Special Feature: Physicians’ Diagnostics & Rehabilitation
Patients in pain want immediate and lasting relief. When an injury does not respond to traditional palliative therapy, it is frustrating for the treating physician and alarming for the patient. Fearful that persistent pain signals a worsening injury, many patients compensate by limiting themselves to nonpainful activities. They are unaware that self-limiting behavior further deconditions their core muscles and can send them on a downward spiral toward chronic pain syndrome.
The physicians and therapists at Physicians’ Diagnostics & Rehabilitation (PDR) clinics have developed a specialty in treating the most difficult chronic cases of neck and low-back pain. Combining diverse medical skills, custom treatment protocols, individualized MedX programs and comprehensive patient education, PDR steps in to treat the 20% of chronic neck and back pain cases that do not respond to traditional treatment.
“First-line treatment of neck and low-back pain typically consists of anti-inflammatory and pain medication, muscle relaxants and/ or traditional physical therapy,” explains Dr. Thomas Kraemer, PDR Medical Directory. “Eighty percent of back-pain episodes respond to palliative therapies within two to four weeks from onset without further intervention. The remaining 20% develop chronic pain, which requires a more comprehensive approach and a shift in focus. To effectively treat these patients, we have to focus on improving their function. To focus on pain means decreasing function by eliminating activities from their lives. When activities are decreased, patients decondition, get worse and can fall into chronic pain syndrome. This is exactly what we want to prevent.
“In general,” says Dr. Kraemer, “when neck or low-back pain persists for more than three months, the probability of resolving pain without more intensive treatment drops notably. Family practitioners are well trained to identify the red-flag causes of neck and back pain like tumors, fractures, infections, and cauda equina syndrome. It’s harder to screen for the psychosocial yellow-flag issues signally chronic pain, yet when these risk factors are identified and treated early on, success rates and much better.”
Dr. Kraemer emphasizes that accurate diagnosis cannot be based on an MRI scan alone, citing a recent study that collected MRI scans from a group of asymptomatic people with no pain complaints. “Sixty-seven percent had disc protrusions, about 18% had disc extrusions and another 33% had disc tears,” he says. “All of these conditions are considered pain generators, but they were not causing p
ain for the research subjects. We cannot use the structural changes on a MRI scan as our sole determinant for treatment. When a MRI shows a disc herniation, but the patient doesn’t have symptoms consistent with herniation, that disc herniation is probably incidental. We have to treat the patient’s specific condition, not just the MRI findings.”
Dr. Kraemer and Dr. Todd Ginkel, Director of Clinical Operations, agree that patient history and physical examination are probably the most important aspects of diagnosis. “We have to be thorough, and we have to know the statistics and outcomes of conditions,” says Dr. Ginkel. “We monitor patients closely, working from a conservative to an aggressive approach. For example, 85% of low-back pain resolves in four to six weeks without aggressive treatment. When we treat patients with a disc herniation without severe extremity pain and accompanied by normal reflex, strength and sensory exams, we know it is not a surgical problem. We’ll try to treat it conservatively first. If the patient fails conservative treatment, surgery may be an option. Experience allows us to practice closer to the line between comprehensive therapy and overly aggressive treatment, adjusting our treatment plan as we monitor the patient’s progress”.
Most patients are referred to PDR specifically for the clinic’s MedX program, which is the cornerstone of the clinic’s practice. PDR’s MedX therapy involves treatment twice a week for 8-12 weeks, following the protocols developed by the University of San Diego Department of Orthopaedics and the University of Florida Department of Human Performance. “Our program is highly individualized,” explains Dr. Kraemer. “For our nonsurgical patients, we have developed internal protocols for strain/ sprain, degenerative disc disease, disc herniation, spondolothesis, fibromyalgia, spinal stenosis, osteoporosis and pregnancy. For postsurgical cases, we have developed specific postsurgical protocols for discectomy, fusion, disc replacement and spinal-stimulator implants. We are constantly developing ways to better utilize specific programs.”
Patient intake begins with an hour-long history and physical examination. Although there might be a genetic component to chronic spine pain, Dr. Kraemer cautions that chronic pain is often multifactorial. “We evaluate for both medical and psychosocial components of pain,” explains Dr. Kraemer. “The complexities of chronic pain make a thorough initial diagnosis critical. We make a specific point to approach the initial evaluation as if we are the first physician to see the patient. We give them a fresh set of eyes.”
“In the acute phase of an injury,” explains Dr. Sunanda Aptekakade, PDR staff physician, “the goal is to control pain and inflammation. In the subacute-chronic phase of an injury, treatment must be focused on function as well as pain. At this phase of an injury, most patients continue to have pain but also exhibit limitations in strength, endurance, range of motion and overall functional status. It’s at this stage that our comprehensive treatment program is appropriate. We utilize MedX to isolate and strengthen the core muscles of the spine. Then, we bring patients to activity-specific conditioning: posture, sitting, standing, lifting boxes; all the things they need to do to get back to work or regain function. With clinic physicians and therapists all on site, our patients benefit from our team approach.”
When a chronic pain patient’s muscle is reactivated during rehabilitative treatment, patients typically experience a pain flare-up. If a treating physician isn’t familiar with this pattern, that increase in pain may be interpreted as a failure, prompting a halt in treatment before the problem is resolved. “As physicians, we’ve all been taught to try to reduce or eliminate people’s pain,” Dr. Kraemer acknowledges, “but passive modalities without active patient involvement are a recipe for failure in chronic cases. We have to focus on improving functionality, not reducing pain. We see the point of flare-up as a great opportunity to use our skills to work with the patient through the flare-up, and help them continue on to success.”
With clinics in Maplewood, Burnsville, Coon Rapids and Edina, PDR treats approximately 2,000 patients each year for chronic spinal pain, including disc herniations, congenital disc disease, strains, sprains, spinal stenosis and cervicogenic headaches. Sixty percent of clinic patients are women between 35 and 50 years of age, though patients range in age from 8 to 88. “The geriatric population responds well to our therapy,” Dr. Ginkel notes. “It doesn’t take as much reconditioning for our geriatric patients to have a significant functional improvement. These patients have modest goals; they want to play with their grandchildren or simply function around the house. They aren’t looking for miracles or marathons; they want to return to simple, everyday activities. Our reconditioning programs can have a big impact on their lifestyle.”
Another segment of PDR’s patients suffer from work-related spinal injuries. The specialized care required to treat such patients while also addressing complex workability issues prompted development of the clinic’s “Return to Work” program. “We utilize MedX to improve spinal function while also incorporating work-specific conditioning,” explains Dr. Kraemer.
Spinal function is made up of spinal strength, endurance and range of motion. PDR’s individualized programs work on all three components to restore optimal spine function. Patients are tested four times through the course of MedX treatment to track their progress. Testing provides a graphical interpretation of the patient’s strength and range of motion, which is compared to that of an uninjured individual of the same age, weight and gender. “Our treatment goal is to rehabilitate the patient back to uninjured norms as possible,” explains Dr. Ginkel. “Because we so closely monitor the individual response to care, we can adjust our protocols as we go, administering calculated doses of exercise to optimize recovery.”
A multidisciplinary staff of medical, chiropractic, physical-therapy and occupational-therapy professionals draws on extensive experience in the nonsurgical management of spinal conditions. Staff training is intensive and ongoing. “All therapists are trained in five core competencies: strain/ counter strain, active-release therapy, muscle-energy techniques, mobilization and MedX training,” notes Dr. Ginkel. “We require demonstrated competency in adjunctive soft-tissue therapies to maximize our MedX outcomes. Therapists undergo internal MedX certification every two years, and must pass regular comprehensive exams to continue with us. We work with basic protocols and formats, but they are highly individualized for each diagnosis.”
“MedX therapy is considered aggressive,” says Dr. Kraemer. “Appropriate use requires continual training; it’s not a turn-key treatment. Like anything in medicine, it is both an art and a science. The uniqueness of the equipment is that it allows us to isolate the core muscles by locking the pelvis in place and forcing each one of the vertebral levels to participate in the motion. Because MedX inhibits improper disc loading and protects the structures of the spine, patients can exercise at a much higher intensity level without damaging their discs. Physicians sometimes refer patients who can’t tolerate the most basic of therapy, and are surprised when those patients not only tolerate but respond successfully to our tailored MedX programs.”
Patient education is continual through PDR’s rehabilitation process. “our patient education emphasizes posture, lifting techniques and body mechanics,” says Dr. Ginkel. “We teach patients how to do things correctly at home and at work so that they won’t hurt themselves. We review office and home ergonomics. Our patient home program incorporates our copyrighted circuit exercise program. We have patients repeat these exercises until they can do them with their eyes closed. Because our exercises are fun and require only 20-30 minutes three times a week, we have a high patient compliance rate, which is crucial to maintaining patient conditioning. The home program is also reinforced with a custom video that gives patients a cardiac workout while they do their strengthening. It includes three different exercise levels, encouraging patients to continue to challenge themselves as they progress.”
The success of PDR’s emphasis on patient education, therapist training and individualized programs is reflected in survey results. “We surveyed with an independent national source to compare our practice to other physical medicine rehabilitation centers across the country,” recounts Dr. Ginkel. “They evaluated patient experience, ease of scheduling, quality of outcome, doctor experience; everything. All of our clinics scored above the 94th percentile in all 36 categories measured.”
“Many patients are so kinesiophobic when they come,” reflects Dr. Kraemer. “They are afraid their back is going to crumble if they move incorrectly. we do a lot of patient education to correct false notions about pain. We explain that even someone with an alarming MRI scan may not have any pain. Part of our job is to take fear away and return patient confidence. Just because patients may have been through a number of different programs, that doesn’t mean they were given the information they need or that it was presented in a way that they could understand. Patients regularly tell us how valuable they find the education component of our program.”
“When chronic complex spinal patients first come in to see us, they have tears of frustration,” says Dr. Ginkel. “We offer hope, education and personalized, comprehensive treatment.”
“Then at discharge,” recounts Dr. Kraemer, “patients tell us how they’ve been able to get back to the activities that they love, sometimes with literal tears of joy. Nothing beats that.”