This is bad news because the outcomes of spinal fusion are less than stellar in the first place, in fact, they’re poor.
We’ve seen the evolution of back surgery, including fusion, an attempt to stop movement in the offending joints, change 180 degrees, to the disc replacement, trying to preserve movement. Both have demonstrated limited utility in addressing back pain. There are exceptions to the rule but studies and reviews prove that the lion’s share of these procedures are ineffectual and can have significant complications.
Let’s not forget microdiscectomy, chymopapain injections, percutaneous discectomy, percutaneous laser discectomy, and percutaneous arthroscopic (endoscopic) discectomy. These procedures are touted as less invasive, which is a good thing because the other procedures leave behind a wound site that looks like a bad accident, with plenty of scar tissue to follow. Not good! The less invasive procedures did reduce iatrogenic complications, but were only successful for a “select few”! Determining who is a good candidate for the procedure was and is the problem today.
So what’s my point? The rule in healthcare as it relates to spinal surgery for back or neck pain is; exhaust all conservative forms of care first. Statistically, once this is done your surgical success outcome increases a great deal!
Also note that the outcomes for all or no procedures are about the same in about nine months to a year. So, don’t rush to surgery, there’s usually no turning back after that fails and subsequent surgery outcome stats get worse and worse.
I practice two mechanical treatment protocols for disc problems, with a good success rate I might add, and with little to no complications. Go to GreathouseChiropractic.com for more information on conservative disc treatment protocols with good success rates.
Be Kind To Your Spine
Cochrane Reviews are systematic reviews of primary research in human health care, and health policy. Internationally recognized as the highest standard in evidence-based health care.
What this abstract is telling us is that it’s probably best to wait a period of time before letting a physical therapist or a chiropractor begin exercise or manual therapy on one’s neck after a motor vehicle accident! Too much too soon is bad. Additionally, if you’re not getting better after at least four weeks of care, something needs to change. That means different care or another opinion. I’ve done enough independent medical exams over the years to tell you that both disciplines (chiros and PT’s) can get a bit too over zealous in their attempts to make you better with too much too soon.
This review indicates not only does care too early delay your recovery it can lead to the development of chronic pain and iatrogenic disability! Iatrogenic means caused by the healthcare provider.
Typically injuries are most painful for 3 to 10 days and will progressively lessen as inflammation reduces and repair begins. The PRICE Rule should be in effect at this time (Protect, Rest, Ice, Compress and elevate an extremity joint). Inflammatory cells and by-products, which are the source of chemically mediated pain, decrease significantly in numbers until the third week (Enwemeka 1989). Gradually, at the end of the acute inflammatory phase, functional range movements can begin.
Treating too long typically isn’t helpful either!
Treating over 8 to 12 weeks will not likely provide further remedial therapeutic benefit (won’t make you better). It may be palliative in nature (makes you feel good short term) but experts feel it leads to dependency on care. Kind of like the classical conditioning of Pavlov’s dog, I hurt a little, therefore I need care. The goals of care should be to abolish/reduce pain, improve physical and functional capacity (as clinically indicated) and wean from care. Most long term therapeutic needs can be achieved with well prescribed exercises you can do at home. If you have exacerbations, then you return to care, but not on a regular basis after the natural history of healing.
For more info on soft tissue healing and management go to http://www.greathousechiropractic.com/physical_therapy__rehabilitation
Feel free to call me with questions: 725-6314
Does Early Management of Whiplash-Associated Disorders Assist or Impede Recovery?
Pierre Côté , DC, PhD , * and Sophie Soklaridis , PhD †
Study Design. Narrative review of the literature and commentary.
Objective. To discuss from an epidemiological and sociological
perspective whether the early clinical management of whiplashassociated
disorders can lead to iatrogenic disability.
Summary of Background Data. There is a lack of evidence
supporting the effectiveness of early rehabilitation care for whiplashassociated
Methods. We describe the epidemiological evidence on the
effectiveness of early rehabilitation on health outcomes for patients
with whiplash-associated disorders and analyze from a sociological
perspective how the medicalization of this condition may have
contributed to increasing its burden on disability.
Results. The evidence from randomized clinical trials suggests
that education, exercise, and mobilization are effective modalities
to treat whiplash-associated disorders. However, the evidence from
large population-based cohort studies and a pragmatic randomized
trial suggests that too much health care and rehabilitation too early
after the injury can be associated with delayed recovery and the
development of chronic pain and disability. These fi ndings suggest
that clinicians may be inadvertently contributing to the development
of iatrogenic disability. The epidemiological evidence is supported
by the sociological concepts of medicalization, iatrogenesis, and
Conclusion. The current evidence suggests that too much health
care too early after the injury is associated with delayed recovery.
Clinicians need to be educated about the risk of iatrogenic disability.
Key words: whiplash-associated disorders , rehabilitation , prognosis ,
iatrogenesis , chronic pain , disability . Spine 2011 ; 36 : S275 – S279
Health Care Myth Busters: Is There a High Degree of Scientific Certainty in Modern Medicine?
Two doctors take on the health care system in a new book that aims to arm people with information
Myth: There is a high degree of scientific certainty in modern medicine
“In America, there is no guarantee that any individual will receive high-quality care for any particular health problem. The healthcare industry is plagued with overutilization of services, underutilization of services and errors in healthcare practice.” – Elizabeth A. McGlynn, PhD, Rand Corporation researcher, and colleagues. (Elizabeth A. McGlynn, PhD; Steven M. Asch, MD, MPH; et al. “The Quality of Healthcare Delivered to Adults in the United States,” New England Journal of Medicine 2003;348:2635-2645.)
Most of us are confident that the quality of our healthcare is the finest, the most technologically sophisticated and the most scientifically advanced in the world. And for good reason—thousands of clinical research studies are published every year that indicate such findings. Hospitals advertise the latest, most dazzling techniques to peer into the human body and perform amazing lifesaving surgeries with the aid of high-tech devices. There is no question that modern medical practices are remarkable, often effective and occasionally miraculous.
But there is a wrinkle in our confidence. We believe that the vast majority of what physicians do is backed by solid science. Their diagnostic and treatment decisions must reflect the latest and best research. Their clinical judgment must certainly be well beyond any reasonable doubt. To seriously question these assumptions would seem jaundiced and cynical.
But we must question them because these beliefs are based more on faith than on facts for at least three reasons, each of which we will explore in detail in this section. Only a fraction of what physicians do is based on solid evidence from Grade-A randomized, controlled trials; the rest is based instead on weak or no evidence and on subjective judgment. When scientific consensus exists on which clinical practices work effectively, physicians only sporadically follow that evidence correctly.
Medical decision-making itself is fraught with inherent subjectivity, some of it necessary and beneficial to patients, and some of it flawed and potentially dangerous. For these reasons, millions of Americans receive medications and treatments that have no proven clinical benefit, and millions fail to get care that is proven to be effective. Quality and safety suffer, and waste flourishes.
We know, for example, that when a patient goes to his primary-care physician with a very common problem like lower back pain, the physician will deliver the right treatment with real clinical benefit about half of the time. Patients with the same health problem who go to different physicians will get wildly different treatments. Those physicians can’t all be right.
Having limited clinical evidence for their decision-making is not the only gap in physicians’ scientific certainty. Physician judgment—the “art” of medicine—inevitably comes into play, for better or for worse. Even physicians with the most advanced technical skills sometimes fail to achieve the highest quality outcomes for their patients. That’s when resourcefulness—trying different and potentially better interventions—can bend the quality curve even further.
And, even the most experienced physicians make errors in diagnosing patients because of cognitive biases inherent to human thinking processes. These subjective, “nonscientific” features of physician judgment work in parallel with the relative scarcity of strong scientific backing when physicians make decisions about how to care for their patients.
We could accurately say, “Half of what physicians do is wrong,” or “Less than 20 percent of what physicians do has solid research to support it.” Although these claims sound absurd, they are solidly supported by research that is largely agreed upon by experts. Yet these claims are rarely discussed publicly. It would be political suicide for our public leaders to admit these truths and risk being branded as reactionary or radical. Most Americans wouldn’t believe them anyway. Dozens of stakeholders are continuously jockeying to promote their vested interests, making it difficult for anyone to summarize a complex and nuanced body of research in a way that cuts through the partisan fog and satisfies everyone’s agendas. That, too, is part of the problem.
Questioning the unquestionable
The problem is that physicians don’t know what they’re doing. That is how David Eddy, MD, PhD, a healthcare economist and senior advisor for health policy and management for Kaiser Permanente, put the problem in a Business Week cover story about how much of healthcare delivery is not based on science. Plenty of proof backs up Eddy’s glib-sounding remark.
The plain fact is that many clinical decisions made by physicians appear to be arbitrary, uncertain and variable. Reams of research point to the same finding: physicians looking at the same thing will disagree with each other, or even with themselves, from 10 percent to 50 percent of the time during virtually every aspect of the medical-care process—from taking a medical history to doing a physical examination, reading a laboratory test, performing a pathological diagnosis and recommending a treatment. Physician judgment is highly variable.
Here is what Eddy has found in his research. Give a group of cardiologists high-quality coronary angiograms (a type of radiograph or x-ray) of typical patients and they will disagree about the diagnosis for about half of the patients. They will disagree with themselves on two successive readings of the same angiograms up to one-third of the time. Ask a group of experts to estimate the effect of colon-cancerscreening on colon-cancer mortality and answers will range from five percent to 95 percent.
Ask fifty cardiovascular surgeons to estimate the probabilities of various risks associated with xenografts (animal-tissue transplant) versus mechanical heart valves and you’ll get answers to the same question ranging from zero percent to about 50 percent. (Ask about the 10-year probability of valve failure with xenografts and you’ll get a range of three percent to 95 percent.)
Give surgeons a written description of a surgical problem, and half of the group will recommend surgery, while the other half will not. Survey them again two years later and as many as 40 percent of the same surgeons will disagree with their previous opinions and change their recommendations. Research studies back up all of these findings, according to Eddy.
To view the rest of this article click on or copy & past the link below into your browser.
For what it’s worth, chiropractors and physical therapists are included in this issue as well.
March 28, 2011
Sounds like they are not recommending surgery based on indication and better outcome potential, but just that, they recommend surgery more than other docs!
Is that code for, they are “surgery happy”!? Hmm…
MONDAY, March 28 (HealthDay News) — “Surgeon enthusiasm” is a major reason why surgeons in some areas are more likely to recommend surgery for low back problems, according to a new study.
Researchers analyzed data on more than 50,000 low back surgeries performed in the province of Ontario, Canada, between 2002 and 2006. As in the United States, Ontario has some significant area variations in spinal surgery rates.
The study found that surgeons in counties with higher rates of spinal surgery were more likely to recommend surgery for back problems, meaning they had more enthusiasm. Spinal surgery rates were 20 percent higher in counties ranked in the top quarter of surgeon enthusiasm, compared with counties in the bottom quarter of surgeon enthusiasm.
Patient or family-doctor enthusiasm for back surgery had no effect on spinal surgery rates, nor did local differences in rates of degenerative spinal disease.
“Surgeon enthusiasm was found to be the dominant potentially modifiable factor influencing surgical rates,” wrote Dr. S. Samuel Bederman, of the University of California, Irvine, and colleagues.
Other factors include the availability of MRI and patient age, sex and income.
The study was published in the March 15 issue of the journal Spine.
“Strategies targeting surgeon practices may reduce regional variation in care and improve access disparities,” the researchers wrote in a journal news release.
The American Academy of Orthopaedic Surgeons has more about low back surgery.
– Robert Preidt
SOURCE: Spine, news release, March 24, 2011
Which LBP patients are more likely to respond favorably to physical medicine procedures?
This question has been asked by numerous scientists interested in back pain, in particular, at the University of Pittsburgh and the University of Utah. In fact, they even went one step further; they asked who would do best with each of the following physical medicine procedures: Manipulation, Therapeutic Directional Movement Strategies (McKenzie a.k.a. Mechanical Diagnoses & Treatment) and Stabilization (physical therapy) Exercises.
Here’s what was found. We provide all four of these procedures.
Patients most likely to respond to manipulation.
- Recent onset of pain < 16 days.
- No pain distal to the knee.
- Low fear avoidance beliefs score.
- Segmental hypomobility.
(Fritz J., Whitman, Archives of Physical Medicine and Rehabilitation, 2005)
Ø When three quarters of these criteria were present the chances of success with manipulation was 95%.
Ø When the criteria was not met, the chances of success was 45%.
(Flynn T, Fritz J. et al. Spine, 2002)
Patients most likely to respond to Therapeutic Directional Movement Strategies.
Those who improve by decreasing or abolishing peripheral or local pain with specific test movements/static tests. Conversely, contralateral movements most commonly exhibit the opposite effects, causing production or increase in focal or peripheral symptoms.
As opposed to a diagnosis, a provisional classification is given to each patient. The principal management is by means mechanical therapy, with an emphasis on active vs. passive care, with specific directional movement application; also known as directional preference exercises. Important to note that this protocol does progress, as clinically indicated, to mobilization and ultimately to manipulative procedures, in a specific directional manner.
(Brennan GP, Fritz J. M. Spine 2006)
Patients most likely to respond to “McKenzie Method” are those who demonstrate a “directional preference”.
In a study by Long A, et al. of “evidence based” versus “directional preference” treatment, it was found that 95% of “directional preference” treated patients recovered versus 56% of “evidence based” treated patients recovered.
Patients most likely to respond to stabilization exercise.
Preliminary evidence suggests the following findings are relevant:
- Positive prone instability test.
- Aberrant motions present (instability catch, reversal of lumbo-pelvic rhythm.
- Average straight leg raise (SLR) > 91°.
- At least three prior episodes.
(Hicks GE, Fritz J. M., Delitto J., McGill SM, Archives of Physical Medicine and Rehabilitation, 2005)
Evidence from Australian (Hides, et al.) showed that Stabilization exercise might not help acute low back pain resolve faster, but that it will reduce recurrence rates.
(Hides J. A., Jull G. A., Richardson C. A. Spine 2001)
Additionally, does traction play a role in low back treatment?
Although there’s not much evidence supporting the efficacy of traction, there is some indication that traction may be of some benefit to individuals with low back pain/leg symptoms who do not qualify for provision classification to directional preference treatment and have a positive Well Leg Raise.
(Fritz J., Lindsay W. Spine, 2007)
A meaningful way to classify non-specific low back pain is of dire necessity!
It is with this in mind that the above research from scientific teams at the University of Pittsburgh & University of Utah has been pursuing a more rational basis for treatment decisions for non-specific low back pain and leg pain.
Ø “Patients receiving matched treatments experienced greater short and long-term reductions in disability than those receiving unmatched treatments.”
Ø “Nonspecific low back pain should not be viewed as a homogenous condition. Outcomes can be improved when subgrouping is used to guide treatment decision making”
(Brennan GP, Fritz J. M. Spine 2006)
Manual Therapy First
These are recommended guidelines for treating back pain. National Institute for Health and Clinical Excellence (NICE) on best practice to improve the early management of persistent, non-specific back pain.
The guidelines recommend exercise, manual therapy or acupuncture as first-line treatments for those with back pain that has lasted more than six weeks. There is then a more comprehensive package of psychological and physical treatments for those who have not recovered after receiving these treatments.
The use of X-rays or injections in diagnosing non-specific back pain is not recommended in the new guidelines. In the vast majority of back pain cases, X-rays and MRI scans do not provide any useful information on where the pain comes from or how it may be treated.
The relevant piece– first refer to quality hands on conservative care before thinking of injection docs or ortho docs.
The National Institute for Health and Clinical Excellence (NICE) provides guidance, sets quality standards and manages a national database to improve people’s health and prevent and treat ill health. Link To NICE Website: http://www.nice.org.uk/aboutnice/ Interesting to note, manual therapy was recommended first over more orthodox forms of medical intervention for back pain. You might be wondering what “non-specific back pain” is, well,
basically it’s 85% of all back pain. The other 15% involves a spinal disease, fracture or nerve root compression.
Also note that diagnostic studies don’t really provide useful information in most cases. As a matter of fact, they typically create
more intervention and a bleaker outlook. All of which cost more money and rarely results in better outcome. The more comprehensive package discussed above is referring to chronic back problems. We offer the therapeutic exercises as well.
Please forward this info to those in need.
Dr. Greathouse’s Website: http://greathousechiropractic.com/
Phone: 321 725-6314
Information on this site/email is provided for informational purposes
and is not meant to substitute for the advice provided by your own
physician or other medical professional. You should not use the
information contained herein for diagnosing or treating a health
problem or disease, or prescribing any medication. If you have or
suspect that you have a medical problem, promptly contact your medical
health care provider.
Reduction of Over Utilization – Passive Care Dependency – Chronic Pain Syndrome – Decondition Syndrome
Can we predict poor outcome and if so what can be done about it?Whether it be contrived or due to extenuating circumstances beyond case management & patient control, there will be cases that even with the best care & management that will fall into the chronic pain quagmire. However, health-care providers (HCP) should systematically and diplomatically avoid allowing passive care dependency to develop.
Because two-thirds of work injury monetary loss is derived from lost wages, prediction of probability outcome is important. The potential for early prediction lies in finding appropriate treatment early in the course of care and eliminating ongoing ineffectual (over utilization) care. Currently, few valid prediction instruments are available, the studies that exist are varied and many times contradictory. However, there are multiple poor outcome indicators with potential and they do offer clues that enable the HCP to be more prudent and adroit about avoiding over utilization mistakes and making better management decisions. These sentinel indicators should be in place as standards of care for work related injuries.
Prediction of outcome not only benefits the third party system, it benefits the patient as well. Although some believe secondary gain is an issue and that patients are looking for secondary gain, the true consensus is that these patients represent only a small fraction. So, potentially identifying poor outcome probability and appropriately addressing the issue early, actually benefits all concerned. Those who oppose this assessment system may have some valid concerns, but both sides of the issue have their own agenda and a balance must be kept.
The balance comes with maintaining the focus of the true goals, which are returning the patient to as near normal function as possible, empowering the patient with independent skills and reducing or averting ineffectual care that fosters the tendency toward disability. The check & balance system should be centered on the physician following good standards of care. Standards that require accountability, proof of efficacy, medical necessity and adherence to reasonable end points of care based on the natural history of the disease or malady.
Is passive care dependency fostered?The literature is replete with “fostered care dependency”. I’m sure that any health expert in their respective specialty would agree that fostered care dependency exists.
Caveat: First and foremost, differentially diagnose the patient. Even bona fide hypochondriacs develop serious illness and disease. Management should remain adroit and prudent.
Actual Physiologic Time Frame for Soft-tissue Healing
All soft tissue injuries go through three basic stages of healing within a relatively standard physiologic time frame, regardless of most complicating issues. The literature supports the following;· Acute Inflammatory Phase: 3 to 5 days.· Fibroblastic Repair Phase: 3 to 8 weeks.· Remodeling Phase: Up to one year.· Inflammatory response is still detectable at 12 weeks.This should be used as a fairly standard template for treatment time frames.
Management should be algorithmic in progression. These algorithms are already established.
Identify Complicating Issues
Complicating issues should be identified and factored into the management equation. This might include pre-existing degenerative arthritis, more severe injury, structural/anatomical anomalies, smokers, overweight, and other medical conditions such as diabetes. These issues factored in will help the third party component as well as and more importantly, the patient, to understand the potential for protracted care and recovery. Nonetheless, it is to be understood that returning the patient to full or as near full function and independence remains paramount as the end goal.
Transition Is the Key
Transitioning the patient from pain modulating modalities and medication to more active forms of care is a critical key to avoiding fostered, passive care dependency and potential chronic pain. Many physicians do not do this, which is like Russian roulette when it comes to exposing that low percentage of people who may be predisposed to becoming chronic pain patients. By not transitioning to active therapy, even in its simplest forms, the patient can become predisposed, a precursor if you will, to developing activity aversion which leads to activity intolerance, which is the first step in the chronic pain cascade. Patients can experience, to varying degrees, delayed maturation of collagen, muscle atrophy, joint lubrication deficits, ligament atrophy and even bone loss due to too lack of activity. In turn this leads to decline in muscle endurance, tone, cardiovascular aerobic capacity and decreased mobility. With decreased mobility one develops proprioception, agility and coordination deficits.
With the above scenario of decreased physical capacity and abnormal overload feedback mechanisms, a vicious cycle of recurrent pain and/or re-injury may occur, as is commonly experienced by chronic pain syndrome sufferers.
A Proposed Standard of Care To Avoid Passive Care Dependency and Over Utilization
· A four-week trial probationary period of care should be adhered to.· By four weeks with the exception of up to six weeks with more severe injuries such as disc herniation, the attending physician should be able to demonstrate objective & subjective improvement.· Objectively this might include reduced muscle spasm, increased gross passive range of motion, increased active range of motion, reduced straight leg raise or nerve root tension signs as well as other initially positive orthopedic signs/tests.· Subjectively the patient should demonstrate decreased intensity, frequency and duration of pain or symptoms. This should be quantified by grading the pain on a 0 to 10 scale and percentage improved as rated by the patient or some other valid symptom or pain rating scale. · Additionally, standard subjective outcome assessment questionnaires shouldbe utilized, demonstrating clear progress, including functional improvement as well. Use of subjective outcome assessment tools are now becoming a more accepted standard of care and should be expected by the third parties (insurance companies) as part of justifying continued care.
· If the HCP cannot demonstrate that the patient is progressing with the treatment program within the trial probationary period, a second medical opinion and discharge of the patient is in order. This should be considered a pivotal point in the management process. Beyond this point continued care providing only short-term palliative relief, without demonstrable remedial therapeutic efficacy, should be considered inappropriate and without clinical merit.
This may seem an overstatement of the obvious but on many if not most independent medical reviews or exams, subjective and objective progress is not reflected in the notes, long after treatment should have been stopped or changed.
· If the patient is progressing, a transition should be seen from passive to active care and should be clearly indicated in the treatment plan. Passive treatment should reduce in frequency.
· Active care in the form of rehabilitation should be specific and based on a valid physical capacity assessment, directed specifically at the individual’s deficits. Generic exercise programs should be avoided, as they may subterfuge care with contraindicated or inappropriate procedures. Tear sheet exercise handouts are not acceptable standards of care.. · All patients partaking in exercise should be appropriately screened for potential risk factors associated with exercise and trained in proper protocol and execution of the exercises.
· As a rule, passive care is remedially therapeutic through 6 to 8 weeks, thus the active care component should begin by at least 6 to 8 weeks.
· Most patients will not require ongoing attendance by a trainer/therapist or extensive rehabilitation.
· Most patients do require some level of rehabilitation and without this vital component the risk of chronicity and or recurrence remains higher. It’s penny wise and dollar foolish for third parties to deny this component of care.
· As with treatment, if rehabilitation is indicated, the same burden of proof of medical necessity and efficacy of treatment should be required by the healthcare practitioner.
Board Certified in Rehabilitation by the American Chiropractic Association ACRB
A healthcare practitioners guide.
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