Are Your Employees Receiving The Most Effective Physical Therapy?

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Are Your Employees Receiving The Most Effective
Physical Therapy?

• Stephen Hunter PT, OCS
• Administrator, Intermountain Rehabilitation Agency

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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

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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

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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.

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Low Back Pain Myth 3

• The medical community knows how to approach the
  problem.

United States United 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
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Traditional Disease Model
Signs/symptoms analyzed
Pathology is determined
Treatment corrects pathology
Signs/symptoms disappear
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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.)

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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

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Traditional Study Design
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Malmivaara et. al. (N Eng J Med 1995332351-355)

• 186 adults with acute and recurrent LBP (lt 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

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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.

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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

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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

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

Treatment A
Significant Effect
Classification A
R
Treatment B
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Changes in Oswestry Scores
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Third-Level Classification Stage I
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Patient Admitted
Evaluation Performed
RANDOMIZATON to a TREATMENT GROUP
Mobilization
Specific Exercise
Immobilization
Outcomes
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Randomized Trials
Mobilization Immobilization Specific Exercise
Mobilization Matched Unmatched Unmatched
Immobilization Unmatched Matched Unmatched
Specific Exercise Unmatched Unmatched Matched
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Results

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

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Where does this lead us?

• Best practices
• More effective treatment
• Lower visits
• Less chronic problems
• Lower cost

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Example

• Work-related Low Back Pain

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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
• Patients age, payment data
• Duration of symptoms, surgery date
• Cost of physical therapy treatment

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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.

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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 lt 16 days
• No symptoms distal to knee
• Age 18-60
• No neurological signs

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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

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Patient Characteristics
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Comparing Manipulation (n143) with no
Manipulation (n72)
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Comparing Manipulation (n143) with no
Manipulation (n72)
mean difference 0.87, 95 CI 0.21, 1.5)
p 0.008
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Cost of Therapy
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Cost of Therapy
p 0.02
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Duration of Treatment (In Days)
p 0.02
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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

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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