Rebecca Courtney, PT, DPT. Supervisor, Ochsner HealthyBack

Transcription

1 Rebecca Courtney, PT, DPT Supervisor, Ochsner HealthyBack

2 What is the Healthy Back Program? A comprehensive treatment approach for patients with sub-acute chronic neck and back pain Includes MD assessment, physical therapy, health coaching, outcome collection, and a predictable progression from pain wellness Started in November 2012 Goal: Improve the way we care for chronic pain patients along with reduce overall healthcare expenditure among Ochsner-insured employees Has grown from a small bundled payment pilot program to a fully operational fee-for-service clinic

3 History and Development About 5 years ago, Ochsner completed a historical analysis of insurance claims to quantify and report the current cost and impact of back and neck pain to the organization ~20% of those insured were utilizing ~80% of the allotted cost on treating back and neck pain Many of these patients were receiving treatment, then re-entering the system with an average cost per year of ~$13,000 utilized on treating their back or neck condition Bottom line: They either weren t getting better or they weren t staying better! But why?

4 History and Development Inconsistency among management leading to overutilization Often a common diagnosis, but no common, predictable trends in treatment Many different providers providing many different interventions independent of each other This analysis helped Ochsner identify the need for an improved, more unified approach to treating chronic back and neck pain

5 Management: What We Know Healthcare is always changing! Emphasis on: -Evidence-based medicine -Accountable Care -Fee for Service Pay for Performance -Proving our worth by tracking outcomes, measuring results These principles combined with the need for process streamlining and improvement when it comes to managing chronic back and neck pain patients lead to the Healthy Back treatment approach

6 Goal Big Picture: To improve quality of care while reducing cost to the organization as a whole Having well-informed patients taking an active role in their care Focusing on return to function in addition to pain reduction Do we want our patients to just FEEL better or to actually GET better?

7 How it Works A multi-disciplinary team of skilled providers work together to deliver consistent, predictable, and effective treatment Treatment is based on evidence-based, research driven principles with measurable results Subjective/Objective Outcomes and Patient Satisfaction Scores are measured over a 12 month period

8 Who is Appropriate? Patients with sub-acute chronic neck or low back pain Patients who will benefit from an active, exercise-based treatment approach Patients who are independently ambulatory Pregnant women (with OB clearance) Post-operative patients >6 months (with surgical clearance)

9 Who is Not Appropriate? Patients with non-mechanical neck or low back pain Patients with acute neck or low back pain Patients with moderately limited mobility (i.e. wheelchair bound, unable to ascend/descend exercise equipment without moderate assistance, etc.) Patients with co-morbidities that would limit participation in an active, exercise-based program (i.e. moderate SOB, etc) Patients requiring only passive treatments such as modalities, (heat, e-stim, ionto), manual therapy, or aquatic physical therapy

10 Treatment Philosophy Treatment is designed to address both physical and psychological limitations in a methodical, reproducible, and highly effective way "If you can't describe what you are doing as a process, you don't know what you are doing." - W. Edwards Deming

11 Treatment Overview Meeting with Health Coach to complete initial intake questionnaires MD examination to screen for red flags. Appropriate mechanical back/neck pain patients referred to physical therapy Physical Therapist evaluation and baseline isometric testing conducted. Results compared to normative data Physical therapy POC developed with treatment ~2x/week for 10 weeks Health Coaching, isometric testing, and outcome collection throughout Transition to a 9-month Wellness Program for maintenance

12 Initial Intake Questionnaire Visual Analog Scale Oswestry Neck Disability Index Australian Quality of Life Index Patient-centered Goals

13 Physical Therapy Evaluation Focused history Posture/alignment Mobility/Movement Loss Motor Function/Sensory/Reflexes Special Tests (when indicated) Mechanical Movements/Loading Response Baseline isometric testing Initiate treatment on day 1!

14 Key Questions to Classify Pain It is important to Identify location of the WORST pain: Back or Leg? Neck or Arm? Is the pain constant or intermittent: Is there ever a time when the pain is a zero even though it might come right back? Does bending make the pain worse? Since your back pain started have there been any changes in your bowel and bladder control?

15 PT Treatment Principles Mechanical - Mechanical diagnosis and therapy (MDT): Repeated movement will reveal a directional preference in patients with mechanical low back pain Physiological - Musculoskeletal strengthening: Strengthening the low back and core muscles increase muscle strength, bone density, soft tissue, and decreases risk for future injury Fact: Muscle strength begins to decrease after age 40 There is a direct correlation between back pain and multifidus muscle atrophy

16 Stop the Cycle! Protective Posture Injury Pain Stiffness Postural Strain Weakness

17 Mechanical Mechanical pain responds to movement and position Determining movement preferences and strategies are key to reducing mechanical pain Goal: Empower individuals to manage their own pain Reduce Anxiety, Correct posture Restore normal joint movement and function Restore spinal and core strength Begin or return to desired activities

18 Movement Response

19 Physiological Muscles help support joints Movement is healthy and necessary Chronic pain inactivity Inactivity stiffness weakness more pain

20 Muscle Isolation A pelvic restraint system limits involvement from the hamstrings and gluteal muscles, isolating the multifidus and deep lumbar extensors for testing and exercise Isokinetic extension exercises load the spine through flexion and extension with progressive resistance

21 Muscle Isolation

22 Isometric Testing Baseline isometric testing of the lumbar/cervical extensors is conducted to obtain initial results and compare to normative data 50 80% of peak torque is used to determine an appropriate starting exercising weight Isometric testing is continued in set intervals Visit 10 Visit 20 6 months 12 months

23 Progressive Strengthening Progressive strengthening is initiated using principles of 7 seconds/rep, 1 set of reps, and working at a 5-9 RPE (Hard Very Hard on the Borg Exertion Scale) Resistance is progressively increased in 5 10% increments as patient is able to complete 20 reps at a slow, controlled pace with proper form Strengthening is continued 2x/week for 10 weeks as part of physical therapy treatment

24 Progressive Strengthening

25 Results

26 Results

27 Benefits of Resistance Exercise Muscular Strength Muscular Endurance Balance Flexibility Singh MF., Elderly Patients and Frailty, Graves JE, Franklin BA editors. Resistance Training for Health and Rehabilitation. Champaign: Human Kinetics, 2001

28 Full Body Strengthening Circuit Because your neck and back don t walk around by themselves! -Tamara Fryer, PT

29 Health Coaching Track and improve compliance with physical therapy treatment Collect and manage patient-reported outcomes Address psychological components of chronic pain through therapy visits Serve as a resource for patients with barriers to participation and success Provide additional health and wellness educational seminars and interactive meetings throughout the course treatment and maintenance

30 Outcomes Initial, midpoint, final, 6 month, and 12 month subjective and performance-based outcomes are collected Subjective outcomes include: VAS, ODI, NDI, PCO, and AQoL Objective, performance-based outcomes include isometric (IM) testing of the lumbar or cervical extensors "Without a standard there is no logical basis for making a decision or taking action." -Joseph M. Juran

31 Results Over the course of 10 weeks, Lumbar strength increased by 48% Lumbar range of motion increased by 15% Cervical strength increased by 51% Cervical range of motion increased by 29% As strength and ROM improve, we see a reduction in pain and disability and an increase in patient reported quality of life "Measurement is the first step that leads to control and eventually to improvement. If you can't measure something, you can't understand it. If you can't understand it, you can't control it. If you can't control it, you can't improve it." - H. James Harrington

32 Wellness 9-month supervised exercise program for continued compliance with mechanical physical therapy and strength maintenance We know age-old cliché to be true: If you don t use it, you lose it! Research supports life-long habits are more likely to be formed after a person has stuck with something for a year After all, we want our patients to not only feel better and get better TODAY, but to STAY better for years to come

33 The End Questions?