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RE: Obama and Chiropractic: Wow...

 
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RE: Obama and Chiropractic: Wow... - June 23, 2009 1:44:58 AM   
rwillcott

 

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Here's a summary of the Long study.....

http://www.aptei.com/library/viewReport.jsp?report=245

Right.....we better get the nurse to see them and send them home with a TENS unit and referral for orthotics.

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RE: Obama and Chiropractic: Wow... - June 23, 2009 4:25:03 AM   
bonez

 

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quote:

ORIGINAL: rwillcott

In order to make this conclusion the patient must be assessed and screened by a trained health professional.  PT's are the perfect professional for this role given our extensive training.  No patient would accept this diagnosis and recommendation from a nurse that does not assess them.




Ok guys I'm climbing in my bomb shelter so let them fly. I have reflected on this and spoke with a relative who supervised the nurse practitioner program here. There is no need for the professional to be a PT. If the protocol and the training is done correctly it could be PT, Chiro Nurse, Practitioneror GP,

The issue is to identify the rare serious problem and advise the rest. Again not treat but advise. Here nurse practitioners give better exams than the local GP. The cost run up is in time loss too much treatment and expensive tests all fostering illness behaviour.

Sorry if this upsets the PT crowd here but this is just my gut feeling over my years of practice.

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RE: Obama and Chiropractic: Wow... - June 23, 2009 4:58:47 AM   
TexasOrtho


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I don't disagree with bonez at all.

_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to bonez)
Post #: 143
RE: Obama and Chiropractic: Wow... - June 23, 2009 12:26:36 PM   
SJBird55

 

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How about a different twist to this discussion?  So right now, bonez, you are saying educate and wait and see (by whoever is the cheapest provider). 

What if... what if instead, specific intake information could be analyzed to determine the level of risk and the prediction of when the person would be back to 80% of normal?  Basically 20% of individuals with low back pain are the ones that cost the most money and become chronic, right?  What we really want is to identify that 20% right?  So the real question becomes, does educating and wait and see actually work on the 20% of the patients that cost the most?

I believe the ability to make a snap decision predicting the final outcome would probably also go a long way in determining the care to provide.  Personally, I do not believe the educate and wait and see philosophy will work on the 20%.  In my opinion, that is what historically happens (along with other bad things like advising bed rest...).

I'm not horribly brilliant, but my Australian friend has come up with something he calls and "Injury Screening, Measurement and Monitoring" decision support computer program.  It looks very interesting and I'm still trying to learn more about it.  I do think that kind of idea is kind of where it needs to go... we aren't taking the time to predict those that are going to be problematic with their return to life...

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RE: Obama and Chiropractic: Wow... - June 23, 2009 1:12:13 PM   
proud

 

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quote:

ORIGINAL: TexasOrtho

I don't disagree with bonez at all.


In theory I don't disagree either. But below( what SJ said) is food for thought.

Bonez said proper training. Of course this is true. But proper training involves a fair amount more than a couple of weekend seminars when it comes to pain, function, impairment, disability.

In fact....we all know way more than we credit ourselves.

The simplistic idea of having someone "adequaltly" trained would not result in results as favourable as having someone who is 'specialist" trained in this area. And when it comes to PT's( who are paid less that NP's and even Nurses in many cases) the cost would actually be less.

I maintain that PT's are proving in the literature that they are the ideal choice to implement appropriate cost saving approaches.

Yes, anyone can do it reasonably well. But if the cost is the same( likely less actually), then why not go with the profession who is specially trained?

(in reply to TexasOrtho)
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RE: Obama and Chiropractic: Wow... - June 23, 2009 1:15:05 PM   
rwillcott

 

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A nurse cannot identify appropriate sub-groups of MLBP accurately.

SJBird is right regarding the chronic group. This group needs to be identified day one. A nurse or PTA does not have the skills to do this. Ask a nurse if they have ever heard of the FABQ. Ask them the best treatment for a patient that presents with fear avoidance beliefs. I bet a referral for massage would be recommended.

More importantly, it is the information (or misinformation) that is being provided to patients. Not to say PT's aren't guilty of this. If a nurse, PTA, chiro and PT's were all screening patients with MLBP could you imagine the spectrum of bogus information these patients would be getting! One provder offering accurate and honest information would reduce the costs of MLBP. The George Mason study is a perfect example.

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Post #: 146
RE: Obama and Chiropractic: Wow... - June 23, 2009 2:40:13 PM   
bonez

 

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Everybody pause....and re read I said acute conditions. The chronic group are often a different beast.

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RE: Obama and Chiropractic: Wow... - June 23, 2009 5:09:04 PM   
rwillcott

 

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A nurse cannot treat acute LBP.

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RE: Obama and Chiropractic: Wow... - June 23, 2009 5:26:44 PM   
SJBird55

 

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bonez... the acute group is the group from which predictions should be made.  It is the perfect group for predictions and for altering a potentially predictable course.  Acute would be defined as within 2 weeks of onset of symptoms (according to my friend's clinical decision-making program that can predict outcome).

Rob... I'm not familiar with the George Mason study - what is it?  Am I missing something?

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RE: Obama and Chiropractic: Wow... - June 23, 2009 7:09:12 PM   
bonez

 

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You missed the flavor of the point noone  is getting treated.

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RE: Obama and Chiropractic: Wow... - June 23, 2009 8:53:12 PM   
SJBird55

 

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I have no clue who you are talking to, bonez.  LOL  But... for me, I didn't miss the point.  The problem is that no one is getting treated.  The 20% who take up the most time and cost are obviously NOT receiving the appropriate intervention.  "Wait and See" doesn't work... the system/process is broken.  I really like the idea of predicting - but whoever "predicts" also needs to do the work to either keep the prediction on track OR alter the current path so that the person doesn't become chronic.  The prediction needs to be addresses ASAP, in particular by the very person who is predicting, otherwise fear/anxiety has a potential to be elevated. 

If you are someone's house and helping in the kitchen and the buzzer goes off for the oven and the cake is done... is it enough to just turn off the timer OR would it also be conducive to either check the darn cake or take it out of the oven?  Turning off the oven isn't an adequate response because the darn thing will continue to cook.  Educating and wait and see might work for the majority, which is great... but that 20% that is problematic will probably continue to be problematic and they need more.

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Post #: 151
RE: Obama and Chiropractic: Wow... - June 23, 2009 11:19:29 PM   
TMondale

 

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Advise and wait is not the best course period.  It's something, and if you wish to be a minimalist then you also accept that sub standard care is acceptable.  These questions aren't a mystery.  It's better to advise and treat; that question has been asked and answered (Early Intervention for the Management of acute Low Back Pain: Spine 2004) by Wand et.al.  With the abundance of accumulated knowledge we have as to the optimal way to treat these patients, why would we choose to default to a non optimal state of care. 

the misguided notion that because there is so much overtreatment with expensive, innefective care that leads to greater risk for patients that, the exact opposite of overtreatment would be the proper solution is ridiculous. 

The problem here isn't care by PT, or even Chiro, it's medical care that's profit driven with incredibly expensive reimbursable options that increase the risk for a patient, and doesn't improve outcomes.  What we need is alot more of ours, and alot less of theirs. 

Our responsibility is to follow the best available evidence, and strive for effeciency (the fewest visits necessary to accomplish our goals)

Tim

(in reply to SJBird55)
Post #: 152
RE: Obama and Chiropractic: Wow... - June 24, 2009 1:38:37 AM   
rwillcott

 

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Great post Tim.

SJBIrd55,

I have no idea where I got George Mason from.  I meant Virginia Mason Medical Center example where they had the PT's screen LBP patients.  This led to a significant reduction in wait times, 30% reduction in people receiving MRI's and 6% of patients lost time from work under this new system.

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Post #: 153
RE: Obama and Chiropractic: Wow... - June 24, 2009 2:56:45 AM   
TexasOrtho


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Hi Tim.  For some folks, advise and wait is the best option given limited funds and the self-limiting nature of most episodes of acute low back pain.  Recent guidelines published in the American Journal of Family Practice and Annals of Internal Medicine support this notion.  There is evidence supporting SMT and other forms of early rehabilitative care, but there is very little strong evidence that early intervention is neccessary for acute LBP.

My personal approach and one I've shared with a local family practice for ACUTE low back pain: Patient gets referred to PT for 1-3 visits after red flags have been ruled out.  The patient is given a thorough orthopedic exam, Oswestry, and FABQ.  Treatment objective at this stage is primarily pain relief.  Activity guidelines and classification-based treatments are initiated with a heavy emphasis on self management.  The goals are to provide quality, evidence-informed, and cost-effective treatment of a common problem.  Of course we could see the patient for 10-12 visits, but the guidelines just don't support it.  Just because we can, doesn't always mean we should.  I lose money in the short run but...

We tell the patient to follow up with FM three weeks after "discharge" from this brief course of PT.  If symptoms persist, we recommend an additional 6-8 visits (highly variable) to address symptoms which may be the result of persistent and identifiable mechanical factors.  Treatments again based on sub-grouping seem to be very effective.  I have recently added more involved neural mobilization techniques per Shacklock and pain education per Moseley and Butler at this stage of the game.  The evidence for neural mobilization and education is not strong, but emerging to the point where I feel it is very useful.  The patient is often seen BIW for 3-4 weeks.

Total episode of care ONLY if the patients pain exceeds four weeks: 10 visits.  Discharge criteria are Oswestry less than 10 percent, full and pain free ROM, pain levels 0/10 at rest and no greater than 2/10 during ADL.  At this stage of the game the patient may not be 100% well, but at least to a point where self-management is well wthin reach.  This model is science-based, evidence-informed, and cost-effective in my opinion.  The really nice thing is the patients loose the notion that someone "cured" their back pain or that they will need periodic "curing" in the form of perpetual manual care.   They will also understand the role imaging and invasive procedures at "finding" the problem and again "curing" it.

I know no one asked what my treatment model was but there it is!  My two pesos. 

_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to rwillcott)
Post #: 154
RE: Obama and Chiropractic: Wow... - June 24, 2009 4:28:40 AM   
SJBird55

 

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Rob... ah... okay. I AM familiar with that one!  You had me going... I was originally thinking George Foreman... (figured you weren't talking grills).. then couldn't figure out Mason - BUT I do want to thank you because you saying George Mason reminded me I wanted to send a thank you note to a Mr. Mason who is one of the owners of Michigan Brewing Company.  He gave my husband and I a nice private tour of how they make beer this weekend.  I did my first 5K and it was a "beer run."  It started in the brewery.. and I just HAD to have a tour!  It was pretty cool.  Oh, and for those of you that only want evidence-based discussion... I do apologize for the interruption.  ;)

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Post #: 155
RE: Obama and Chiropractic: Wow... - June 24, 2009 12:20:12 PM   
rwillcott

 

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SJBird,

No problem! I knew there must have been a reason I said George Mason. Must have had beer on my mind too!

Rod,

Thanks for posting your approach. I think that's an excellent example of how to handle these patients.

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Post #: 156
RE: Obama and Chiropractic: Wow... - June 24, 2009 1:38:54 PM   
TMondale

 

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Rod,

You're process seems completely reasonable to me.  Far from advise and wait though.  I just don't agree that they have to go through primary care for safe practice.  You may not have direct access, or any control over how patients get to you, but as you know we are fully capable of ruling out red flags, and much less likely to refer to a medical specialist (because we actually have a skill set to help these people), who will then order an MRI (often), which has the potential to drive all sorts of expensive, risky, and costly care, prescribe medications that may or may not be helpful, and likely increase the risk of ending up in surgery.  For the people that are kept out of surgery appropriately; we reduce mortality and morbidity.  We literally save lives.  Sounds melodramatic but it's true. 

As far as the strong evidence that care for acute low back pain may not be necessary, I think it's improtant to understand that all chronic pain started at some point.  There is evidence that the lack of appropriate care at the start of symptoms does have some measurable consequences that could lead to a much bigger problem.    Again I agree completely with your approach as listed; far better than advising and sending them home and hoping it goes away. 

In my mind advise and treat may be 1-3 visits, but it includes treatment.  That means thrust manipulate if appropriate, proper exercise advice including directional preference, and yes absolutely a sound, simple, and non-fear based biopsychyosocial explanation.

Tim

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Post #: 157
RE: Obama and Chiropractic: Wow... - June 24, 2009 2:15:53 PM   
proud

 

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quote:

ORIGINAL: TMondale


In my mind advise and treat may be 1-3 visits, but it includes treatment.  That means thrust manipulate if appropriate, proper exercise advice including directional preference, and yes absolutely a sound, simple, and non-fear based biopsychyosocial explanation.

Tim


Love it. I also think if this model was applied early....less people would progress to persistent pain situations.

Awsome Tim.

(in reply to TMondale)
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