JULY 20219Method), 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 (1). 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 (PMCS). Her recently published book, from 2015, a World of Hurt (2), covers how to classify what type of pain a patient has and how each classification of pain has a specific treatment. No longer are they just managing pain they are now able to provide effective treatment.The third and final program was started at the Catholic Health System in Buffalo, NY by two physical therapists, Ron Schenk and Joe Lorenzetti. They got me involved three years ago, as the medical director, and we now have over 10 physical therapists that are fully trained in the methods and are located throughout Buffalo and Western New York. The physical therapists in the program are all certified or diploma status in The McKenzie Method, have taken Annie O'Connor's courses on The Pain Mechanism Classification System, including the Overview Course and Central Pain Mechanisms Course as a minimum. Also, they have had either The McGill Method Course or a similar stabilization exercise course and additional training in neuromobilizations and manual medicine. I have reviewed the results of each of these programs (Table 1) and all have provided a significant reduction in the number of visits to treat, reduction in medication usage, imaging, injections, and spine surgery. The IMC group has their results published and the group at the Shirley Ryan Ability Lab has over 30,000 patients in their study (3) and ours at Catholic Health has over 400 patients (4). The latter groups have yet to submit their results for publication. All of the groups have achieved very similar results and have demonstrated significant improvements in treatment and outcomes when the clinicians are trained in the areas not adequately covered in their formal training. Interestingly all three groups had the majority of the patients seen by a physical therapist first.In conclusion, to change the way patients are treated and referred to other spine care clinicians several things need to change. Imagine in other areas of medicine a patient would see a medical specialist before surgical one. As an example when a primary care physician sees a patient with a heart problem and can no longer manage or treat that patient, the logical choice would be to refer to a cardiologist, not a cardiothoracic surgeon. Our primary care physicians (PCPs) need to consider doing this when a low back pain patient is not improving with their care. However, this will not change without providing them with the necessary training. The IMC Group has recognized this and has incorporated training for PCPs involved in their program. Most importantly they have done this successfully. The other areas that will need to change for all spine specialists should include formal training in MDT, PMCS, and Spine Stabilization Exercises as these are the areas deficient in all formal training. These were the main reasons for better outcomes in the three groups which undertook some or all of this training and then applied it to their spine patients resulting in better results when compared with community or usual care. Michael Geraci
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