This is a different conversation, but it also plays a role in why clinicians may choose on intervention over another.

Soapbox

***For instance, if there are 3 people in the clinic at the same time (which could be considered fraudulent if this is occurring for patients using Medicare as insurance), the therapist has to make the patient perform some activities independently (which also should not be billed for patients with Medicare) or they would have to place the patient on a non-effective piece of equipment in order to be paid, while the PT works with another patient. ***

It then makes sense that the use of PT is increasing if we are performing ineffective techniques in order to maximize reimbursement. Not all PTs operate in this fashion, but if the above scenario sounds familiar…go get a second, third or fourth opinion.

“…Consistent in recommending an active approach to pair with emphasis on maintaining and promoting activity, while avoiding passive interventions such as bed rest or physical methods (heat/cold, ultrasound, etc.)”

Look folks, doing nothing gets you nothing. We know this in many aspects of life. Don’t work, don’t get paid. This is no different.

If the patient doesn’t play an active role in the process of rehabilitation, the results tend to be no better than doing nothing…because that’s exactly what the patient is doing in many cases.

For instance, if a patient goes to physical therapy and the patient lays there while “therapy” is performed on the patient, then the patient has little active role aside from showing up and paying.

This has become such a problem in our profession that our national organization had to come up with a short read to help patients understand what generic therapy look like during an episode of care.

“…Adherence to this recommendation for an active approach was associated with better clinical outcomes of physical therapy, with fewer visits in lower charges for care.”

If a patient learns a home program that has been shown, in the clinic, to be effective at reducing that specific patient’s complaint, why should that patient go to a physical therapy session to get unproven passive treatment or to simply repeat the same exercises over and over?

I’ll wait for your response…because I don’t know the answer to this question aside from the fact that increasing a patient’s frequency in therapy also increases the total profits of the company benefitting from the therapy.

“… it is now understood that the natural history of LBP includes subsequent periods of exacerbation and recurrence for most individuals.”

A high percentage of patients, anywhere from 25% up to 80%, experience multiple periods of low back pain during the lifespan.

How one defines recurrence has a huge role in how this number is determined. It used to be that researchers would look at a group of patients with low back pain and then see how many of them had back pain one year later. The problem with this approach is that for many of the patients, the pain never went away from the first episode.

How can this be classified as a recurrence if it never went away?!

Better questions were then asked and about 25% of patients experience at least a period of one month of relief before having a recurrence.

Because of this, it is prudent for the PT (physical therapist, not personal trainer) to teach the patient how to self-manage and to reduce as many risk factors that one particular patient has for developing back pain in the future.

“The ratio of active: passive codes had to be at least 3:1 for each phase, and every visit had to have at least one active code for the patient care to be considered inherent to guideline recommendations.”

I think that this is very conservative.

This means that for each hour a patient is seen, anywhere from 8-22 minutes are spent on manual (hands on) therapy, ultrasound, electrical stimulation, heat, ice.

The other 38-52 minutes are spent working on balance, exercise, returning to a functional activity.

This type of scenario would allow for 3 units of an active charge (75% of the session) and 1 unit of a passive charge (25% of the session).

Keep in mind, a clinician doesn’t have to follow this type of ratio, but a higher ratio of passive treatment is not consistent with the guidelines of treating patients with back pain.

“Consistent with previous studies, a successful outcome was defined as achieving at least 50% improvement on the 0SW – disability score.”

I’ve seen many patients that have gone through an episode of care without any relief before coming to see me in the clinic. For patients to get a 50% improvement in symptoms and ability to live the life they want, many would be happy with that outcome. In the research, we see as little as a 2-3 point change being considered significant when using the (pain scale). A 50% improvement is considered significant.

“471 patients with LBP met the criteria for inclusion. (18-60y, at least 3 visits of PT, duration of PT at least 10 days, initial OSW >10%, and no surgery recorded)”

This simply shows that there were a large number of patients that could be studied.

The inclusion criteria is important because it’s hard to take a study and apply it to a patient that doesn’t fit the inclusion criteria. For instance, this study included people from age 18-60. The results of the study may not apply to those under the age of 18 or over the age of 60.

Also, the study may not be applicable to those that experienced a back surgery.

“132 patients (28.0%) received adherent care and 339 (72.0%) received non-adherent care.”

Less than 1/3 received care that was consistent adherent to an active plan of care. This is disturbing!

This means that many patients going to therapy are having treatment DONE TO THEM instead of DONE WITH THEM!

There are many treatments that can be billed without the therapist directly treating the patient one-one. For instance, mechanical traction can be performed while the therapist is treating another patient. Other treatments that can be performed while the PT is treating another patient is “electrical stimulation”, moist heat and cold packs.

“Patient receiving adherent care experience greater improvement in disability, and pain intensity, and were more likely to experience a successful physical therapy outcome than patient receiving nonadherent care.”

This literally means that when patients are doing more for themselves, they get more from PT. It doesn’t have to be hard.

The PT should act as the guide in order to introduce the patient into a more pain-free, more functional and self-sustaining state. If the PT is acting as the “hero” of your story and not the “guide” in your story, it may be time to find another PT.

“Patient receiving adherent care also attended fewer physical therapy visits, had a shorter length of stay, and lower charges for physical therapy care.”

Fewer therapy visits = less money!

Is it getting easier to see why some clinics are more than happy to perform traction and electrical stimulation to patients?

💵💸💰

In the end, the patients are rarely at the center of care. Physical therapy is also is a business. Businesses function based on profit.

When you find a PT that treats you as a patient and not a $$$, then you have found the right person.

“296 patients (62.8%) had billed charges for additional healthcare related to the management of LBP in the 1-year period After completion of the physical therapy episode of care.”

It is common for patients with back pain to go to multiple providers, such as pain management, orthopedic surgeons, chiropractors and other PTs in order to seek treatment throughout the year.

“Receiving adherent care was associated with decreased use of prescription medication…also associated with a decreased likelihood of receiving diagnostic imaging procedures…associated with decrease use of MRI”

This is simply saying that when patients do more activity in physical therapy (PT), that the patient is less likely to seek out imaging.

There could be many reasons for this outside of just being active in therapy. This is purely conjecture, but if the therapist is able to educate the patient on when imaging is needed and the patient buys in, then it may have a rom in future imaging.

If the therapist demonstrates to the patient that they are strong and robust through the exercises or movements performed in therapy, then the patient may believe that the injury is less severe than initially believed.

If the therapist can change the patients belief system in order to understand that what is seen in imaging may not give them the answer they are looking for, the patient may be less likely to get imaging.

The one constant in all of this is the patient-PT relationship. It may be harder to foster that patient in an environment where multiple patients are being seen at the same time compared to when a patient is seen one-one.

These are great questions to ask when calling a PT clinic to inquire about treatment prior to actually signing up

1. How comfortable are your PTs at treating LBP

2. Do I need to use electrical stimulation and how many patients is this used on in your clinic?

3. Will the therapist be treating more than one patient at a time?

You have the right to this information prior to signing up. If you don’t care about this information, then don’t bother. If it is important to you that you have the individual attention you are paying for…ask away.

“Similar to other healthcare providers, it appears that physical therapy care for patients with LBP is characterized by widespread and unwarranted variations in practice”

We see PTs using craniosacral therapy , dry needling, MDT and other methods/interventions to treat back pain. Because of the variability, it is imperative that the PT ask about previous treatments because there is no common standard with physical therapy.

“…it may be surprising that adherence to an active approach has been reported to be low in studies of both primary care physicians and physical therapists”

Nope! ❌🙅‍♂️

When determining what interventions have the least amount of friction in order to get paid, the passive interventions win every time.

It’s unfortunate, but until insurance based physical therapy is linked to total costs for the treatment issued to a patient (such as a large lump sum issued to the clinic at the beginning of the year in order to manage a patients physical therapy needs and complaints), we will continue to see passive treatments as they reimburse with little time spent with patients.

Excerpts from:

Fritz JM, Cleland JA, Speckman M et al. Physical Therapy for Acute Low Back Pain: Associations with Subsequent Healthcare Costs. Spine. 2008;33:1800-1805.



Start Back Screening Tool

“Lifetime prevalence for LBP (low back pain) has been reported to be between 60% and 95% and 34% of the participants in a large population study in Norway reported to have had LBP last week”

These numbers are scary, but are consistent with other published research that notes about 80% of the population will have back pain at some point in life. Think of how lucky you would have to be to go an entire lifetime without having back pain based on these numbers?

It can happen, as I’ve seen patients in their 80’s with a first time occurrence of back pain.

The part that is sad for me, as a PT, is that less than 10% of these people will ever get in to see a PT for back pain.

“Due to the lack of diagnostic tests that can identify objective signs of the condition, most of the patients are characterized as having ‘non-specific LBP'”

If you’re not familiar with the numbers, it has been said that any diagnosis trying to name a specific tissue (disc herniation, arthritis, spondylisthesis, spinal stenosis etc) is only correct about 10% of the time. The more severe the diagnosis the more likely that the specific tissue is the correct diagnosis (such as a tumor, spinal cord injury, infection).

Because of this, a majority (90%) of back pain is just labeled as “non-specific low back pain”. The problem with this is that the treatment for a non-specific problem tends to be…non-specific.

Don’t get me wrong, a majority of back pain doesn’t need much treatment, if any at all, and tends to improve over the course of 6 weeks. Some pains from the back require a specific treatment and a treatment outside of this Specific treatment can worsen symptoms.

This means that we have to actually attempt to classify a patient’s presentation. Understand please that a classification is not a diagnosis but instead more of putting the symptoms into a non-specific “bucket” that most resemble that presentation. For instance, there could be a bucket for fast changing, slow changing and unchanging. There could be buckets for a primarily psychosocial component, chemical component or a bio mechanical component.

“Based on the SBT (Keele Start Back Tool) scores, patients can be categorized into three subgroups: patients with low, medium, or high risk for developing persistent LBP and activity limitations….the low risk group should receive minor attention from health professionals and self management strategies are recommended for these patients. The medium risk group should be offered physiotherapy. For the high risk group more psychologically informed interventions are recommended”

This statement may upset some of my colleagues in PT, but we aren’t always needed for patients that experience back pain. For instance, it is advocated to see a PT if you have pain lingering more than a couple of Days. I’m not sure I completely agree with this, as much back pain reduces spontaneously. The last thing you, as the patient should want is to pay for unneeded treatments. The last thing that I want to do as a PT is to take a patients money if I am not needed at that time.

Again, don’t get me wrong there is a group of patients, with back pain, that should be treated by a Physical Therapist. These patients will score higher on the Start Back Screening Tool.

With that said, it is important that the patient be classified correctly within the first 6 weeks of experiencing symptoms. Some research demonstrates an early classification is beneficial and others demonstrate that it should be done within 6 weeks of symptoms. The reason for this is that the patient may benefit from more psychologically informed interventions, which should be performed by someone with

“To be useful as a screening tool in physiotherapy practice, it is important that the SBT-scoring is reliable and that the allocation to risk groups reflects the severity of the patients back problems.”

There are two things that we look at in terms of performing testing. One, is the test valid. This means does the test actually tell us what we think it tells us.

The second thing is reliability. This means that if I have multiple therapist from different settings performing the same exact task, would I get similar or exact scoring if performed on the same exact patient by different therapists.

“The SBT consists of nine items; referred leg pain, comorbid pain, disability, bothersomeness, catastrophizing, fear, anxiety, and depression…. The total score range from 0 to9, with nine indicating worst prognosis. The last five items are summarized into a psychosocial sub scale with five as the maximal score, indicating high risk for development of chronic LBP”

For more information about scoring, I personally like to use the Shirley Ryan website of outcome measures found here.

“Patients with a total score of 0-3 are classified as low risk (minimal treatment, eg self-management strategies).

I use this tool frequently in PT. I rarely have patients score a 3 or less, but this may be because they are already filtered out by the physician in primary care.

I recently had a patient score a 3 and lo and behold his symptoms were abolished in 6 weeks without intervention.

It’s a small sample size, but it seems to match the research.

To summarize: the STarT Back Screening Tool is an option to utilize in practice in order to determine if a patient

1. Requires little/no intervention and will return to prior level of function (PLOF) through regression to the mean (time > interventions).

2. Requires PT/Rehab only

3. Requires a more psychologically intensive approach to care.

Click here for original research article.

STarT Back Screening tool revisited

“…changes in psychosocial risk factors during the course of treatment may provide important information for a patient’s long-term prognosis”

As professionals, we should be performing repeated assessments of patients during the plan of care (POC) and not waiting until the patient is ready for discharge (either because their benefits have been exhausted, the insurance company dictates that an assessment needs to be performed or the patient self-discharged). Performing repeated assessments throughout the POC allows us, as professionals, to understand if the patient is improving, worsening or remaining unchanged with care and to assist us in modifying the POC.

The STarT Back Screening Tool is one method of assessing psychosocial factors that may impede rehab potential.

“… repeated assessments during an episode of care can also provide valuable information about changes in a given variable that can be used for treatment monitoring”

Utilizing a standardized approach to assessing a patient will enable the professional (PT in my case) to determine if a patient is catastrophizing, losing hope, or requires the assistance of a more psychologically focused treatment approach.

“The STarT Back Tool (SBT) is a Screening questionnaire consisting of nine items related to physical and psychosocial statements that are used to categorize patients based on risk (low, medium, or high) for persistent LBP-related disability.”

Here is a copy of the tool in question.

“Wideman et al found that early changes in SBT scores were predictive of four month treatment related changes in several relevant psychological and clinical outcome measures.”

This is a little different than what is expected from an outcome tool. For instance, many tools are utilized to tell the clinician where the patient is at currently and if this patient Hs a risk of developing chronic pain.

When we utilize multiple scores instead of a standalone score, this is indicative of how a patient will progress over the course of time.

“all patients (in this study) were referred for physical therapy by a physician and did not seek physical therapy services through direct access… this setting was considered secondary care.”

This is an important topic. For instance, the previous blog post indicated that the tool gives us information when read minister over a 4-week time period. This indicates that there are changes that occur over the course of 4 weeks.

Many complaints of low back pain improve independently over the course of 6 weeks. If a patient is issued this test at the first visit and classified as low, medium or high, this may lead to an inaccurate classification. Seeing as this study issued the tool to patients in a secondary care (meaning that the patients were referred by a physician) indicates that the patient is not being seen within the first few days of injury.

“1. Aged 18-65 years,

2. Seeking physical therapy for LBP (symptoms are T12 or lower, including radiating pain into the buttocks and lower extremity), and

3. Able to read and speak English”

“treatment was not standardized or tracked in this study and was provided at the discretion of the physical therapist.”

This may also be an issue, as there is a newer study that indicates the treatment interventions may have a role in the patient’s scoring.

Please see the previous post about how to utilize this tool.

“…123 patients (84.2% of the entire sample) who completed the SBT at intake and 4 weeks…The percent of patients for each SBT risk category who were classified differently at intake and four weeks was 81.8% for SBT high risk, 76.0% for SPT medium risk and 11.3% for SBT low risk.”

This indicates that a patient’s initial score should be interpreted with caution because there is a high probability that it will change over the course of 4 weeks.

“most patients either improved (48.8%) or remained stable (40.6%) based on changes in SBT categorization.”

“Thirteen (10.6%) patients were categorized as worsened based on changes in SBT categorization, with six of those patients categorized as SB team high-risk at intake and four weeks later.”

This is interesting to me. Typically, in PT, a therapist will cite regression to the mean. This essentially states that given time the patient will transition from an extreme score towards a more moderate score. This doesn’t account for those that transition from a moderate score towards a more extreme score. To me, this indicates that the episode of care had an effect, albeit a negative effect, on this patient encounter.

Primary findings of this present study were as follows:

1. At over 4 weeks, approximately 11% of patients worsened SBT risk;

2. Clinicians should be less confident in the stability of an intake SBT categorization of high risk than that of medium and low risk;

3. Prediction of 6-month pain intensity scores was not improved when considering intake or 4-week change for SBT categorization; and

4. Prediction of 6-month disability scores was improved when considering intake, 4-week, and 4-week-change SBT categorization”

This indicates that the first measurement may not be a good indication of what will take place with the patient regarding disability over time and some patients can be made worse with therapy. We already knew the second part from previous blog posts.

Excerpts from:

Beneciuk JM, Fritz J, George SZ. The STarT Back Screening Tool for Prediction of 6-month Clinical Outcomes: Relevance of Change Patterns in Outpatient Physical Therapy Settings. J Orthop Sports Phys Ther. 2014;44(9):656-664.

Cervical myelopathy: how to test clinically

“… The onset is often insidious with long periods of episodic, stepwise progression, and may present with a vast array of clinical findings from patient to patient.”

Cervical myelopathy is like neck pain to the extreme. It isn’t just a neck issue, but it ends up encompassing anything below the neck. It can cause arm symptoms, leg symptoms, difficulty walking, weakness throughout the body, spastic robot-like walking, and breathing issues.

This is a neck problem that needs to be addressed ASAP!

Let’s take a look at some of the research on this problem, what your therapist should check, and when it’s time for the patient to be sent back to a physician for imaging to determine if the patient is a candidate for surgery…it is that important.

Some quick stories (or not so quick).

I’ve had two patients with cervical myelopathy. One patient had symptoms of this, but also had arm problems from a previous injury. Because of this, the CSM (cervical spine myelopathy) was delayed in diagnosis until the patient demonstrated abnormal gait…10 months later!

The second case was picked up in the clinic immediately on the first day. I performed this cluster, to be learned later, on the patient and he was very positive. We had a conversation about the need for imaging and a consult with a neurosurgeon. The patient essentially said…thanks but no thanks.

Unfortunately this patient lost use of his hands and developed a walking pattern that was very abnormal before he decided that surgery was the right choice.

Here’s a quick Video describing CSM.

“May involve lower extremities first, weakness of the legs, and spasticity”

Spasticity is an issue that could be seen in walking for some people, but is testing using movements under speed like in this Video

What we will see is that the body reflexively slows down or stops the movement from happening rapidly.

“lower motor neuron findings in the upper extremities such as loss of strength, atrophy, and difficulty in fine finger movements, may present”

This means that we may see generalized weakness, loss of muscle mass (smaller muscles) and difficulty with picking up pennies and buttoning buttons.

“neck stiffness, shoulder pain, paresthesias in one or both arms or hands, or radiculopathic signs”

Neck stiffness is self explanatory. The neck movement may not be fluid or it may be restricted due to pain. There may be symptoms such as pain, tingling or numbness radiating into the shoulder(s) regions, arm(s) region or down to the hand(s) region. We may also see changes in sensation or reflexes.

“An MRI is most useful because the tool expresses the amount of compression placed on the spinal cord, and demonstrates relatively high levels of sensitivity and specificity.”

There is little reason for a PT to recommend an MRI, unless there are specific conditions found during the evaluation. The type of presentation notes above is one reason for a PT to recommend an MRI to the referring physician or the patient’s primary care physician.

X-rays do not do a good job of demonstrating any soft tissue (muscle/spinal cord/disc/ligaments/tendons) abnormalities.

Mind you, this presentation is not common and for the most part, an early MRI is not indicated for neck or back pain.

“The tests, when used alone, are not overtly diagnostic and may lead to a number of false negatives and in rare occasions, false positives”

It is recommended that, when CSM is suspected, the physical therapist use the cluster (groups) of testing in order to strengthen the likelihood of this suspicion. One test used alone is not enough to consider other testing.

“in reality, the diagnosis of CSM involves MRI findings and clinical findings, with equal weighting of both results”

Because the clinical exam is so important for this diagnosis and subsequent imaging, it is important that the PT and physician be familiar with the testing described.

“Of the 10 variables included in the regression modeling, the tests of Babinski and Hoffman’s signs, the Inverted Supinator sign, gait Abnormality, and age > 45 years were retained.”

I’ll be honest. In my first 10 years, I never tested for the inverted supinate sign or Hoffman’s sign until I read this paper. This is a testimony to continuing one’s education beyond taking courses. I don’t recall (those that know me know that I have a pretty good memory) ever learning this cluster through any of the coursework that I took since 2007.

After reading this article, I practiced these tests on a bunch of healthy individuals, those with neck pain in which I didn’t suspect a spinal cord issue, so that I could get better st the test and understand the normal response. This way, I learned the test mechanics and felt confident performing the test on anyone. It enabled me to understand the difference between the “healthy” patients on which I tested this specific cluster and the few in which had a positive test.

Rant: I hear it from so many students and new grads that they feel like they haven’t learned how to perform the tests or what to see as a result of the test because they only get to test healthy individuals. Having gone through the mechanics of this cluster for years, I hope that students understand that they must become confident at performing the mechanics of the test (kinesthetic learning) and know how a healthy response looks. One may go his/her entire career without ever seeing this presentation, but that doesn’t mean that one can’t perform the test and understand a normal result. I bring this up because I hear the same type of arguments regarding vestibular testing and ocular testing.

Every patient that has a history of stroke gets a vestibular-ocular exam because there may be lingering positive testing after the neurological event. This again strengthens my ability to perform the test and increases my likelihood that I will see positive testing…so I know what it looks like for future patient evaluations that may come in off of the street through direct access.

“A finding that included three of five positive tests yielded a positive likelihood ratio of 30.9 and a post test probability of 94%”

Even if you’re not a statistician, this is important information.

A positive likelihood ratio greater than 10 is an indication that your testing is giving a result that increases the chances of that being the diagnosis.

A post-test probability of 94% indicates that there is less than a 10% chance that the diagnosis or classification is incorrect after testing.

This is a much better percentage than we have of most orthopedic issues.

“”this study found that selected combinations of clinical findings that consisted of (1) gait deviation; (2) + Hoffman’s sign; (3) inverted supinator sign; (4) + Babinski test and (5) age > 45 years were affective in ruling out and ruling in cervical spine myelopathy.”

If you are a student and plan on treating patients…you must know these tests.

If you are a therapist treating these patients…you must know, be confident administering and understand the repercussions of a positive test.

If you are a patient…know that not all therapists have the same training and some may not even know these tests exist. I hope this makes you take a more thoughtful approach in choosing your next PT.

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Cervicogenic dizziness

“…characterized by the presence of imbalance, unsteadiness, disorientation, neck pain, limited cervical range of motion, and may be accompanied by a headache.”

Dizziness can have multiple factors. The cervical spine, or neck region, can have a role in a person feeling unsteady or dizzy.

“…when all other causes of dizziness are excluded”

Before making a jump to the cervical spine, the professional performing the evaluation/examination should rule out red flags. Some of these include an active stroke, instability of the neck region after a major trauma, a severing or tear in an artery that supplies the brain.

Other causes of dizziness are BPPV (Benign Paroxysmal Positional Vertigo), vestibular hypofunction, Ménière’s disease, issues affecting the inner ear such as a fistula and many other conditions. Click here to learn more about vestibular issues and dizziness.

“… dizziness should be closely related to changes in cervical spine position or cervical joint movement”

In order to state that the dizziness is coming from the neck, movements of the neck should create a change in symptoms.

It seems like common sense, but I’ll never state that common sense is in abundance in healthcare.

It’s like a person comes in complaining of shoulder and arm pain when looking down, which goes away when looking up, but the clinician spends all of the allotted time moving the shoulder and arm 🤦🏻‍♀️

“diagnosis of exclusion”

This is important. In order to get to this as the cause of the patient’s symptoms, the clinician has to rule out red flags (really bad stuff), BPPV (fast changing symptoms), vestibular dysfunctions (slow changing), brain issues (really slow changing) and then finally get to the neck.

The reason this is called a diagnosis of exclusion is this: when a person is thorough all of the possibilities have been ruled out. This is all that’s left.

“…no single test is able to diagnose the condition, and the diagnosis can not be verified by outcomes, imaging, laboratory values, or unique signs and/or symptoms”

This is important. If there are no tests to determine that this is the problem, it truly is a last resort to treat. We are hoping that this is the cause, and it takes a hard sell job to get the patient on board for treatment of this problem.

“…a systematic process is a pragmatic tool for differential diagnosis of CGD…with utilization of a rule out, rule in paradigm”

This is important. The rule in/rule out paradigm is another way of sayin whiteboarding, at least in my head.

This not so short video series speaks to performing differential diagnosing. Although as a PT, I am not allowed to issue a medical diagnosis, we have to be able to perform differentials and I’ll explain why.

When a physician refers a patient to PT for these issues, many times the diagnosis code given is “dizziness and giddiness”, “frequent falls”, or generalized weakness. No offense to any physician, but this doesn’t tell me what’s wrong with the patient.

In defense of the physician, they may not be trained to perform the testing required in order to determine what is the underlying, or root cause, of the dizziness. Also, on average physicians don’t get to spend the allowed time with the patient in order to perform these tests. I surely can’t treat something if I don’t have an idea of what is wrong. There must be some clue telling me where to start, and this is the power of doing a differential in order to classify what is the major problem and what may be the lesser problems causing a person to be dizzy or off balance.

Because there is not just one cause, there can not be just one treatment.

Hope this makes sense.

“CGD should not be considered if the patient does not have neck pain…neck pain can occur at rest, with movement or with palpation”

It only makes sense that if we believe that there is a problem in the neck that is causing a major disruption in that persons ability to function that we should also be able to find a problem in the neck if we try hard enough.

Pain is so elusive that it may not present in a typical manner. I have patients that only have neck pain provoked at their end-range, which is limited. This would fit the category.

“Vertigo as an illusion of movement;a sensation as if the external world were revolving around the individual (objective vertigo), or as if the individual were revolving in space (subjective vertigo). Vertigo is not a symptom arising from cervical spine, but rather is caused by peripheral vestibular disorders or lesions within the vestibular pathways of the central nervous system”

This is where things become fun. It reminds me of taking my daughter to a fun house. First, getting into the house was hilarious. It started as a house of mirrors. I can’t believe how many times she hit her face into the mirror because she thought it was the exit. The first time she hit her face on the mirror, I was a concerned dad and tried to offer help. By the time she hit her face on the mirror the third time I couldn’t constrain myself any longer. Because it was a house of mirrors she saw me laughing…1,000 mirrored reflections laughing.

I digress.

To get out of the fun house, we had to cross a bridge that had a tunnel spinning around it, which gave the illusion that we were moving. If one closed the eyes and walked, it was easy. If one kept the eyes opened it was a scene out of a sinking ship. My daughter was holding onto the rails for dear life…even though nothing she was standing on or touching was moving.

Vertigo is something like that 😂.

“The duration of symptoms for CGD can range from days to months to years”

This is where I start to have some issues.

A classification of dizziness that we can’t prove, have no great testing to show us that it is happening can have a duration of a short period of time to a long period of time.

Holy specific Batman! This is why, as healthcare professionals, we can struggle at time. The research doesn’t give us concrete information that is useful when in front of the patient.

Patient: how long can this last

Doctor: 🤷‍♂️ months to years

Patient: how long do you think it will last for me

Doctor: (silence)

“Ménière’s disease is a chronic vestibular disorder characterized by episodic bouts of aural fullness, vertigo, and hearing loss. Cervicogenic dizziness however, typically does not include aural fullness, tinnitus or hearing loss”

What in the world is aural fullness?

This is a full feeling within the ear. Think of feeling pressure or a buildup of within the ear. In Ménière’s disease, this feeling comes and goes. The sensation may be accompanied by spinning sensations and hearing loss.

If the patient is experiencing hearing loss, then we can state that the cervical spine is not having a role in this symptom and additional testing of the vestibular, or balance gauge, system needs to be checked to ensure that nothing was missed.

As Johnnie Cochran has become famous for saying:

“If it doesn’t fit, you must acquit”

Some reading this may not be old enough to u see stand this phrase, but the meaning is that if part of the evidence presented doesn’t fit the case then there must be a different perspective followed.

This means that if you are experiencing dizziness that stems from the neck, you shouldn’t also experience hearing loss. If your provider is not listening to your symptoms, you may be wasting both time and money by undergoing treatment for the wrong classification.

“BPPV is the most common vestibular pathology… crystals become dislodged from the utricle and migrate into one of the three semicircular canals located within the inner ear.”

Benign (not harmful) Paroxysmal (sudden occurrence or intensification of symptoms) Positional (relating to the position of the body against gravity) Vertigo (illusion of movement when no movement is occurring) (BPPV) is very common to experience in one’s lifetime. About 3 out of every hundred will experience this. Although it doesn’t come close to the statistics for back pain, it is the most likely reason for experiencing vertigo.

The bad news: it really sucks to have this happen because any activity becomes difficult when you are experiencing your world spinning.

The good news: it’s treatable in a high percentage of cases with very few visits.

“if a patient has symptoms of vertigo accompanied by nystagmus in response to changing head position in space, then BPPV is more likely than CGD”

The nystagmus is the quick movement of the eyes. If we see a nystagmus (it is visible to the clinician) when moving patients through different positions, this helps to clarify not only that the patient has a positional dizziness, but also where the problem is located based on the position and the movement of the eyes.

For instance, if the patient has symptoms during a Dix-Hallpike, we can assume posterior canal, we then have to know if it is the left side or right sided canal in order to understand the proper direction of treatment.

If the patient has a positive Roll test, then this would implicate the horizontal canal, but again we would have to understand the side of dysfunction.

“… symptom duration lasting only a few seconds were significantly more common in the BPPV group. Cervical neck movement, fatigue, anxiety, and stress were also found to be more common precipitating factors for exacerbation of symptoms in the CGD group as compared to the BPPV group”

BPPV has short lasting symptoms. Once the crystals settle, then the symptoms subside.

The other symptoms of anxiety and stress do not tend to be causative factors in BPPV.

“…acute, unilateral, peripheral vestibular loss due to labrythitis or vestibular neuronitis…marked vertigo, imbalance…nausea and possibly vomiting…spontaneous horizontal, direction fixed nystagmus in room light”

When we see an acute peripheral vestibular loss it’s pretty cool, at least for me, as the eyes are all over the place. Because the eyes have difficulty focusing, the patient will see objects blurred or moving. This can create an imbalance and the movement seen, paired with the lack of actual movement of the body, can create a nausea feeling.

Although it is fun to work with, it is never fun to be vomited 🤮 on. My first year, I had no clue what I was doing and got a lot of vomit on my shoes.

“Key symptoms frequently present in vestibular migraine, but not CGD, are aura, true vertigo , throbbing headaches, sensitivity to auditory or visual sensory stimulation, and oculomotor changes”

If you’ve ever had a migraine, these can be debilitating. The sensitivity to light and sound are the two symptoms I hear the most, along with nausea. Cervicogenic dizziness should not present with the auditory or visual issues as these are controlled by cranial nerves (think brain nerves) and not neck nerves.

“Cervical arterial dysfunction (CAD) and whiplash associated disorders (WAD) are non-vestibular pathologies that can mimic CGD”

I had one patient with cervical artery dysfunction that presented with a dizziness. The dizziness was produced with neck movements, but not with other testing. It wasn’t until he started to demonstrate a nystagmus with the seated rotation extension test, along with neck pain, that I sent him back to his referring physician. An ultrasound confirmed arterial dissection.

It’s common in my practice to see proprioceptive issues, as tested by the JPET, in patients after a car accident. We use the laser frequently with these patients.

“…as CAD related dizziness presents with only one symptom in less than 1% of the cases. Other symptoms of CAD include severe headache, diplopia, nystagmus, numbness around the lips or mouth, dysphagia, dysarthria, and upper motor neuron signs”

The patients that present with a suspicion of cervical artery dysfunction or dissection should be referred back to the physician immediately, as this is a risk factor for major complications like stroke.

“Common symptoms of WAD are cervical neck pain and hypersensitivity, decreased cervical ROM, dizziness, tinnitus, and headache”

I see the hypersensitivity frequently in the clinic, along with reduced movement in the neck and a fear avoidance mentality. We don’t expect to see hypersensitivity in those with cervical based dizziness.

“Positive results on cervical instability testing or CAD testing indicate a need for immediate medical attention and imaging”

Again, this was stated above, but I will leave the quote as it is very important to get these patients medical attention immediately.

“A neurological screen should include an assessment of radicular symptoms, myotomes, dermatomes, deep tendon reflexes, upper motor neuron signs and cranial nerve function”

This is a basic evaluation.

Has your PT ever checked your lower reflexes or

“…the vestibular examination should be next”

This type of evaluation is looking at the health of the vestibular nerve and possibly the cochlear nerve through special tests.

The semicircular canals are also tested through positional testing, described later in the post.

Some of the testing performed in the clinic are as follows:

Head Impulse Test or Head Thrust

Head shaking test

The DVAT is described below.

“A thorough evaluation of the cervical spine is best performed in step 4 because first ruling out vestibular dysfunction increases the probability that the cervical spine is the cause of the dizziness”

This goes back to the classification of exclusion. If we’ve cleared the brain of signs of stroke, cleared the canals for signs of BPPV, cleared the nerve of signs of hypofunction and looked at other possibilities such as fistula, then we are left with the neck.

Treating the neck can be helpful for many, but it shouldn’t be the first line of treatment for a patient walking off of the street with complaints of dizziness.

The JPET is one way to test the cervical spine for deficits in spatial awareness.

The Head neck differentiation test is another way of assessing the neck region for dizziness.

“…oculomotor evaluation should include evaluation of nystagmus, skew, smooth pursuit, saccades, Dix-Halpike test, static and dynamic visual acuity, and the vestibule-ocular reflex (VOR) including VOR cancellation and the head thrust test”

Another video showing a nystagmus

The Test of skew is a part of the HINTs exam, which could indicate an active stroke.

Smooth pursuit is another test to measure brain involvement in dizziness.

Saccadic testing is easy to perform in the clinic.

The Dix-Hallpike maneuver is classic for testing of the posterior semi-circular canal, which is typically implicated in BPPV.

The DVAT is used to classify BVH and UVH. (I am choosing to use a student page for this one to help support student programs).

“A horizontal, direction, fixed nystagmus, is consistent with unilateral peripheral vestibular hypofunction.”

These are hard to imagine without context. This video is perfect to demonstrate a quick horizontal beat towards the stronger side.

The eyes will slowly drift in one direction and rapidly correct towards the other direction. This is an indication that one vestibular nerve is “stronger” than the opposite nerve.

This can be treated successfully through rehab.

Article

PT and tendons: where are we at?

“Complicating matters further is the mismatch between reported pain (and disability) and imaging (and pathology), as well as evidence of widespread sensory nervous system sensitization in some tendonopathies.”

A little background. Pain is not always viewable. This is a large debate even among the highest level of pain organizations. The IASP (Thanks to Colin Windhu for catching a mistake) is looking to change the definition of pain to include tissue based problems, or at least perceived problems.

Not all pain has a tissue based component, as some have a cognitive and emotional based component. For instance, I treated a person that was so afraid of performing activities that this person developed a pain from the thought of movement. After establishing that movement was safe, this person more than 10X increased the ability on a functional test…in less than 6 weeks.

This person, and others that I’ve worked with, have a “stinking thinking” type of pain. This may not be the fault of the patient, but instead it may be the fault of the faulty medical system. One that drives fear.

How many people have heard a physician say

“This is the worst spine I have seen”

“You shouldn’t squat/run because it’s bad for your knees”

“You shouldn’t work with heavy weights because it’s bad for your back”

“Your knees/hips are bone on bone and you will need a new knee/hip in the future”

Your pain is because you have a rotator cuff tear/disc herniation/arthritis etc”

These types of interactions do more to hurt the patient than help the patient and can start the cycle of inactivity out of fear of breaking oneself.

Don’t buy into the hype. A little stat, when a physician diagnoses your back pain as a herniated disc, arthritis, muscle strain, stenosis, etc do you know that the diagnosis is only right about 10% of the time?!

People are hanging their health habits in a guess that has a worse chance of being right than flipping a coin. You would have better odds of getting 4 of a kind in Texas Holdem.

Let’s start by not placing too much weight into the diagnosis because it’s a best guess at best.

Here’s what we think may happen. Some pain can cause more pain. Nerves can communicate with each other.

It’s similar to an infection. Any nerve that comes in contact with the nerve that is irritated can then become infected (irritated). Hmm?

I’ve seen many patients that experience widespread pain even though “everything is healthy”.

Yet another reason not to hang your hat on one specific tissue problem.

“… A diagnosis of tendinopathy is reasonably easy to make clinically, on the basis localized pain over the tendon that is associated with loading of the tendon.”

If you hurt your biceps and you ask your biceps to work, it makes sense that it may not like that.

If you hurt/injured your biceps and it hurts when you make your ankle muscles work, we wouldn’t expect that to create a problem in the biceps if the problem is localized to the biceps.

Make sense?

In other words, when a tendon is injured, we expect specific behaviors like

1. Pain with contraction under load that may increase with increasing loads

2. Pain with compression of that area

3. Pain with stretching that specific area

4. No issues when that area is not moving.

If the symptoms operate outside of this narrow set of parameters, it may not be only a tendon issue. This is not to say there isn’t a tendon issue, but instead is meant to say that the tendon may only be a part of the problem and we have no idea how much of a part it is until more assessment is done.

“…management of tendinopathy should optimally involve addressing loading of the tendon”

A tendon connects a muscle to a bone. It doesn’t have a ton of blood flow and can be slow to heal.

It needs to work in order to get back to its normal function.

This is what it means to load the tendon. Make it work, but don’t irritate/create harm. As long as the tendon/pain is not worse following an activity…awesomesauce…no harm done.

“Management of load…usually commenced with complete removal of offending activities and the introduction of appropriate and graduated loading activities”

If you break your leg, you will expect to be on crutches. This is to allow the bone time to heal. This stage lasts anywhere from 4-6 weeks. Loading before then one is ready to accept load can result in worsening the injury. You would know this because the pain worsened or you would break it further.

Loading a tendon before it is ready to be loaded OR more than it is ready to accept will lead to increased pain in that area, pain that is lasting and worsening function over time.

These are the clues a patient needs to give their attention towards.

Sometimes you need to remove all load from a tendon to allow it to rest and others you can perform your normals daily activities, but any more would result in increased pain that lingers.

When the pain no longer lingers after an activity, it is time to do more activities and create a new norm.

It doesn’t have to be any more complicated than this. Some research shows that 1200 repetitions of calf raises should be performed weekly, but it doesn’t have to be this structured.

“…requires patient buy-in…involves the clinician educating the patient about the nature of the tendinopathy, its relationship to loading, and a likely recovery trajectory.”

This is by far and away the most important detail.

If the patient is not educated on how the body should respond AFTER performing the activity, then the patient may be reluctant to continue anything that creates transient (short-lived) pain.

This is one of those issues that only gets better with direct loading. It doesn’t “fix” with time because it needs to be strong enough to handle the loads that you would throw at it on a daily basis.

“This exercise program should be adequately supervised, reviewed, and progressed to ensure adherence and resolution of the tendinopathy.”

SOAPBOX: ADEQUATELY SUPERVISED DOES NOT MEAN THREE TIMES PER WEEK FOR SIX TO EIGHT WEEKS. THE PATIENT SHOULD BE PERFORMING THE HOME PROGRAM AND THE THERAPIST IS IDEALLY ONLY A PHONE CALL AWAY. THE PATIENT SHOULD RETURN IF SOMETHING U EXPECTED HAS OCCURRED OR THE PATIENT NO LONGER IS ABLE TO REPRODUCE THE SYMPTOMS WITH THE LOAD THEY ARE USING AT HOME.

“(a) symptom-guides management, (b) symptom-modification management (c) compressive versus tensile load (d) stages of loading through the rehabilitation process (isometric and isotonic strengthening, energy storage and release, return to play), and (e) what I will refer to as movement competency…in a way that does not provoke pain.”

This doesn’t need to be summarized and is great advice for most soft tissue disorders.

“In the lower limb (Achilles tendon, patellar tendon), it appears that pain up to 5/10 on a numeric pain rating scale during and after training is not harmful and may be desirable”

This is a little more aggressive than I go initially, but the patient’s response gets to dictate how hard we push.

If there is a 3 point change and the patient is no worse after repeatedly creating a 3-point change, the. They have earned the right to go to a 4-point change. At some point, we would predict that too much of an increase would lead to an inflammatory effect, but we just don’t know what that number is for that specific patient.

The only way we will ever know is to test it.

“The fad of giving all patients with tendinopathy an eccentric exercise program from the onset has largely abated; however, after adequate strength of the muscle has been achieved, it is necessary to use eccentric exercises to reinstitute the energy storage/return capacity of the musculotendinous complex”

Not sure if this is any different than just load the tissue. The tissue needs to be able to contract under load and stretch under load. That’s normal mechanics for a muscle.

“Movement competency…is mainly about the form and shape (posture and alignment) with which physical activity is performed.”

This is consistent with what Dr. Kelly Starrett has been preaching for years through his books, videos and interviews.

A squat should look like a certain shape and many things look similar, such as a lunge (squat with one leg), clean start position, deadlift start position, standing up from the toilet etc.

Of course I know there are nuances between the squat and deadlift regarding hip height and back angle, the clean and lunge regarding shin angle etc, but in the end the basic shape still applies (knee bent and hip bent with shoulders forward and back fairly flat with head looking straight ahead). The similarities are where most people need to function and the nuances are what make the exceptional athletes different.

Link to article

The influence of patient choice

“Approximately $85 billion are spent annually on spine-oriented conditions, and an additional $10 to $20 billion are attributed to economic losses in productivity…Per-patient costs have increased by 49% from 1997 to 2006.”

Spine related issues cost our country about $1 Trillion over the course of a decade. Seeing as how we are dealing with a pandemic, people now have a better understanding what $1T can do for the country.

It can give each person thousands in financial relief. It can give small businesses hundreds of thousands in relief.

The number seems arbitrary until you actually see what a Trillion dollar bailout looks like.

If we can reduce the impact of back pain on society, we could keep this money in the economy because there wouldn’t be lost productivity, out of pocket spending and other expenses that come with back pain.

Healthcare would forever be changed if we can reduce the economic impact of back pain, as it is the most prevalent issue seen in outpatient clinics, many emergency departments and most primary care physician offices.

There would be so much opportunity to actually focus on maintaining a healthy population instead of trying to solve a pain/disability problem.

“despite the rising costs, there has been no real improvement in terms of disability or reduction in the proportions of individuals who report back or neck pain.”

This is a little bit of a controversial fact for me. Our ability to treat back pain through classification has improved over the years. For instance, a recent study on downstream costs shows that when using MDT there is fewer follow-up visits and extensive diagnostics required.

I don’t think that we will ever stop people from experiencing pain, back pain or any other locations. People experience pain. This is a fact. Pain can be a good sign to keep us from doing things that create pain in the first place. The problem, in my opinion, is when we allow pain to prevent us from doing things that are considered a normal part of life.

For example, most experience pain when touching a hot stove. This can be used as a warning signal that hot stoves are dangerous.

Unfortunately, many experience pain when bending forward. The same logic applies and some believe that they are actually creating harm when bending forward, so it’s avoided altogether.

This is where I believe a good PT can be worth his/her weight in gold. Teaching a patient to return back to normal activities that the patient previously believed to be dangerous could increase the patients quality and possibly quantity of life.

I now want to address the rising costs of treating pain. The next unfortunate issue is that I personally know practitioners that are so out of touch with current research that they continue to treat patients as if it is 1980. We wonder why, as a whole, we are no better at treating patients.

Why do you think this happens?

One reason is that healthcare is a business.

There’s a ton of conspiracy theorists out there that believe the government is hiding the cure for cancer so that the businesses that treat cancer can continue to make money. For some reason this same conspiracy hasn’t made its way down to back pain.

I’m not sure if you saw the amount of money spent on back pain, but if not then go back up to the top of the post.

There’s big money in back pain.

Why should providers want to get you better faster?

In all honesty, I think the providers want you to get better faster. The providers don’t typically make much less if you get better faster.

The business on the other hand stands to lose a lot of money if the patient gets better at a faster rate.

I’ll speak specifically to physical therapy and use real numbers.

On average a clinic with 2 PT sees about 10 new patients per week. Let’s just say that 8 of the 10 are for some version of spine pain.

This would mean that on average we are seeing 400 new cases of spine related pain in a two person clinic per year.

On average, the reimbursement per treatment session in IL is $95-$100 per session.

If the business asks (more like demands) that a PT keeps the patient for 13 sessions, where’s the therapist with less supervisory demands sees the patient for 8 visits, there is a major difference in the overall income for the clinic.

Clinic 1:

400 (new patients) x 13 (visits)= 5,200 visits

At $95/visit

5,200(visits) x $95(per visit)= $494K

Clinic 2:

400(new patients) x 8(visits)=3,200 visits

At $95/visit

3,200(visits) x $95(per visit)=$304K

Are you starting to understand the problem?

The clinic that requires PTs to see a patient for a specific number of visits stands to generate an extra $190K. This is an example for a two therapist clinic.

Multiply that by the hundreds of thousands of PTs in the country treating back pain and you see how the costs are artificially inflated.

Until insurance companies cut back on what is reimbursed, we will not see a change in practice. What we are seeing insurance companies do is a step in the right direction, bu I personally believe that they are doing it incorrectly.

Right now the insurance companies are giving us typically 8-12 visits that are to be used over the course of 6-8 weeks.

What I would like to see is an insurance company give us a stipend of a few thousands of dollars to care for that one patient over the course of the year. Meaning any problem that occurs with that particular patient is our responsibility to rehab. We become accountable for that patients health.

We are seeing this with some Medicare Advantage Plans, and it seems to be effective at countering the rising costs of healthcare.

Until a drastic change in how we get reimbursed happens, we will continue to see the numbers rise like they have.

I just don’t think that the changes that have happened, restricting the number of visits, is enough to make companies take responsibility for actually helping patients.

“The estimated proportion of persons with back or neck problems to self-report physical functioning limitations increased from 20.7% to 24.7% from 1997 to 2005, suggesting that current care models may be insufficient.”

I have personally seen patients reporting increased disability with time.

Part of what has to be considered is “how many of these individuals reporting disability also have secondary gain issues?”

Meaning, how many people reporting increased disability are actually receiving disability payments?

Secondary gain issues would have to be considered a limiting factor when reporting these numbers.

The next aspect to be considered is the affective component of the impairment. Meaning, how many people are experiencing increased disability due to the environment they spend their time and the situations they surround themselves.

It’s like the opposite of herd immunity. I’ve been part of many FB groups specifically designed for support, but the groups offer anything but support. These groups offer misrepresentation of diagnoses and prognoses. Many people looking for support and assurance are met with information about lifelong disability, surgical options and nocebo language.

There’s more to disability than pain.

A persons belief about pain has an impact on disability. We know this.

We really need to look at changing the narrative about back pain.

“Clinical practice guidelines for primary care management of spinal conditions generally suggest initial management strategies of self-care and nonsteroidal anti-inflammatory medications. Referral to specialist, including physical therapist or for diagnostic imaging is only encouraged for those who failed to respond after period of watchful waiting.”

This is part of the problem. Instead of stratifying the patient based on risk factors for developing persistent pain, which I’ve written about one tool previously, they are treating all back pains similarly.

Some patients will get better on their own without any treatment.

Others would benefit from early treatment.

The medical system has to do a better job of separating these groups in order to maximize outcomes and reduce disability numbers.

“recommended best practices based on such clinical practice guidelines are to avoid bedrest, to use opioid medications for a limited time, and to obtain magnetic resonance imaging only for specific presentation of radicular symptoms.”

This seems very basic.

Unfortunately, these aren’t necessarily followed. I have many patients, over my career that are opioid dependent. There is research showing that long term opioid usage can actually increase a person’s sensitivity to pain. Think about that, medication that initially makes a person unable to sense pain, over time makes a person feel more pain (either frequency or intensity).

I believe that the idea that imaging should be minimized until needed has be adopted more so than the short term usage of opioids.

I rarely see patients coming into the clinic for an evaluation that received an MRI prior to physical therapy. Part of this has to do with insurance companies not approving MRIs until conservative care has been attempted. This has to be commended.

Now we just need our profession to stop looking at patients like an ATM and start to see each case as one that could go to surgery if we don’t make progress.

We have to see the months that the patient would be unable to work and function. We have to employ empathy.

The state of the profession currently sees patients as widgets to be accounted for in productivity measures.

Again, this needs to change in order for us to have an impact on the disabling mentality that is growing with regards to back pain.

“… alternative care models offering direct access (The ability to seek and receive the examination, valuation, and intervention by physical therapist without requiring physician referral for legal or insurance coverage) to physical therapy have suggested fewer days of care and lower costs.”

Looking purely at costs, direct access has the potential to save insurance companies and patients money. This savings would come at the expense of the physicians, hospital systems and emergency departments.

But how you ask?

As it stands, patients would require a referral in most states to be evaluated and treated in a physical therapy environment for longer than 4 weeks. Because of this, a patient would need to go to a physician in order to receive a referral for physical therapy. Each time the patient sees the physician, the costs is about $80.

If PTs has direct access, which in my mind doesn’t just include the ability to be assessed and treated by a physical therapist, but also consists of having that particular patient’s insurance pay for the assessment and treatment, then we would have fewer trips to the emergency department, quick care or physician.

This would save money immediately for the healthcare system and saves the patient time. Instead of waiting to get into a physician and then waiting to see the PT, the patient could walk into the PT office and be assessed within 24-48 hours.

“The majority of the 447 patients included in the analysis chose traditional medical referral (61.7%).”

This is interesting for me to navigate. The group that chose to go the route of direct access ended up saving about $1,500 in total cost of care. This number is misleading though because it didn’t take into account the amount of money that the patient actually paid out of pocket.

For instance, in a 90%/10% coverage plan, the patient would have only paid an extra $150 out of pocket (assuming the deductible was met). That’s a large difference from the patient paying an extra $750 if the patient has an insurance that pays 50%.

Because this $1,500 can vary patient to patient, I’m not sure if it is a good metric to use because it really tells us how much money we are saving the insurance company, instead of telling us how much money we are saving the patient.

I understand the argument that if we save the insurance company money, then we would save the patient money on a lower premium, but I just don’t believe that we will make enough of a dent in healthcare costs to ever drop premiums. It is a business after all and the scenario I more likely see is the business pocketing a larger profit for the money we save them.

This brings us to the next topic : why would patients choose to go to see a physician first before going to PT as a direct access visit?

I think that this would make a good quantitative study to determine what are the factors that correlate with seeing a physician first for back pain prior to seeing a PT.

The other questions to be asked are what would make one choose a chiropractic physician, naprapathic doctor, accupuncturist, massage therapist or physical therapist for specific ailments?

In the end, we know that we have the potential to save the patient money if the patient chooses a direct access (walk into the clinic off of the street) when compared to seeing a physician prior to receiving a referral for physical therapy. Because a majority of patients in this particular study still chose the physician first, there must be other issues in play as to why patients aren’t choosing direct access OR the patients aren’t aware that we could actually save them money.

Link to article

A novel case study

I was just speaking about this case to one of the PTs that works with me this week, and felt it a good learning opportunity to post to the inter webs.

78 year old male was referred to me from another PT. The patient underwent 6 weeks of PT with another therapist also certified in MDT.

I helped train that PT and she felt that the patient should be referred to me to see if there was anything missed during the appointments.

The patient had an extrusion at L3, affecting quad strength. He also had a loss of light touch sensation at the anterior thigh.

His only complaint was pain that would wake him up at 2 AM, which was very intense. He would take a Norco and walk for 30-45 minutes to reduce his pain. He could sleep until 6 or 7 AM, which is when the excruciating pain would return. Again, he would take a Norco and walk. The pain would go away and not return the rest of the day until 2AM. He was very active with Tai Chi and Kung Fu over 10 hrs per week.

His only complaint was pain in the middle of the night.

I couldn’t provoke his pain during the evaluation.

He had already been through 6 weeks of PT without change, so I was only trying to figure out his sleep issue.

I had a working hypothesis

1. Overnight, the disc imbibes fluid and increases in size.

2. It was possible that the change in fluid content was increasing his pain since the pain went away when he was up walking during the night

3. If I could prevent the disc from taking on fluid, his pain might shut off

That was my only thought pattern that made sense for his symptoms.

I had him sleep in a recliner and to call me in 2 days with the result.

He was painfree in the recliner and did not wake at all.

Because he already had 6 weeks with an MDT trained clinician, I didn’t feel that bringing him into the clinic was going to be productive, so I followed by phone.

After two weeks, which is how long it is expected to see results if given the right direction and load, he was able to return to bed without waking.

This patient returned to therapy for a different issue a year later and we had a conversation about his back (he was seeing a different therapist). His strength recovered and he didn’t require surgery.

Moral of the story:

1. Sometimes you have to think outside of the box

2. Don’t let the image dictate treatment

3. Only treat the patient if we can improve their lot in life

4. Always develop a relationship with the patient you are treating.

Second opinion

How many people will choose to get a second opinion before going in for a major surgery?

I would hope 💯%!

I had an awesome conversation about 10 years ago when I was visiting Canada. There was a guy that traveled to Canada in order to get an opinion regarding back surgery. He was from San Diego. That’s a pretty far trip to see if he needs back surgery.

I asked him why travel that far for an opinion and he said that he wanted to reduce any bias on the doctor’s part regarding whether he was a candidate. For instance, the doctor in Canada would not be performing the surgery and it was unlikely that the doctor giving the opinion would be able to benefit from recommending surgery, since the patient would have surgery in California.

He avoided going for the opinion in California because the hospital system would profit from the surgery. The surgeon may have an arrangement with the hospital to ensure that the hospital gets a percentage of the money. We know that the hospital will make money during a surgery. Many people stand to profit from a surgery and the patient would do well to get an opinion from someone that doesn’t stand to benefit.

This brings me to my rant for now. 👇

Why don’t patients get a second opinion regarding physical therapy?

1. It’s not a huge expense

Physical therapy, on average will cost the insurance company about $1200 per episode of care. If the patient is paying 20% for the coinsurance, then it will only cost the patient $240/episode. This works out to about $50/week.

That’s relatively inexpensive compared to a large surgery. The question is: why not spend an extra $25 to see if a second therapist agrees with the first? If there is a disagreement in how treatment should be performed, then the cost may not be the chief factor.

This leads us to 👇

2. All therapists do the same thing

Not all PTs are trained the same! Don’t let a non-PT (such as surgeon or family doctor) tell you that it’s all alike.

Not all surgeons have the same reputation and skills. Not all PTs have the same reputation and skills. The only way that you, as a patient, will know about other’s skills and reputation is to ask and try.

If you are absolutely in love with your PT or MD, then so be it. Sing from the rooftops so that the reputation gets built. If you’re not…try someone different.

Sometimes the grass IS greener.

3. Convenience

I get it. A drive around the corner is much easier than a drive for an hour. It makes sense.

If we believe that not all therapists have the same training or passion for treating a specific issue, then we must also believe that these therapists are worth the drive.

Follow this example:

1. Patient A decided to go to a therapist close to home or work (we know that regarding gyms most people won’t drive more than 15 minutes from work/home). The therapy session costs the patient $240 out of pocket and the insurance pays $1000.

Let’s also say that the patient is being seen for low back pain or sciatica, since this is the number one reason to seek PT. The patient is seen in a clinic in which the therapist is there to punch a clock and see as many patients as possible because that’s how 💰 is made.

The patient doesn’t get much better and then returns to the doctor for a series of shots (more money and time). The shots are a 50/50 chance of working.

Half of the patients will then still have pain and now be shuffled to the next step, either pain management or surgical consult.

2. Patient B spent a little time to search for the therapist in a 20 mile area that best treats low back pain or sciatica. The patient makes an extra 20 minute drive. The therapist decides that the patient would ben for from 8 visits of PT over 6 weeks and the patient gets better because the therapist enjoys the job and works well with patients having this diagnosis.

The patient made a little more of an effort up front, but saved 💵 and ⏳ by choosing the right therapist instead of moving further along in the medical system.

Want a second opinion, send me a message.