DECEMBER - 20209one a neurosurgeon and the other an orthopedic surgeon respectively, you might say the surgeons had a head start on treating spine problems. After all, our specialty of Physical Medicine and Rehabilitation not only did not become a board-certified specialty until shortly after World War II but we did not even have a driving force and a strong voice in spine care until the early 1990s. This is when a small group of physiatrists, interested in musculoskeletal disorders, formed a separate counsel within our academy, to advance education, research, and clinical care in this area. The Physiatric Association of Spine, Sports and Occupational Rehabilitation (PASSOR) was formed and accelerated and advanced the field of medical spine care. Eventually, PASSOR set up guidelines for fellowship training in the areas of spine and sports medicine. Fellowship programs that met these guidelines would be designated as PASSOR "recognized" fellowships.Even today it is estimated, we are still training 100 spine surgeons in fellowship programs to every medical spine specialist trained in a physiatry spine fellowship. It is generally accepted that the spine surgery fellowships offered by the specialties of Orthopedics and Neurosurgery do not offer extensive medical spine care training. Not surprisingly, this has led to an opposite ratio of what is needed from the spine practitioners based on the fact that most spine problems can be successfully treated medically. It should also be noted that no subspecialty board certification is currently offered in spine care as the three specialties currently offer fellowship training that being Orthopedics, Neurosurgery and Physiatry would have to agree on a fellowship curriculum as well as the content and of a board certification examination. Even though this has been accomplished, with even more specialties involved, in sports medicine we are unlikely to see this happen in spine care. Unfortunately, this has led not only to less standardization of fellowship training, but also to the overtraining of surgical vs medical spine specialists. To some extent, NASS has developed some guidelines for surgical spine fellowships and recently has taken on the medical fellowships as well.The whole field of spine care has failed the patient in providing the best and most effective treatments. There are a wide variety of fields that have a role in evaluating and treating patients with spine problems. These include, but are not limited to, Orthopedic Spine Surgeons, Neurosurgical Spine Surgeons, Physiatrists, Physical Therapists, Chiropractors, and Anesthesiologists trained in pain management fellowships. None of these specialties have adequate training in some of the most effective treatments that research has demonstrated work for treating spine problems. This is best exemplified by the fact the World Health Organization and many United States agencies have stated that low back pain has gone from the number five reasons to be out of work to number two and more recently to the number one reason. If all of these specialties were doing such a great job this would not likely have happened. Some of the most effective treatments that are not routinely taught in these specialty training programs are Mechanical Diagnosis and Therapy (MDT or The McKenzie Method), The Pain Mechanism Classification System (PMCS), and The McGill Method of Spine Stabilization.In general, health care costs are rising in our country, however, spine care costs are skyrocketing. A 10-year trend exemplified by CMS data shows that costs for spine surgery are up 220 percent, MRI's up 307 percent, Opioid Addiction up 423 percent and I am not proud to say, as a physiatrist, spinal injection costs are up the most at 629 percent. If all of these specialties I have listed above are doing such a great job how could this happen?There is hope. There are three separate programs that I am aware of, where the training in one or all of the three areas I mentioned earlier has been undertaken with a dramatic reduction in the average number of visits, lost time from work, and cost reductions have occurred. The first is an organization from Tallahassee, FL headed by Mark Miller and Chad Gray both experienced physical therapists, trained in MDT that started Integrated Mechanical Care or IMC (d.b.a. Integrated Musculoskeletal Care) that have published their results recently. They have expanded on The MDT Model and provided their clinicians with extensive additional training and have outstanding results when compared with community care (or usual care). The second is a program developed by Annie O'Connor a physical therapist at the Shirley Ryan Ability Lab (formerly known as the Rehabilitation Institute of Chicago) where she is responsible for the training of about 185 physical therapists throughout the Chicagoland area where they have multiple clinics. Her clinicians have training in MDT, stabilization exercises, neuromobilizations, manual medicine, and a strong background in The Pain Mechanism Classification System Michael Geraci
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