1. Are Your Employees Receiving The Most Effective Physical Therapy? Stephen Hunter PT, OCS Administrator, Intermountain Rehabilitation Agency

2. Presentation Outline Review current low back pain “myths” Discuss shortcomings of the current medical model for low back pain Discuss shortcomings of research examining physical therapy Review new research identifying more effective physical therapy treatment Give an example from work related low back pain “Take Home” message

3. Low Back Pain Myth #1: “Most people with low back pain will get better no matter what you do.” –Croft et al (BMJ, 1998) 490 individuals consulting GP with LBP 92% discontinued consultation within 3 months 25% had fully recovered within 12 months

4. Low Back Pain Myth #2: “The situation is improving.” –Back surgery rates rose 55% in the past decade –Chronic LBP disability has risen dramatically in the past 25 years.

5. Low Back Pain Myth #3: “The medical community knows how to approach the problem.” United StatesUnited Kingdom LBP Consults 24 million (9.4%)7 million (12.5%) % MRI, CT 7.5% 1.4% % surgery 1.2% 0.3% Total avg. cost $1375 $143

6. Traditional Disease Model Signs/symptoms analyzed Pathology is determined Treatment corrects pathology Signs/symptoms disappear

7. Shortcomings of the Traditional Medical Model Treatment choices are guided by the ability to identify the underlying structural pathology Only about 15% of cases with LBP can be given a specific pathoanatomical diagnosis The remainder of patients are grouped as a homogenous entity (low back strain, lumbago, mechanical low back pain, etc.)

8. Shortcomings of the Traditional Medical Model Consequences of the Traditional Model for low back pain: –Patients with LBP are considered a homogenous group –Any treatment is therefore equally likely to succeed in any patient –Research studies have been conducted using this approach

9. INTERVENTION B ANY PATIENT WITH LOW BACK PAIN INTERVENTION A OUTCOME RANDOM ASSIGNMENT Traditional Study Design

10. Malmivaara et. al. (N Eng J Med 1995;332:351-355) 186 adults with acute and recurrent LBP (< 3 weeks duration) Patients randomized into 3 treatment groups: –complete bed rest for 2 days –“back-mobilizing exercises” (standing AROM) –continuation of normal activities as pain permits

11. Results and Conclusions at 3 weeks, normal activity group had less work absence at 12 weeks, bed rest group had greater sick days and pain intensity, higher Oswestry and less perceived ability to work exercise group had greater sick days, more MD visits than normal activity group “among patients with acute LBP, continuing ordinary activities within limits permitted by pain leads to more rapid recovery than bed rest or back mobilizing exercises.”

12. Overall Conclusions In studies involving acute LBP –studies in which all subjects are given stereotypical exercise regimens without regard to clinical presentation other than a loosely defined criteria of “acute” result in equivocal outcomes –This has led to the conclusion that exercise does not have a role in patients with acute LBP

13. Classification Approach to the Treatment of Low Back Pain Several classification schemes have been proposed Delitto et al proposed scheme designed for patients with acute LBP –Classifications are based on findings from the history and physical examination –Each classification has specific treatments

14. Mobilization/M anipulation Immobili- zation Specific Exercise Traction LumbarSIFlex.Ext. Manual therapy and exercise Stabilization exercises End-range exercises Mechanical /autotraction Classification Scheme

15. CLASSIFICATION-BASED RANDOMIZED TRIAL CLASSIFICATION ACUTE LOW BACK PAIN PATIENTS MATCHED TREATMENT UNMATCHED TREATMENT RANDOM ASSIGNMENT OUTCOME

16. Classification Approach to the Treatment of Low Back Pain An effective classification system should result in improved outcomes in patients receiving matched versus unmatched treatments. Classification A Treatment A Treatment B R Significant Effect

17. Changes in Oswestry Scores

18. Mobilization/M anipulation Immobili- zation Specific Exercise Traction LumbarSIFlex.Ext. Manual therapy and exercise Stabilization exercises End-range exercises Mechanical /autotraction Third-Level Classification: Stage I

19. Patient Admitted Evaluation Performed RANDOMIZATON to a TREATMENT GROUP MobilizationSpecific ExerciseImmobilization Outcomes

20. Randomized Trials MobilizationImmobilization Specific Exercise MobilizationMatchedUnmatched ImmobilizationUnmatchedMatchedUnmatched Specific Exercise Unmatched Matched

21. Results Matched patients averaged 20% greater reductions in pain and disability compared to the unmatched groups. Improvements lasted for at least one year

22. Where does this lead us? Best practices More effective treatment Lower visits Less chronic problems Lower cost

23. Example Work-related Low Back Pain

24. Importance of Measuring Outcomes Rehab Outcomes Management System (ROMS) Web-based Database recording: Pain and disability scores for each visit Number of visits, length of stay Patient’s age, payment data Duration of symptoms, surgery date Cost of physical therapy treatment

25. Purpose Examine patients with occupational LBP who should benefit from a manipulation treatment. Clinical outcomes and physical therapy costs were compared between patients who received or did not receive any manipulation, during the first two physical therapy treatment sessions.

26. Subjects Patients with work-related LBP seen in 2004 in 10 outpatient clinics at Intermountain Health Care Retrospective review to determine utilization of manipulation among patients fitting the 2-factor rule –Duration of pain < 16 days –No symptoms distal to knee –Age 18-60 –No neurological signs

27. Outcomes Measured Outcome variables recorded for each patient: –Number of visits –Length of stay in PT –Initial and Final Oswestry and Pain Rating –Cost of physical therapy treatment

28. Patient Characteristics

29. Comparing Manipulation (n=143) with no Manipulation (n=72)

30. *p = 0.008 mean difference 0.87, 95% CI: 0.21, 1.5) Comparing Manipulation (n=143) with no Manipulation (n=72)

31. Cost of Therapy

32. *p = 0.02 Cost of Therapy

33. *p = 0.02 Duration of Treatment (In Days)

34. Study Summary When therapists used the best evidence treatment: –Greater improvements in pain and disability –Patients improved at a faster rate and were discharged earlier –The overall cost was less

35. “Take Home” Message Select providers who measure outcomes Select providers who use evidence-based treatment When the right treatment is applied to the right patient: –Patients improve faster –Less treatment is required –The overall cost is less