Are Your Employees Receiving The Most Effective Physical Therapy?

Stephen Hunter PT, OCSAdministrator, Intermountain Rehabilitation Agency

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

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

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.

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

Traditional Disease Model

Signs/symptoms analyzed

Pathology is determined

Treatment corrects pathology

Signs/symptoms disappear

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.)

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

INTERVENTION B

ANY PATIENT WITH LOW BACK PAIN

INTERVENTION A

OUTCOME

RANDOM ASSIGNMENT

Traditional Study DesignTraditional Study Design

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

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.”

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

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

Mobilization/Manipulation

Immobili- zation

Specific Exercise

Traction

Lumbar SI Flex. Ext.

Manual therapy and exercise

Stabilization exercises

End-range exercises

Mechanical /autotraction

Classification Scheme

CLASSIFICATION-BASED RANDOMIZED TRIAL

CLASSIFICATION

ACUTE LOW BACK PAIN PATIENTSACUTE LOW BACK PAIN PATIENTS

MATCHEDTREATMENT

UNMATCHEDTREATMENT

RANDOM ASSIGNMENT

OUTCOMEOUTCOME

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

05

1015202530354045

Initial 3 Days 5 Days

UnmatchedMatched

Changes in Oswestry ScoresChanges in Oswestry Scores

Mobilization/Manipulation

Immobili- zation

Specific Exercise

Traction

Lumbar SI Flex. Ext.

Manual therapy and exercise

Stabilization exercises

End-range exercises

Mechanical /autotraction

Third-Level Classification: Stage I

Patient Admitted

Evaluation Performed

RANDOMIZATON to a TREATMENT GROUP

Mobilization Specific Exercise Immobilization

Outcomes

Randomized Trials

Mobilization Immobilization Specific Exercise

Mobilization Matched Unmatched Unmatched

Immobilization Unmatched Matched Unmatched

Specific Exercise Unmatched Unmatched Matched

Results

• Matched patients averaged 20% greater reductions in pain and disability compared to the unmatched groups.

• Improvements lasted for at least one year

Where does this lead us?

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

Example

Work-related Low Back Pain

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

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.

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

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

Patient Characteristics

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

48.4

24.3

44.2

15.3

0

10

20

30

40

50

Initial Final

Osw

estr

y Sc

ore

No Manual

Manual

6.9

3.8

6.4

2

0

2

4

6

8

10

Initial Final

Pain

Rat

ing

No Manual

Manual

*p = 0.008mean difference 0.87, 95% CI: 0.21, 1.5)

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

$606.49 $648.80

0

200

400

600

800

1000

Manipulation No Manipulation

Cost of Therapy

$586.63

$753.99

0

200

400

600

800

1000

Manipulation Mobilization

*p = 0.02

Cost of Therapy

14.2

19.6

02468

101214161820

Manipulation Mobilization

*p = 0.02

Duration of Treatment (In Days)

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

“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