Beyond Manual Therapy: Working with the WHOLE

patient

Bodhi G Haraldsson, RMTMTABC research department director

Musculoskeletal pain or injury is the greatest cause of work disability.• Low back, neck and shoulder pain are

most common.

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Neck and shoulder pain are common and costly, and are similar to low back pain in their potential to cause difficulties and resist treatment

(Cote et al 2000; Brosseau et al. 2001)

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Individuals with spinal problems often have significantly higher medical expenditures than those without

(Marin et al., 2008)

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The exact origin of neck pain is often difficult to identify, despite much effort that has been directed to determining its various causes (Borghouts et al 1998).

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This failure to clearly uncover its origins has mandated the use of a classification system for neck pain that is based on pain severity, as opposed to its basis in anatomy or pathophysiology

(Guzman et al 2008b)

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Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? A systematic review

very cautious evidence supporting the notion that treatment targeted to

subgroups of patients with NSLBP may improve patient outcomes

Kent et all. BMC Medicine 2010, 8:22

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Lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a WC setting is associated with significant increase in disabil ity, opiate use, prolonged work loss, and poor RTW status.

Long-term Outcomes of Lumbar Fusion Among Workers’ Compensation Subjects: A Historical Cohort Study

Nguyen, Trang H. MD et all

Spine . 36(4):320–331, 15 February 2011.

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Why Return to Work:

• It is generally accepted that after 6 months of an off-work status, there is a less than 50% chance that the injured person will RTW

• Returning to daily work and life activities can help an injured worker's recovery and reduce the chance of long- term disability

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• Adopt the team approach in formulating the RTW plan; injured worker, employer, physician, employer’s insurance liaison, usually the claims adjuster

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• Early and open communication between all parties

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Formulate a return-to-work plan

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Extensive reviews of neck pain prognoses show that 50 to 85% of persons with neck pain do not experience a complete recovery, and less optimal outcomes are associated with increased age, poor overall health, and the existence of prior painful conditions. Reduced mental health and an absence of effective health coping skills also predict poorer outcomes

(Carroll et al. 2008a, 2008b, & 2008c).

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• Most neck pain results from complex relationships between individual and workplace risk factors.

The Burden and Determinants of Neck Pain in WorkersResults of the Bone and Joint Decade 2000 –2010 Task Force on Neck Pain and Its Associated DisordersPierre Coˆte et all

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• When you’re creating a treatment plan, keep the focus on return to work and involve the worker.

• Ensure the focus remains on function and return to work, and that these goals are viewed to be just as important as the relief of pain or related symptoms.

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• Promote return to work and functional goals along with the treatment goals of relieving pain/symptoms.

• During the first therapy session, develop specific return- to-work goals with the worker and target realistic expectations of rehabilitation.

• Write down the goals and provide the worker with a copy.

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Return to Work

Appropriate workplace accommodations

• A RTW plan should accommodate the worker’s injury and be adaptable. Both the injured worker and employer should agree on the plan. It should clearly indicate which tasks are restricted, what level of support is needed and what accommodations are available.

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Therapeutic relationship

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“We propose that it may be necessary to integrate patients’ beliefs and expectations into drug treatment regimes alongside traditional considerations in order to optimize treatment outcomes.”

(Beliefs About Pain Levels Appear to Override Effects of Potent Pain-Relieving Drug)

The Effect of Treatment Expectation on Drug Efficacy: Imaging the Analgesic Benefit of the Opioid Remifentanil. U. Binge et all. Sci. Transl. Med. 3, 70ra14 (2011).

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Non-specific low back pain symptoms seem to improve in a similar pattern in clinical trials following a wide variety of active as well as inactive treatments. It is important to explore factors other than the treatment, which might influence symptom improvement. (Artus, van der Windt, Jordan et al)

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Pain is a - BioPsychoSocial entity

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• Exercise and manual care create a healing response.

• Equally important to a successful outcome is the therapeutic alliance between the patient and the provider.

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A systematic review found that a positive therapeutic alliance consistently correlated with improved pain, disability, and treatment satisfaction in rehabilitation.

(Hall AM, Ferreira PH, Maher CC, et al. 2010)

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“A patient-centered approach is recommended as the basis for the development of a good working relationship between the therapist and patient, with enhanced effectiveness of communication regarding specific tasks required to achieve treatment goals.”

 

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Language of Influence –

• Words That Harm or Heal• The First Question (1st impressions)• Listening• Motivation Styles

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Challenging Return-to-Work Situations

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•Barriers to RTW were often mundane and procedural in nature

•RTW decision-makers don’t always see full picture or communicate well....leading to poor decisions & development of RTW problems

•Barriers to RTW were often mundane and procedural in nature

•RTW decision-makers don’t always see full picture or communicate well....leading to poor decisions & development of RTW problems

Problems occurred at all stages of the RTW process

•Employer delays filing accident report

•Worker has no family doctor, uses walk-in clinic

•Physician fills in WorkSafe form quickly

•Work not properly modified

•‘Broken telephone’ and lack of in- person contact between worker & adjudicator

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• 1) Recognise RTW problems when they are developing

• 2) Assist in managing those problems

Download the Red Flags/Green Lights RTW Problems Guide (free) at:

http://www.iwh.on.ca/rtw-problems-guide

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Fear avoidance/pain behavior/malingering/pain-related catastrophizing

• Initial Pain intensity is a prognosis factor for RTW

• Psychosocial factors strongly predicted persistent pain, pain-related work disability, and pain severity.

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• Evidence is accumulating that pain severity plays a more important role in disability than previously assumed....it is also important to note that the fear-avoidance model only accounts for ... problems in a sub-group of chronic low back pain patients.”

(Swinkels-Meewisse et al. 2003)

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Individuals with neck and low back pain were more likely than those without pain to have depression and other painful conditions, including headache and osteoporosis.

(Fernández-de-las-Peñas, César PT, PhD et al 2011)

 

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Prognostic factors for disability have been identified and they include pain intensity; well-being; and expectations of treatment. If the patient has several of these factors, the possibility of disability increases. (Kjellman, Skargren, & Oberg. 2002)

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Clinical tests and radiological evidence do not help to predict those who proceed on to the path to chronicity and disability (Malik & Lovell. 2004)

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Yellow flags

Yellow Flags are psychosocial risk factors that may potentially increase the risk of developing long-term disability and work loss. Yellow flags should be identified early in order to determine if these factors need to be addressed to improve the patient outcomes through cognitive and behavioural management strategies. (Bernard BP. 1997)

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Some of the “Yellow Flags” or indicators for future disability are:

• Attitudes and beliefs about neck pain

• Fear- avoidance behaviours – fear of pain and subsequent avoidance behavior.

• Job dissatisfaction

• Disability compensation35

• A history of failed previous treatments

• Financial problems

• Anger

• Depression

• Substance abuse

• Stress36

Screening Questions

• Have you had time off work in the past with neck pain?

• What do you understand is the cause of your neck pain?

• What are you expecting will help you?

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• How is your employer responding to your neck pain?

• Your co-worker? • Your family?• What are you doing to cope with neck

pain?• In reassessments if you suspect

underlying psychosocial issues you could ask: When do you think you will return to work?

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What skills are you developing?

• manual skills, relationship skills, condition knowledge (prognosis, etiology etc)

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Outcome measures – Can be found in MTABC low back and neck literature reviews

• Why use them?

 

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What is Evidence-Based Medicine?“Evidence-based medicine is the integration of best

research evidence with clinical expertise and patient values”

- Sackett & Straus

Ask

Acquire

Appraise

Apply

Act & Assess

Patient dilemma

Principles of evidence-based

practice

Evidence alone does not decide – combine with otherknowledge and values

Hierarchy of evidence

Process of EBP

Background & Foreground

‘Background’ Questions• About the disorder, test, treatment, etc.

2 components:

a. Root* + Verb: “What causes …”

b. Condition: “Rheumatoid arthritis”

• * Who, What, Where, When, Why, How

‘Foreground’ Questions• About patient care decisions and actions

4 (or 3) components:

a. patient, problem, or population

b. intervention, exposure, or maneuver

c. comparison (if relevant)

d. clinical outcomes (including time horizon)

10 Common Questions• Clinical findings

• Harm/etiology

• Differential diagnosis

• Manifestations

• Diagnostic tests

• Prognosis

• Therapy

• Prevention

• Experience, Meaning

• Learning

(Not exhaustive or mutually exclusive)

Keeping up to Dateby “Just in Time” Education

•Shift focus to your current problems– Relevant to YOUR practice – More memorable (and practice changed)– Up to date

•But Four Barriers– Admitting we don’t know– Skills in obtaining current best evidence– Evidence Resources at the point of care– Time