Date: Mon, 15 Jun 1998 From: valuenet Subject: Stir the brew... Let's make the assumption that the following statements have some element of truth... 1] 80% of the adult population will experience back pain at some point in their lives... 2] Those experiencing back pain are 5x more likely to report recurring episodes... 3] The general public recognizes the chiropractor as a specialist, not a primary health care provider, who treats mostly neck and back -pain patients... 4] In a survey reported through ACA, I remember reading that many who choose not to seek chiropractic treatment do so because they believe once they start...they will have to keep coming. 5] Approximately 90% of those experiencing back pain will report symptoms resolving within a 4 -week period. Here's the question based upon #5.... Since chiropractors are underutilized by the public at large, and our primary objective is to "get new patients through the door", then why don't we send a simple and clear message which goes as follows... Given up to 90% of those experiencing back pain report resolution within 4 weeks time...one of chiropractic primary objective is to make sure you're not part of the other 10%. Once the patient is in the door...then you can expand upon the many things chiropractic has to offer.. What d'ya think... Sig (Sig Miller, DC) -------------------------- Date: Mon, 15 Jun 1998 08:16:33 -0400 From: "David Ferguson, D.C." Subject: Re: Stir The Brew... At 11:10 PM 6/14/98 -0700, Sig Miller wrote: >5] Approximately 90% of those experiencing back pain will report symptoms >resolving within a 4 -week period. >Here's the question based upon #5...... 75% of the patients who visit their medical physician for LBP still have pain and/or disability one year later.(BMJ, 1998) Spines are like teeth, they need to be on a maintenence schedule. That "90% rule" is one that medicine likes to throw out there to try and negate our efficacy. As for patients "not wanting to start 'cause they won't be able to stop" well, I agree. It's a pain in my butt to go to the dentist every six months to lay there and let them clean my teeth, take some x-rays, and dice my gums with floss. However, if my teeth go bad I can get some falsies. What are your patients to do when their spine is at the end of it's rope? Educate patients as to what subluxations are and to their importance. Explain how spines need to be checked regardless of symptoms. Just like teeth. Then leave it up to them to decide what they want to do. Everyone of us has those patients who come about every 4 months "dying" of pain. After they get 6 adjustments they are off and running and you won't hear from them again for another 4 months. 90% of LBP does resolve in 4 weeks. Then it returns. What is the percentage of new patients with this being their very first episode? "I've had this off and on for years, but this time it's worse and it won't go away". Teach them about correcting the problem so that you can keep the problems away. David Ferguson, D.C. -------------------------- Date: Mon, 15 Jun 1998 08:20:35 -0400 From: Ivan Delman Subject: Re: Stir The Brew... Sig...Before I opened my office in Southern California, I visited most of the local DCs. I was looking at their operations trying to determine what did/did not work. I found that, when first accepting a patient, if I gave a timeline to the patient. If I told them unless we start seeing some sort of resolution within a given period of time, I might not be helping them and a second opinion will be recommended. I had on and off debates with my colleagues throughout the 18 years we practiced, however, my "deadline" theory remained in the minority. It remains my opinion that when your patient is told they should see the beginning of problem resolution within X number of visits, their concern about " The Forever Treatment Syndrome" diminishes. The few that fell into the no-resolution category, were usually helped by local DCs with different techniques...Ivan -------------------------- Date: Mon, 15 Jun 1998 09:04:28 -0400 From: Ivan Delman Subject: Re: Stir The Brew... Dave wrote: > It's important to give them maintenece information in the first few visits. > I say "it's your spine and you can do what you want with it but this is what > we have found to be effective for long term results without pain. Dave...I'm afraid I was not as diplomatic as you. I used to tell them, "As sure as the sun will come up tomorrow, you will revert back to your present pain level unless you keep this under maintenance control" This was told to them as soon as they started feeling some relief. Also reinforced by staff. If we got the, "Insurance won't pay" bit. We told them that "Insurance" don't give a hoot if they are well or not. That's the patient's responsibility. I guess, Dave, we're making the same point from another angle. Regards...Ivan ---------------------------- Date: Mon, 15 Jun 1998 07:14:06 -0700 From: robetw9@idt.net (Rob & Wendy Ward) Subject: Re: Stir The Brew... Sig wrote: >Let's make the assumption that the following statements have some element >of truth... >5] Approximately 90% of those experiencing back pain will report symptoms >resolving within a 4 -week period. A faulty assumption. 90% of those experiencing low back pain will *cease treatment* within 4 weeks. The disappearance of the patient from the doctor's appointment book is a poor measurement of treatment success. In a recently published study (BMJ 1998, 316:1356-9), 463 adult patients were followed closely. 92% did indeed stop seeking treatment within 3 weeks. However, directly polling the patients about their condition revealed that at 3 months only 21% reported a complete recovery (with 50% reporting both pain and functional disability), and at 12 months only 25% reported complete recovery (and 50% still reported residual pain and functional disability). A reasonable assumption is that the vast majority of back pain patients simply give up on the treatment being received, rather than that recovery has been achieved. In this light, your question on assumption #5 needs some reworking. Rob Ward, DC Clinical Sciences Dept LACC -------------------------- Date: Mon, 15 Jun 1998 12:41:56 -0700 From: valuenet Subject: Stir the brew... When reviewing the posts...I don't believe that when sx resolve within several weeks in the majority of patients...that they won't recur at some point down the road. I always believed that data referred to "an episode" of back pain. It appears that the responses imply that maintenance care "prevents anything". Where is it suggested that 1-2x p/mo treatment prevents the patient from experiencing their next episode of back pain? This is not dentistry so stop using that example. I believe supportive care..provided at opportune times when sx flare might very well best serve the patient. After a brief acute course of effective tx, the patient is discharged with the ability either to actively control any persistent sx which have now been reduced to more manageable levels, or if sx resolved, the patient is implementing proper body mechanics and posture throughout the day along with an at -home exercise program. The patient knows that if sx flare..that they should again return for additional tx. Sig ---------------------------- Date: Mon, 15 Jun 1998 14:18:01 -0700 From: "Mark Street, D.C." Subject: Re: Stir the brew... At 12:41 PM 6/15/98 -0700, valuenet (Sig) wrote: >It appears that the responses imply that maintenance care "prevents >anything". Where is it suggested that 1-2x p/mo treatment prevents the >patient from experiencing their next episode of back pain? This is not >dentistry so stop using that example. Where does it not suggest it? We need studies in this area. I happen to believe that it does help in certain cases, but I have no hard evidence. Only my limited 10.5 years of clinical experience. >I believe supportive care..provided at opportune times when sx flare might >very well best serve the patient. After a brief acute course of effective >tx, the patient is discharged with the ability either to actively control >any persistent sx which have now been reduced to more manageable levels, or >if sx resolved, the patient is implementing proper body mechanics and >posture throughout the day along with an at -home exercise program. >The patient knows that if sx flare..that they should again return for >additional tx. Where is the hard evidence for this type of management? If it were only this cut and dry in a real clinical setting. Give specific references for these recommendations if possible in both the medical and chiropractic literature. Band-Aid management. Pretty soon the patient's tissues are worn out and they are on to the next invasive form of therapy and possibly years of contracted pain and disability. Eventually severe health comprimise, disability and surgery. Is there any hope for humanity?? Fact: The validity of spinal manipulation has been scrutinized, verified, and accepted in the scientific community. Fact: Spinal manipulation has been shown superior to most all other forms of conservative management for low back pain. Fact: The medical paradigm for management of low back pain has, in the opinions of medical experts, essentially failed. Fact: The cost savings of chiropractic care over traditional medical care of low back pain ---- the single leading cause of absenteeism and morbidity in industry --- are substantial and could amount to nationwide savings of hundreds of millions of dollars in the workers' compensation area alone. 1. What should be done with medical providers who frequently treat patients who need chiropractic care but never refer patients to a doctor of chiropractic? 2. Some health care groups have their patients screened by a medical provider and patients are then sent to the providers which the "gate keeper" thinks most appropriate. What action should be taken if a review of the records indicates that a screening doctor is not making proper utilization of chiropractic services? 3. Workmen's compensation may request that a patient be referred to a medical provider. Are they negligent if they do not request a chiropractic consult in appropriate cases? Do they have a responsibility to attempt to structure their rules so that patients in their program receive the most appropriate care? 4. If a medical plan does not include chiropractic care, should they be required to leave a warning stating that this action may drive patients toward less effective care which may result in higher costs and greater suffering by the patient? 5. A CEO, personnel director or other person in a position of responsibility may cause chiropractic care to be dropped from a company's insurance coverage. This is obviously illogical. Should share holders take action to prevent a possible drop in stock prices due to increased medical costs? 6. If a medical group or board does not actively encourage their members to refer appropriate cases to doctors of chiropractic, is that group or board acting in a responsible manner? 7. If rules, restrictions or regulations are written, encouraged or enforced by any group, including chiropractic groups, that cause patients to receive less than adequate chiropractic care or push them toward less appropriate care, are these groups responsible for any suffering that results? Discussion and disagreement are sometimes necessary in order to advance the quality of care. But reasonable people, thinking of the interests of the patient first, should be able to come to reasonable decisions. Chiropractic can take an appropriate place in the health care system to the benefit of patients and society as a whole. An informed consumer who is free to choose is a potent weapon in the fight for optimum care. Your well thought out and honest answers to these questions are thoroughly appreciated. Mark Street, D.C. ------------------------ Date: Tue, 16 Jun 1998 07:25:46 -0700 From: robetw9@idt.net (Rob & Wendy Ward) Subject: Re: Stir the brew... Sig wrote: >When reviewing the posts...I don't believe that when sx resolve within >several weeks in the majority of patients...that they won't recur at some >point down the road. I always believed that data referred to "an episode" >of back pain. Sig, you (and everyone else it seems) has been mistaken all these years. The majority of back pain *does not* resolve within several weeks. The truth appears to be instead that within several weeks the vast majority of back pain patients give up on their medical provider and stop seeking treatment, in spite of the persistence of symptoms. At 3 months, 50% have residual pain and functional disability, 29% have residual pain or disability, and 21% have recovered. At *one year*, 50% have residual pain and functional disability, 25% have residual pain or disability, and 25% have recovered. It is time we abandon this myth of "90% recover no matter what you do (or don't do)", because this myth has incorrectly characterized chiropractic care as being no different from the natural history of the condition. See the recent BMJ article. BMJ 1998; 316:1356-9 Full text available at www.bmj.com/cgi/content/full/316/7141/1356 Rob Ward, DC ---------------------- Date: Tue, 16 Jun 1998 10:24:33 -0700 From: valuenet Subject: Re: Stir the brew... Rob and Wendy, I appreciate the info. Does that mean the entire premise is unfounded. A clear majority of back -pain patients that I've treated and others treat do resolve within a 2-4 week period. Yes many experience recurring pain as a result of other ADL etc...but then again we should be available to provide short -term care for those instances as well. In the interim, it makes sense to have the patient do all they can in active capacity for their overal well -being. With other strains/sprains of upper and lower limbs...don't the vast majority of injuries resolve in short order...why should back pain be any different. The question that should be raised is does the tx scheduled in consistent and predictable fashion have any impact on reducing future sx? Sig ---------------------- Date: Tue, 16 Jun 1998 13:55:09 -0400 From: Daniel Becker Subject: Re: Stir The Brew... Why is it that the provider community insists on finding the all inclusive cure for LBP? Why does the same community not have a problem with infections being a repeat event in the course of living. Such repetition is not referred to as chronic. This study has shed light on what our profession has known. Back pain is reoccurring. Hopefully, the allopathic community will take the next step and under stand that labeling it chronic based on this one study is also wrong and ignores the chiropractic/manipulation studies which show longer time intervals between episodes, greater number of people reporting no or little pain. Such suggests that LBP is a fact of life, just like getting sick and not a problem that can not be resolved. We need to repeat this exact same protocol study with just our doc's (Of course Mead already did something similar). And also, repeat this study exactly, only after one yr post allopathic, let the DC's treat, follow up one year later and see what is different. Dan Becker, DC, DABCN --------------------- Date: Mon, 15 Jun 1998 13:49:18 -0700 From: "Mark Street, D.C." Subject: Re: Stirring the pot, clinical criteria & DC Failures First may I suggest you read the BMJ article Outcome of low back pain in general practice: a prospective study, May 1998 at www.bmj.com, or find it in the links section at http://www.chiro.org. Then download the Manga paper from February 1998 entitled Enhanced chiropractic coverage under OHIP as a means of reducing health care costs, attaining better health outcomes and achieving equitable access to health services. I converted it to Adobe PDF format so it should be easy to print out and read. http://www.sonic.net/jet/manga2.pdf If you do not have the Adobe Acrobat Reader, get it FREE at http://www.adobe.com and install it before attempting to download these files. Also read Consumer Choice Between Chiropractic and Medical Care: A Microeconomic Analysis which I have also converted to Adobe PDF format at http://www.sonic.net/jet/microanalysis.pdf My comments to your assumptions are listed below. At 08:45 PM 6/9/98 -0700, valuenet (Sig) wrote: >Here's a brief yet I believe accurate summary... Capitation = Underutilization of tx Fee for services = Overutilization of tx >So much for tx guidelines and criteria.... Which puts a band-aid on the problem for the time being, which allows for greater corporate profit now, patient dissatisfaction now and increased health problems in the future.... Is that a 10% increase in health care premiums this year?? Maybe More?? That is OK for big corporate business since 100% of health care premiums are tax deductible. The patient is actually paying for their increasingly inefficient and insufficient health care. The costs have shifted to the patient and the doctors. Why all the Patient's Bill of Rights legislation?? >Sig wrote; >I have spent a good deal of time posting information that other companies >would consider proprietary...I have always believed that putting this type >information out there is necessary and appropriate. All I see for the most >part is bitching, moaning and groaning. >Moses Jacob wrote; >Ah now we have it. Proprietary is it? But remember subpoena power breaks >down this wall. The Third Circuit Court of Appeals in the Barnett v Suliivan case >showed that the carriers can not run over the rights of the patient. If the >Supreme Court agrees, a big ? for now , all your positions and arguments will >be declared "unconstitutional". Peer-review and Utilization Review will not >be doomed if this should come to pass. It will just have to be restructured >to include the patient. Gee what a novel idea health care rights and benefits >for the good of the patient. Not the Dr. not the ins co. not the reviewers. Sig wrote: >I believe the clear majority of DC's would prefer tx short term and then discharge >so to get on with the next challenge...but that impacts profit margins given >the limited number of patients walking through the door. No, I believe DC's would prefer tx of sufficient dosage and duration within their recommendations to get a positive clinical and educational outcome. And be reimbursed for their efforts without extraordinary attempts and means. Sig wrote: >Consider this...there is no indication that DC tx will prevent sx from recurring, >etc. although we sell this concept to the public. I believe the patient can >be taught active ways to either reduce pain levels or the possibility of sx >recurring. Having said that, in reality, the majority of patients presenting >cannot recall or report how sx came about.... WRONG WRONG WRONG, you are trying to sell that to us. I would venture to say that simple stretching exercises at home or at the workplace demonstrate questionable therapeutic value. The theory that stretching muscles reduces muscle activity and tension levels has shown to be false. Supervised chiropractic care along with rehabilitative exercise with specific protocols provides increased compliance and superior clinical results. Physical exercise has been prescribed for many years and is just now getting recognition for treatment and prophylaxis of painful spinal conditions. Successful results depend on several factors, dosage, duration, and relative disregard for pain. Dosage is most important, determined by the number and frequency of training sessions as well as the amount of exercise done per session. High intensity programs have been shown to attain superior results than low intensity. High intensity is 70-80% of maximal voluntary contraction levels. The increased strength gain results in decreased pain levels and improved functional capacities. Duration, to attain maximal strength gain and subjective improvement, supervised instruction should last a minimum of 2 months with 2-3 sessions per week. Post OP and post traumatic patients will probably take 3-4 months or longer to achieve maximum benefit. Home exercises can be done on off days to encourage exercise when clinical training is over. The final goal to achieve post-treatment status in which the patient assumes total responsibility for their own well being. This can be done at home or in fitness centers. Disregard for pain, to maximize the psychological benefits of active treatment. The theme of which the patient is going to restore the functional capacities of the injured area. Pain is not a major focus in rehab, the patient should not focus on it and dwell on it. Any patient suffering from chronic or recurrent spinal pain condition should undergo a treatment regimen leading up to and ending with intense active rehabilitation. With the amount of static work environments, repetitive stress disorders that are getting out of control we need to perform this form of therapy and we need it reimbursed at adequate levels. A rehabilitation program of sufficient duration and intensity will strengthen almost all tissue types involved in pain production and will also provide psychological benefit to the patient. JMPT vol 19, No. 1 1996, Reviews of the Literature, Rehabilitation of Neck/Shoulder Patients in Primary Health Care Clinics, Alan Jordan, D.C., and Keld Ostergaard, D.C., M.D. Sig wrote: >Therefore I would approach the public at-large a little differently. Given >approx. 90% of back pain patients will experience resolution of sx in short >order [we can argue the data, but I'll accept the 4 -week benchmark], then >I would suggest to the patient that the point of visiting the chiropractor >would be to assure them they don't become part of the remaining 10%. Since >sx recurring some time later are more likely than not..and the fact that >nothing would make me believe that passive tx, such as chiro care prevents >anything, then I would hope to accomplish two things regarding patient >management that is both believable and realistic.. Again your assumption is off, the clinical picture here alot different than what is replayed in the soup of mis-information. It is widely believed that 90% of episodes of low back pain seen in general practice resolve within one month. BUT... in the BMJ study published in May 1998 it was noted that "90% of subjects consulting general practice with low back pain ceased to consult about the symptoms within three months, most still has substantial low back pain and related disablity. Only 25% of the patients who consulted about low back pain had fully recovered 12 months later. Since most consulters continue to have long term low back pain and disability, effective early treatment could reduce the burden of these ymptoms and their social, economic, and medical impact." In another study on neck and shoulder pain it was noted that 30% of the population have experienced neck/shoulder pain within the past 12 months, with approximately 30% of these having experienced symptoms of more than 6 months duration. Symptomatology increases with age in both men and women. Sick leave and individual suffering are becoming a major problem area in post-industrial societies and are expected to increase in the future. Considerable research has focused on the debilitative effects of static work on the musculature of the neck/shoulder area. The deleterious effects of stress, pace and repetitiveness were recognized several hundred years ago. Bovin G, Schrader H, Sand T. Neck pain in the general population. Spine 1994; 19:1307-9 Sig wrote: >1] I want the patient to know that when sx recur, DC tx will assist in >bringing about resolution in short order and >2] That sx will recur at some point in time regardless of what they do, > and I would therefore hope they would consider a more active approach >that will either 1] reduce the frequency of flares occurring over a >12-month period, or 2] allow them to more effectively control their >sx at more manageable levels. >I believe all along that the patient appreciates this straightforward >approach...and that they are not interested in the philosophy stuff, >[although I am not saying it should not be presented]...I do believe what >the patient wants mostly is to feel better so they can return to either >required or more enjoyable activities of daily living. I say you are not looking at the facts Sig, you are looking at corporate profits and hiring chiropractors to work in band aid factories to perform chiropractic band aids to people seeking REAL chiropractic care. You are trying to convert chiropractic/chiropractors into "SHORT ORDER" cooks. All the fluff aside about philosophy and what you believe the patient wants. Instead of assuming that symptoms are going to recur, HOW do you propose to decrease flares and have the patient control their symptoms?? Without supervised care.... Our utilization rates are NOT due to patients fearing that they have to keep coming back. This is a smoke screen of the most ominous type. The public would much rather see a chiropractor and preferred to see chiropractors despite a strong financial deterrence by payors and HMO's. This demeans our profession and you propogate this mis-information to get workers. The REAL reason is economic competition to the medical model and economic deterrance by payors. IF the financial deterrance was reduced to the point that it became relatively insignificant I bet we would expect to see a large increase in the proportion of the public visiting chiropractors, especially for the common NMS complaints and injuries for which we have been shown to be safer and more effective. If we look at fee for service insurance data ~ 2 million beneficiaries, where patients had equal access to chiropractors and medical doctors allowing them to commence and obtain all the care needed for their conditions from either a chiropractor or a medical doctor, though co-payment levels were diffferent....of course much higher than medical docs. The distribution of first episodes shows that 75% of the patients visited MD's for their care versus 25% for DC's. For total episodes of care, 70% of episodes were manged by MD's versus 30% by DC's. This suggests that the retention rate by DC's is higher than for MD's and that patient are more likely to switch from MD's to DC's for their subsequent episodes rather than the reverse. This is consistent with other studies. Is this not threatening to MD's and insurance companies? YOU BET!!! The cases have longer average episodes of care for chiropractors than for MD's but the longer average length of episode does not mean higher costs. The average total insurance payments for medically managed episodes was virtually double that of chiropractic managed cases. Note that these differences are underestimated since reports often exclude prescription drug payments. The overall findings are that medical management of NMS disorders is as much as 61% greater than chiropractic management per episode, which would probably be greater if drugs were included. Data for patients who suffered 2 episodes of care over 2 years show chiropractic significantly lower than medical management, MD management for the second episode was more 2X that of chiro management. With continuing episodes the retention for chiropractors is much higher than MD's suggesting a much higher patient satisfaction with chiropractors over time for these disorders. This is consistent with other studies. Is this not threatening to MD's and insurance companies? YOU BET!! Why can't payors see the benefits of the MEDSTAT database, or can they see the benefits and are they seeking to get a ring in the profession's nose, to economically harness the profession to work for peanuts to serve out a fast food approach of chiropractic clinical management. They already have us under their thumb. Who will sell out and who will stick to their chiropractic profession and principles?? Let us think as clinicians and solve these problems with the tools and knowledge available. Let us not give out band aids to have patients return again and again, only to have society pay a higher price down the road when these conditions deteriorate into chronic hopeless conditions. Just talking about the problem and the solution to it does not make it right. It makes good business sense to the corportate payors and HMO's but in the long term health of the population it does little good and alot of harm. I repeat, Sig is a corporate chiropractic doctor manager sent to increase recruitment into his corporate chiropractic armed force that is due to battle it out in the trenches with the chiropractic profession and the medical profession. Until he can point out my glaring assumptions about him as false, I will assume I am partly correct. At 06:08 AM 6/9/98 -0700, valuenet wrote: >Mark, >You've got a lot of juice...and I admire and respect that. We just see the >landscape differently. You make many assumptions about me....they are >incorrect....nothing that a beer and dealing with each other face-to-face >couldn't clear up...ahh but maybe another time. Who and what should Sig really be fighting for?? You make the call. Mark Street, D.C.