Clinical Reasoning in Mechanical Diagnosis and Therapy ... · PDF file10/10/2014 1 Clinical...

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Clinical Reasoning in Mechanical Diagnosis and Therapy (MDT) and OMPT: Classification, Intervention, and Impact on

Musculoskeletal Health Care

Ron Schenk, Brian McClenahan

McKenzie Institute, USA Fellowship

Daemen College OMPT Fellowship 1

Learning Objectives:

Analyze the similarities and differences between the Delitto, Maitland, Sahrmann, and McKenzie (MDT) classification systems.

Understand the MDT clinical reasoning process.

Analyze movement to determine centralization vs. non‐centralization with consideration of patient response

Synthesize examination findings to categorize patients into directional preference, thrust and non‐thrust manipulation and stabilization categories.

Analyze the impact of MDT on health care costs and utilization

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At the completion of this presentation the learner will be able to:

Pathoanatomical DiagnosisExpert Quotes

Back pain diagnosis• “80% of back pain is caused by weak or tense muscles.”

• “The majority of LBP actually originates in the sacral ligaments.”

• “In 50% or more...the facet joint is the site of dysfunction.”

• “90‐95% of back pain is due to disks.”• “An extremely high percentage...have fascial problems.”

• “50%‐70% of chronic symptoms are psychological in origin.”

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Medical Model of Disease

Signs/symptoms analyzed

Pathology is determined

Treatment corrects pathology

Signs/symptoms disappear

Classification Systems for Low Back Pain

Identifiable source of LBP present in <10%

Classification systems often based on anatomical (theoretical) model

No one classification system is more reliable than others (Riddle, 1998)

Certain characteristics of particular classification systems may have appropriateness based on symptom chronicity (International Classification for Functioning 2013)

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Diagnosis: “ The process of determining the cause of a patient’s illness or discomfort”

Classification: “The process of classifying clinical data into named categories of clinical entities for the purpose of making clinical decisions regarding therapeutic management”

(Rose, 1989)

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Diagnosis vs. Classification

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Classification

• Riddle, D. Classification and low back pain: a review of the literature and critical analysis of selected systems. Phys Ther. 1998;78:708-735.

• Fritz JM, Delitto A, Erhard RE. Comparison of Classification-Based Physical Therapy with Therapy Based on Clinical Practice Guidelines for Patients with Acute Low Back Pain. Spine. 2003;28(13):1363-1372

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Acute Low Back Problems in Adults

Bigos S et al. Agency for Health Care Policy and Research (AHCPR) 1994

AHCPR 1994 Manipulation can be helpful for patients with acute low back

problems without radiculopathy when used within the first month of symptoms (Strength of Evidence = B).

This was the first clinical practice guideline to recommend the use of manipulation in the care of acute LBP. Spinal manipulation is a safe, effective, and recommended intervention in the management of LBP.

Spinal manipulation received the highest level of evidence of any intervention in the 1994 Agency for Health Care Policy and Research (AHCPR) Guidelines

Final recommendations included stay active approach, education, and general exercise.

www.ahcpr.gov

Systematic Reviews & Meta-analyses of RCTs

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Comparison of a Guideline‐Based Approach versus a Classification Approach in the

Treatment of Acute, Work‐Related Low Back Pain

Julie M. Fritz, PT, PhD, ATCAnthony Delitto, PT, PhDRichard E. Erhard, PT, DC

Department of Physical TherapyUniversity of Pittsburgh

Fritz J, Delitto A, Erhard R. Comparison of a Guideline-Based Approach versus a Classification Approach in the Treatment of Acute, Work-Related Low Back Pain. Spine. 2003;28:1363-1372

Patient with acute LBP

Baseline Evaluation

R

AHCPR Group Classification Group

All patients treated based on AHCPR Guidelines

Patients receive treatment specific to classification


Low Back Pain Classifications

Manipulation/Exercise

Stabilization exercises

Activities to Promote

Centralization

Specific Exercise

Stabilization Traction

INTERVENTION

Mechanical/ auto-traction

Manipulation


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A clinical prediction rule for classifying patients with low back pain who

demonstrate short‐term improvement with spinal manipulation.

Flynn T, Fritz J, Whitman J, et al.

Spine 2002;27:2835‐2843.

Pre-test Probability of Dramatic Success with

Manipulation

45%

4 or more present:

Recent onset (<16 days)

Low FABQ (<19)

No symptoms below knee

Lumbar stiffness

Good hip IR (>350)

95%

Post-test Probability of Dramatic Success with

Manipulation

Predicting Success with Manipulation

+LR=24.3

Flynn et al, Spine, 2002

Passive Intervertebral Motion

• Gonella C, Paris S, Kutner M. Reliability in evaluating passive intervertebral motion. Phys Ther. 1982;62:436-444.

• Insaco EL, et al. Reliability in evaluating passive intervertebral motion of the lumber spine. J of Man and Manip Ther.1995;3:135-143.

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Joint provocation testing

Posterior‐anterior central vertebral pressure (PACVP)

Posterior‐anterior unilateral vertebral pressure (PAUVP)

Tranverse vertebral pressure (TVP) Maitland – Patient Response Method

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Movement System Balance Theory

Van Dillen LR, Sahrmann SA, Norton BJ, et al. Movement system impairment-based categories for low back pain. J OrthopSports Phys Ther. 2003;33:126-142.

Sahrmann – Patient Response Method

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When should we not test end range?

Clinical decision making

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Mechanical Diagnosis and Therapy (MDT)

Examination

for centralization and direction of preference

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Why test end range?

• Confirm classification

• Reduce derangement

• Elicit centralization

• Expose dysfunction

• Expose relevant lateral compartment

• Determine prognosis

Repeated End Range Movements

• Flexion in standing

• Extension in standing

• Sidegliding in standing

• Flexion in lying

• Extension in lying

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Repeated end range movements

• Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain: a predictor of symptomatic discs and annular competence. Spine. 1997;22:1115-1122.

• Razmjou H, Kramer JF, Yamada R. Intertester reliability of the McKenzie evaluation in assessing patients with mechanical low-back pain. J Orthop Sports Phys Ther. 2000;30:368-389. 22

CentralizationWerneke M, Hart DL, Resnik L, Stratford PW,

Reyes A. Centralization: prevalence and effect on treatment outcomes using a standardized operational definition and measurement method. J Orthop Sports Phys Ther; 38:116-125, 2008.

Long A, May S, Fung T ; The comparative prognostic value of directional preference and centralization: a useful tool for front-line clinicians? J Manual Manip Ther; 16.248-254, 2008.

Directional preference23

Directional Preference

• Long A, Donelson R, and Fung T “Does it matter which exercise? A RCT of exercise for LBP. Spine. 2004. 29 (23):2593-2602.

• Schenk RJ, Jozefczyk C, Kopf A. A randomized clinical trial comparing therapeutic interventions for low back pain. J Man Manip Ther. 2003;11(2).

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Patient Reponse Method

Manipulation/Exercise

Stabilization exercises

Activities to Promote

Centralization

Repeated end range

loading/MDT

Provocation/ MSB Neuro/

No DP

INTERVENTION

Traction

Provocation test

• “Centralization is liberally defined as a movement, mobilization, or manipulation ‘technique’ targeted to pain radiating or referring from the spine, which when applied abolishes or reduces the pain distally to proximally in a controlled predictable pattern.”

• Cook, C. “Orthopedic Manual Therapy: An Evidenced Based Approach” 2nd edition. pp268; article cited in text: Aina A, May S, Clare H. The Centralization phenomenon of spinal symptoms: A Systematic Review: Manual Therapy 2004; 9; 134‐143

McKenzie Institute Fellowship

• “Centralization is defined in the classification system of occurring when a movement or position results in abolishment of pain or paraesthesia, or causes migration of symptoms from an area more distal or lateral in the buttocks and/or lower extremity to a location more proximal or closure to midline of the lumbar spine”

• MUST have Lower Extremity Pain• Fritz J, Cleland J, Childs C. Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to Physical Therapy. JOSPT 2007; 37 (6):

296


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DEFINING CENTRALIZATION

• “Abolition Centralization: the most distal pain was abolished and pain was recorded more proximally on the second drawing than on the first.”

• “Reductive Centralization: the pain was located at the same distal location but with reduced intensity.”

• “Unstable Centralization: the pain was reduced or abolished during the repeated movement testing or positioning but after resuming a weight‐bearing position for one minute, the pain intensity level returned to the pre‐testing intensity”

• Albert H, Hauge E, Manniche C. Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions? Eur Spine J 2011,21(4):630‐636


Centralization is Frequently Misunderstood

McKenzie’s Method of Mechanical Diagnosis and Therapy (MDT) definition of centralization has evolved:

• 1981 Lumbar Spine Text

• “I would define this phenomenon as the situation in which pain arising from the spine and felt laterally from the midline or distally, is reduced and transferred to a more central or near midline position when certain movements are performed.”

• McKenzie R: “The Lumbar Spine” Spinal publications 1981 pp22


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• 2003 Lumbar Spine Text

• “In response to therapeutic loading strategies, pain is progressively abolished in a distal to proximal direction with each progressive abolishing being retained over time until all symptoms are abolished. If back pain only is presents, this moves from a widespread to a more central location and then is abolished”

• McKenzie R, May S “The Lumbar spine: Mechanical Diagnosis and Therapy” Spinal publications 2003 pp 167.


• 2008 MDT Research:

• Centralization is characterized by spinal pain and referred symptoms that are progressively abolished in a distal to proximal direction in response to therapeutic loading strategies.

• Very Objective Measures included to further remove clinician bias

• Werneke’s el al Centralization: Prevalence and effect on Treatment Outcomes Using a Standardized Operational Definition and Measurement Method; JOSPT March 2008 Vol 38 (3) pp116


Centralization: Operational Definition

• Directed by precise application of movement & positioning

• Proximal change in pain location only

• Remains better – lasting effect during treatment

• Midline pain abolishes

• Overlay template

May & Aina. Manual Therapy 2004 & 2012


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Centralization: Standardized Measurement

• Overlay Template

• Donelson et al Spine 1991

• Werneke et al. Spine 1999

• Delitto et al. JOSPT 2012


Centralizationvs.



Symptomatic Responses

• The changes in the patient symptoms that are elicited and recorded with the application of assessment procedures, treatment procedures or in response to functional activities and positions.


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Mechanical Responses

• The measurable changes that occur in movement loss, dural tension, neurologic function, tolerance to functional activities and positions, or change in tested physical abilities.


Centralization

• Describes the phenomenon by which pain emanating from the spine is progressively abolished in a distal to proximal direction in response to therapeutic loading strategies, with each progressive abolition being retained over time. (Lasting Change)

• Symptomatic Response


Peripheralization

• Describes the phenomenon by which pain emanating from the spine spreads distally into or further into the limb as a result of loading strategies. (Lasting Change)

• Symptomatic Response


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• Phenomenon of preference for Postures/Movements that decrease, abolish or centralize symptoms and often decrease a limitation of movement. (Lasting Change).

• Symptomatic and/or Mechanical Response


Pain Response Subgroups

PAIN RESPONSE

Non-CEN

2. DP/Non-CEN 3. No-DP/non-CEN

1. CEN/DP


CASE STUDY


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Impact

• Integrated Mechanical Care (IMC) – McKenzie based physical therapist owned practice in Talahassee, Fla

• IMC President ‐ Chad Gray PT, Cert. MDT IMC Vice‐President and Chief Clinical Officer ‐Mark Miller PT, Dip MDT

• IMC Mission and Description

IMC Mission and Description

• Mission ‐ To revolutionize the standard of care for musculoskeletal injuries and pain

• Description – The IMC BestCare Method was developed to effectively treat musculoskeletal injury and disease in a non‐invasive, conservative manner. Additionally, the method focuses on prevention of injury, educating patients on proper movement.

National Business Coalition on Health (NBCH)A Cost‐Saving Solution for SIEs Around Musculoskeletal Disorders

(MSDs)

Outcomes‐Accountable™ Care

for Musculoskeletal Disorders

(c) 2014 Integrated Mechanical Care, Inc. / Confidential & Proprietary

Chad Gray, PresidentMark Miller, Vice President &

Chief Clinical OfficerIntegrated Mechanical Care,

Inc.

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IMC Objectives

• Focus on self‐insured employers (SIEs)

• Find solutions with rapid and verifiable cost‐savings and outcomes improvements for musculoskeletal disorders (MSDs)

• Offer early intervention, outcomes‐accountable™ programs to SIE members

• Provide program planning, oversight, and guarantees


Reduce the Cost, Incidence and Prevalence of MSDs and Inappropriate Care

Target High‐Risk and High‐Cost MSD Diagnoses

Fortune 500 Case Study – Before IMC

• > $34.7 million in annual claims costs for 12,127 MSD sufferers

• > $285,600 in annual claims costs per 100 MSD sufferers

• > $2,861 in annual claims costs per average MSD sufferer

• > $238 in MSD‐related expenses PMPM

• > 4,000 images ordered, overall

• > 13% rate of surgeries (vs. a reasonable rate of 3‐4%)

• > 45 weeks in an avg. episode of care

• > 50% one‐year recurrence rate

• > 44% of cases unresolved


Sell Outcomes Associated With 100% Steerage

Quantify the Problem and Forecast Savings


Fortune 500 Case Study:

Target w/ 100% Steerage

• < $18.8 million in expenditures

• < $155,026 per 100 MSD cases

• < $106.26 spent PMPM

• < 500 images ordered

• < 2.0% rate of surgeries

• < 30 days in avg. episode of care

• < 10% one‐year recurrence rate

Fortune 500 Case Study:

Results of 830 Cases*

• < $875,426 in expenditures

• < $127,453 per 100 MSD cases

• < $106.21 spent PMPM



• < 30 days in avg. episode of care


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Participate in Steerage Initiatives

Work with RBCHs and SIEs To Triage All MSD Cases

Before IMC

• > $34.7 million in annual claims costs

for 12,127 MSD sufferers

• > $285,600 in annual claims costs

per 100 MSD sufferer

• > $2,861 in annual claims costs

per MSD sufferer

• > $238 in MSD‐related expenses PMPM

• > 4,000 images ordered

• > 13% rate of surgeries

• > 45 weeks in an avg. episode of care

• > 50% one‐year recurrence rate


Forecast Based on 830 Cases Across 686

Members

• $18.8 million in annual claims costs

for 12,127 MSD sufferers

• < $127,455 in annual claims costs

per 100 MSD cases

• < $1,274 in annual claims costs

per MSD sufferer

• < $107 in MSD‐related expenses PMPM



• < 30 days in an avg. episode of care


Quantify and Guarantee Cost Savings

Replicate Proven Cost‐Saving Model


Location of MSD

Pre‐IMC MSD PMPM

Post‐Pilot MSD PMPM

Avg. PMPM Savings for MSDs

Lumbar Spine $187.41 $107.52 $79.89

Cervical Spine $163.31 $85.84 $77.47

Shoulder & Arm $362.76 $87.89 $274.87

Knee $311.72 $75.14 $236.58

Hip $86.73 $66.67 $20.06

Elbow $80.61 $33.33 $47.28

Foot & Ankle $94.18 $33.33 $60.85

Thoracic Spine $30.99 $27.77 $3.22

Wrist‐Hand $33.53 $27.77 $5.76

Other Body Regions

$44.59 ‐‐ ‐‐

Quantify and Guarantee Outcomes

Focus on Patient‐Reported Outcomes


Pilot Program Results, Phase I

Percent Improvement

Area of Improvement on Functional Indices

IMC’s Clinical Data

One of IMC’sFortune 500 Clients

One of IMC’sS&P 600 Clients

Pain Score 73.0% 76.9% 80.0%

Daily Functional Status 40.0% 36.2% 28.0%

Low Back Function73.0% 82.7% 63.0%

Neck Function 69.0% 71.6% 67.0%

Lower Extremity Function 72.0% 72.4% 68.0%

Patient Satisfaction98.2% 98.3% 98.9%

PMPM Cost Savings44.0% 46.0% 65.0%

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Note How Quickly Cost‐Savings Accrue

Use Actual Claims To Prove Cost Savings


Pre‐IMC MSD PMPM(Based on 2012 & 2013 Claims)

Guaranteed MSD PMPM (Based on 40% Cost Savings )

Actual MSD PMPM c/o IMC Affiliate (1/2014 ‐ 5/2014, n = 147)

$254.11 & $272.48 $163.49 $94.42

Cost Savings @ Current PMPM,Considering Only “n” of 147

Forecasted Cost Savings at 40%,Considering Only “n” of 147

$314,097.84 $192,258.36


Get the Diagnosis Right to Get the Treatment Right

Triage MSD Patients Through IMC’s Reliable Assessment Program

Patients enter medical system with

musculoskeletal injuries or conditions

Diagnostic triage sub‐groups patients into

reliable treatment groups

Surgical careInjection care

OtherConservative care supports

95‐97% of all patients

Appropriate care generates greater savings & “clean data”

Referrals

Specialties

Create Benefit Plan Savings

Build on IMC’s Successes


Key Performance Indicator (KPI)

National Statistics

IMC Living Laboratory

Statisticsn = 7,000+

Fortune 500 CompanyStatisticsPre‐Pilotn = 10,770

Fortune 500 CompanyStatisticsPost‐Pilot

n = 942 cases & 772 members

PT Visits per Referral

17 6.1 14.2 5.7

Advanced Imaging Procedures

25% 5.3% 42% (4,482) 3.1% (24)

Pain Injectionsor Procedures

10% 3.2% 32% (3,437) 2.6% (20)

SurgicalProcedures

15% 3.8% 13% (1,406) 1.0% (8)

Beneficiary Satisfaction Rate

‐‐ 98.0% ‐‐ 98.3%

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Promote Breakthrough Results

Deliver Unprecedented Value to RBCHs and SIEs

• Individual

• Improved speed to recovery & socioeconomic status

• Organizational Outcomes

• Enhanced cost reductions & cost containment

• Improved human‐capital ROI

• Societal Outcomes

• Improved population health & socioeconomic development


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Medical Model of Disease

Signs/symptoms analyzed

Pathology is determined

Treatment corrects pathology

Signs/symptoms disappear

Drive Savings with a Clinical vs. Administrative Solution

Inter‐Tester Reliability Appropriate Treatment

Appropriate Treatment Better Patient Outcomes

Better Outcomes Reduced Costs & Human‐Capital ROI


Assessment

Diagnosis

Treatment

Clinical Outcomes

Economic Outcomes

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QUESTIONS?

McKenzie Institute, USA FellowshipDaemen College OMPT Fellowship

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Saviola K, Schenk R, Coleman TCatholic Health System, Buffalo, NY

Daemen College OMPT Fellowship

Cervicogenic dizziness post-concussion:

A case report

Research question

Will a 6 week cervical stabilization program improve functional outcomes and performance on the cervical relocation test in a patient with cervicogenic dizziness?

Case descriptionA 23 year old former collegiate soccer player was screened and managed for post-concussion syndrome and vestibular involvement prior to the physical therapy (PT) initial examination.

The PT exam revealed constant and unchanging cervical pain. Of particular concern to the patient was an inability to visually focus and dizziness that followed reading, computer work, and turning of the head.

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Recruitment of the deep neck flexors

Intervention and Outcomes –Phase II

• Intervention – 6 week stabilization program emphasizing recruitment of the deep neck flexors and extensors.

• The outcomes related to Phase II management included an improvement in the cervical relocation test to an error of less than 4.5 degrees for each of the 6 attempts

• Improvement in the NDI to 8%

• Improvement in function on the FOTO tool to a score greater than predicted

Clinical Reasoning in Mechanical Diagnosis and Therapy ... · PDF file10/10/2014 1 Clinical...

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