Dr Ron Donelson Makes the Case for Optimal Medical Therapy for Musculoskeletal Conditions
Better Health at Lower Cost
A colleague and friend, Dr. Ron Donelson, wrote this piece as an extension of the concept reviewed in my post on the McDonald’s system on Feb 19.
Health care is a service industry ideally based on standardized diagnostics that hopefully identify precise diagnoses and diagnosis-specific treatment for each condition. OMT should be the product of systems and steps to produce that product.
Dr. Bestermann has conceptualized and defined OMT in the care of cardiometabolic disease, his clinical specialty. That disease is of course very common and its care very expensive, adding to the great interest in identifying and delivering OMT. But his OMT model also guides the clinical training needed to produce optimal results in a high percentage of any targeted subgroup, assuming of course that subgroup members and non-members can be reliably identified.
He defines OMT as a comprehensive set of integrated evidence-based care processes consistent with best practices. Usual care on the other hand is treatment that we find in the broader community. Quality is a systems property and OMT is a product of a system. The system of care that produces this product must be developed. In his recent posting entitled “The Founder: What is, and What Could Be! A Parable About Fast Food and Healthcare”, he models health care’s and OMT’s future after McDonald’s very successful fast-food system.
A similarly large and expensive health space is the care of musculoskeletal (MSK) and spinal disorders. That is my own clinical and research specialty. But 85% of those cases cannot even be diagnosed using conventional clinical and imaging testing. The quality of medical therapy consequently suffers greatly as treatment selection becomes mostly an educated guess.
Highly profitable surgery results in an estimated 150,000 unnecessary low back surgeries performed each year in the U.S. Any form of unnecessary surgery greatly reduces the overall quality of care while substantially increasing its cost. So the value of current low back care and its OMT is quite low.
Low back pain of course is just a symptom, not a diagnosis. Actual LBP diagnoses can only be made in 15% of cases using conventional clinical and MRI evaluations. Low back treatment has therefore been highly variable and very often misdirected. OMT for conventional spine care is therefore very weak.
On the other hand, the care of low back pain (LBP) is remarkably improving because of one specific form of care that is definitely elevating OMT. That exceptional care is called Mechanical Diagnosis & Therapy (MDT). Unlike other forms of care, it starts with a unique patient assessment with many studies reporting the ability for it to make a “precise diagnosis” in up to 90% of acute and 50% of chronic LBP cases. Clayton Christensen defines a precise diagnosis as one that also identifies a predictably effective treatment that addresses the cause and not just the symptom.
That one important exception is why I am writing this. This well-researched testing process also identifies how 50% of those heading for surgery can still recover quite easily without an operation. That is all highly-disruptive to the low back industry that is accustomed to performing high volumes of surgery and generating large profits.
MDT makes its precise diagnosis by identifying common patterns of pain response to standardized spinal bending test movements. The 90% with acute and 50% with chronic LBP rapidly and easily recover by demonstrating what is called a “directional preference”. That’s a single direction of repeated lumbar bending tests where the most distal pain first disappears from the leg (called “pain centralization”) and then the remaining LBP is fully eliminated with additional patient-specific directional spinal test movements.
Those high rates of recovery create a very high OMT in stark contrast to conventional low back care. This high volume of outstanding MDT studies are simply ignored by most members of the profit-driven low back pain “industry” that prefer to prescribe unproven but more profitable care including unnecessary medications, imaging, injections, and especially surgery.
In the absence of these MDT mechanical tests, treatment selection remains a guessing game with a greatly reduced OMT. With only 15% of LBP diagnosed with conventional diagnostics, the bar for identifying OMT is very low.
MDT is the only form of low back care that easily identifies a reliable diagnosis based on patterns of pain response in 90% of acute cases. Again, non-MDT LBP diagnostics can only diagnose 15% of cases.
Evidence supports MDT as low back pain’s exceptional OMT. One study reported a total MDT savings of 51% compared with “usual care” while reducing imaging by 50%, injections by 40%, and low back surgeries by 78%.
Upton Sinclair summarized: “It is difficult to get a man to understand something when his salary depends upon his not understanding it.”
LBP’s OMT is already transforming the quality of LBP care and its cost. There are plenty of resources to learn more and find resources for its delivery. The most recent is a publication coming out in March entitled: “Rapid Recoveries For Back, Neck, and Joint Pain: The Power of a Precise Diagnosis”, available on Amazon.com. Other resources can also be found on www.selfcarefirst.com and Amazon.
Ron Donelson, MD, MS
I have had two shoulder episodes and three back episodes managed using MDT by Dr Mark Miller at Integrated Mechanical Care. My most recent back episode was the same as the two prior ones. I remembered the intervention Dr Miller taught me and my pain was resolved in two days via self-management. They don't merely address your current episode. They teach you how to deal with future episodes in conditions that are usually recurrent. I had experienced these symptoms and the usual care route. Standard PT for my shoulder discomfort was terribly painful and ineffective. My symptoms only resolved with a steroid injection. Worse, there was a small rotator cuff tear and they had begun to discuss surgery. I don't even remember now which shoulder was involved, so obviously I did not need surgery.
I could not raise the impacted arm out to the side in a standing position beyond 40% without terrible pain. That was one of the test maneuvers. Dr. Miller saw that one motion and told me that the problem was not in my shoulder, it was in my neck He had me put my hands under my chin and bend my neck backwards as far as I could 8 times. With that one exercise I could raise my arm by 70% and by repeating it 3 times a day in 10 days I was well. Primary care doctors, nurse practitioners, PAs, chiropractors, and other physical therapists can learn these fundamentals quickly and then refer the most difficult cases to an MDT specialist. MDT first-before MRI-relieves symptoms and restores function more quickly while saving payers up to 50% per episode on average. A primary care team can do this very well in rural and small town America. What are you waiting for?