But how much impact has this had on true patient-focused care? The majority of patients in the orthopedic realm are non-surgical and require effective, conservative care. Just take a look at those with back pain as a prime example of the challenges facing orthopedic clinical practice these days. More and more clinical guidelines are indicating support for fewer and fewer assessment methods and treatment interventions. Costs continue to rise. Patients are unable to access their provider of choice given the antiquated gatekeeper model. The health care system as we know it is failing the patient, in terms of access to care, fiscal responsibility and outcome. Such is the world of back pain – as but one orthopedic example.
Mechanical Diagnosis And Therapy, or MDT, will redefine how orthopedics is practiced – by providing a framework for problem solving, diagnosis, and patient-focused care.
Robin McKenzie has long envisioned a system of care based on mechanical loading strategies. In his first text, published in 1981, he noted …
“With this book I present a new concept of diagnosis for the whole musculoskeletal system. The procedures I developed for the lumbar spine to arrive at appropriate conclusions regarding diagnosis and treatment, may also be applied successfully to the thoracic and cervical spine, and indeed to all peripheral joints and their surrounding soft tissues.”
This was a mere 31 years ago. Sometimes change is a slow process.
Here are five ways that MDT will change orthopedics:
1. MDT is a true “systems approach” to orthopedics. Mechanical Diagnosis and Therapy provides an assessment process that seeks to understand the behavior of the musculoskeletal system under various mechanical loading strategies. It employs a clinical reasoning process based on strict operational definitions that utilize the symptomatic, mechanical, and (perhaps most importantly) functional responses to repeated movements and sustained postures. This systems approach applies to the whole musculoskeletal system in a consistent manner, not just one joint or region - much as McKenzie noted in 1981.
2. MDT is not based on a patho-anatomical model. This is perhaps the most challenging step for the traditional orthopedic community. The advent of technologies such as MRI and CT scan have provided the orthopedic community with more detailed diagnostic procedures. However, when 70% of asymptomatic people have what are considered an abnormal MRI, then there is a significant diagnostic conundrum present. Does MRI serve as a good predictor of pain generator or outcome? No. Most clinical guidelines and research frown upon its use as a first line of assessment, yet physicians continue to utilize it.
MDT is based on mechanical loading strategies and their effect on symptoms and function – perhaps far more “real-world” for the patient than a high technology, high cost assessment process that provides little predictive value in diagnosis or outcome.
3. MDT has a diagnostic classification leading to treatment – not a protocol. We have heard of countless “protocols” in the world of orthopedics. MDT has an assessment algorithm that has mutually exclusive sub-groups based on responses to mechanical loading – that then define treatment. Treatment is not selected in a “protocol” or “shotgun” fashion.
The MDT assessment also serves as prognostic indicator. Centralization is a tremendously successful prognostic indicator – and this can be reliably assessed with mechanical loading strategies. Mechanical assessment can provide orthopedists with more effective selection criteria (inclusion and exclusion) for surgery. This would lead to higher rates of surgical success and improved outcomes. Surgery will, at times, be the necessary and best option for a patient. But as surgeons are quick to say, surgery is only as good as the inclusion and exclusion criteria. MDT can assist in this process.
4. MDT changes the economics game – at multiple levels. One of the keys of MDT is self care. Very few visits are typically required. This decreases the overall per-case cost. In back pain alone, this could save the health care system (and the patient) billions of dollars. In many cases, surgery can be avoided. How many patients with back pain are immediately referred for spinal fusion – when a proper mechanical assessment could improve inclusion and/or exclusion criteria and save billions of dollars in the process?
5. MDT provides patient-focused competent self care. The vast majority of orthopedic complaints require competent self care strategies, not more complex treatment approaches. MDT provides a platform for competent self care. Patients can understand their problem and find solutions that they can implement on a day-to-day basis. When the power of the mind plays such a huge role in health, should we not be moving away from dependence and “fixing” and moving towards independence and “educating”?
It is time for the orthopedic community to truly embrace not only true patient-focused care, but the use of Mechanical Diagnosis and Therapy. MDT has all the elements necessary to redefine orthopedics. The question is not if, but when.
Photo credits: abesselink