PhD FOTO 15 th Annual Outcomes Conference 2015 Level of McKenzie Education Functional Outcomes and Utilization in Patients with Low Back Pain JOSPT Dec 20144412925936 ID: 421909
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Slide1
Daniel Deutscher, PT, PhDFOTO 15th Annual Outcomes Conference2015
Level of McKenzie Education Functional Outcomes and Utilization in Patients with Low Back PainSlide2
JOSPT
Dec 2014;44(12):925-936.Slide3
Background
Common use of PT and MDT in treating LBP (Battie 1994; Foster 1999; McKenzie & May 2003; Byrne 2006 ) Recommendation for classification based treatment (Delitto 1995; Brennan 2006; Fritz 2007…)
McKenzie = Mechanical Diagnosis and Therapy (MDT)Slide4
Background
Deutscher et al: Arch Phys Med Rehabil 2009; Associations between treatment processes, patient characteristics, and outcomes in outpatient physical therapy practiceSelf-exercise compliance predicts higher
outcomesLower self
exercise compliance in patients with spinal impairments (lumbar & Cervical) compared to peripheral impairments (shoulder &
knee)
Therapeutic exercise
prescribed
more to patients with peripheral
impairmentsSlide5
Background
Therapists’ confidence in prescribing exercises to peripheral compared to spinal joints…?Need for more education on effectiveness of exercises for spinal impairments…?Slide6
Background
Maccabi initiates an intensive MDT educational program
Supervised
and home exercise therapy customized to a patient’s clinical presentation for LBP have been suggested as effective means to improve
outcomes
These therapy
principles are
important components of
the McKenzie
treatment-based
classification systemSlide7
Background
McKenzie Training process and data collection periodSlide8
Background: McKenzie Classification SystemSlide9
Purpose
Examine associations between Level of McKenzie post-graduate training (A-D and post certification) and:Functional status at dischargeUtilization (number of PT visits)
controlling for patient and therapists risk factors at admissionSlide10
Methods: Design
Practiced based evidence (PBE)ProspectiveNo alteration of normal treatmentPatient informed consent exempt by IRBSlide11
Methods: Patients
18 years old or olderSelected lumbar area as primary impairment between April 2006 to December 2012Two or more visitsIntake FS data; N=36,34893% Participation rateIntake & Discharge FS data; N=20,88257% Completion rate
No exclusion criteria!!!Slide12
Methods: Clinicians
72 outpatient clinics throughout Israel195 Therapists with no prior MDT educationTook at least Part AHad at least one year of experience treating patients with LBP>= 40% overall completion rate per therapist>= 30 complete episodes per therapistSame therapist throughout the episode of careSlide13
Methods: Patients & ClinicianSlide14
Methods: Analysis
Descriptive statistics to examine categorical and continuous measures.Assess possible patient selection bias by comparing patients with complete vs. incomplete outcomes dataHierarchical linear regression models with patients nested within therapists.Assess associations
between MDT educational levels & FS outcomes & number of visits after controlling for patient risk factorsSlide15
Results…Slide16
Selection bias?
--++Slide17
--
++Slide18
--Slide19Slide20Slide21Slide22
Results…
Selection bias?
Patients with complete or incomplete data had higher values or prevalence for characteristics
predictive of both lower and higher FS change
No support for
a systematic patient selection
biasSlide23
Results: Outcomes measuresSlide24
Results: Functional Status Change
FS change(SD) during 2005-2008=11.1(12.9), N=7,216(Deutscher et al 2009)MCII=5(Hart et al 2010)Unadjusted FS changeSlide25
Results: Risk Adjusted FS OutcomesSlide26
R2=35%Slide27
Results: Risk Adjusted FS OutcomesSlide28
Results: Risk Adjusted FS OutcomesSlide29
Results: Risk Adjusted FS Outcomes
Adjusted FS changeSlide30
Results: Utilization
Unadjusted utilizationSlide31
Results: Utilization
R2=6%Adjusted utilizationSlide32
Study limitations
Possible patient selection bias not supported but still exists57% completion rate, 31% dropout (57/69=83%)Imbalances in group characteristics, some in favor of the selected group, and some in
favor of the group not selectedNegligible potential selection
bias probably not differing by level of McKenzie educationSlide33
Study limitations
Possible therapists selection biasGeneralizability to other countries with differing physical therapy education?Level of professional commitment for therapists engaged in continuing education?Most therapists did not take all
levels of educationNon-formal education between therapists with different levels of educationSlide34
Study limitations
Causal factors related to better outcomes are not known due to the observational designPossible time confounder (better outcomes over time due to the passage of time and general experience), although therapists with no McKenzie education were
treated during most of the study periodMissing confounders
(patient education, socioeconomic levels, psychosocial factors, patient-therapist working alliance)Interventions were not included Slide35
Main results – Functional Status
Potential for improved FS outcomes after engaging in a post-graduate McKenzie educational programImprovement in FS was modestSimilar FS outcomes between educational levels Part A to CRDSlide36
Main results – Utilization
Significant decrease in utilization associated with McKenzie training 11-13% decrease in number of visits at advance levels (Part C and above), 7-9% decrease in number of visits at basic
levels (Parts A & B)Lower utilization associated with higher outcomes
after adjusting for significant patient risk factorsPotential of 1.5-3% improvement in the overall physical therapy service efficiency due to patients with lumbar impairments only (~20% of all patients).Slide37
Implications
McKenzie education may lead to a small improvement in functional outcomes over a shorter episode of careSlide38
Future research
McKenzie education impact on clinician practice behaviors (intervention) and outcomesOutcomes at diplomat postgraduate training level (Rodeghero 2015: PT fellowship-higher outcomes than residency or none)Impact of a modified educational process?
More active student involvement in classification & treatment decisions?Long
term post-course implementationOngoing follow-up training between coursesInteractive learning in small groups (audit circles)
Additional accreditation
requirementsSlide39
Future research
Specific therapists’ responses to MDT (or other) education?Improved outcomesNo changeDecreased outcomesTherapist-Patient working alliance influence on outcomes
(Hall et al 2010)Reflection,
collaborative clinical reasoning, and patient empowerment influence on outcomes (Resnik & Hart 2003)
Therapists explained
2.2
% of variance (P
<.
001)Slide40
Thank You
195 participating therapistsPT Clinic & District managersDistrict PT directors of R&DPT Dept. head directors(Moshe
Gutvirtz & Ditza Gottlieb)
McKenzie Inst. InstructorsCo-authors: Mark
Werneke
,
Dr. Linda
Resnik
,
Dr. Julie Fritz
and
Ditza
Gottlieb