ron donelson, md, ms selfcare first, llc
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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Ron Donelson, MD, MSSelfCare First, LLC
Directional Preference:Classification through
Mechanical Assessment
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Matched DirectionalExercises +
Postures, Remains better
Matched DirectionalExercises +
Postures, Remains better
Trunk StabilizationTrunk Stabilization
Patient Specific Functional Reactivation
Patient Specific Functional Reactivation
NN
Functional Optimization: Quota
based exercise
Functional Optimization: Quota
based exercise
NN
YY
NN
YY
Red Flags?Red
Flags?
YY
Enter
Enter
Motor Control RestorationMotor Control Restoration
YY
NN
Independent Management
Surgical/Interventional Appropriate Candidate?Surgical/Interventional Appropriate Candidate?
YY
NN
NN
Adjunct Treatments
PRN
Active Rest, Activity
Modification CBT, FRP,
Manual Therapy
Classification through Mechanical Assessment
and Diagnosis
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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?
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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.
“U.S. Spine Care System ina State of Continuing Decline”
(BackLetter, Oct 2013)
Context: Our Dilemma#1
Mafi J, McCarthy E, Davis R, BE L. Worsening trends in the managementand treatment of back pain. JAMA Intern Med. 2013
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A huge effort has been invested to improve RCT design and the Levels of Evidence research construct:
1. Systematic reviews typically conclude: “insufficient evidence”, “more research must be done”
2. Many treatments persist with little supportive evidence
3. Spine care costs keep increasing with no evidence of better outcomes
WHY?
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Every process is perfectly designedto get the results it gets.
Paul Batalden
Insanity: doing the same thing overand over again and expecting
different results.Albert Einstein.
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“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.”
Quebec Task Force Report:
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.
Context: A Fundamental Shortcoming#2
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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.
Quebec Task Force Report:
#2Context: A Basic Clinical Shortcoming
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ConventionalClinical
Examination
Red FlagsTumor
InfectionFracture
HNP’s w/Neuro Deficit
All Others!(Non-specific)
MuscleHNP
Inflammation
LigamentSI Joint
Subluxation
Facet Spondys
Internal Disc
“Black Box” Classification
“Diagnostic Triage”
“The fundamental source of error.”
QTF Report
85%Clinical Guidelines?
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Intuitive Empirical Precision medicine
Context: A Glimpse at the Solution
• 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”)
#3
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Convent’lClinicalExam
Red flags
HNP
Non-SpecificLBP
Our most precise anatomic diagnosis….
But how precise is it?There is no standardized
predictably-effective treatment.
How precise are our diagnoses now?
85%
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Our dilemma
85% - no diagnosis
10% - anatomic diagnosis, but it’s imprecise
Need a paradigm shift!
RCTsGuidelines
Levels of Evidence
Yet spine careis in decline!
The best treatment for
NS-symptom?
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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
#4
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T-O Link
D-T Link
A-D Link
A-D-T-O Research Model for Validating Subgroups
Assessment
Diagnosis
Treatment
OutcomeSubgroup RCTs: Which is the best treatment?Prospective subgrp cohorts: Does subgroup-specific treatment improve outcomes? Reliability studies: ∙ test findings ∙ subgroup classification
Kevin Spratt, AAOS 2003
RCTs that target NS-LBPare “doomed”.
To validate diagnostic subgroups that enhance individualized care……
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Matched DirectionalExercises +
Postures, Remains better
Matched DirectionalExercises +
Postures, Remains better
Trunk StabilizationTrunk Stabilization
Patient Specific Functional Reactivation
Patient Specific Functional Reactivation
NN
Functional Optimization: Quota
based exercise
Functional Optimization: Quota
based exercise
NN
YY
NN
YY
Red Flags?Red
Flags?
YY
Enter
Enter
Motor Control RestorationMotor Control Restoration
YY
NN
Independent Management
Surgical/Interventional Appropriate Candidate?Surgical/Interventional Appropriate Candidate?
YY
NN
NN
Adjunct Treatments
PRN
Active Rest, Activity
Modification CBT, FRP,
Manual Therapy
Classification through
Mechanical Assessment
and Diagnosis
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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
How would your car mechanic evaluate your car?A history A test-drive
Mechanical Diagnosis & Therapy (MDT):
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Key: perform movements repeatedly and to end-range.
Directional Preference Reduce Centralize Abolish
MDT
Directional Vulnerability Produce Increase Peripheralize
Monitor Pain Response Relatedto Directional Loading StrategiesMonitor Pain Response Related
to Directional Loading Strategies
Insight: persistence / recurrences
Single direction
“Rapidly Reversible LBP”
Lateral
2
Flexion3
Extension
1
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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
How common is dir. pref.: a reducible derangement?
Acute, ChronicAxial pain, SciaticaDegenerative disc
Pseudo-claudicationSpondys
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• 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
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The underlying pain-generator is:
1. mechanical
2. reversible (mechanically, directional, & lasting)
3. likely something displaced (a “derangement”)
DP and centralization:clues that help make a diagnosis
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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
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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.
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The Use of Lumbar Extension in the Evaluation and Treatment of Patients with Acute Herniated Nucleus
Pulposus: A Preliminary Report
Anatomic AND mechanical diagnosis:
Kopp, Alexander, et.al. CORR 202:211-8, 1986
Trial of Extension
67 pts. w/ sciatica + neural deficits
33 (48%) irreversible
32 under-went surgery
2-5 day: all 34 pain-free; no surgery
Extension: 3-4 sessions/day
34 (52%) reversible
Same anatomic dx: 52% reducible, 48% irreducible der’tsIf fully tested, 10-15% more had a dir. pref.
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Pt. Type Resolved Improved No Chge Worse
Duration Acute (13%) 90% 10% 0% 0%
Subacute (32%) 44.5% 52% 3.5% 0%
Chronic (55%) 32% 59% 9% 0%
Location LBP-only (47%) 51% 49% 0% 0%
Thigh (18%) 42% 50% 8% 0%
Leg/Foot (17%) 42% 50% 8% 0%
NeuroLoss (17%) 33% 50% 17% 0%
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
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A-D D-T T-O Construct
Reliability Predictive Validity RCTs Disc ModelSpratt – 90 Kopp – 86 Karas - 97 Schenk - 03 Kopp – 86
Kilby – 90 Williams – 91 Donelson – 97 Fritz - 03 Donelson – 90
Spratt – 93 Donelson – 90 Snook – 98 Long – 04 Alexander – 92
Riddle - 94 Donelson – 91 Sufka – 98 Brennan – 06 Spratt – 93
Wilson – 99 Delitto - 93 Werneke - 99 Browder - 07 Donelson – 97
Fritz - 00 Spratt – 93 Werneke – 01 Kilpikoski - 09 Snook – 98
Razmjou – 00 Erhard - 94 Larson - 02 Petersen - 10 Derby – 00
Werneke – 01 Long – 95 Oliver - 10 Guzy - 11 Laslett – 05
Kilpikoski - 02 Scannell - 09
Clare - 04 8 Alexander - 12
Fritz - 06
11
168
10
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
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A-D D-T T-O Construct
Reliability Predictive Validity RCTs Disc ModelSpratt – 90 Kopp – 86 Karas - 97 Schenk - 03 Kopp – 86
Kilby – 90 Williams – 91 Donelson – 97 Fritz - 03 Donelson – 90
Spratt – 93 Donelson – 90 Snook – 98 Long – 04 Alexander – 92
Riddle - 94 Donelson – 91 Sufka – 98 Brennan – 06 Spratt – 93
Wilson – 99 Delitto - 93 Werneke - 99 Browder - 07 Donelson – 97
Fritz - 00 Spratt – 93 Werneke – 01 Kilpikoski - 09 Snook – 98
Razmjou – 00 Erhard - 94 Larson - 02 Petersen - 10 Derby – 00
Werneke – 01 Long – 95 Oliver - 10 Guzy - 11 Laslett – 05
Kilpikoski - 02 Scannell - 09
Clare - 04 8 Alexander - 12
Fritz - 06
11
168
10
Reducible Derangement (DP/Cent’n) Literature
Outcomes improve >7X if exercise dir. matches DP.
50% of disc surgeries avoidedAcute, chronic, axial, sciatica: rapid recoveries in 2 weeks
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Outcome Prediction(D-T Link)
DP and Centralization are better than:
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A-D D-T T-O Construct
Reliability Predictive Validity RCTs Disc ModelSpratt – 90 Kopp – 86 Karas - 97 Schenk - 03 Kopp – 86
Kilby – 90 Williams – 91 Donelson – 97 Fritz - 03 Donelson – 90
Spratt – 93 Donelson – 90 Snook – 98 Long – 04 Alexander – 92
Riddle - 94 Donelson – 91 Sufka – 98 Brennan – 06 Spratt – 93
Wilson – 99 Delitto - 93 Werneke - 99 Browder - 07 Donelson – 97
Fritz - 00 Spratt – 93 Werneke – 01 Kilpikoski - 09 Snook – 98
Razmjou – 00 Erhard - 94 Larson - 02 Petersen - 10 Derby – 00
Werneke – 01 Long – 95 Oliver - 10 Guzy - 11 Laslett – 05
Kilpikoski - 02 Scannell - 09
Clare - 04 8 Alexander - 12
Fritz - 06
11
168
10
Reducible Derangement (DP/Cent’n) Literature
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Author
MatchingDirectional
Exercises vs. Alt.Treatments
Prev (%)
FollowUp
Subjects (N)
Pain
Function
Disability
Meds
Depression
Withdrew
/ Wors
e (%)
Brennan Manipulation 1 yr 123 +
Brennan Stabilization 1 yr 123 +
Browdr Stabilization 6 mon 48 + +
Kilpkski Manual Ther. 89 6 mon. 119 * * +
Kilpkski Advice-Only 89 6 mon. 119 + + +
Schenk Jt. Mobilztn Disch 31 + +
Long Opp. Dir’n Ex. 74 2 wks 230 + + + + 33/15
Long “Guidln-Based” 74 2 wks 230 + + + + 34/15
Petersen Manipulation 6 mon. 350 + + +
RCTs of the Directional Preference subgroup
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After TESIs, MDT exam repeated
69 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.
16% 16%
22%
46%@ 1-year: 62%
remained excellent w/o surgery
??
16%46%11%73%Non-Centralizers
underwent TESIs.
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Why is Dir. Pref. Determination the First Stopin this Decision-Making Algorithm?
Strong evidence across the entire ADTO modelHigh prevalence of dir. pref. across all durations and
all LBP presentationsTreatment is highly consistent with current guidelines:
activity/movement, self-care educ’n, re-assuranceSafety: no known risk or reported complicationsMeets Christensen’s ‘precise diagnosis” definition.No question or controversy on Exer. Com.
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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.
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If operating on the wrong leg is considered a “medical error”,
John Wennberg, MDDartmouth Atlas
what do we call operating on (injecting) someone who doesn’t need it?
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