The Diagnostic Revolution in Musculoskeletal Care

Ron Donelson

No area of clinical over-treatment is as egregious as musculoskeletal (MSk) care. Mis-diagnoses resulting in mis- and over-treatment and wildly excessive spending are especially blatant within low back pain (LBP) care. The conventional LBP clinical exam and imaging diagnostics are unable to identify an accurate diagnosis in 85% of cases. That same inability pervades the care of painful extremity joints as well.

Clinicians utilize this void to select a diagnostic label that justifies their use of their favorite and often most lucrative treatment: the classic case of one with a hammer seeking lots of nails. U.S. surgical rates compared with other similar countries suggests that 50% of all orthopedic and spinal procedures are simply unnecessary.

Every clinician knows the importance of an accurate diagnosis but we too often just don’t know how to do it. For example, isn’t there some way to identify the hundreds of thousands who are undergoing risky, costly, unnecessary surgeries….prior to surgery? We need a diagnostic revolution.

Is such a revolution possible?

YES!!  That revolution is in the form of a highly valuable change occurring in MSk and spinal diagnostics. Extensive published data within the LBP literature validates a unique clinical examination that elicits common patterns of pain response from each patient. Any change in the pain’s location or intensity is revealed during and after performing a standardized series of repeated spinal bending and positioning tests.

Remarkably, very beneficial patterns of change are very common. For example, a single direction of spinal bending, performed repeatedly, first diminishes and then fully eliminates the pain of 70-90% of acute and 50% of chronic LBP and neck pain. Complete pain elimination often occurs within a single session of testing.  Read that again.

That beneficial direction is called the pain-generator’s “directional preference” (DP).  Once a DP is identified, the clinician then becomes the coach by teaching patients how to perform their own matching directional movements and positions at home, at work, and during leisure activities. These self-care strategies also easily eliminate any recurring pain, both short- and long-term.

This form of care is known as “Mechanical Diagnosis & Therapy” (MDT).(1)

Compared with other countries, it is estimated that 50% of spine surgeries are unnecessary.(2)That happens to be the same percentage of pre-surgical candidates that have been reported in four independent studies to have a DP.(3-6) So instead of risky, expensive surgery, these studies report that 50% have a previously undiscovered DP with a high likelihood of easily and rapidly resolving their own problem. That means a very high percentage of unnecessary surgeries can now be identified pre-surgically and avoided. So why isn’t that happening?

Tragically, for most patients, self-insured payers, and unions, only a small percentage of primary care providers or specialists provide their MSk patients the opportunity to undergo this inexpensive, safe, and very informative assessment. If we “follow the money”, it’s understandable why specialists, hospitals, pharmaceuticals, and commercial payers would not want patients examined and successfully treated this way. In contrast, what person facing surgery wouldn’t jump at a 50% chance of full recovery within days using safe, simple exercises rather than go through the pain, risk, including worsening, and rehab ordeal with surgery?

MDT care is best delivered today by Integrated Musculoskeletal Care (IMC), a Florida-based national MSk management practice that delivers their own outcomes-accountable version of MDT. An independent claims analysis comparing the cost of IMC’s care of 400+ LBP Fortune 500 manufacturer employees with usual community-based care found that IMC saved the employer 50% of its LBP costs. That included reductions of 78% in spinal surgeries, 50% of MRIs, and 40% of spinal injections. IMC produces similar savings when managing painful extremity disorders (see below).

But what about those without a directional preference?

Some MSk patients are unable to recover without an injection or surgery. But who are they? How do we identify them? Certainly not from their MRI findings with so many false positive findings. No one, repeat no one, should be considered for an injection or surgery (or even an MRI) without first undergoing a high-quality MDT exam. There is otherwise great risk of performing unnecessary procedures in those with a DP. Those in need of an injection or surgery are understandably in the non-DP subgroup. This assessment easily identifies them as surgical cases that enables them to undergo surgery earlier. Surgical outcomes then greatly improve since early surgery avoids patients becoming deconditioned and substantially reduces the risk of any motor loss becoming permanent.

MDT also excels in correcting flawed diagnoses for painful shoulders, hips, and knees.

Extremity pain, even without a spinal pain complaint, is often referred pain from the spine. Most doctors, including orthopedists, regularly overlook that possibility while focusing only on the body part where the pain is occurring. Some patients have even undergone unsuccessful rotator cuff, total hip, or knee surgery because the treating surgeon misdiagnosed the pain source and operated on the completely wrong body part.

Whenever evaluating any painful extremity disorder, MDT clinicians are taught to always “clear the spine first” using their unique and reliable spinal screening exam. Thirty percent of those referred to MDT clinicians for treatment of a shoulder complaint are reported to have a cervical pain source with a DP, not a shoulder origin.(7) Their shoulder pain then recovers easily and quickly using directional spinal movements. Another 37% were found to have a DP during the shoulder exam itself that, like the spine, enabled patients to quickly and easily eliminate their own pain. In total, 67% have a rapidly reversible condition either in the spine or in the shoulder that rapidly recovers without needing any other care. Without these findings, many would undergo unnecessary and ineffective conservative care, shoulder injections, and surgeries, at very high cost.  

Patients referred to MDT care with hip complaints, often have degenerative changes on their imaging. But they commonly have pain not from their hip but from the lumbar spine (unpublished data). Like the shoulder, their problem is due to an easily self-corrected spinal disorder with a DP. But most surgeons would much more commonly and confidently recommend a total hip replacement without ever considering offering this simple MDT evaluation to greatly enhance the diagnosis?

Conventional spinal, extremity, and imaging diagnostics are often very misleading. Done well, this MDT assessment provides rapid, easy recoveries that make MRIs, pain medications/opiates, injections, and surgeries unnecessary in 80-90% of these disorders. This exam should become a routine part of LBP, neck pain and extremity evaluations just as an ECG is routinely performed in evaluating chest pain disorders.  

Primary care is perfectly positioned to lead this revolution. By working in tandem with well-trained MDT/clinicians, primary care can transform MSk care by routinely providing patients with a reliable, precise diagnosis that saves so many from unnecessary ineffective treatments as well as save 50% of MSk costs. That represents 2% of the entire U.S. economy. As value-based reimbursement emerges, primary care’s revenue stream can be greatly enhanced.

The Challenge…

This revolution is meeting great resistance from many MSk specialists who shun anything that disrupts their beliefs and revenue streams. After all, what business would embrace a change in their product that might significantly reduce their revenue stream? Better outcomes won’t occur until we start paying for them rather than for activity. Alternatively, as that transition takes place, primary care has tremendous potential for receiving outcomes-based reimbursement by widely providing access to this MDT form of assessment.

Meanwhile, those who are aware of the benefits of MDT but still don’t provide it demonstrate a willingness to perform unnecessary, risky care for their own benefit. Revenue is the analgesic that deadens the pain and awareness of inappropriate patient care.

Because current care exposes multi-millions every year in the U.S. to either iatrogenic disability or unnecessary procedures, there is urgency in transforming conventional MSk diagnostics to this MDT form of care early in care-seeking for every individual with a painful MSk condition.

References

1. McKenzie R, May S. Mechanical Diagnosis and Therapy. Second ed. Waikanae, New Zealand: Spinal Publications New Zealand Ltd.; 2003.

2. Weinstein S, Yelin E. The burden of musculoskeletal disease in the United States, United States Bone and Joint Initiative, 3rd Edition. http://wwwboneandjointburdenorg 2014.

3. Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain: A predictor of symptomatic discs and anular competence. Spine. 1997;22(10):1115-22.

4. Kopp JR. The Use of Lumbar Extension in the Evaluation and Treatment of Patients With Acute Herniated Nucleus Pulposus, A Preliminary Report. Clinical Orthopedics and Related Research. 1986;202:211-8.

5. Laslett M, Oberg B, Aprill C, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. The Spine Journal. 2005;5:370-80.

6. Rasmussen C, Nielsen G, Hansen V, Jensen O, Schioettz-Christensen B. Rates of lumbar disc surgery before and after implementation of multidisciplinary nonsurgical spine clinics. Spine. 2005;30:2469-73.

7. Abady H, Rosedale R, Chesworth B, Rotondi M. Application of McKenzie system of Mechanical Diagnosis & Therapy in patients with shoulder pain; a prospective longitudinal study. Journal of Manual & Manipulative Therapy. 2017;25:235-43.

Ronald Donelson, MD, MS is a board-certified orthopaedic surgeon who specialized in non-operative spine care for 20 years, first in private practice and then in academia at The Institute for Spine Care at the State University of New York in Syracuse. Dr. Donelson was granted the Diploma in Mechanical Diagnosis & Therapy in 1991 and completed a Master of Science program in 1998 at the Dartmouth Medical School for Evaluative Clinical Sciences in New Hampshire. He is currently President of SelfCare First, a consulting, publishing, and low back pain disease management company.

His numerous research publications have focused on the assessment, classification, and non-operative treatment of neck and low back pain. He has also written many chapters, review articles, scientific abstracts, and posters, and he has presented more than 100 research papers, conference workshops, courses, and symposia in more than 15 countries. He authored the book Rapidly Reversible Back Pain, published in 2007.