MDT Prospects

Written by Marie BOURGEOIS and Julien LOUIS

Back from the JEPPA (Journées d’Echanges Pluri-Professionnelles de l’Association Française McKenzie – AFMcK Multi-Disciplinary Collaboration Congress), a small summary from a standpoint of MDT prospects seemed essential to me. #JEPPA2018

Saluting our predecessors

Mark Laslett  says himself that this is the best congress he attended since 40 years:

Amen to that!! Having a great time here. Hospitality is outstanding, food is great and the #JEPPA2018 conference has been of a very high quality in content and organisation. One of the best I have attended in 40 + years

— Mark Laslett (@marklaslett_NZ) 26 mai 2018

Sur les épaules du géant Mark Laslett ! Merci @Agence_EBP @FlavioBonnet et #JEPPA2018 ! And thank you really so much @marklaslett_NZ !! https://t.co/h7lCTvb6WO pic.twitter.com/cuBaA63NQH

— Clé Ment (@clement_blt) 27 mai 2018

Why does he put this forward?

First of all, maybe it is the scientific level of the Congress, associated with a dynamic and an enthusiasm he hoped to happen since he graduated from physiotherapy.

Secondly, beyond producing a situational analysis of particular research points, MDT (Mechanical Diagnosis and Therapy) prospects were a lot discussed.

The congress began under the best possible auspices, with a really well-prepared opening from Sylvain PETERLONGO, the President of the AFMcK. He saluted the people who worked for the progress of science, especially in MDT, by quoting Bernard De Chartres, in latin please:

« nani gigantum humeris insidentes, ut possimus pour eis et remotiora videre »

« même un nain sur les épaules d’un géant, voit plus loin que lui »

“Even a dwarf on the shoulders of a giant see further than him”

Let me point out that Sylvain cut the ground under Mark Laslett, who had planned the same introduction for his lecture.

Those giants, without whom we would not be here today, opened channels for us. Channels that we need to explore, refine, confirm, belie. Those giants are the knowledge base that allows you to look further…

The end of anatomical diagnosis?

Let’s go to the main topic, with Ron Donelson. You know, THIS Ron: https://www.researchgate.net/profile/Ronald_Donelson/amp.

Take a look at the articles list to have an idea of the man…

American neurosurgeon, his lecture was on diagnostic precision. Indeed, he argues that for a majority of low back pain (further LBP) patients, an anatomical diagnosis – ie. finding a structure responsible for pathology – is useless. Indeed, 85% of the patients suffer from non-specific LBP. For them, imageries as MRI, for example, are useless and even counterproductive, due to the high false positives results. And if we trace Chronic LBP patients’ pathways, nothing allows us to think that making an anatomical diagnosis would influence this pathway, despite colossal costs for all countries.

Precision diagnostic is the heart of the problem, and we should be more interested in the different pain patterns, rather than in anatomical structures responsible for pathologies, especially when talking about surgery decision-making. Research of a Directional Preference (mechanical diagnosis) is useful for around 50% of chronic LBP patients. Ron Donelson then ask an open-ended question: “what if one of the causes of chronicity for LBP was a Directional Preference not discovered?”.

I will ask for another one: what allows us, nowadays, scientifically speaking, to not looking for a Directional Preference in LBP patients care?

The exploration of pain patterns and their evolution follow-up seem to be prognostic tools helping for therapeutic decision-making…

Is it, however, time to record the worthlessness of diagnostic?

At first glance, Mark Laslett could be the antithesis of what supported Ron Donelson. Indeed, Laslett is passionate about the research of a patho-anatomical cause in LBP. If my understanding was good (but maybe I am extrapolating), psycho-social factors are confounding factors for research of a patho-anatomic diagnosis.

But if he is passionate about patho-anatomic, he does not negate the usefulness of a mechanical diagnosis, which is the basis of his diagnostic by substraction approach. At any time, we need to eliminate the biggest sub-group…

MDT assessment has prognostic and diagnostic roles. Identifying a Directional Preference in LBP allow to identify the biggest subgroup. Pursuing assessment with substraction diagnosis will increase diagnosis results.

The entry point in Mark Laslett’s logic is certainly to understand that diagnosis’ prevalences are affected by environment (especially selection of your practice population) and by the patient (the famous n=1). To illustrate this, randomized controlled trials are often based on participants from 38 to 42 years old, more likely to be men. We are far away from our n=1 patient consulting at our practice… Ruling out, at each step, the biggest subgroup, starting from our patient n=1 seems then a good diagnostic idea…

Assuming our failures

Pr Philippe RIGOARD, neurosurgeon in Poitiers: « Course of a patient in treatment failure »

The n=1 patient will not receive the same treatment depending on his entry point into the health system. A surgeon will not propose the same therapeutics than a rheumatologist or a physiotherapist in primary care. It is a bias, devolved to practitioners, whatever the latter is a physio, surgeon, … “Are we trained to fail?” questioned Pr. Rigoard, supported by imageries of surgery failures.

Le patient n=1 en fonction de son entrée dans le système de soin, ne bénéficiera pas du même traitement. Un chirugien ne proposera pas la même thérapeutique qu’un rhumatologue ou un kiné en première intention. Cela constitue effectivement un biais, qui incombe aux thérapeutes. C’était le sujet d’intervention du Pr Philippe RIGOARD, neurochirurgien à Poitiers: « Parcours d’un patient en échec de traitement ». Nous sommes tous conscients que certains patients sont en échec de traitement avec des erreurs de prise charge, des errances thérapeutiques, des accidents médicaux, etc. Mais est-on prêt à reconnaître nos propres erreurs de jugement et de prise en charge. Ceci relève parfois de la psychopathologie du thérapeute, qu’il soit kiné ou chirurgien… « Sommes-nous formés à l’échec? » interroge le Pr. Rigoard, images d’erreurs chirurgicales à l’appui.

The reasons: ego, hidden motivations, insufficient skills, society, … For a surgeon, it is needed to understand that “a patient suffering for more than 6 months does not present only an anatomical issue”.

Collaboration with medical body

Borders between professions are fading, and we all need each-others. It was well illustrated by the presence of Pr Donelson, Pr Rigoard, Pr Rannou, Pr Gagey, Dr Gras Combe at the JEPPA.

Why is this collaboration achievable? Well, it is not because ego deflated, or because laws softened. It is because well-conducted patients pathways require collaboration…

The level of science for musculoskeletal disorders directed by physiotherapists worldwide around is good enough to showcase physio’s skills, especially to innovate on care which are conservative, effective and economical.

Dr Hanne ALBERT, physiotherapist, and Pr RANNOU, rheumatologist, were both lecturers about inflammatory discopathies (MODIC signs on MRI). The first one made the proposition that antibiotic therapy is beneficial on a subgroup, while the second one put forward the hypothesis that corticosteroids are beneficial for the same (same? “That is the question”) patients. Very good example of two different approaches by two different professions, supported by scientific evidence…

Ready for primary care?

More than 40 countries worldwide allowed patients to physiotherapists for primary care. Is it the same in France?

Dr Angela Cadogan and Mark Laslett are two of the 8 physiotherapists specialists in New-Zealand, experts in musculoskeletal diagnosis and can prescribe imagery, specialized in triage and referral to physiotherapy or medical/surgical body.

Are French physiotherapists, like them, qualified to received patients in primary care?

This is the question asked by Dr Alexandre Kubicki (French physiotherapist, director of the physiotherapy school on Belfort).

A useful article: : Give patients direct access to physiotherapy. Middleton K. 2016 BMJ

Is it potentially harmful to the patients?

It requires a musculoskeletal expertise, including a good knowledge of red flags detection. Meanwhile, different countries experiences showed a positive benefit/risk balance for patients when they can seek physiotherapists attention in primary care.

Is it expensive?

Helen Clare (New-Zealand) and Mark Miller (USA), both MDT instructors, are unanimous: MDT assessment in primary care would allow the health care system to save funds by bringing a better efficiency in patient care. Mark Miller supported the idea that we can even commit to a minimum score to private insurance companies…

Is the healthcare system ready for that?

I let the question opened, as did Mark Miller, adding that “Yes, actual health care systems walk on the head!”

Self-analysis is also assessing our practices (1)

We discussed the need to produce quality scientific evidence. But further than research, are we ready to assess our practices?

Today, a patient finishes his 10 physiotherapy sessions for LBP, and he is feeling better… Do you know if he is keeping this improvement for a long term? Wouldn’t he have fewer recurrences if he had sawn one of your colleagues? You will say, not a big deal, if he is feeling bad, he just has to come back to me… OK, but do you pay of your own pocket if you are less effective than your neighbor?

Practices’ assessment of MDT practitioners: this was Sylvain PETERLONGO’s lecture topic. He presented statistical results from the recent AFMcK study about patients’ compliance to MDT exercises. Results: about 1 patient on 2 does not do, or not properly, his exercises between session 1 and session 2…

 

I just cannot believe it… ½!!!

The plus is that we all think we are better than the others, so in my clinical practice it is more than ½, I am sure!

We note that this study was performed with MDT therapists, who are trained to exercises prescription… it says much about the road ahead.

We all think we give good advices.

Maybe it is where motivational interviewing can help. You know, the course I followed in January and did not publish about (Théo C., if you are reading me… ;) ). Prescribing exercises is one thing, that patients perform them is another one. There is always the old good directive approach “Exercises are not for me, but for you, I am not the one with back pain when going back home”. In any case, firstly it does not work, secondly it is not in agreement with recent evidence about learning. And Guillaume DEVILLE (“Patients performing their exercises: manual”) and Dr Philippe MICHAUD (“Introduction to motivational interviewing”) will not contradict this. The aim is a treatment patient-centered: what if he was the one deciding the care you will provide to him? It was maybe also the topic of the practical session from Matthieu GUIRAUD and Jean-Philippe DENEUVILLE: “the session you are the heroes”, from which I had excellent returns. By the way, if some who had attended this session could comment on this article to share their congress…

As an introduction to motivational interviewing, my advice would be to look after the behavior change model, from Prochaska and Di Clemente. It explains the difference between I smoke, I would like to quit, I try to quit, I am quitting, I quitted and I smoked again. We will not approach the patient the same way, depending on where he sits on the spiral… If we transpose this to LBP, “I smoke” corresponds to “I have back pain”, which is quite far away from “I did my exercises” – corresponding to “I am quitting smoking” – and farther from “I do not have back pain anymore”…

Self-analysis is also assessing our practices (2)

It was developed above, assessing our practices, assessing our patients, following progress is crucial. This small paragraph is here to showcase Jean-Philippe DENEUVILLE lecture: “Objective results measures, an essential for modern physiotherapy”.

Jean-Phi talked about algorithms and artificial intelligence… Or how, in a few questions, a software can learn to detect the patient with red flags, to bring to light the one with evolution deviant from the standard, to select the relevant questions for that patient, while analyzing itself and learning constantly from its new data, thanks to deep learning and big data…

A software of the future, to create?

Not at all. This software already exists (alongside others). It is named FOTO (Focus On Therapeutic Outcomes)…

This software includes a database of 22millions patients assessments, from 22,000 therapists. What are the chances that your patient does not behave as a patient’s group of those 22millions? Well, the software knows it and can differentiate between the patient with chances to deviate from the standard evolution, and the one behaving as the most represented subgroup (for who we know by heart the treatment and the prognosis).

Jean-Philippe works in association with a French lab developing similar software. He focused on the software’s interpretation of pain topography for LBP patients, and the evolution over time.

Sharing professional experiences

Seeing distinguished therapists working, this is the Graal for every physiotherapist. This congress was the opportunity to look for therapists treating patients.

Live patients’ assessments by Mark LASLETT, Scott HERBOWY, Simon SIMONSEN, Hans VAN HELVOIRT, Angela CADOGAN, Mark MILLER, and our Frenchies’ translators Patrice BOUDOT, Gabor SAGI (himself – in English in the text), Jérôme OSTALIER, Fred STEIMER, Paco GONZALES, were simply AMAZING.

Nothing is better than seeing those speakers, that we would easily consider as theorists, getting their hands dirty to share their experience.

Participants were young…

In attendance of Evangelos KAPLANIS, Jacky OTERO and Gabor SAGI, major actors of French MDT, participants’ average age drives to think that the future of research in physiotherapy and in MDT is assured.

500 participants, that is extremely encouraging, it is not only one seed that was planted, but a whole field. Still needing to know whether the ground is fertile enough to allow them to grow…

Any advice for future generations?

I will speak for myself, but maybe this can inspire some others…

• Rising our scientific level
• Reading, understanding and speaking English
• Stopping navel-gazing by being more open to the International
• Encouraging personal initiatives, in terms of research, communication, development, innovation
• Going for MsC and PhD
• Taking part in multicentric studies through inter and intra-branches cooperation
• Participate in further training

What about perspectives for MDT?

It looks a little like a Manifest for MDT’s future:

• Empowering ourselves in patients’ assessment with the plus added by substraction diagnosis, pushing forward the MDT assessment,
• Integrating metrology to clarify mechanical and anatomical diagnosis
• Deepening research, especially for research about extremities
• Integrating the neuroscience of pain
• Improving patients’ empowerment by the use of motivational interviewing, supporting collaboration with the patient,
• Improving treatment plans’ designs by clarifying prognostics data for our patients,
• Refining triage for an earlier referral of patients needing it
• Contacting health care branches for a better cooperation regarding patients’ care (multidisciplinary care)
• Impacting directly the cost for the health care system by being effective and decreasing therapeutic wavering – and thus the avoidable chronicity,
• Taking advantage of the digital revolution to digitize MDT’s decisions algorithms, completing a patients’ database and assessing our personal practices.