If you have enjoyed the previous articles about EXSTORE the assessment and treatment system from Doctor of Chiropractic, Dr Anthony Lombardi, now you get to try it out. Today Anthony has some more information he would like to share about how he believes medical doctors, chiropractors, physiotherapists, osteopaths, occupational therapists and probably any healthcare professional could benefit from this standardised system for diagnosing and treating a patients pain.
In the article below Anthony explains in a lot more detail about: what is EXSTORE, how it actually works, how different professions can integrate it into their practices and finally how much taxpayers money could be saved. I see it all the time where a patient sees a GP for a back or neck pain and doesn’t get it resolved quickly. Remember in the UK on the NHS a GP consultation is on average 13 minutes. They have limited time and so can only prescribe medication and refer to other healthcare practitioners. Their job is not to use hands on care. I feel some GP’s feel obliged to send a patient for x-rays when most of the time it is not going to change the treatment plan anyway. I hope this EXSTORE (from examine+restore) system would give medical doctors confidence in not needing an x-ray for biomechanical back pain.
EXSTORE: New Musculoskeletal Assessment System Could Save Government Health Plans Millions And Improve Clinical Results For Chiropractors, Physiotherapists, & Massage Therapists
by Doctor of Chiropractic, Dr Anthony Lombardi.
The latest attainable statistics tell us that approximately 6.7 million visits per year are made to Ontario, CANADA medical doctors for non-complicated musculoskeletal conditions alone (Benjamin et al, 2005). This does not include systemic illness or other maladies that affect the muscle, joint, and nervous systems. Non-complicated refers to injuries like repetitive strain injury (RSI), mechanical low back/neck pain, and insidious onset of joint pain.
On average, patients visit their family physicians 3.7 times per year for those conditions (Benjamin et al, 2005). This costs the Ontario Health Insurance Plan (OHIP) over $439 million per year (Benjamin et al, 2005; McGuinty et al, 2012). This does not include the OHIP costs of additional prescription medication, surgery, and post-surgical rehabilitation.
To date medical doctors, chiropractors, physiotherapists, and other therapists do not use a consistent method of musculoskeletal assessment. The EXSTORE system which has been referenced in medical textbooks by Ma (2012) and Lombardi (2012), has the capacity to save millions of dollars for health systems in general. Once this system is learned by medical doctors and other health professionals it will decrease the cost of OHIP expenditures and the amount of time needed for acceptable resolution of musculoskeletal injuries.
In addition, the use of EXSTORE will make health professionals more efficient in practice as it can be completed in under two minutes. EXSTORE is ideal for: chiropractors, physiotherapists, and massage therapists who use acupuncture or myofasicial work.
Conventional Assessment Is Inaccurate And Expensive
Diagnostic imaging has shown us that there are large inconsistencies between changes in joint function (disc bulges, cartilage tears, muscle tears) and actual signs and symptoms. This has been demonstrated through several landmark studies which have shown that tissue tears revealed on such imaging are very common in patients who are completely asymptomatic (Jensen et al, 1994; Worland et al, 2003; Oschmann et al, 2007). Since there is a lack of a relationship between diagnostic imaging results and symptoms, we must look further into what is happening on a musculoskeletal level when patients are experiencing pain and dysfunction.
Research also suggests that conventional orthopedic testing is not accurate in diagnosis. Simpson et al (2006) concluded that over-reliance on single orthopaedic tests is not appropriate and that there is a lack of research to support the accuracy of spinal orthopedic testing.
Cadogan et al (2011) revealed that the reliability of results in orthopedic shoulder testing between different examiners is inconsistent. Contant (2003) did a systematic review of 34 studies and concluded that the reliability and validity of these assessment procedures remain questionable.
It would be very difficult to standardize musculoskeletal treatment among all health professions, but it would be much easier to create a standardize assessment that is both time efficient and tissue specific so that the areas of soft tissue dysfunction can be addressed directly.
EXSTORE Saves Time
Starting With MD’s (medical doctors).
Medical doctors are the most utilized doctors in Ontario for uncomplicated musculoskeletal injuries (Benjamin et al, 2005). So naturally they are very busy and their time is limited.
This year I performed an anonymous independent survey of MD’s who said they spend between 5-7 minutes with each patient during a visit. Dugdale et al (1999) reported that doctors in a government health care system spend between 5-8 minutes per visit with a patient.
The EXSTORE system works well in such a time sensitive atmosphere because it only takes 2 minutes to perform on the patient. This means within the timeframe of 5-7 minutes they will be able to provide a specific, time efficient assessment and they will be able to write down specific direction to the therapist they refer their patient to. By doing this, not only is the patient more likely to improve in less time, they will be less likely to be referred back to their medical doctor or medical specialist, which OHIP would have to pay for once again. This would also decrease the amount of money spent on expensive diagnostic imaging and unnecessary doctor referrals.
EXSTORE Focuses On Muscle Motor Inhibition
What is Muscle Motor Inhibition?
Muscle Motor Inhibition (alpha-motor neuron muscle inhibition) is when the nerve that sends the impulse to contract a muscle becomes unable to function at its optimal capacity due to chemical or physical trauma (Le Pera et al, 2001). This results in a perceived weakness of that muscle which changes the biomechanics of the entire region.
The concepts of pain adaptation, neurogenic inflammation, nociception, and arthogenous muscle weakness all support the fact that motor inhibition is a constant factor in musculoskeletal dysfunction (Lund et al, 1999; Svennson et al, 1996; Devor et al, 1999; Ljung et al, 2004; Cote et al, 2010; Njis et al, 2012; Zimmermann et al, 1991; Stokes et al, 1984; Hurley et al, 1993 & 1997).
Alpha-motor neuron muscle inhibition has been consistently demonstrated in injuries which demonstrate neurogenic inflammation and nociception, which are present during pain or dysfunction (Zimmerman et al 1991; Njis et al, 2012).
Nociception and Neurogenic Inflammation interact with alpha-motor neurons to cause neuro-muscular inhibition in skeletal muscle, which is often processed without conscious thought (Nijs 2012). These motor inhibitions have been also been found in patients without any symptoms at all.
Hurley discovered in several studies that even in those with mild arthritis have a motor inhibition of the quadricep muscle and Horre (2006) complied a dissertation of 31 separate studies that demonstrated motor inhibition due to changes in spinal, hip, knee, and ankle joints. Further, Sedory (2007) concluded that changes in the knee or ankle joints inhibited muscles in the pelvis and hip.
In short, in all pain or dysfunction, the nerve that controls the muscle becomes irritated by chemical inflammation that then causes that muscle to become weaker.
Why Should We Focus On Muscular Inhibition In Rehabilitation?
Ingersol (2003) concluded:
“removing neuro-muscular inhibition will reduce the cost of rehabilitation.”
Nijs (2012), in the Clinical Journal of Pain, concluded:
“Nociceptive motor inhibition might prevent effective motor re-training.”
Ingersoll (2003) in Rehab Management concluded:
“Without removing or reducing arthrogenous muscle inhibition (AMI), rehabilitation may essentially begin after healing occurs. We might also reduce long-term consequences associated with AMI, including susceptibility for further or other injury.”
Sedory et al (2007) in the Journal of Athletic Training summarized:
“Treatments that have been shown to reverse the effects of arthrogenic muscle inhibition should be used immediately before therapeutic exercise is performed in an effort to activate motor units that may have been previously inhibited.”
How Does The Health System Work Now?
In my example I use the flow chart in which the patient, the stick figure (who we will call Mike), has a non-complicated musculoskeletal complaint and so he visits his medical doctor. Typically, the most common first step is to prescribe the patient with NSAIDs or a similar analgesic. Mike returns to his doctor after a week because he is still having a problem. At this point, his doctor sends him for some diagnostic imaging (x-ray or ultrasound) and based on the results of the imaging he may do the following options:
1. For more advanced imaging.
2. To a medical specialist.
3. To therapy (for simplicity this also includes chiropractic, physiotherapy, acupuncture, and massage therapy)
4. All of the above.
The “Catch-22” for the OHIP health system occurs because in #1, #2 and #4 the patient must return to either their medical doctor for imaging results, or to the medical specialist (who will request their own advanced imaging to be done if the medical doctor did not order it).
Either way, the patient will at least be visiting a doctor paid for by OHIP an additional number of times before any other treatment is recommended.
How EXSTORE Creates Opportunity
How EXSTORE Assessment Overcomes Limiting Factors
Lets look at the option #3 of the medical doctor referring to therapy.
If our patient Mike had shoulder pain, the medical doctor would refer him to a therapist with a note that typically reads: “Right shoulder pain”, or “Right AC joint pain”. The therapist then would typically focus on the area of injury in addition to which ever method of shoulder assessment they choose.
However, if the referring physician was focused on restoring dysfunction first, his directions based on his EXSTORE assessment would possibly be: “Right shoulder pain associated with inhibition of pectoralis major and serratus anterior muscles”. In the latter option, the physician primes the therapist to look at specific tissues which were found to be inhibited. Then, the therapist is more likely to not only address the area of pain, but to correct the dysfunction as well.
Deferring The Costly Options Of #1, #2, & Surgery
Diagnostic imaging, visits to medical specialists and surgery are all viable treatment options and necessary in certain situations. However, in the absence of red or yellow clinical flags, the physician could defer those options in favour of performing a functional EXSTORE assessment first.
For example, referring to the flow chart, Mike’s doctor could prescribe NSAID’s and a referral to a therapist that reads “right shoulder pain associated with inhibition of pectoralis major and serratus anterior.” He could then provide instructions that if in 2-3 weeks the problem is not resolving to then return to his office for further testing. Naturally, if the patients’ respond to therapy then that eliminates the need to proceed further through the health system which is a savings of time and money.
How does EXSTORE Work?
Exstore is a standardized system that focuses on assessing range of motion and specific muscle testing around the skeletal foundations of human movement (Hamill et al, 2006) – the scapular and pelvic girdles. All soft tissue and peripheral nerves connect to or interact with these skeletal girdles. Also the kinetic chain of movement in our trunk and extremities begins in one or both of our skeletal girdles.
As an example, long-standing elbow pain cannot be present without some degree of shoulder girdle dysfunction and/or long-standing shoulder pain cannot be present without some degree of elbow or wrist dysfunction. Injuries related to soft tissue can no longer be isolated to one area or one joint. It has to be understood that a shoulder problem carries elbow and wrist dysfunction (Horre 2006). Conversely, very often low back pain and sacroiliac pain is associated with dysfunction of the tissues that support the pelvic girdle and stabilize the lumbar spine.
A directed musculoskeletal assessment system is required to assess global mechanical function of the body. This system will provide information about the nature of the dysfunction, the adaptability of the tissues and the origin of nociception . By doing this, our treatment can be focused on correcting mechanical dysfunction which will consequently address the chief complaint. This system reveals the areas of motor inhibition so that they can be addressed first which defers the cost of diagnostic imaging or costly medical referral because the patient is getting treatment right away . Due to the efficiency of EXSTORE, the entire system takes less than 2 minutes to complete which makes it very attractive to doctors who have very limited time with their patients.
How Much Money Will EXSTORE Save?
Simply put, a standardized assessment system like EXSTORE will reduce the number of patient visits to their family physicians. This is because physicians would be turning their focus away from the pain and their attention towards correcting dysfunction. Correcting dysfunction will decrease the need for unnecessary advanced imaging and further referral to medical specialists.
Even If we made it a goal to reduce the average number of MSK visits per person from 3.7/yr to 3.0/yr we would save over $83 million per year. This would reduce OHIP expenses for musculoskeletal injury from $439 million/yr (Benjamin et al, 2005) to $356 million/yr reducing the number of musculoskeletal visits from 6.7 million (Benjamin et , 2005) to 5.4 million per year.
Learn How To Do EXSTORE
Click the link to order the EXSTORE Assessment System Book/DVD for $157 CAD (inc. shipping and taxes if shipped in the US or Canada).
Or you can order EXSTORE by calling toll-free in US or Canada on 1-877-267-3473
Dr. Anthony J. Lombardi is a chiropractor in Hamilton, Ontario, Canada who uses manual techniques and medical acupuncture to improve performance and reduce pain in patients with neuro-musculoskeletal disorders. He is the creator of EXSTORE. For any EXSTORE related questions please send an email here or on twitter @exstoresystem.
- Benjamin et al. (2005). Institute of Clinical Sciences, 8, 1-77
- McGuinty et al. (2012). MOHLTC. “Schedule of Benefits”. Province of Ontario
- Dugdale et al. (1999). J Gen Intern Med, 14(S1): S34–S40.
- Ma,. (2012). Contemporary Dry Needling. New York: Elsevier
- Lombardi,. (2012) Exstore Assessment System. Hamilton: AJL Publishing Co
- Jensen et al. (1994). N Engl J Med, 331,69-73
- Worland et al. (2003). J South Orthop Assoc, 12(1), 23-26
- Oschman et al. (2007). SAJSM, 19, no.1
- Simpson et al. (2006) Chiropr Osteopat. 2006 Oct 31;14:26.
- Le Pera et al. (2001). Clin Neurophysiol, 112(9), 1633-1641
- Ljung et al. (2004). Journal of Orthopaedic Research, 22 (2), 321-327
- Devor, (1999). Evaluation and Treatment of Chronic Pain Baltimore: Williams, & Wilkins.