The evidence for SMT in CLBP

Transcription

1 The evidence for SMT in CLBP Peter Tuchin BSc, GradDipChiro, DipOHS PhD FACC Associate Professor, MU ( ) Past President, COCA 1 Peter Tuchin

2 Peter Tuchin 2

3 WCA 2007 Peter Tuchin 3

4 Number of injuries 1997:2007 Peter Tuchin 4

5 Injury costs Peter Tuchin 5

6 Indirect costs Some studies have estimated that for every dollar paid in compensation, there is between $3-$8 in additional (indirect) costs. Walker (2003)- LBP = $8billion Peter Tuchin 6

7 Indirect costs These include: replacement personnel, higher casual rates of pay, loss in production, extra costs due to training, investigating the injury, administrative costs lowered staff morale. STRESS Peter Tuchin 7

8 Chronic claims Peter Tuchin 8

9 Peter Tuchin 9

10 Peter Tuchin 10

11 Prognosis of LBP 50% return to previous level in < 14 days 83% return to previous level in 3 mths 72% return to previous level at 12 mths NB 28% = CLBP Henschke,et al BMJ 2008 Peter Tuchin 11

12 Henschke, Maher, et al N= 933 Peter Tuchin 12

13 Peter Tuchin 13

14 Chiropractic, Medical, Physiotherapy & Rehabilitation Costs ($): 1993/94 to 1999/00 180,000, ,000, ,000, ,000, ,000,000 80,000,000 60,000,000 40,000,000 20,000,000 0 Chiropractic Medical Physiotherapy Rehabilitation Peter Tuchin 14

15 Work stress Work stress costs than $1.2 billion pa 34% of workers are falling asleep at work 42% had near misses due to fatigue 78% worked more than 5 days in a row Peter Tuchin 15

16 Peter Tuchin 16

17 LBP = 6 Neck pain = 21 Peter Tuchin 17

18 Peter Tuchin 18

19 Peter Tuchin 19

20 Peter Tuchin 20

21 Peter Tuchin 21

22 660 min/day = weekday 510 min/day = weekend Peter Tuchin 22

23 Peter Tuchin 23

24 What causes pain? Chiro = bone/joint Physio = muscles Orthopod = disc Rheum = arthritis Neuro = nerve EP = weakness Psych = mind Peter Tuchin 24

25 Peter Tuchin 25

26 MRI Findings of rotator cuff tears in 100 asymptomatic people Age groups Partial tears (%) Complete (%) ALL (%) > ALL Peter Tuchin 26

27 A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society Ann Intern Med. 2007;147: Peter Tuchin 27

28 ACP - Ann Int Med 2007 Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). 28 Peter Tuchin

29 ACP - Ann Int Med 2007 Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderatequality evidence). 29 Peter Tuchin

30 ACP - Ann Int Med 2007 Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). 30 Peter Tuchin

31 ACP - Ann Int Med 2007 Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderatequality evidence). 31 Peter Tuchin

32 Ann Intern Med. 2007;147: Recommendation 5: Clinicians should provide patients with evidence- based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderatequality evidence). 32 Peter Tuchin

33 Ann Intern Med. 2007;147: Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate- quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. 33 Peter Tuchin 2011

34 Recommendation 7: For patients who do not improve with self care options, clinicians should consider the addition of non-pharmacologic therapy with proven benefits for acute low back pain, spinal manipulation; Peter Tuchin 34

35 Recommendation 7: chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence). Peter Tuchin 35

36 Meade, BMJ Large RCT (n=741) showed short and long term benefit with chiropractic SMT Peter Tuchin 36

37 Large RCT (n=1331) showed better benefit with exercise and chiropractic SMT than single treatments Peter Tuchin 37

38 38 Peter Tuchin 2011

39 Bronfort 2010 Large SLR N= 60 RCT s on LBP Peter Tuchin 39

40 40 Peter Tuchin 2011

41 Cochrane findings for LBP- Tuchin reports on LBP treatments 16 =positive (85% had low evidence) 6 = inconclusive 7 = negative Peter Tuchin 41

42 Cochrane -positives NSAIDS (but not more than paracetamol and more AE; COX 2 better) Exercise (but not clear which type better) Muscle relaxants (but high AE) Advice to remain active Massage CBT SMT Herbal treatments (but AE not assessed) Peter Tuchin 42

43 Chronic Pain The role of treatment providers in injury management Tuchin PJ. J Occ H Safety 2014 (in review)

44 NSW Claims INJURY NUMBER AVERAGE COST LBP 44 $367,514 Knee 21 $312,887 Shoulder 17 $309,563 PTSD 15 $286,116 Anxiety/Depression 12 $292,902 Carpal tunnel 11 $184,144 Occupational overuse 9 $245,284 syndromes Neck injury 4 $273,409 Ankle 3 $148,869 Other* 11 $188,992 TOTAL 147 $260,968

45 Results: The vast majority (n=93) of cases reviewed had poor or minimal active treatment included in the chronic pain management strategy. In comparison, treatments which are passive and do not have a strong evidence basis from the literature, still appeared to be more commonly recommended.

46 Treatments INJURY AVERAGE INITIAL UNFIT PERIOD INITIAL TREATMENT PROVIDED LBP 4.4 weeks (0-12) Rest, NSAIDS, Physiotherapy PTSD 8.1 weeks (4-52) Antidepressants, Psychiatrist Knee 5.6 weeks (2-26) Imaging, Surgery Shoulder 4.8 weeks (0-26) Imaging, Surgery Carpal tunnel 6.4 weeks (4-16) Imaging, Surgery Occupational overuse syndromes 4.1 weeks (0-12) Imaging, Surgery

47 Conclusions Multidisciplinary treatment Good evidence for SMT as part of the team Working together gets better results Chronic pain cases? Peter Tuchin 47