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9/8/17
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Team-based care for low back pain: A panel discussion
Clifford Lee, L.Ac., Melissa Nagare, D.C., L.Ac. & Robb Russell, D.C. SCU Health System Southern California University of Health Sciences
Academy of Integrative Pain Management San Diego, California
October 21, 2017
Team-based care for low back pain
Melissa Nagare, D.C., L.Ac. Vice President and Chief Clinical Officer Robb Russell, D.C. Assistant Vice President and Clinical Chief of Staff Clifford Lee, L.Ac. Clinician SCU Health System Southern California University of Health Sciences Disclosures / Conflicts of Interest No financial or other conflicts to report
Team-based care for low back pain
Learning Objectives 1. Address how fragmentation and misdirected care, inappropriate incentives
and inefficient communication lead to poor outcomes for low back pain
2. Explain how team-based, relationship-centered care can refine the approach to low back pain to produce optimal patient outcomes
3. Explain how integrative care options can be pragmatically incorporated in a care plan
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Team-based care for low back pain
Usual care
• Educational, practice and policy silos• Supermarket approach to treatment • Lack of coordination • Perverse incentives
Team-based care for low back pain
Emerging, team-based care options • Interprofessional education and practice• Evidence-informed / Experience-informed• Team-based, relationship-centered care
Team-based care for low back pain
The goal of integrating care should be the provision of comprehensive care that is safe and effective care, that is collaborative and interdisciplinary, and care that respects and joins effective interventions from all sources. Institute of Medicine: Committee on the Use of Complementary and Alternative Medicine by the American Public Board on Health Promotion and Disease Prevention. Institute of Medicine. Complementary and Alternative Medicine (CAM) in the United States. Washington D.C.: National Academy of Sciences Press, 2005
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Team-based care for low back pain
Uncomplicated Acute LBP
• 31yearoldmale• 2½weeksofLBPw/radia;on• 3-5/10;almostconstant• Non-trauma;conset• NoRedFlags• Moderatedisability(ODI-24)• Noneurologicalfindings• Nopriorsimilar• +Findings-RSIJoint
Dysfunc;on/Painw/Flexion/MyofascialTenderPoints
• Noclearpaingenerator
Team-based care for low back pain
Uncomplicated Acute LBP
Team-based care for low back pain
Uncomplicated Acute LBP
A relatively straightforward presentation. Now what? • What is the most efficient way to proceed? • Is imaging advisable? • Are medications appropriate? • What integrative approaches are warranted? • What team-based care is relevant? • What does the Keele STarT Back Screening
Tool add to decision-making?
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Team-based care for low back pain
Uncomplicated Acute LBP • Keele STarT Back Screening Tool (SBST)
• 5/2 Moderate risk of chronicity • Reassurance
• SCU / SBST / ACP • Advice sheet (regarding LBP)
• SCU / SBST • Self-management
• SCU / SBST / ACP • Imaging is not recommended
• SCU / ACP • Medication (NSAIDs)
• Patient preference per ACP • Manual therapy (HVLA)
• SCU / SBST / ACP • Ergonomic and advice regarding ADL
• Per practitioner experience • Specific exercises
• Extension bias per practitioner experience; SCU
Resolution with three visits in two weeks
Team-based care: Case 1
A 49-year old female referred by PCP for constant, 7-10/10 severity LBP with radiation to left buttock and leg. Concurrent diagnoses:
– fibromyalgia, type 2 diabetes, Raynaud’s disease, hypertension, rheumatoid arthritis, scleroderma, restrictive lung disease, psoriasis
Functional challenges: – Inability to drive, do housework, and go for a walk
Goals: – Drive, do housework, go for walks, do DIY household craft projects
Initial SBST score: high-risk for poor clinical outcome
Team-based care for low back pain
Team-based care: Case 1 Treatment:
– 6 chiropractic treatments over four weeks – Chinese medicine treatment (acupuncture and herbs) added at 4 weeks
Outcomes after four weeks of integrative treatment: – Pain scale 2-3/10 severity – Improvements in her ability to drive, do housework, and walk – Improved confidence and depression levels
SBST score: moderate risk for poor outcome The patient has required long-term supportive care but has achieved a higher level of self-efficacy and functional abilities.
Team-based care for low back pain
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Team-based care: Case 1
Team-based care for low back pain
Team-based care: Case 1
Team-based care for low back pain
Team-based care: Case 3 Referral for Adjunct Treatment
• 67 yo male with progressive neck and low back pain and stiffness since radiation treatment in 2003 (throat cancer)
• Consultation and examination through Spine Care (chiropractic), referred to AOM upon mutual decision between examiner and patient
• With 10 months of treatment involving acupuncture, cupping and tui-na: • Low back pain minimal or not even felt by patient. • Neck pain/stiffness reduced by 60-75% with increased AROM (specifically, rotation). • Patient referred for regular massage therapy (1x/2 weeks) and periodic AOM follow-up (1x/
month) • Neck pain/stiffness has maintained at reduced levels.
Team-based care for low back pain
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Questions? Comments? [email protected]
[email protected] [email protected]
Team-based care for low back pain