Michael Geraci, Medical Director Comprehensive Spine Program, Catholic Health
Why would a specialty ever want to be described by what they do not do? This is exactly what happened for many years and to some extent still continues when describing an aspect of spine care not delivered by a spine surgeon. Let me give you an example. When I began to co-direct a mid-year spine meeting for the North American Spine Society (NASS), the largest spine society in the world, about 10 years ago our sessions were divided into three distinct areas named joint, surgical, and non-operative. Since we had four surgical co-directors and two physiatrist co-directors, I politely asked them why our sessions are called non-operative spine. After a brief discussion, we all agreed that moving forward our sessions will be described by what we do and not by what we do not do. Therefore, the term medical spine was used going forward.
Ever since the first disc surgery article was published in 1934, by Mixter and Barr, one 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 (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.