Happy 2009 from NPA Think Tank!
Greetings loyal NPA Think Tank readers. It's that time of year to offer my thanks for reading this wandering blog and offer my best wishes for your new year. As a "gift," I present to you three links:
1. New York Times Year in Pics. Excellent photos and richly packed with events.
2. Festive Medical Myths. BMJ takes a look at those testy poinsettias and others sources of holiday stress.
3. Some polka-dotted egg nog. Shouldn't every year end with a solid swig of nog before the champagne is popped?! Of course, I opt for the less health version of this delectable treat.
Best Wishes,
ERIC
Lee Trevino Would Like to Sell You a Surgery
Lee Trevino would like you to know that if you get struck by lightning and then happen to fall down into a sand bunker, his surgeon can help!
Trevino, famous for back pain and some decent golf, is now an advocate for low back pain, giving interviews to raise the awareness of low back pain..with his physician. I'm not sure Trevino is really as much concerned with awareness of back pain, as much as his surgeon is an advocate of surgery for spinal stenosis. Are these interviews thinly vield propaganda for this fellow's X-Stop Spacer?
I'm not into debating about how this device works or doesn't work for spinal stenosis, but I do have issue with yet another public statement of: low back pain = surgical repair, not to mention Trevino's guise of acting like a good guy.
Is Trevino looking to raise awareness for back pain or simply fullfilling his role as the spokesperson for the X-Stop?
The Bionic PT
Most in physical therapy profession are a bit slow on the uptake of technology. Most…but surely not all! Some of my colleagues are really doing some interesting things with bionics. As practitioners with expertise in prosthetics, it's a natural progression to this new generation of prosthetic technology.
The first "real" bionic woman was Claudia Mitchell, who was part of the bionic? program at the Rehabilitation Institute of Chicago.
Silicon valley is also getting into the mix, with the new PowerKnee by Tibion. This device seems like an external brace vs. what is pictured above. Physical Therapist Nancy Byl, Chair of the Physical Therapy Department at UCSF, was interviewed about a patient using this new device. Key to progressing this technology is mastering user interfaces with the machine components.
Those really interested in the topic might find this New Yorker article (pdf) on the new generation of bionic prosthetics a good read.
ERIC
The Best First Choice
Congratulations to BJ Lehecka, from Wichita State University, who won the EIM Elevator Pitch competition with this entry. Simply, elegant, drives the point home. Awesome!
Head on over to EIM to see the other winners.
Dissecting Manipulation, Q&A with John Childs
The current issue of JMMT includes a very nice review of evidence supporting Spinal Manipulative Therapy (SMT) for low back pain. This interesting review is a solid piece of work, and useful in bringing to light the current picture of where we stand: namely that SMT should be used for low back pain, but questions still exist about the best way to use it.
The authors of the review have recently published some evidence that calls into question some of the recent guidance we have been getting in terms of clinical prediction rules for spinal manipulation. In one study published this year, they conclude:
"The clinical prediction rule proposed by Childs et al. did not
generalize to patients presenting to primary care with acute low back
pain who received a course of spinal manipulative therapy."
I was interested in speaking with Dr.Childs and getting his opinion about the recent review and what he considers the current big picture in SMT. He was kind enough to oblige my questions!
NPATT: The authors of this review have suggested a return to a paradigm focused on making a specific patho-anatomical diagnosis for low back pain patients. This seems in contrast to the treatment-based classification approach where treatment decisions are made according to patient presentation, not a patho-anatomical cause. What does history, and current evidence tell us about finding a specific diagnosis for low back pain?
John Childs: Pathoanatomy is only relevant for guiding treatment decisions in roughly 10-15% of cases of LBP. Even in these cases, the pathoanatomy may be serious (ie, cancer, fracture, etc) so the percentage of cases in which pathoanatomy is relevant for guiding physical therapy treatment decision-making is even less. This is the reason why concepts of “treatment-based classification” and “subgrouping” patients with LBP based on clinical examination findings have become such an important research priority over the last 10 years. The elusive search for the pathoanatomic diagnosis and “magic bullet” treatment lies at the root cause for the disaster of LBP management in the U.S. and a re-focus around identifying pathoanatomy would be a big step backward rather than forward.
NPATT: The authors speak at length about the generalizability your CPR validation. Can you respond breifly on the issue?
Childs: The manipulation CPR as developed by Flynn and validated by Childs can only be generalized to similar patients that were included in these 2 initial studies and only using similar treatments. In both the Flynn and Childs studies, the SMT intervention was standardized and limited to a single high velocity thrust technique. Childs et al also included a comprehensive exercise strengthening program to the intervention. In contrast, Hancock et al allowed therapists wide latitude in which manual therapy techniques to use. The large majority of therapists (97%) elected to use lower velocity mobilization techniques and the 4-week intervention did not include an active exercise component (strengthening or otherwise), thus it’s difficult to compare the 2 studies. It is not surprising at all that Hancock did not find any differences in outcome based on whether patients fit the manipulation prediction rule because they tested an altogether different treatment approach. Their study does provide strong evidence that lower velocity mobilization procedures, in the absence of an active exercise component, is likely ineffective for patients with LBP.
NPATT: Along the same lines, the authors suggest focusing SMT treatment on specific painful segments. I've also seen evidence arguing that SMT is not, by nature, able to address specific segments and is a more global approach. Couple this with a proposed neurophysiologic mechanism, and I'm not sure targeting a specific segment is realistic or necessary. What is your opinion on this?
Childs: There is no evidence to suggest that SMT directed to a specific segment can be done in a reliable and valid way. Even presuming it could be done, there is no data to suggest that a “specific” approach is more clinically effective than a general approach. Many studies have demonstrated that the effects of SMT are likely occurring above and below the targeted segments. Much research is now being directed at understanding the mechanism through which SMT acts to improve pain and function. It seems that selection of the right patient is a more important priority than which technique is used. There is data now in the lumbar spine to suggest that SMT incorporating high velocity thrust manipulation is more effective than mobilization in the subgroup of patients who fit the manipulation rule.
NPATT: What's the big picture here for SMT and low back pain?
Childs: Pick the right patient and use SMT frequently in conjunction with an active exercise strengthening program. Don’t lose sleep if the models of “diagnosing” presumed biomechanical dysfunctions confuse you or don’t make sense. In all likelihood, they are mostly invalid and not useful for decision-making anyways. The key is being able to match patients to the right treatment based on key clinical examination variables associated with a successful outcome from a particular standardized treatment approach.
Thanks for the great conversation, John! This is an important debate and I'm eager to see where it ultimately leads us.
ERIC
High Costs, Bad Outcomes
In an Epidemic of Overtreatment, John Halamka and Rick Parker check in on the Health Care Blog with a great list of contributing factors to the the high cost, and low value of the U.S. health care system.
The list can be summarized in the following manner: Unhealthy lifestyles and overtreatment combine with a culture that promotes defensive medicine and a cycle is born. The authors note, that while the causes of this crisis are easy to identify, the remedy for them is not.
Back pain gets a mention as an illustrative example of the problem.
"Some patients are not willing to accept risk or shared decision making with their doctors. They want to begin the evaluation of back pain with an MRI instead of trying a course of gentle exercise and pain medications."
While this blog post is opinion-based, the high costs and poor outcomes in the case of low back pain are well documented by research findings.
Solid reading.
ERIC
Cyberchondria
Just about everyone I know has experienced some form of this condition. I'm particularly susceptible to the pet version of this. Basically, doing a web search for a health condition can leave you feeling anxious and sure you are facing a serious crisis. Have a headache? It must be a brain tumor, right? After all, that's what all the results are about!
This is a serious issue that, as a health professional, I deal with frequently as patients come in to the clinic with many questions, often concerned about the serious complications they are facing. A patient with back pain may come into the clinic well-versed about spine surgery, but not so aware of the fact that most back pain gets better on its own! Microsoft has published a research paper on this issue that is extremely useful in understanding how and why cyberchondria happens.
The table I pulled from the article lists probabilities of certain conditions occurring during web searches. If we stick with our headache example, a common benign condition, we see that we have a probability of seeing "brain tumor" 0.03 of the time. In actuality, the probability of your headache being a brain tumor is more along the lines of 0.000116, or 1:10,000.
The bottom line is that web searches are weighted unequally toward serious conditions. You are more likely to read about serious things than common things. Web searches currently do not allow you to make judgments about the frequency or likelihood of a certain condition…pretty important parameters in making a diagnosis!
Beware the web search next time your head is pounding, your dog has a fever, or your back is sore!!
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