28/10/16

1

MarcusMancerSportsPhysiotherapistMemberAPA,SPA,SMA

NTrepOccHealthNaAonalGroup

Degenera'onDeshmenera'on!

Clinicalterminologyandlabeling–helpingorhur'ngindegenera'veLBP?

Whythesarcasm?

DegeneraAonismoreanobservaAonthanadiagnosis

Anormalprocessofageing

DegeneraAvechanges…•  Occurfasterthanothermusculoskeletalsystems

•  Commencesinlateteens&20’s•  PredominantlyasymptomaAc•  EpisodicallysymptomaAc

Othercontributors

•  Trauma•  Mechanicalloadinghistory•  GeneAcpredisposiAon•  Smoking•  Weight•  Diet

GRAVITY

Thechallengeforresearchersandclinicians

•  VerydifficulttodifferenAatenormalageingprocessfrompathologicaldegeneraAoninpaAentsshowingsymptoms.

28/10/16

2

SowhatexactlyaredegeneraAvechangesinthespine? MRIDDD-ananatomicalnormality?

CadavericDDD CadavericDDD

Fortunately,someinjuriesaren’tasbadastheyseem! AcontextforthispresentaAon

•  57y.o.femalecareworker,LBP1week,assisAngresidenttransferintobed.Hoistfaulty.Year10educaAon.Smoker40years.

•  Persistentpainincentral/rightlowback,noreferredsymptomstolegs.

•  Worsegeangupfromsiangorlying,slightlybeberacertakingashortwalk&NSAIDs.

28/10/16

3

ContextconAnued…

•  PhysiodiagnosesNSLBP,saysdegeneraAve.ReturnstoGPweek2.Nobeber.ReferredforMRI.

•  MRI:severedegenera'vechanges.Broadbasedcentral/rightL3/4,L4/5,L5/S1discbulgewithoutnerverootcompromise.Annulartears.Bilateralfacetjointarthrosisandosteophytes.Moderatecanalstenosis.

•  Doctor&physioconcludeirrespecAveofoutcome,workernolongersuitedtocarejob.

Warning,statsalert!

Dataonwork-relatedmusculoskeletaldisorders(MSDs)

•  SafeWorkAustraliaNDS2016•  MSDsaprioritydisorderinTheAustralianWHSStrategy2012-2022

•  Seriousclaims=anacceptedclaim≥1weekawayfromwork,excludingfataliAesortravelinjuries

ScopeofMSDs

1.MSDInjuries•  TraumaAcjoint&socAssueinjuries2.MSDDiseases•  Diseasesinvolvingthesynovium,muscle,tendon,etc.

•  Joint&otherarAcularcarAlagediseases•  Spinalvertebrae&intervertebraldiscdiseases

TypesofMSDs

2000-2014MSDs59-61%ofallseriousclaimsMSDInjuries76%MSDDiseases24%

MSDInjuries,76%

MSDDiseases,24%

BodylocaAonofMSDs2009-2014,35%MSDclaimsinvolvelowback

Lowback

Shoulder

Knee

Ankle

Wrist

Hand,fingersand

thumb

Neck

Elbow

Footandtoes

Neckand

shoulder

Lowerleg

Other

MSDInjuries

Lowback

Shoulder

KneeAnkle

Wrist

Hand,fingersand

thumb

Neck

Elbow

Footandtoes

Neckandshoulder Lowerleg

Other

MSDDiseases

28/10/16

4

MechanismofMSD

Bodystressing,62.9%

Falls,tripsandslips,22.9%

Beinghitbymoving

objects,6.3%

Vehicleincidentsandother,

5.5%

Hiangobjectswithapartofthebody,2.3%

2009-2014

Sex&ageofMSD

0

1

2

3

4

5

6

7

15-19years 20-24years 25-29years 30-34years 35-39years 40-44years 45-49years 50-54years 55-59years 60-64years

2009-2014

Female Male

OccupaAonofMSDs

Labourers

Communityandpersonal

serviceworkers

Machineryoperatorsand

drivers

Techniciansandtradeworkers

Salesworkers

Professionals

ClericalandadministraAve

workers

Managers

2009-2014

IndustryandMSDs

0

2

4

6

8

10

12

14

16

18

20

Healthcare/socialassistance

Transport/postal/warehousing

Manufacturing

Agriculture,forestry&fishing

AdministraAve/supportservices

PublicadministraAon&safety

ConstrucAon

Retail

Wholesaletrade

Accomm

odaAon&foodservices

Mining

EducaAon&training

Finance/insurance

Electricity/gas/water

Realestate

Professional/science

Media/Telcos

Arts&recreaAon

Other

2009-2014

So…whatdoesNDStellus?

2000-2014•  MSDclaimsproporAonunchangedat59-61%•  MSDclaims35%longerLTI•  MSDclaims59%moreexpensive•  Healthcare&socialassistanceishighestrisk

InjuryprevenAonstrategiesneedarethink

HigheststaAsAcalrisk

•  Females(just)•  50-54yearoldagegroup•  Healthcareindustry–especiallyagedcare•  Bodystressingmechanism•  Lowbackregion•  MSDdiseasemorelikely

28/10/16

5

Along-rangeforecast?

•  AgeingpopulaAonworkingandlivinglonger•  Oldieshavehigherrisks&ratesofinjury•  Oldiesocenworkinsocialassistance(they’reocenmorecompassionate!)

Agedcareistheboomindustry

Notallagedcareworkersarecompassionate!

3must-do’sfordoctors&physiosworkinginthecompensablesector

1.  CarefulwithMRIAming2.  Mindyourlanguage-plainandsimple3.  PrioriAsejobretenAonorRTWasaclinical

outcomeandtreatmenttarget

1.MRI-Holdyourhorses!

Studiesshow…

•  Brinjikji(2015).EvidenceofspinedegeneraAonpresentinhighproporAonsofasymptomaAcsubjects,increasingwithage.(37%of20yo’sand96%of60+yo’s)

•  Webster(2010).PaAentswithwork-relatedLBPwhohadearlyMRI<6/52had8xincreasedriskofsurgery

•  Jarvik(2003).PaAentswithLBPwhohadMRItwiceaslikelytoundergosurgerythanthosewhohadplainfilmXR

Carragee(2006)

ArefirstAmeepisodesofseriousLBPassociatedwithnewMRIfindings?•  200historicallyasymptomaAcsubjects,5yearobservaAon.Baselineandpost-LBPXR,MRI,VAS,Oswestryandworkloss.

•  2independentblindedradiologists•  51subjectsevaluatedwithMRI<12/52postLBP•  43/51(84%)unchangedMRIorregressionofbaseline.

28/10/16

6

Suggestwait6weeks

Why?•  Noredflags?Noneed.Befirm!•  Unnecessarycost–especiallyforinsurers!•  Allowsmanualtherapytotakeeffect•  AllowsAmeforLBPepisodetoseble/stabilise•  DecreasesriskofreferralescalaAon+/-surgeryCarefullyexplaintopaAent.E.g.,thegoodnewsis…

MRIforthegravitaAonallychallenged!Whenzoosrefuse!

2.Mindyourlanguage

DopaAentsunderstand?

•  OurenArehealthcaresystemreliesontheassumpAonthatpaAentscanunderstandcomplexwribenandspokeninformaAon.But…

•  Manyadultshavelimitedliteracyskills•  Lowliteracyastrongpredictorofpoorhealthoutcomes

•  Highliteracy≠highhealthliteracy

Healthliteracy

“Thedegreetowhichindividualshavethecapacitytoobtain,processandunderstandbasichealthinforma'onandservicesneededtomakeappropriatehealthdecisions.”Nielsen-Bohlmanetal(2004)USInsAtuteofMedicine.

Problemsarisewhen…

•  ThepaAenthaspoorcomprehensionofinformaAonfromHCPandmedicalliterature

•  TherearemisunderstandingsamongHCPsconcerningterminology

•  TherearelackofstandardiseddefiniAons•  TheHCPtalksingobbledygook!

28/10/16

7

Manycommontermshaveunintendedmeanings

Barkeretal(2009)Dividedbyalackofcommonlanguage?AqualitaAvestudyexploringtheuseoflanguagebyhealthprofessionalstreaAngbackpain.•  GPs,physios,chiros,osteosandlaypeople•  Fewofthemedicaltermswereunderstood•  Misunderstandings,unintendedmeaningsandnegaAveemoAonalresponseswerecommon

Backtoourcontextualcareworker

Shehearsthesewordsbandiedabout

Acute,severe,NSLBP,degeneraAve,herniaAon,prolapse,tear,arthriAs,life-long,irreversible,abnormal,nocure,notsuitedtocarework.

Andquicklybelieves…

Damnhoist.Workcausedthisandnowmyback’s

properF’d(NTvernacular!)

WhatisNSLBPanyway?

HCP•  PainlikelyfromanynumberofsourcesPaAent•  Notfamiliarwiththeterm•  HCPdoesn’tknowwhatitisorhowtotreat•  HCPthinksit’snon-existent•  MightneedfurtherinvesAgaAons/referral

OtherlaymisconcepAons

Chronic–forever,couplestepsfromwheelchairUnstable–loose,mightcollapse,nothingIcandoNeurological–inmyhead,nerves=brain,couldbeatumour!ArthriAs–old,ill,onlygoingtogetworseTrappednerve–sciaAca,temporarySlippeddisc–myback’sout,needscracking

Barriers

•  Commonlyusedtermindisabilityandimpairment

•  Conjuresupimagesofaphysicalstructurethatpreventsmovement

•  CarrieswithitnegaAvepercepAonsofabilityChallengesorconstraintsmaybebeberchoices

RetenAonofinformaAon

Pa'entstypicallyretainaroundhalfoftheinforma'ontheyreceiveinaconsulta'on,andonlyhalfofwhattheydoretainisgenerallycorrect.Kessles,2003.

•  PaAentstendtofocusondiagnosisinfo•  PaAentstendtoforgettreatmentinstrucAons

28/10/16

8

AverybasicsuggesAon!

BecauseifHCPscan’t…

…goodol’DrGooglewill!NPSMedicinewisesurvey2016•  80%18-34AustraliansgoonlinetosourcehealthrelatedinformaAon

PaAent’spreferitdumbeddown!

•  NeverassumeapaAent’slevelofhealthliteracy•  EstablishwhatthepaAentknowsandunderstands•  Speakslowlyandavoidjargon•  Usegraphics,mulAmedia,3DmodelsandillustraAons•  Repeat/reinforceimportantpoints•  CheckrecalloftheconsultaAonbyaskingpaAentstorepeatbackcriAcalinformaAonintheirownwords(checksyourownabilitytocommunicate,notjustthepaAent’sabilitytounderstand)

•  EncouragepaAentstoaskquesAons,phoneback,etc.

3.PrioriAsejobretenAonorRTW

Waddell&Burton•  Work:centraltoindividualidenAty,socialrolesandsocialstatus

•  Nowork:poorermentalhealth,psychologicaldistress,highermedicalconsumpAonandhospitaladmissionrates

It’sano-brainer!

Predictorsofnon-RTW

Remeetal(2009)•  HighintensityresAngpain•  PercepAonofconstantbackpainwhenworking•  NegaAveexpectaAonsofRTW•  Age?•  Sociodemographicparameters?•  Previousphysiotherapytreatment?

Physiotherapyisnotanexactscience,it’shighlyrelaAonal.

•  RTWocenmoredependentoncogniAvefactorsthanphysicalpathology(Waddell,2004)

•  Therapist-paAentalliancestronglyassociatedwithpaAentsadherencetotreatment(Fuertes,2007)

28/10/16

9

ManagementofacuteNSLBP0-6weeks

Firstlinecare•  Advice,simpleanalgesic,r/v1-2weeksSecondlinecare•  IncreasedanalgesiaincNSAIDS•  Physicaltherapies

–  SpinalmanipulaAvetherapy–  Acupuncture–  Structuredexerciseprograms

•  Hotpacks,heatwraps50%ofpa'entspainfreewithin2weeks(Maher,2011)

HCPmust…

Reassure•  Noevidenceofseriousdamage•  GoodnaturalhistoryprovidedyoustayacAveAvoid•  RouAneimaging,bedrest•  Labeling,esp.useofDDDEncourage•  normalacAviAesasfaraspossible,takingresponsibility,stayingatwork

Myfellowphysiotherapists… WorkersCompensaAonisafairandgeneroussystemin

themain,withsomeunfortunatesAgmaAsms.

•  Useappropriateoutcomesfromtheget-go•  SimplifyyourPMPs•  MakeRTWtheNo.1goal•  KnowthylimitaAons,referifneeded•  UsemeasuredtreatmentbreakseffecAvely

Thetaildoesn’twagthedog

Thankyouforlistening