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Clinical Reasoning in Mechanical Diagnosis and Therapy (MDT) and OMPT: Classification, Intervention, and Impact on
Musculoskeletal Health Care
Ron Schenk, Brian McClenahan
McKenzie Institute, USA Fellowship
Daemen College OMPT Fellowship 1
Learning Objectives:
Analyze the similarities and differences between the Delitto, Maitland, Sahrmann, and McKenzie (MDT) classification systems.
Understand the MDT clinical reasoning process.
Analyze movement to determine centralization vs. non‐centralization with consideration of patient response
Synthesize examination findings to categorize patients into directional preference, thrust and non‐thrust manipulation and stabilization categories.
Analyze the impact of MDT on health care costs and utilization
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At the completion of this presentation the learner will be able to:
Pathoanatomical DiagnosisExpert Quotes
Back pain diagnosis• “80% of back pain is caused by weak or tense muscles.”
• “The majority of LBP actually originates in the sacral ligaments.”
• “In 50% or more...the facet joint is the site of dysfunction.”
• “90‐95% of back pain is due to disks.”• “An extremely high percentage...have fascial problems.”
• “50%‐70% of chronic symptoms are psychological in origin.”
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Medical Model of Disease
Signs/symptoms analyzed
Pathology is determined
Treatment corrects pathology
Signs/symptoms disappear
Classification Systems for Low Back Pain
Identifiable source of LBP present in <10%
Classification systems often based on anatomical (theoretical) model
No one classification system is more reliable than others (Riddle, 1998)
Certain characteristics of particular classification systems may have appropriateness based on symptom chronicity (International Classification for Functioning 2013)
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Diagnosis: “ The process of determining the cause of a patient’s illness or discomfort”
Classification: “The process of classifying clinical data into named categories of clinical entities for the purpose of making clinical decisions regarding therapeutic management”
(Rose, 1989)
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Diagnosis vs. Classification
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Classification
• Riddle, D. Classification and low back pain: a review of the literature and critical analysis of selected systems. Phys Ther. 1998;78:708-735.
• Fritz JM, Delitto A, Erhard RE. Comparison of Classification-Based Physical Therapy with Therapy Based on Clinical Practice Guidelines for Patients with Acute Low Back Pain. Spine. 2003;28(13):1363-1372
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Acute Low Back Problems in Adults
Bigos S et al. Agency for Health Care Policy and Research (AHCPR) 1994
AHCPR 1994 Manipulation can be helpful for patients with acute low back
problems without radiculopathy when used within the first month of symptoms (Strength of Evidence = B).
This was the first clinical practice guideline to recommend the use of manipulation in the care of acute LBP. Spinal manipulation is a safe, effective, and recommended intervention in the management of LBP.
Spinal manipulation received the highest level of evidence of any intervention in the 1994 Agency for Health Care Policy and Research (AHCPR) Guidelines
Final recommendations included stay active approach, education, and general exercise.
www.ahcpr.gov
Systematic Reviews & Meta-analyses of RCTs
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Comparison of a Guideline‐Based Approach versus a Classification Approach in the
Treatment of Acute, Work‐Related Low Back Pain
Julie M. Fritz, PT, PhD, ATCAnthony Delitto, PT, PhDRichard E. Erhard, PT, DC
Department of Physical TherapyUniversity of Pittsburgh
Fritz J, Delitto A, Erhard R. Comparison of a Guideline-Based Approach versus a Classification Approach in the Treatment of Acute, Work-Related Low Back Pain. Spine. 2003;28:1363-1372
Patient with acute LBP
Baseline Evaluation
R
AHCPR Group Classification Group
All patients treated based on AHCPR Guidelines
Patients receive treatment specific to classification
Fritz J, Delitto A, Erhard R. Comparison of a Guideline-Based Approach versus a Classification Approach in the Treatment of Acute, Work-Related Low Back Pain. Spine. 2003;28:1363-1372
Low Back Pain Classifications
Manipulation/Exercise
Stabilization exercises
Activities to Promote
Centralization
Specific Exercise
Stabilization Traction
INTERVENTION
Mechanical/ auto-traction
Manipulation
Fritz J, Delitto A, Erhard R. Comparison of a Guideline-Based Approach versus a Classification Approach in the Treatment of Acute, Work-Related Low Back Pain. Spine. 2003;28:1363-1372
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A clinical prediction rule for classifying patients with low back pain who
demonstrate short‐term improvement with spinal manipulation.
Flynn T, Fritz J, Whitman J, et al.
Spine 2002;27:2835‐2843.
Pre-test Probability of Dramatic Success with
Manipulation
45%
4 or more present:
Recent onset (<16 days)
Low FABQ (<19)
No symptoms below knee
Lumbar stiffness
Good hip IR (>350)
95%
Post-test Probability of Dramatic Success with
Manipulation
Predicting Success with Manipulation
+LR=24.3
Flynn et al, Spine, 2002
Passive Intervertebral Motion
• Gonella C, Paris S, Kutner M. Reliability in evaluating passive intervertebral motion. Phys Ther. 1982;62:436-444.
• Insaco EL, et al. Reliability in evaluating passive intervertebral motion of the lumber spine. J of Man and Manip Ther.1995;3:135-143.
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Joint provocation testing
Posterior‐anterior central vertebral pressure (PACVP)
Posterior‐anterior unilateral vertebral pressure (PAUVP)
Tranverse vertebral pressure (TVP) Maitland – Patient Response Method
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Movement System Balance Theory
Van Dillen LR, Sahrmann SA, Norton BJ, et al. Movement system impairment-based categories for low back pain. J OrthopSports Phys Ther. 2003;33:126-142.
Sahrmann – Patient Response Method
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When should we not test end range?
Clinical decision making
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Mechanical Diagnosis and Therapy (MDT)
Examination
for centralization and direction of preference
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Why test end range?
• Confirm classification
• Reduce derangement
• Elicit centralization
• Expose dysfunction
• Expose relevant lateral compartment
• Determine prognosis
Repeated End Range Movements
• Flexion in standing
• Extension in standing
• Sidegliding in standing
• Flexion in lying
• Extension in lying
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Repeated end range movements
• Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain: a predictor of symptomatic discs and annular competence. Spine. 1997;22:1115-1122.
• Razmjou H, Kramer JF, Yamada R. Intertester reliability of the McKenzie evaluation in assessing patients with mechanical low-back pain. J Orthop Sports Phys Ther. 2000;30:368-389. 22
CentralizationWerneke M, Hart DL, Resnik L, Stratford PW,
Reyes A. Centralization: prevalence and effect on treatment outcomes using a standardized operational definition and measurement method. J Orthop Sports Phys Ther; 38:116-125, 2008.
Long A, May S, Fung T ; The comparative prognostic value of directional preference and centralization: a useful tool for front-line clinicians? J Manual Manip Ther; 16.248-254, 2008.
Directional preference23
Directional Preference
• Long A, Donelson R, and Fung T “Does it matter which exercise? A RCT of exercise for LBP. Spine. 2004. 29 (23):2593-2602.
• Schenk RJ, Jozefczyk C, Kopf A. A randomized clinical trial comparing therapeutic interventions for low back pain. J Man Manip Ther. 2003;11(2).
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Patient Reponse Method
Manipulation/Exercise
Stabilization exercises
Activities to Promote
Centralization
Repeated end range
loading/MDT
Provocation/ MSB Neuro/
No DP
INTERVENTION
Traction
Provocation test
• “Centralization is liberally defined as a movement, mobilization, or manipulation ‘technique’ targeted to pain radiating or referring from the spine, which when applied abolishes or reduces the pain distally to proximally in a controlled predictable pattern.”
• Cook, C. “Orthopedic Manual Therapy: An Evidenced Based Approach” 2nd edition. pp268; article cited in text: Aina A, May S, Clare H. The Centralization phenomenon of spinal symptoms: A Systematic Review: Manual Therapy 2004; 9; 134‐143
McKenzie Institute Fellowship
• “Centralization is defined in the classification system of occurring when a movement or position results in abolishment of pain or paraesthesia, or causes migration of symptoms from an area more distal or lateral in the buttocks and/or lower extremity to a location more proximal or closure to midline of the lumbar spine”
• MUST have Lower Extremity Pain• Fritz J, Cleland J, Childs C. Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to Physical Therapy. JOSPT 2007; 37 (6):
296
McKenzie Institute Fellowship
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DEFINING CENTRALIZATION
• “Abolition Centralization: the most distal pain was abolished and pain was recorded more proximally on the second drawing than on the first.”
• “Reductive Centralization: the pain was located at the same distal location but with reduced intensity.”
• “Unstable Centralization: the pain was reduced or abolished during the repeated movement testing or positioning but after resuming a weight‐bearing position for one minute, the pain intensity level returned to the pre‐testing intensity”
• Albert H, Hauge E, Manniche C. Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions? Eur Spine J 2011,21(4):630‐636
McKenzie Institute Fellowship
Centralization is Frequently Misunderstood
McKenzie’s Method of Mechanical Diagnosis and Therapy (MDT) definition of centralization has evolved:
• 1981 Lumbar Spine Text
• “I would define this phenomenon as the situation in which pain arising from the spine and felt laterally from the midline or distally, is reduced and transferred to a more central or near midline position when certain movements are performed.”
• McKenzie R: “The Lumbar Spine” Spinal publications 1981 pp22
McKenzie Institute Fellowship
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• 2003 Lumbar Spine Text
• “In response to therapeutic loading strategies, pain is progressively abolished in a distal to proximal direction with each progressive abolishing being retained over time until all symptoms are abolished. If back pain only is presents, this moves from a widespread to a more central location and then is abolished”
• McKenzie R, May S “The Lumbar spine: Mechanical Diagnosis and Therapy” Spinal publications 2003 pp 167.
McKenzie Institute Fellowship
• 2008 MDT Research:
• Centralization is characterized by spinal pain and referred symptoms that are progressively abolished in a distal to proximal direction in response to therapeutic loading strategies.
• Very Objective Measures included to further remove clinician bias
• Werneke’s el al Centralization: Prevalence and effect on Treatment Outcomes Using a Standardized Operational Definition and Measurement Method; JOSPT March 2008 Vol 38 (3) pp116
McKenzie Institute Fellowship
Centralization: Operational Definition
• Directed by precise application of movement & positioning
• Proximal change in pain location only
• Remains better – lasting effect during treatment
• Midline pain abolishes
• Overlay template
May & Aina. Manual Therapy 2004 & 2012
McKenzie Institute Fellowship
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Centralization: Standardized Measurement
• Overlay Template
• Donelson et al Spine 1991
• Werneke et al. Spine 1999
• Delitto et al. JOSPT 2012
McKenzie Institute Fellowship
Centralizationvs.
Directional Preference
McKenzie Institute Fellowship
Symptomatic Responses
• The changes in the patient symptoms that are elicited and recorded with the application of assessment procedures, treatment procedures or in response to functional activities and positions.
McKenzie Institute Fellowship
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Mechanical Responses
• The measurable changes that occur in movement loss, dural tension, neurologic function, tolerance to functional activities and positions, or change in tested physical abilities.
McKenzie Institute Fellowship
Centralization
• Describes the phenomenon by which pain emanating from the spine is progressively abolished in a distal to proximal direction in response to therapeutic loading strategies, with each progressive abolition being retained over time. (Lasting Change)
• Symptomatic Response
McKenzie Institute Fellowship
Peripheralization
• Describes the phenomenon by which pain emanating from the spine spreads distally into or further into the limb as a result of loading strategies. (Lasting Change)
• Symptomatic Response
McKenzie Institute Fellowship
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Directional Preference
• Phenomenon of preference for Postures/Movements that decrease, abolish or centralize symptoms and often decrease a limitation of movement. (Lasting Change).
• Symptomatic and/or Mechanical Response
McKenzie Institute Fellowship
Pain Response Subgroups
PAIN RESPONSE
Non-CEN
2. DP/Non-CEN 3. No-DP/non-CEN
1. CEN/DP
McKenzie Institute Fellowship
CASE STUDY
McKenzie Institute Fellowship
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Impact
• Integrated Mechanical Care (IMC) – McKenzie based physical therapist owned practice in Talahassee, Fla
• IMC President ‐ Chad Gray PT, Cert. MDT IMC Vice‐President and Chief Clinical Officer ‐Mark Miller PT, Dip MDT
• IMC Mission and Description
IMC Mission and Description
• Mission ‐ To revolutionize the standard of care for musculoskeletal injuries and pain
• Description – The IMC BestCare Method was developed to effectively treat musculoskeletal injury and disease in a non‐invasive, conservative manner. Additionally, the method focuses on prevention of injury, educating patients on proper movement.
National Business Coalition on Health (NBCH)A Cost‐Saving Solution for SIEs Around Musculoskeletal Disorders
(MSDs)
Outcomes‐Accountable™ Care
for Musculoskeletal Disorders
(c) 2014 Integrated Mechanical Care, Inc. / Confidential & Proprietary
Chad Gray, PresidentMark Miller, Vice President &
Chief Clinical OfficerIntegrated Mechanical Care,
Inc.
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IMC Objectives
• Focus on self‐insured employers (SIEs)
• Find solutions with rapid and verifiable cost‐savings and outcomes improvements for musculoskeletal disorders (MSDs)
• Offer early intervention, outcomes‐accountable™ programs to SIE members
• Provide program planning, oversight, and guarantees
(c) 2014 Integrated Mechanical Care, Inc. / Confidential & Proprietary
Reduce the Cost, Incidence and Prevalence of MSDs and Inappropriate Care
Target High‐Risk and High‐Cost MSD Diagnoses
Fortune 500 Case Study – Before IMC
• > $34.7 million in annual claims costs for 12,127 MSD sufferers
• > $285,600 in annual claims costs per 100 MSD sufferers
• > $2,861 in annual claims costs per average MSD sufferer
• > $238 in MSD‐related expenses PMPM
• > 4,000 images ordered, overall
• > 13% rate of surgeries (vs. a reasonable rate of 3‐4%)
• > 45 weeks in an avg. episode of care
• > 50% one‐year recurrence rate
• > 44% of cases unresolved
(c) 2014 Integrated Mechanical Care, Inc. / Confidential & Proprietary
Sell Outcomes Associated With 100% Steerage
Quantify the Problem and Forecast Savings
(c) 2014 Integrated Mechanical Care, Inc. / Confidential & Proprietary
Fortune 500 Case Study:
Target w/ 100% Steerage
• < $18.8 million in expenditures
• < $155,026 per 100 MSD cases
• < $106.26 spent PMPM
• < 500 images ordered
• < 2.0% rate of surgeries
• < 30 days in avg. episode of care
• < 10% one‐year recurrence rate
Fortune 500 Case Study:
Results of 830 Cases*
• < $875,426 in expenditures
• < $127,453 per 100 MSD cases
• < $106.21 spent PMPM
• < 46 images ordered
• < 1.3% rate of surgeries
• < 30 days in avg. episode of care
• < 6% one‐year recurrence rate
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Participate in Steerage Initiatives
Work with RBCHs and SIEs To Triage All MSD Cases
Before IMC
• > $34.7 million in annual claims costs
for 12,127 MSD sufferers
• > $285,600 in annual claims costs
per 100 MSD sufferer
• > $2,861 in annual claims costs
per MSD sufferer
• > $238 in MSD‐related expenses PMPM
• > 4,000 images ordered
• > 13% rate of surgeries
• > 45 weeks in an avg. episode of care
• > 50% one‐year recurrence rate
(c) 2014 Integrated Mechanical Care, Inc. / Confidential & Proprietary
Forecast Based on 830 Cases Across 686
Members
• $18.8 million in annual claims costs
for 12,127 MSD sufferers
• < $127,455 in annual claims costs
per 100 MSD cases
• < $1,274 in annual claims costs
per MSD sufferer
• < $107 in MSD‐related expenses PMPM
• < 673 images ordered
• < 1.3% rate of surgeries
• < 30 days in an avg. episode of care
• < 6% one‐year recurrence rate
Quantify and Guarantee Cost Savings
Replicate Proven Cost‐Saving Model
(c) 2014 Integrated Mechanical Care, Inc. / Confidential & Proprietary
Location of MSD
Pre‐IMC MSD PMPM
Post‐Pilot MSD PMPM
Avg. PMPM Savings for MSDs
Lumbar Spine $187.41 $107.52 $79.89
Cervical Spine $163.31 $85.84 $77.47
Shoulder & Arm $362.76 $87.89 $274.87
Knee $311.72 $75.14 $236.58
Hip $86.73 $66.67 $20.06
Elbow $80.61 $33.33 $47.28
Foot & Ankle $94.18 $33.33 $60.85
Thoracic Spine $30.99 $27.77 $3.22
Wrist‐Hand $33.53 $27.77 $5.76
Other Body Regions
$44.59 ‐‐ ‐‐
Quantify and Guarantee Outcomes
Focus on Patient‐Reported Outcomes
(c) 2014 Integrated Mechanical Care, Inc. / Confidential & Proprietary
Pilot Program Results, Phase I
Percent Improvement
Area of Improvement on Functional Indices
IMC’s Clinical Data
One of IMC’sFortune 500 Clients
One of IMC’sS&P 600 Clients
Pain Score 73.0% 76.9% 80.0%
Daily Functional Status 40.0% 36.2% 28.0%
Low Back Function73.0% 82.7% 63.0%
Neck Function 69.0% 71.6% 67.0%
Lower Extremity Function 72.0% 72.4% 68.0%
Patient Satisfaction98.2% 98.3% 98.9%
PMPM Cost Savings44.0% 46.0% 65.0%
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Note How Quickly Cost‐Savings Accrue
Use Actual Claims To Prove Cost Savings
(c) 2014 Integrated Mechanical Care, Inc. / Confidential & Proprietary
Pre‐IMC MSD PMPM(Based on 2012 & 2013 Claims)
Guaranteed MSD PMPM (Based on 40% Cost Savings )
Actual MSD PMPM c/o IMC Affiliate (1/2014 ‐ 5/2014, n = 147)
$254.11 & $272.48 $163.49 $94.42
Cost Savings @ Current PMPM,Considering Only “n” of 147
Forecasted Cost Savings at 40%,Considering Only “n” of 147
$314,097.84 $192,258.36
(c) 2014 Integrated Mechanical Care, Inc. / Confidential & Proprietary
Get the Diagnosis Right to Get the Treatment Right
Triage MSD Patients Through IMC’s Reliable Assessment Program
Patients enter medical system with
musculoskeletal injuries or conditions
Diagnostic triage sub‐groups patients into
reliable treatment groups
Surgical careInjection care
OtherConservative care supports
95‐97% of all patients
Appropriate care generates greater savings & “clean data”
Referrals
Specialties
Create Benefit Plan Savings
Build on IMC’s Successes
(c) 2014 Integrated Mechanical Care, Inc. / Confidential & Proprietary
Key Performance Indicator (KPI)
National Statistics
IMC Living Laboratory
Statisticsn = 7,000+
Fortune 500 CompanyStatisticsPre‐Pilotn = 10,770
Fortune 500 CompanyStatisticsPost‐Pilot
n = 942 cases & 772 members
PT Visits per Referral
17 6.1 14.2 5.7
Advanced Imaging Procedures
25% 5.3% 42% (4,482) 3.1% (24)
Pain Injectionsor Procedures
10% 3.2% 32% (3,437) 2.6% (20)
SurgicalProcedures
15% 3.8% 13% (1,406) 1.0% (8)
Beneficiary Satisfaction Rate
‐‐ 98.0% ‐‐ 98.3%
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Promote Breakthrough Results
Deliver Unprecedented Value to RBCHs and SIEs
• Individual
• Improved speed to recovery & socioeconomic status
• Organizational Outcomes
• Enhanced cost reductions & cost containment
• Improved human‐capital ROI
• Societal Outcomes
• Improved population health & socioeconomic development
(c) 2014 Integrated Mechanical Care, Inc. / Confidential & Proprietary
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Medical Model of Disease
Signs/symptoms analyzed
Pathology is determined
Treatment corrects pathology
Signs/symptoms disappear
Drive Savings with a Clinical vs. Administrative Solution
Inter‐Tester Reliability Appropriate Treatment
Appropriate Treatment Better Patient Outcomes
Better Outcomes Reduced Costs & Human‐Capital ROI
(c) 2014 Integrated Mechanical Care, Inc. / Confidential & Proprietary
Assessment
Diagnosis
Treatment
Clinical Outcomes
Economic Outcomes
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QUESTIONS?
McKenzie Institute, USA FellowshipDaemen College OMPT Fellowship
10/10/2014
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Saviola K, Schenk R, Coleman TCatholic Health System, Buffalo, NY
Daemen College OMPT Fellowship
Cervicogenic dizziness post-concussion:
A case report
Research question
Will a 6 week cervical stabilization program improve functional outcomes and performance on the cervical relocation test in a patient with cervicogenic dizziness?
Case descriptionA 23 year old former collegiate soccer player was screened and managed for post-concussion syndrome and vestibular involvement prior to the physical therapy (PT) initial examination.
The PT exam revealed constant and unchanging cervical pain. Of particular concern to the patient was an inability to visually focus and dizziness that followed reading, computer work, and turning of the head.
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Recruitment of the deep neck flexors
Intervention and Outcomes –Phase II
• Intervention – 6 week stabilization program emphasizing recruitment of the deep neck flexors and extensors.
• The outcomes related to Phase II management included an improvement in the cervical relocation test to an error of less than 4.5 degrees for each of the 6 attempts
• Improvement in the NDI to 8%
• Improvement in function on the FOTO tool to a score greater than predicted