It’s coming up – soon.  Friday is the last week of clinical affiliations and then on to graduation.  It’s been a long, interesting, tiring, invigorating, troubled, amazing, blah blah blah – three years. 

I look forward to getting out and being part of the American medical system (which despite our flaws, is still pretty good). 

There has been a ton of press on the newly published article in the Journal of the American Medical Association (JAMA) discussing expenditures for back and neck pain from 1997-2005.  All the major newspapers have ran stories and thousands of blogs have discussed the topic. 

This article points out some of the major flaws in treating spine problems.  The increase in dollars spent on surgeries and drugs alone are enough to make you sick while reading the 9 pages.  For instance, narcotic analgesic use increased 423% between 1997-2004.  423%!  That’s ridiculous.  It’s no surprise that thousands to millions of individuals are addicted to drugs like oxycontin that do nothing but mask symptoms. 

Why are we (medical providers) so bad at treating some of these problems?  It’s really not all that complicated to figure out.  We have the wrong people – treating the wrong things.  Our system requires a person who hurts their back t0:

  1. See their family doc who is in no way prepared or equipped to evaluate or treat musculoskeletal complaints.  You may get some drugs and an x-ray.
  2. Receive referral to the Orthopedic specialist.  Wait about 2 weeks.  Receive a prescription pad full of anti-inflammatories, muscle relaxants, and maybe narcotics.  Heck, they may even throw in an MRI.  Lastly, after being told you have a “disc problem” or “arthritis” – they’ll send you to PT.
  3. Finally at the PT.  It’s been between 2 and 6 weeks since onset, but hey – you finally make it.  Uh oh – now there’s the whole “lack of standardization” issue in my beloved profession.  Depending on which PT you go to – you may bet evidence-based quality treatment or status quo, highly ineffective treatment.  Roll the dice. 

It’s been two months since onset and your pain is right where it was (for the most part) and you are starting to feel like there’s nothing you can really do.  Wonder what the bill for this scenario looks like?  God forbid you go on and they recommend surgery to “decompress and stabilize your spine”.  All of this and all you have is “non-specific low back pain” regardless of what they found on all the wasted imaging and in the ICD-9 book.

When will we ever learn?  How should this work?

  1. Individual hurts their back on Saturday.
  2. Monday morning, they walk into the Physical Therapy clinic (direct access is legal in most states you know)
  3. The Physical Therapist provides a thorough evaluation and screens for “red flags” that would require referral to another medical provider (we are trained and skilled at doing this you know).  The PT would then classify you based on clustering of signs and symptoms and treat you with matched interventions that could included directional preference exercises, stabilization exercises, manipulation, or even traction.  In a few short visits (and for a lot cheaper), you decrease your pain and disability by greater than 50% or more. 
  4. You are discharged with a do-it-yourself maintenance plan.  Back to work – back to life.

Sounds good huh?  So what’s the hold up.

It’s multifactorial.  It’s easy to throw the blame around and point the finger, but let’s look in the mirror first.  Physical therapy has an identity crisis.  We have allowed who we are and what we do to be confused as a bunch of “stuff” labeled as “physical therapy”.  The totally randomness of what many PT’s are doing across the country makes it nearly impossible at times to ensure a patient/client is getting quality care.  Clinicians are ignoring the evidence and choosing to practice based on tradition and comfort.  It’s time to standardize how we treat these problems.  Then we can be recognized as what we are – THE provider of choice for musculoskeletal conditions. 

Now to finger pointing.  Physicians are guilty of the same things mentioned above.  They consistently fail to recognize they simply aren’t prepared to treat these conditions.  Useless imaging and drugs (in most cases) comprise the majority of their involvement.  Not the mention the prevalence of spinal fusions that lack evidence for their use in many many cases (look at the failure rates).   In efforts to “hold on” as the gate-keepers, they fight PT’s direct access and professional protection like they’ll be out of jobs.  Who is hurt more?

I was going to save this space for Chiropractors but have chosen not to discuss their role.  To state it simply, you can see a chiro 37 times for modalities and repeated manipulation only to pay a huge bill and get no better.  But hey, the stories are good.  Just ask about the subluxation and how it can cause everything from radiculopathy to bed-wetting.

Any way, the fact remains that medical care in this country for back and neck pain isn’t where is should be.  It’s time for everyone to wake up and realize who are the go-to-providers (FIRST LINE) for musculoskeletal conditions. 

 As Dr. Tim Flynn says, “You have drugs, you have surgery, or you have us (PT)”. 

 FYI – Where do PT’s stack up as far as managing musculoskeletal conditions?  Physical Therapists AND physical therapy students rank higher than anyone outside of physicians trained as orthopedic specialists.  Who should be the “gate-keeper” for musculoskeletal care?  The family practictioner or physical therapists?  Leave the serious and complicated cases to the specialists.  Leave the rest (the majority) up to us.

 References:

Martin et al.  Expenditures and health status among adults with back and neck problems.  JAMA.  2008; 299(6):656-64.

Childs et al.  A description of physical therapists’ knowledge in managing musculoskeletal conditions.  BMC Musculoskeletal Disorders.  2005; 6:32.

Pain is a big deal, just ask anyone who has it or treats it.  There are as many theories about pain, chronicity, and interventions as there are people who have it. 

Interestingly enough, I found myself in a platform presentation at CSM on this very topic.  I’m sure some of the information presented is old news to those who study pain, but I found it extremely interesting and clinically relevant.

Several researchers from the University of Florida continue to look at possible mechanisms for effectiveness of spinal manipulation performed by Physical Therapists.  Steven George (I must mention he is an alum of West Virginia University), Mark Bishop, Joel Bialosky, and others have focused in on a possible dorsal horn mediated mechanism. 

Without getting into the neuroanatomy and physiology too deep, this mechanism basically says that manipulation causes an inhibition of some nerve fiber input that carries pain information.  This creates a hypoalgesic response that appears to be a local phenomenon. 

 I’ll be reading more deeply into the proposed neurophysiological mechanisms and will pass along information as I gather it.  For now, here are two articles that discuss this topic – take a peek.

 George et al.  Immediate effects of spinal manipulation on thermal pain sensitivity: an experimental study.  BMC Musculoskeletal Disorders.  2006; 7:68

Bialosky et al.  The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects.  BMC Musculoskeletal Disorders.  2008; 9:19.

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