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1 !"#$%"&'%()*+'!!%!"#$%&'()*"+,'-%$.$)/0(1203).0)4",03%&)/-%3'()!'%3! 2,6=-,55%?.>%!.5;9.68B% ",-./01%23%451667%$"7%$0*% *,896:;,80<=%$>.?<88.>% ",-./01%23%451667%$"7%$0*% *,896:;,80<=%$>.?<88.>%!/.C%/0<%$D,6%%!/.C%/0<%(D=6<88%% $)E+% FG%HD;8<%.?%D=;5/% =,8DI,5,/1%,6%/0<%J!) $)E+ % G%,6%K%C<.C5<%5,L<%M,/0%H0>.6,H%CD,6! NOP%"#!$%%!$&'%()!*$+,!*$&! -*."/0-!".!.,-'..,/(!1$0/!0/!(*,! %$)(!2,$.! 1

2 ONP%.?%C<.C5<%-DA<%D=Q;8/-<6/8%/.% /0<,>%5,?<8/15<%I<HD;8<%.?%/0<,>%CD,67%% KNP%"#!1$3,/()!40(*! =<C><88,.6!.,1".(,&!(*$(!(*,2! 4,.,!0/!1*2)0-$%!1$0/5!! 6$/2!*$&!*,$&$-*,)7!8$-9!1$0/7!$/&! :"0/(!1$0/5! Lets focus on just one pain condition for a moment $><LD5<6H<%.?%% R&S#+ER%!$E+)@%$)E+)%$)GTP% U$D,67%VWWNX 2

3 )%/./D5%.?%YY%-,55,.6%C><8H>,C9.68%M<><%=,8C<68<=%?.>%IDHA%CD,6%,6%/0<%J3!3)3%,6%/0<%1<D>%VWWW3% Fills 2 Stadiums Total costs of prescription opioid abuse were estimated at $55.7 Billion in Pain Med, 2011 ">D=,9.6D5%+!)E*!%Z%R#[\V8% OW7WWW%]%VWW7WW%;8<>8%D66;D551% *"+)55)-'%6)70,)8%$%.$).0)60&.0,$9)0:&+$;)&(%3%&$;) $1,<+,#;)'36)-,+$&,%-203)=+6%&%3+$)) 70,)@.M%^DHA%$D,6)%3)>??@)A'$)) _`K%^,55,.6% Jarvik et al, 2003 ;<=!1$3,/()!40(*!>?@!4,.,!.$/&"A0B,&!("!.,-,0+,!.$&0"C.$1*)!".!6DE!!!C,6D5%4;8,.6! O*,!C"$%!"#!)10/$%!#')0"/!)'.C,.2!0)!("!)($80%0B,!$!),CA,/(!"#! (*,!)10/,!(*$(!*$)!A+'B+3+6!$/&!,%0A0/$(,!A"3"/!$(!(*$(! ),CA,/(5!O*0)!)($80%0B$3"/!40%%!%6+'((#!><=;H<%/0<%CD,6! (*$(!0)!$))"-0$(,&!40(*!+,.(,8.$%!A"+,A,/(5! FG!A"/(*)H!I"!&0J,.,/-,!8,(4,,/!C."'1)!#".!#'/-3"/! ".!)$3)#$-3"/! K'.C,.2L!!!!KP%?.>%(SE%%%%%%%%%%VP%?.>%[\>D1% M")()!1,.!N10)"&,!!!(SE%a%_Vb`W%%%%[\>D1%a%_VWNT% 3

4 Spine 2011;36: Spine 2011;36: ! )%H.0.>/%.?%OVN%?;8,.6%HD8<8%L<>8;8%OVN%H.6/>.583%!!;>:,HD5%HD8<8%0D=%D%G%,6%Y%H0D6H<%.?%D%><C<D/% 8;>:<>17%D%G%,6%b%H0D6H<%.?%D%H.-C5,HD9.67%D6=%b%,6%Y%H0D6H<%.?%6<L<>%M.>A,6:%D:D,63c%%! "0<><%M<><%D58.%-.><%=<D/08%,6%/0<%8C,6D5%?;8,.6%:>.;C3! Age, BMI, diagnoses, education, surgical fusion approach, sex, marital status, the number of lumbar levels with degenerative changes, and the number of vocational sessions were not significant predictors of RTW. In summary, lumbar fusion may not be an effective operation in workers compensation patients with the diagnoses of disc degeneration, disc herniation, and/or radiculopathy. This procedure is offered to improve pain and function, yet objective outcomes showed increased permanent disability, poor RTW status, and higher doses of opioids. K5P5!60.B$5!O*,!K10/,!Q"'./$%!FF!RG=FFS!TUVWTUU! Efficacy for fusion in relieving back pain is extremely suspect. Only one trial has shown an advantage for surgery compared with routine nonsurgical care and three trials showing no advantage compared with structured rehabilitation. Benefit with fusion was roughly the same in all four trials. K10/$%H#')0"/)!."),!82!OOP%% OXY!$/&!OPY!0/-.,$),&!82!"/%2!F;Z! K10/$%H#')0"/!-")()![_bY7WWW%+C&(16%3<)-,07+$$%03'()7++$) $ $ $ $ $ In 2004, spine fusion procedures totaled $16.9 Billion. -Ann Intern Med,

5 Spine Surgery Industry Misleading Information There is one thing stronger than all the armies in the world, and that is an idea whose time has come. -Victor Hugo Use Comparisons (big numbers are hard to envision) $ BILLION DOLLARS G=! F<! F\! FT! FG! F=! <! \! T! G! J3!3%4.><,:6%),=% RD6H<>%S<8<D>H0% U^><D8/7%@;6:7% $>.8/>D/<X% Use Local Comparisons (in my back yard) J+2)SS)+"'*%)+*%J+'[$@)E+)^@'%d)SE)"E#+%E+%!$E+'%!JSe'Sf%S)"'!% Use Local Comparisons (in my back yard) #S%^'""'S%f'"g% 5

6 Use Local Comparisons (in my back yard) #S%^'""'S%f'"g% For every 2 miles you drive up I-25 the rate of spine surgery increases by 1%. Pose Unlikely Questions (or really??? ) 20D/%,8%/0<%FG%C><=,H/.>%.?%M0</0<>%1.;%M,55% 1.;%0DL<%5.M%IDHA%8;>:<>1%,6%/0<%J!)B% Y5!!6DE!"#!X,./0$(,&!]0)-!?5!!@$0/!K,+,.0(2!^!>"-$3"/! M5!!>"))!"#!K(.,/C(*!$/&!D,_,`,)! ]5!!a01!M"&,! Source: Dartmouth Atlas of Healthcare Take Numbers & Make Them Personal Take Numbers & Make Them Personal >,()!1'(!(*0)!$/"(*,.!4$2b!! Risk Death! Spend $60-80K! Worse odds of success than not having surgery! Not Die! Spend $1-2K!As good or better odds of success than having surgery Empower your patients with simple questions 20D/%80.;5=%E% D8A%-1%=.H/.>B% Among patients receiving orthopaedic surgery care the likelihood of having spinal surgery increases by 34% if the orthopods own the MRI! Sugar Daddy 6

7 #6<%-.><%h;<89.6%?.>%1.;>%CD9<6/8% /.%D8A%/0<,>%8C,6<%8;>:<.63% *.%1.;%.M6%/0<% (SE%(DH0,6<B% 2011;41(11): ;41(11): PROVIDE EXAMPLES We should reiterate to the patient that the image of a disc lesion of some sort represents a picture of a single moment in time and that we have no compelling evidence that this indicates or indicts them to a prolonged course of impairment of disability. "0<%9-,6:%.?%HD><%-Di<>83% 2011;41(11): ;41(11): Patients require frequent reassurance that there is no serious damage or disease and that the overall prognosis is good for example, a consistent positive message informing the patient that, regardless of the imaging findings, the vast majority of low back pain resolves fairly quickly, the risk of chronic LBP is very low, and, therefore, the odds for recovery are good. Old approach Average cost $2,100-$2,200 The initial meeting might not happen for up to a month, and then there is no set procedure for treatment Initial meeting with doctors New approach Average cost $900-$1,000 Immediately see Physical Therapist Initiate evidence based conservative program Physical therapy Patients with complicated back pain are sent for additional treatment Patient follows up with doctors Patient might see a specialist Patient might undergo diagnostics, such as MRI Fuhrmans V. A Novel Plan Helps Hospital Wean Itself Off Pricey Tests. WSJ. 2007:1/12. 7

8 *"+)%=-'&.)07)."+)2=%3<)'36)&03.+3.)07)&',+)03)71.1,+)"+'(."&',+) 12(%D'203)'36)&0$.$E% % % % % %\%4>,/k7%R0,5=87%2D,66<>7%45166%%UE6%S<L,<MX%! $>,-D>1%HD><%><?<>>D5%.?%CD9<6/8%M,/0%D%6<M%H.68;5/D9.6%?.>%5.M%IDHA%CD,6%/.% C018,HD5%/0<>DC1j%/0<%,-CDH/%.?%/0<%9-,6:%D6=%H.6/<6/%.?%HD><%.6%?;/;><% 0<D5/0HD><%;95,kD9.6%D6=%H.8/83\%4>,/k7%R0,5=87%2D,66<>7%45166%%UE6%S<L,<MX%! SETTING Data extracted from Mercer HealthOnline a database of members of employee-sponsored health plans. PATIENTS 32,070 patients with a new primary care consultation for LBP from November 1, January 31, $>,-D>1%HD><%><?<>>D5%.?%CD9<6/8%M,/0%D%6<M%H.68;5/D9.6%?.>%5.M%IDHA%CD,6%/.% C018,HD5%/0<>DC1j%/0<%,-CDH/%.?%/0<%9-,6:%D6=%H.6/<6/%.?%HD><%.6%?;/;><% 0<D5/0HD><%;95,kD9.6%D6=%H.8/83\%4>,/k7%R0,5=87%2D,66<>7%45166%%UE6%S<L,<MX%! $>,-D>1%HD><%><?<>>D5%.?%CD9<6/8%M,/0%D%6<M%H.68;5/D9.6%?.>%5.M%IDHA%CD,6%/.%C018,HD5% /0<>DC1j%/0<%,-CDH/%.?%/0<%9-,6:%D6=%H.6/<6/%.?%HD><%.6%?;/;><%0<D5/0HD><%;95,kD9.6% D6=%H.8/83%%%%%%%%%\%4>,/k7%R0,5=87%2D,66<>7%45166%%UE6%S<L,<MX%! RESULTS! Physical therapy was utilized within 90 days in just 7% of patients.! Early PT (within 14 days of primary care) occurred with 53% of physical therapy utilizers, and was associated with decreased risk of advanced imaging, additional physician visits, lumbar surgery, lumbar injections, and opioid use as compared with delayed physical therapy.! Total medical costs for LBP were $ lower for patients receiving early physical therapy.! The content of physical therapy was associated with subsequent healthcare utilization and costs, but not as strongly as the timing of physical therapy. _b7www3ww%% _V7NWW3WW%% Total Costs: $3148 $5884 #6<%-.><%h;<89.6%?.>%1.;>% CD9<6/8%/.%D8A%/<55%/0<,>%C018,H,D63% _V7WWW3WW%% _G7NWW3WW%% _G7WWW3WW%% E%M,55%I<%:.,6:%/.% 8<<%-1%C018,HD5% /0<>DC,8/3% _NWW3WW%% _W3WW%% Imaging Procedures Surgical/Injection Procedures Inpatient Non-Surgical Procedures Prescription Meds Other LBP Related Costs Early PT Delayed PT 8

9 I get my back into my living What s Next I don t need to fight, to prove I m right 201%=.%M<%=.%M0D/%M<%=.B% Mobilize Manipulate Hold-Relax O*,.$10)(! c$-(".)! D,C0"/$%! c$-(".)! We were lacking a recognized body of knowledge. 9

10 What tests matter? 201%"0,8%"<H06,h;<B% S<8;5/8% %#8M<8/>1%*,8DI,5,/1%E6=<l%U#*EX%! YNP%CD9<6/8%,-C>.L<=%=>D-D9HD551%D6=%M<><%%%%%%%%%%%%%%%%%%%%%%%% H5D88,m<=%D8%!;HH<88% ODI! #IQ<H9L<j%".%LD5,=D/<%D%H5,6,HD5%C><=,H9.6%>;5<% I<6<m/%?>.-%8C,6D5%-D6,C;5D9.63%!!/;=1%*<8,:6j%%)%>D6=.-,k<=%H5,6,HD5%/>,D53% dd5,=d9.6%.?%/0<%s;5<% BMC Musculoskeletal 45% 2 factors present:!recent onset (<16 days)!no symptoms below knee 91% In the study by Childs and colleagues, spinal manipulation seemed to offer a slam dunk effect if patients met certain criteria. -Deyo, Ann Int Med, 2004 Pre-test Probability of Dramatic Success with Manipulation +LR = 12.6 Post-test Probability of Dramatic Success with Manipulation 10

11 D,)'%()! 240 Patients with LBP R SMT & Placebo SMT & Diclofenac Placebo SMT & Placebo Placebo SMT & Diclofenac SMT Group Placebo Group Does the Australian Tool Kit no longer include manipulation? Cleland et al., Spine )'8:,-()!.,-,0+,&!5.M%L<5.H,/1%(,-*/0d',)!40(*! $!)A$%%!UNPX%1."1".3"/!$%)"!.,-,0+0/C!0,:0% L<5.H,/1%(*.')(!(,-*/0d',)5% The results of the current study support the hypothesis that the CPR is generalizable to thrust manipulation techniques, but not to non-thrust manipulation techniques. Manual Therapy (2009) *,'3$%+3.)=+&"'3%&'()$2=1(1$).0)."+)2$$1+) &'1$+$)')&"'%3)07)3+1,0-"#$%0(0<%&'()+F+&.$E) g,/%d,6n/%q;8/% /0<%Q.,6/8B% 11

12 6,-*$/0-$%!! K3A'%')! O0))',! 6,-*$/0-$%!! K3A'%')! O0))',! $<>,C0<>D5%+<>L.;8%%!18/<-%!C,6D5%R.>=% I,'."A')-'%$.!D,)1"/),)! ],-.,$),!K1$)A!!E/-.,$),!De6! ],-.,$),!K1$)A!!E/-.,$),!De6! E/_$AA$(".2!6,&0$(".)! X21"$%C,)0$! Neurophysiological I"/!K1,-0f-!D,)1"/),)! $D,6% 'lc<>,<6h<% USD96:X% $D,6\ S<5D/<=%% ^>D,6% R,>H;,/>1% $D,6%(.=;5D/.>1% R,>H;,/>1% Y'("/"A0-!D,)1"/),)! N/&"-.0/,!D,)1"/),)! Peripheral Nervous System Spinal Cord Mech Supraspinal Mech 6,-*$/0-$%!! K3A'%')! I,'."A')-'%$.!D,)1"/),)! O0))',! $<>,C0<>D5%+<>L.;8%%!18/<-%!C,6D5%R.>=% ],-.,$),!K1$)A!!E/-.,$),!De6! E/_$AA$(".2!6,&0$(".)! X21"$%C,)0$! September 19, 1881 Why PT?! b#".!"+,.!;=!2,$.)! Q"),1*!>0)(,.!*$&! (.$+,%,&!(*,!4".%&! 1%,$&0/C!40(*!1*2)0-0$/)! ("!)(,.0%0B,!(*,0.!*$/&)! $/&!0/)(.'A,/()5!! ].5!KA0(*!O"4/),/&! 12

13 BORN TO MOVE A Quiet Tribe, Healthcare Disrupters, and the Greatest Profession Musculoskeletal Care Has Never Seen Why PT? *"+)71.1,+)%$)$0)G,%<".) H)<0I')A+',)$"'6+$! 13