Treatment Based Classification of the Spine- An Evidence Based Journey for the Physical Therapist - PowerPoint PPT Presentation

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Treatment Based Classification of the Spine- An Evidence Based Journey for the Physical Therapist

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Treatment Based Classification of the Spine-An Evidence Based Journey for the Physical Therapist Tara J. Manal, PT, DPT, OCS, SCS Gregory E. Hicks, PT, PhD – PowerPoint PPT presentation

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Title: Treatment Based Classification of the Spine- An Evidence Based Journey for the Physical Therapist


1
Treatment Based Classification of the Spine-An
Evidence Based Journey for the Physical Therapist
  • Tara J. Manal, PT, DPT, OCS, SCS
  • Gregory E. Hicks, PT, PhD

2
Development of a Classification Scheme for the
Spine
3
Neck Pain
  • 54 of people have experienced neck pain in the
    last 6 months
  • Economic burden associated with treatment is high
  • Second only to LBP in US for workers
    compensation costs
  • Patients with neck pain make up 25 of all
    patients in outpatient physical therapy

4
Low Back Pain
  • Next to the common cold, LBP is the most common
    reason for people to see physician
  • Billions of dollars in expenditures are spent on
    management of LBP annually
  • Nearly 50 of all patients who go to outpatient
    physical therapy are there because of LBP

5
Classification Schemes
  • Physical Therapists use a wide range of
    interventions for managing people with spine
    problems
  • Manual Therapy (manipulation/mobilization)
  • Exercise
  • Traction
  • Modalities
  • Functional Training

6
Classification Schemes
  • Although all are accepted as standard of care-
  • Very little high quality evidence from randomized
    clinical trials (RCT) exist
  • Over 1000 RCTs for LBP (conservative and surgical
    interventions), but evidence is still conflicting
    for many interventions

7
Classification Schemes
  • Why is there such a lack of evidence for most
    interventions used in the conservative care of
    spine patients?
  • As clinicians we know that.
  • All patients with neck pain are not the same
  • All patients with LBP are not the same
  • Heterogeneity is the key issue!

8
What Has Been The Result of Ignoring
Classification in Exercise RCTs for Spinal Pain?
9
Faas et al Spine 1995
363 SUBJECTS Inclusion Criteria 1) LBP lt 3
weeks 2) Age gt 18
R
Placebo ultrasound
Usual Care group
Flexion Exercise
10
Results and Conclusions
  • The percentage of patients with sickness absence,
    and number of days of absence in the first year
    was not different among groups
  • at 1 yr, no difference in total work days lost
    among the groups
  • exercise therapy for patients with acute LBP does
    not reduce sickness absences

11
Cherkin et al (New Eng J Med 1998)
323 SUBJECTS Inclusion Criteria LBP persisting
more than 7 days after visit to GP
R
McKenzie Approach
Educational Booklet
Chiropractic
12
(No Transcript)
13
(No Transcript)
14
Viljanen et al BMJ 2003
393 Female Office Workers Inclusion Criteria 1)
Neck pain gt12 weeks 2) Age 30-60
R
Dynamic Muscle Training
Ordinary Activity
Relaxation Training
15
Results and Conclusions
  • No significant difference found in neck pain
    between the groups over a year
  • But, better rotation and lateral flexion ROM in
    the intervention groups

16
Classification Schemes
  • Most likely to be successful if you can match an
    intervention to the most appropriate sub-group of
    patients
  • Most can agree upon this idea of appropriate
    matching
  • But, there is little agreement about how to
    classify patients into these sub-groups

17
The Medical Model of Disease
Signs/symptoms analyzed
Pathology is determined
Treatment corrects pathology
Signs/symptoms disappear
18
The Medical Model of Disease(Waddell, Spine
1987, Engel, Science 1977)
  • The biomedical model has transformed from a model
    into cultural dogma.
  • All disease must be explained in terms of
    derangement of underlying physical mechanisms.
  • Not all conditions appear to fit, this is
    particularly true for LBP and also true for much
    of musculoskeletal medicine.

19
Traditional Medical Diagnosis
Classification Using Lumbar Pathology is
Unsuccessful
Low Back Pain No Low Back Pain
Pathology 10-20 80-90
No Pathology 20-30 70-80
20
The medical model and LBP
What happens if you cant find relevant pathology?
  • Use some pathology labels
  • facet, muscle strain, disc herniation
  • Use some syndrome labels
  • Low back strain
  • Lumbago
  • Mechanical low back pain
  • Backache
  • No direction for treatment

21
Diagnosis vs. Classification
  • Diagnosis The process of determining the
    cause of a patients 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)

22
How do you develop a classification system?
23
Levels of Evidence
24
No classification system should remain static!
  • Constant evolution should be occurring based on
    new evidence
  • Systems should be refined and potentially
    simplified, if possible

25
Finding Common Ground
  • Classification Systems
  • Reliable
  • Guide Interventions
  • Treatment Techniques
  • Effective
  • Generalizable
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