Lumbar Spine How do you treat? How do you classify? “T” “D”
Patho-anatomical “Facet” What’s your Rx? Derangement What’s your Rx?
Facet A D T ? ?
Refs… Laslett 2006 Laslett 2004 Dreyfuss 2003 Young 2003 Revel 1998 Dreyer 1996 Schwarzer 1994 Jackson 1988 etc
Big picture look at “evidence”. What is the best treatment for chest pain? What is the best study design to answer this question?
Chest Pain Outcome Measures Are the small benefits worth the additional costs? 20% Improved25% Improved NothingAnti-acidsNTG 80% Improved10% Improved 80% Improved10% Improved T O Cardiac Pain A D Esoph’l Pain Black Box RCT
“Symptoms” are poor candidate for RCTs Chest pain Abdominal pain Low back pain Leg pain “sciatica” Non-Specific LBP Black Box Model
Non-Specific LBP Black Box Model Black Box RCTs Non-specific results Our recent research reality…. No intervention is any better than “doing nothing”. Out- comes Treatment
Spratt (02): RCTs of non-specific LBP “are doomed”. By persisting with studies of non-specific LBP, “the results of RCTs will continue to be frustrating, meaningless, and even misleading.” Bouter, van Tulder, Koes (Spine 98): “There is urgent need for good ideas about how to identify homogeneous subgroups.” “The efficacy of interventions in the subgroups should be studied in RCTs.” Likewise our guidelines!!
Understanding the science behind the “evidence”. 25 years & approx 1,000 RCTs (black box) Systematic reviews – (dozens) International “evidence” based-guidelines What do we have?
Not much. Screen for red flags Advice to remain active Reassurance Review psychosocial yellow flags Generic – “one size fits all” guidelines Is this the best we can do?
The best treatment for LBP? We have been asking the wrong questions! Testing questions in the wrong order!
Out- comes Treatment Assessment Diagnosis “The single most important thing: establishing the validity of any one link requires that all previous links have been established.” “Statistical Relevance” K. Spratt, Ph.D. Book: Orthopaedic Knowledge Update Spine ‘02, AAOS, p The ADTO Model
Out- comes Treatment Assessment Diagnosis RCTs of subgroups Reliability studies: test findings/results subgroup classification Prospective subgroup studies: outcome prediction, with or w/o treatment(s). Start by building the FOUNDATION:
How does MDT measure up? Treatment Outcomes Assessment Diagnosis
Directional Preference Mechanical loading examination including RMs Identification of specific directional exercise Symptoms centralize or decrease or range increases Confirms classification of Derangement
Contrast with other treatment approaches Repeated movements for assessment and management Emphasis on patient independence Avoidance of therapist dependency Use of minimal intervention Exercise and therapist intervention Exercises used for pain relief
Red flag clues Age > 55 History of cancer Unexplained weight loss Constant, progressive, non-mechanical pain, worse at rest Systemically unwell Persisting severe restriction of lumbar flexion
Red flag clues Systemic steroids History of IV drug use History of significant trauma History of trivial trauma and severe pain in osteoporotic individual No movement or position centralises, decreases, or abolishes pain
Cancer “ A previous history of cancer has such high specificity (0.98) that such patients should be considered to have cancer until proven otherwise” Deyo 1992
If Age > 50 OR History of cancer OR Unexplained weight loss OR Failure to improve with conservative therapy THEN… sensitivity = 1.00
Aims of the Physical Examination Usual posture Symptomatic response to posture correction Any obvious deformities or asymmetries Baseline measures of mechanical presentation Neurological examination Symptomatic and mechanical response to repeated movements