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Directional Preference: Classification through Mechanical Assessment. Ron Donelson, MD, MS SelfCare First, LLC. Enter. Red Flags?. Classification through Mechanical Assessment and Diagnosis. Independent Management. Y. N. Y. Patient Specific Functional Reactivation.

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slide1

Directional Preference:

Classification throughMechanical Assessment

Ron Donelson, MD, MS

SelfCare First, LLC

slide2

Enter

Red Flags?

Classification through Mechanical Assessment and Diagnosis

Independent Management

Y

N

Y

Patient Specific Functional Reactivation

Matched DirectionalExercises + Postures, Remains better

N

Re-Enter after Surgical/Interventional

Y

N

YELLOW FLAGS

Trunk Stabilization

Adjunct Treatments PRN

Active Rest, Activity Modification CBT, FRP, Manual Therapy

Y

N

Directional Preference?

N

Maladaptive Motor Control Patterns?

Prior Functional Level Fully Restored?

Motor Control Restoration

Y

N

Functional Optimization: Quota based exercise

Instability?

(Radiograph/Clinical)

Surgical/Interventional Appropriate Candidate?

what i ll cover

What I’ll cover:

Context: Four challenges with our spine care dilemma. Where do we need to go?

Directional preference: How it’s determined; Reliability and validity evidence; Why is it first in the algorithm?

How does it impact the remaining algorithm and future research?

slide4

#1

Context: Our Dilemma

“U.S. Spine Care System ina State of Continuing Decline”(BackLetter, Oct 2013)

Mafi et al (2013) – National Ambulatory and Hospital Medical Care Survey: An acceleration of the development of chronic pain, work disability, more opioid prescriptions and narcotic addiction, use of injections and surgery, and guideline-discordant care.

Mafi J, McCarthy E, Davis R, BE L. Worsening trends in the managementand treatment of back pain. JAMA Intern Med. 2013

a huge effort has been invested to improve rct design and the levels of evidence research construct
A huge effort has been invested to improve RCT design and the Levels of Evidence research construct:
  • Systematic reviews typically conclude: “insufficient evidence”, “more research must be done”
  • Many treatments persist with little supportive evidence
  • Spine care costs keep increasing with no evidence of better outcomes

WHY?

slide6

Every process is perfectly designedto get the results it gets.

Paul Batalden

Insanity: doing the same thing overand over again and expectingdifferent results.

Albert Einstein.

slide7

#2

Context: A Fundamental Shortcoming

Quebec Task Force Report:

“There is so much variability in making a diagnosis that this initial step routinely introduces inaccuracies which are then further confounded with each succeeding step in care.”

Spitzer, et al: Scientific approach to the assessment and management of activity-related spinal disorders (The Quebec Task Force). Spine, 1987. 12(7S): p. S16-21.

slide8

#2

Context: A Basic Clinical Shortcoming

Quebec Task Force Report:

The diagnosis “is the fundamental source of error….. Faced with uncertainty, physicians become inventive.”

Spitzer, et al: Scientific approach to the assessment and management of activity-related spinal disorders (The Quebec Task Force). Spine, 1987. 12(7S): p. S16-21.

slide9

Clinical Guidelines?

All Others!

(Non-specific)

Muscle

Ligament

SI Joint

HNP

Inflammation

Internal Disc

Subluxation

Spondys

Facet

Red Flags

Tumor

Infection

Fracture

85%

“Black Box” Classification

ConventionalClinical

Examination

“The fundamental source of error.” QTF Report

HNP’s w/

Neuro Deficit

“Diagnostic Triage”

intuitive empirical precision medicine

#3

Context: A Glimpse at the Solution

Intuitive  Empirical  Precision medicine
  • Intuitive: highly trained professionals solve med. problems through intuitive experimentation (“Experience-Based Medicine”)
  • Empirical: data amassed to show certain ways of treating patients on average (“Evidence-B medicine”)
  • Precision: diseases diagnosed precisely; standardized, predictably effective treatment that addresses the cause, not the symptom(Diagnosis-Based medicine”)
slide11

How precise are our diagnoses now?

Red flags

Convent’lClinical

Exam

HNP

Our most precise anatomic diagnosis….

But how precise is it?

85%

There is no standardized predictably-effective treatment.

Non-Specific

LBP

our dilemma
Our dilemma

85% - no diagnosis

10% - anatomic diagnosis, but it’s imprecise

The best treatment for NS-symptom?

RCTsGuidelinesLevels of Evidence

Yet spine careis in decline!

Need a paradigm shift!

two surveys of international lbp researchers

#4

Two surveys of international LBP researchers:

#1 LBP research priority:

Identifying and validatingLBP subgroups

Borkan, et al: A report from the second international forum for primary care research on low back pain: reexamining priorities. Spine. 1998

Costa, et al: Are we making progress? Spine, 2012

slide14

A-D-T-O Research Model for Validating Subgroups

Outcome

T-O Link

Treatment

D-T Link

Diagnosis

A-D Link

Assessment

RCTs that target NS-LBPare “doomed”.

Subgroup RCTs: Which is the best treatment?

To validate diagnostic subgroups that enhance individualized care……

Prospective subgrp cohorts: Does subgroup-specific treatment improve outcomes?

Reliability studies:∙ test findings ∙ subgroup classification

Kevin Spratt, AAOS 2003

slide15

Enter

Red Flags?

Classification through Mechanical Assessment and Diagnosis

Independent Management

Y

N

Y

Patient Specific Functional Reactivation

Matched DirectionalExercises + Postures, Remains better

N

Re-Enter after Surgical/Interventional

Y

N

YELLOW FLAGS

Trunk Stabilization

Adjunct Treatments PRN

Active Rest, Activity Modification CBT, FRP, Manual Therapy

Y

N

Directional Preference?

N

Maladaptive Motor Control Patterns?

Prior Functional Level Fully Restored?

Motor Control Restoration

Y

N

Functional Optimization: Quota based exercise

Instability?

(Radiograph/Clinical)

Surgical/Interventional Appropriate Candidate?

slide16

Mechanical Diagnosis & Therapy (MDT):

How would your car mechanic evaluate your car?

A history

A test-drive

MDT - a dynamic mechanical test-drive:patients perform standardized end-range spine bendingand loading tests to see how the symptoms respond.

Reproducible response patterns characterize & classify the underlying problem into mechanical subgroups:

  • most have subgroup-specific mechanical treatments
  • others have objective indications for other diagnostics
slide17

Extension

1

3

Flexion

 Reduce Centralize Abolish

Directional Preference

2

Directional Vulnerability

  • Produce Increase Peripheralize

Lateral

Monitor Pain Response Relatedto Directional Loading Strategies

Monitor Pain Response Related to Directional Loading Strategies

MDT

Key: perform movements repeatedly and to end-range.

Single direction

Insight: persistence / recurrences

“Rapidly Reversible LBP”

slide18

How common is dir. pref.: a reducible derangement?

Acute

Chronic

Prevalence of dir. pref. & centralization:

Donelson (Spine 1990) 84-89 %

Sufka (JOSPT, 1998) 60-83 %

Werneke (Spine, 1999) 77 %

Karas (Phys. Ther. 1997) 73 %

Donelson (Spine 1991, ISSLS 1991) 58 %

Delitto (Phys. Ther. 1993) 61 %

Erhard (Phys. Ther. 1995) 55 %

Kopp (CORR, 1986) 52 %

Long (Spine, 1995) 43 %

Donelson (Spine ,1997) 49 %

Laslett (Spine Jrnl, 2005) 32 %

Acute, Chronic

Axial pain, Sciatica

Degenerative disc

Pseudo-claudication

Spondys

slide19

Rapid recovery from current episode

  • Decreased recurrences (50-70% first yr)
    • not well-documented in the literature….yet
    • Where recurrence prevention is rewarded: payers’ claims data of 5,000 patients shows that re-utilization of services after MDT care: <10%
  • Immense cost savings

What is the Treatment for a Dir. Pref?

Matching Directional Exercises, Posture, Education

slide20

DP and centralization:clues that help make a diagnosis

The underlying pain-generator is:

1. mechanical

2. reversible (mechanically, directional, & lasting)

3. likely something displaced (a “derangement”)

a derangement a patho mechanical diagnosis
A derangement:a “patho-mechanical” diagnosis

2 types are identified by mechanical testing:

  • Reducible: a directional preference that centralizes the pain and restores full motion
  • Irreducible: no centralization or dir. pref.; every direction of testing increases or peripheralizes the pain
patho anatomic vs patho mechanical diagnosis
Patho-Anatomic vs. Patho-Mechanical Diagnosis?

Patho-Anatomic Diagnosis:

1. disc herniation: MRI can’t differentiate betw a painful and non-painful finding.

2. even if it is: a. only 10% of LBP population; b. “imprecise”: doesn’t identify a standardized, effective treatment.

Patho-Anatomic Diagnosis (reducible derangement):Reliable dx: a. 70-89% of population; b. the treatment is standardized and predictably-effective.

A patho-mechanical diagnosis is far more precise thanknowing the anatomic identity of the pain source.

slide23

Anatomic AND mechanical diagnosis:

The Use of Lumbar Extension in the Evaluation and Treatment of Patients with Acute Herniated Nucleus Pulposus: A Preliminary Report

67 pts. w/ sciatica + neural deficits

Trial of Extension

34 (52%) reversible

33 (48%) irreversible

2-5 day: all 34 pain-free; no surgery

32 under-went surgery

Extension: 3-4 sessions/day

Same anatomic dx: 52% reducible, 48% irreducible der’ts

If fully tested, 10-15% more had a dir. pref.

Kopp, Alexander, et.al. CORR 202:211-8, 1986

treating dir pref n 72 with 2 weeks of matching exercises
Treating Dir. Pref. (N = 72) with 2 weeks of matching exercises

Donelson R, Long A, Spratt K, Fung: Influence of DP on two clinical dichotomies: acute versus chronic pain and axial low back pain versus sciatica. PM&R, 2012

slide25

Reducible Derangement (DP/Cent’n) Literature

9: Formal MDT training:Kappa = 0.9, 0.823, 0.7

% agreement: 88-100%

2: Little MDT training:

Kappa = .2 to .4

8

16

10

11

slide26

Reducible Derangement (DP/Cent’n) Literature

Outcomes improve >7X if exercise dir. matches DP.

50% of disc surgeries avoided

Acute, chronic, axial, sciatica:

rapid recoveries in 2 weeks

8

16

10

11

outcome prediction d t link dp and centralization are better than
Outcome Prediction(D-T Link) DP and Centralization are better than:
  • Gender
  • SLR
  • Neurological signs (QTF)
  • Pain duration
  • Pain location
  • Leg pain intensity
  • Overt pain behaviors
  • Non-organic physical signs
  • Fear of work activities
  • Perceived disability
  • Smoking
after tesis mdt exam repeated

69 non-centralizers

underwent TESIs.

After TESIs, MDT exam repeated

@ 1-year: 62% remained excellent w/o surgery

46%

22%

Centralizers

16%

16%

??

16%

46%

11%

73%

Non-Centralizers

van Helvoirt H, et. al. Transforaminal epidural steroid injections followed by Mechanical Diagnosis and Therapy to prevent surgery for lumbar disc herniation. Pain Medicine. 2014.

why is dir pref determination the first stop in this decision making algorithm
Why is Dir. Pref. Determination the First Stopin this Decision-Making Algorithm?
  • Strong evidence across the entire ADTO model
  • High prevalence of dir. pref. across all durations and all LBP presentations
  • Treatment is highly consistent with current guidelines: activity/movement, self-care educ’n, re-assurance
  • Safety: no known risk or reported complications
  • Meets Christensen’s ‘precise diagnosis” definition.
  • No question or controversy on Exer. Com.
consequences of starting with dir pref determination
Consequences of Starting WithDir. Pref. Determination
  • The DP subgroup, successfully treated and very large, leave a much smaller subset to move to next decision point.
  • Prior RCTs of NS-LBP: the DP subgroup was not excluded, so many with a dir. pref. are randomized and treated with a non-directional approach.
  • Future research: should follow the ADTO model and existing subgroup evidence. First: identify/exclude those with a dir. pref.
if operating on the wrong leg is considered a medical error
If operating on the wrong leg is considered a “medical error”,

what do we call operating on (injecting) someone who doesn’t need it?

John Wennberg, MD

Dartmouth Atlas