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Classification-based treatment
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Classification-based treatment - August 17, 2007 3:05:00 PM
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proud
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Curious what classification-based treatment approach for LBP clinicians here have had good outcomes using?
There are a few out there.
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RE: Classification-based treatment - August 17, 2007 5:40:13 PM
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FLAOrthoPT
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i use the find out what is wrong and treat it approach
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RE: Classification-based treatment - August 17, 2007 5:59:52 PM
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Kaden
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I am not a big fan of classification based treatment. I feel what we do for each patient - if we are doing a good job - should be individualized to that patient and trying to catagorize them into a group rather than individualizing treatment can be a mistake. I agree with the find what is wrong and treat them approach.
Why do we need 16 different rules and 6 different classification systems to find out the best treatment approach. It is like tyring to make all part of PT protocol based and we all know how well that works with post op patients.
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RE: Classification-based treatment - August 17, 2007 10:08:00 PM
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proud
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quote:
ORIGINAL: FLAOrthoPT
i use the find out what is wrong and treat it approach
Find out what is wrong....okay. How do YOU go about doing that?
And Kaden. I find it curious that you use the word "individualized" and then somehow insinuate that classification-based Tx is not individualized.
Interesting that using these approaches are now being shown to improve outcomes....in controlled studies.
Also Kaden. Medicine uses "rules". Prediction rules and firm knowledge of the evidence guides most credible medical Tx. Relying on our clinical intuition has not proven to be reliable or valid...and worse yet....outcomes have not been great. Ask yourself why re-embursement for PT services is quite low when you analyse your education level? It's simple: We have not proven ourselves...yet. classification-based( read: evidence based) is a step in the right direction. Finally. In my opinion.
I think we are in the early stages of developing these things. The reason for the post is that very fact. I have yet to see a system that is flawless in my eyes. But I can assure you that after 10 years of intuition based Tx including motion palpation etc....my outcomes are far better using classification-based approaches. In line with the literature. What do you know...
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RE: Classification-based treatment - August 18, 2007 11:45:29 AM
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steve
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We all use some form of "Classification" - florida, if you treat what you find, you are making decisions to classify patients to recieve a specific treatment. Using the NAOIMT system is a classification of sorts to segmental level and type of manual therapy system to be used. Even if you simply treat every problem with lets say "Continuous mobilizations" you classify each patient to a segmental level etc. The only difference is that the classification is not a formal system per se.
The problem from my perspective is that not using a classification system of sorts is that it leads to intervention "chaos" - see 10 therapists and get 10 different treatments and ten different explanations for your problem. This has been repeatedly shown to lead to poor outcomes - look at all the studies with non standardized "Physical therapy" (Treatment at therapist discretion) tested as an intervention - virtually always a non significant outcome and a poor reflection of our profession. When we intervene with a standardized treatment based on specific criteria we tend to get significant results, ie. manipulation for acute, non radicular pain, stabilization for radiographic spondys, directional preference exercise for patients who centralize. I am by no means suggesting that we eliminate therapist/patient freedom of choice and experience in the decision making process but rather would suggest that when thought of as a continuum between chaos where each therapist selects their own treatment and a standardized approach, we are much closer to chaos than standardization.
Steve
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RE: Classification-based treatment - August 18, 2007 12:25:36 PM
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proud
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quote:
ORIGINAL: steve
We all use some form of "Classification" - florida, if you treat what you find, you are making decisions to classify patients to recieve a specific treatment. Using the NAOIMT system is a classification of sorts to segmental level and type of manual therapy system to be used. Even if you simply treat every problem with lets say "Continuous mobilizations" you classify each patient to a segmental level etc. The only difference is that the classification is not a formal system per se.
The problem from my perspective is that not using a classification system of sorts is that it leads to intervention "chaos" - see 10 therapists and get 10 different treatments and ten different explanations for your problem. This has been repeatedly shown to lead to poor outcomes - look at all the studies with non standardized "Physical therapy" (Treatment at therapist discretion) tested as an intervention - virtually always a non significant outcome and a poor reflection of our profession. When we intervene with a standardized treatment based on specific criteria we tend to get significant results, ie. manipulation for acute, non radicular pain, stabilization for radiographic spondys, directional preference exercise for patients who centralize. I am by no means suggesting that we eliminate therapist/patient freedom of choice and experience in the decision making process but rather would suggest that when thought of as a continuum between chaos where each therapist selects their own treatment and a standardized approach, we are much closer to chaos than standardization.
Steve
Well stated Steve. At this point, I think it would irresponsible for any PT to proceed without very careful consideration of classification-based approaches.
having said that, although my outcomes have improved through this management style( and I think most would), often some patients do not respond...in which case I do turn to my experience. I recently had outstanding results with a guy using the mulligan, traction SLR approach.
Here was a guy with radicular symptoms and a marked ipsilateral deviation. Finger to floor measured 52 cm. He was like this for 6 weeks. He did not fit into the classification shcemata that I use, he did however fit well into the inclusion criteria for the mulligan SLR technique. In 3 days he had pain reduction from 7/10 to 3/10. His finger to floor measured 22 cm and has been maintained. I still use my clinical experience. Using classification-based approaches does not relegate one to a "Protocol monkey" at all. It does however ensure the best tx approach is selected and it does bring a certain credibility to our profession that has been missing.
Foolish to ignore it. So back to my question. What classification-based approaches are people using out there?
< Message edited by proud -- August 18, 2007 12:36:58 PM >
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RE: Classification-based treatment - August 18, 2007 1:15:13 PM
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steve
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I use treatment based classification for low back pain and a similar system for neck pain but like you proud, I do deviate sometimes into using neural techniques and mulligans techniques when patients dont respond to their initial intervention.
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RE: Classification-based treatment - August 18, 2007 3:42:48 PM
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Kaden
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Okay Proud, I was not trying to imply that we should throw all evidence based treatment out the door and that all classification based systems are bad. I constantly am reading journals and gleeming from some of the evidence. I also use a standardized screen/eval and then yes will put someone in a category based on what I found - however from there I often find it necessary to step out of the box when treating each person differently.
My point was that it can be hard to apply the results of clinical prediction rules and classification systems to our patients. Many times my patients don't neatly fit into a clinical prediction rule and I have to be able to "step out of the box" to provide them good treatment.
I think PT is art and science and trying to study what we do in some kind of blinded study can be very difficult. Therefore, I think evidence based gurus only using techniques from peered reviewed journals are missing the boat.
Much of what we do in a PT setting has not thourougly been studied in blinded studies but that does not mean it does not work and we should simply not use it.
If I have done somehting 100 times before and it worked 90 percent of the time I am not going to throw it out of my approach simply b/c the evidence has not proven it to be effective....yet.
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RE: Classification-based treatment - August 18, 2007 5:19:50 PM
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proud
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quote:
ORIGINAL: Kaden
Okay Proud, I was not trying to imply that we should throw all evidence based treatment out the door and that all classification based systems are bad. I constantly am reading journals and gleeming from some of the evidence. I also use a standardized screen/eval and then yes will put someone in a category based on what I found - however from there I often find it necessary to step out of the box when treating each person differently.
My point was that it can be hard to apply the results of clinical prediction rules and classification systems to our patients. Many times my patients don't neatly fit into a clinical prediction rule and I have to be able to "step out of the box" to provide them good treatment.
I think PT is art and science and trying to study what we do in some kind of blinded study can be very difficult. Therefore, I think evidence based gurus only using techniques from peered reviewed journals are missing the boat.
Much of what we do in a PT setting has not thourougly been studied in blinded studies but that does not mean it does not work and we should simply not use it.
If I have done somehting 100 times before and it worked 90 percent of the time I am not going to throw it out of my approach simply b/c the evidence has not proven it to be effective....yet.
Yes. I understand that Kaden.
But the start of you last post was...." I am not a big fan of classification-based treatment....". I guess I took that as it sounded.
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RE: Classification-based treatment - August 18, 2007 5:57:23 PM
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jesspt
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Don't worry Proud. I took it the same way.
I hear a lot of the sentiments noted above when I talk to my colleagues...that "blindly" following some classification system or clinical prediction rule is somehow providing a disservice to our patients, when it's actually the other way around.
The manipulation CPR is a good case in point. The number needed to treat (NNT) is around 2. So, If a PT sees two patients who fit the rule and chooses not to manipulate, at least one of those patients will get a substandard outcome. Essentially, they are choosing to provide their client with sub-standard, non-evidenced based care. But, many of our PT bretheren don't like to hear that they are making a choice - and it's the wrong one. "I don't manipulate" That's what chiros do", etc. are some of the excuses I've heard.
All across medicine, outcomes are imporved when care is provided in a standardized fashion, but for some reason, too many PT's have fallen in love with the "art" of physical therapy and not the science. We like to ignore these truths.
FLA - The figure out what's wrong approach? Since we can only identify "what's wrong" in about 15% of the cases of LBP, what do you do with the other 85%?
Kaden - evidence based medicine gurus is an oxymoron.
Proud- back to your original question. I use the Delito Treatment Based Classification system. I to have to deviate from it if a patient doesn't respond, but I've found the more consistently I apply the system, the less I have to "step outside the box"
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RE: Classification-based treatment - August 18, 2007 7:19:42 PM
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Jon Newman
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Hi Proud,
quote:
Ask yourself why re-embursement for PT services is quite low when you analyse your education level? It's simple: We have not proven ourselves...yet.--Proud
It seems to me that market forces and historical professional decisions are likely more responsible for this situation than the fact that we haven't proven ourselves. For example, a good massage therapist can earn just as much via private pay as a PT despite their lack of proving themselves in the manner I think you're referring to. I do think your question is interesting and I'm curious why people choose one classification scheme over another since there hasn't been a bake-off between classification schemes (that I'm aware of). I'd be interested in any references if I'm mistaken about that.
Hi jesspt,
quote:
So, If a PT sees two patients who fit the rule and chooses not to manipulate, at least one of those patients will get a substandard outcome.--jesspt
I'm not sure what you define as a "substandard outcome" but it seems to me that you can't accurately predict this based on evidence we have at our disposal. Don't take this as an argument against SMT, it's not. In fact, I have no reason to think SMT won't work for the appropriate population. On the other hand, maybe I'm behind on some reading. What source(s) are you using to come to your conclusion?
Thanks
< Message edited by Jon Newman -- August 18, 2007 7:24:10 PM >
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RE: Classification-based treatment - August 18, 2007 8:43:51 PM
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jesspt
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Jon -
You're right. I should have been more clear. In the case of the manipulation CPR, a substandard outcome would be achieving less than a 50% reduction in the Oswestry disability Index. I'm paraphrasing a post from John Childs on the evidence in motion blog where he explains the NNT statistic, which I believe you contributed to as well. Your point in that thread was quite astute - that NNT looks only at a comparison of two treatments.
Don't mistake me for a manic manipulator, either. You and I agree that SMT works well in a given population. I don't go around perfomring SMT on even the majority of my patients, but if the fit the CPR, or have acute, non-radicular low back pain, i certianly give it a go.
I don't know of any recent compairson of classification schemes, but Dan Riddle did look at this in 1998:
Classification and low back pain: a review of the literature and critical analysis of selected systems. Phys Ther. 1998 Jul;78(7):708-37.
Jess
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RE: Classification-based treatment - August 18, 2007 9:19:51 PM
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proud
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Hello again Jon,
quote:
It seems to me that market forces and historical professional decisions are likely more responsible for this situation than the fact that we haven't proven ourselves. For example, a good massage therapist can earn just as much via private pay as a PT despite their lack of proving themselves in the manner I think you're referring to.
Actually, you made my point for me Jon. In reverse. Without evidence of better treatment options and outcomes...we have become lumped into every other snake oil salesman out there. And rightfully so. In the eyes of third party payors, it does not make much of a difference where patients go, the outcomes seem to be fairly close. So re-embursment as a result is....fairly close.
However, we all have known for quite some time that certain things we do...seem to work( like centralization or manipulation or stabilization...). Better question was, why does it work for some and not others? How can we best determine what treatment approach will work?
PT's have excellent education when you compare it to say...a massage therapist. Yet here we are lumped right in there. However thanks to some valuable research, we will eventually prove that we can produce superior outcomes. We all must transition from guru based to evidence based as soon as possible in my opinion.
Cases like the Virginia Mason medical center increasing re-embursment is an example of how the evidence can change the mind-set of third party payors from lumping PT's in with every other junk treatment making wild claims and no evidence to back it up( ....skin stretching anyone....).
And bake-off. That's good. That is what I was looking for on this thread. Any evidence to support the classification scheme's being used. Jesse...anything on Delitto?
< Message edited by proud -- August 18, 2007 9:53:01 PM >
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RE: Classification-based treatment - August 18, 2007 9:45:45 PM
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Jon Newman
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Hi Proud,
I think you missed my point. When I ask myself why reimbursement is low relative to our education I don't think "we haven't proven ourselves". I think we already have created a far more compelling evidence base for ourselves than either chiropractic or massage therapy (our main market competitors), yet we work hard for our place in the market. It seems to me that the general public isn't particularly tuned into scientific realites in general so I'm not holding my breath about that suddenly changing although I'm trying to do my part.
I agree that we need to keep producing research and hopefully that alone will be sufficient to sway the hearts and minds of the public but I doubt it.
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RE: Classification-based treatment - August 18, 2007 10:00:23 PM
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proud
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quote:
ORIGINAL: Jon Newman
Hi Proud,
I think you missed my point. When I ask myself why reimbursement is low relative to our education I don't think "we haven't proven ourselves". I think we already have created a far more compelling evidence base for ourselves than either chiropractic or massage therapy (our main market competitors), yet we work hard for our place in the market. It seems to me that the general public isn't particularly tuned into scientific realites in general so I'm not holding my breath about that suddenly changing although I'm trying to do my part.
I agree that we need to keep producing research and hopefully that alone will be sufficient to sway the hearts and minds of the public but I doubt it.
Edited my last post then saw your reply Jon. I would say more compelling evidence. Maybe not FAR more compelling.
Anyway, wait for it. With an aging population and ever increasing demands on healhcare dollars, we will see certain parctice patterns squeezed....squeezed...and eventually squeezed out. Ya, it's 10 years away, but those who "get it" and have 15 or more years in this profession will become providers of choice.
I wish it would happen sooner...but I agree with you, it will take market forces( ie healthcare cash crunch) rather than public perceptions that make the change.
I wish our profesional associations would do more to police silly PT practices. For example, here in canada, our main association journal allows advertisments from the like of Jhon Barnes, cranio-sacral therapy, etc.
It's a real shame our "leaders" are not getting it...
< Message edited by proud -- August 18, 2007 10:07:24 PM >
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RE: Classification-based treatment - August 20, 2007 7:40:40 AM
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jesspt
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From: Illinois
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Some things in support of Delitto's TBC :
Identifying subgroups of patients with acute/subacute "nonspecific" low back pain: results of a randomized clinical trial.
Spine. 2006 Mar 15;31(6):623-31
An examination of the reliability of a classification algorithm for subgrouping patients with low back pain.
Spine. 2006 Jan 1;31(1):77-82
These give some support to the ability to relaibly classify patients with LBP in to the treatment catagories of manipulation, stabilization, specific exercise or traction. They also give support to the fact that patients get a better outcome (in this case a more greatly reduced ODI) if they are matched to the appropriate treatment rather than assigned a treatment randomly.
_____________________________
Jess Brown, PT
Board Certified in Orthopaedic Physical Therapy
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RE: Classification-based treatment - August 20, 2007 9:05:42 AM
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MS_PT
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General question regarding TBC:
Do you use the same classification for chronic pain, or just acute/sub acute?
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RE: Classification-based treatment - August 20, 2007 9:14:20 AM
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Shill
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From: Madison WI USA
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Jon,
I loved the bake-off reference. That is funny.
All,
One of the issues with classification is that in order to place someone into a category, one has to be very good at subjective interview, follow up questions, and then do the appropriate objective testing and evaluation directed by these responses to the questions. If the questions suck, the information gleaned from them will be equally bad.
I happen to think that most of the patients with neck or back pain can fall nicely into the centralization category, if one listens and looks with enough focus and detail. I can back this brash statement up with outcomes too. Not 100% of the time, but good outcomes nonetheless.
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RE: Classification-based treatment - August 20, 2007 12:46:49 PM
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jesspt
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From: Illinois
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Shill,
I think we need to be careful to go in to a subjective and objective exam with an entirely open mind. If we're focused on the specific exercise category, I'm sure we'll find evidence to classify them in that category. Likewise with the manipulation or stabilization category.
As for myself, I don't see nearly that many patients fall in to the specific exericse cateagory. But, I see a lot of acutely injured workers with non-specific, non-radicular low back pain of recent onset, so our caseloads may be vastly different.
Anyone out there with info on what percentage of patients with LBP fall into which category?
_____________________________
Jess Brown, PT
Board Certified in Orthopaedic Physical Therapy
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RE: Classification-based treatment - August 20, 2007 1:31:08 PM
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Shill
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Joined: February 13, 2003
From: Madison WI USA
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Jess,
I would beg to differ a bit. Focused questions do not close one's mind, but rather they give you the answers that direct your treatment, regardless of your patient population. The wording of the questions can be the key to getting to the true nature of the symptoms. For example, if it hurts someone to bend, I would like to know if this is an end range pain, mid range pain, and/or what happens as a result of the movement. If I dont ask these things, I can wrongfully assume that the symptoms are made worse by bending, or are due to end range stress, etc, etc. Which symptoms are felt with this bending, is it leg, back, or big toe? My point is that the reason many patients "dont fit" into these categories, is that their therapist didnt ask the questions with the detail needed to dig this out.
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