Physical Therapists and Physicians

Transcription

1 Physical Therapists and Physicians Working Together for Optimal Patient Outcomes 2018 Spine Care and Physiatry Symposium

2 Objectives 1. Understand key points from Providence system spine pathway work, particularly related to appropriate patients for physical therapist services 2. Psychosocial risk stratification and how it helps improve success and efficiency in treating people with back pain 3. Gain a greater understanding of how Providence Rehab Services is working to improve outcomes for your patients with back pain Overview of evidence-based physical therapist services for identification of back pain subgroup and matched treatment for optimal results Providence Rehab Services options for people with back pain 4. Working together to optimize patient outcomes 5. Time to address your questions

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4 People with Back Pain Common reason for seeking care in primary care, physiatry, and physical therapy Pain is a multidimensional experience Controversy continues to exist regarding most effective treatment Wide variability in treatment and referral patterns affects health care costs

5 Providence/Swedish System Spine Pathway Work groups Primary care Physiatry and neurology Surgery Pain Physical therapy Pharmacy 37-page document outlining best practice guidelines Right provider, right time Guidelines for pharmacy, imaging, surgical implants

6 Proposed System Spine Pathway

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8 Providence Oregon Rehab Services Back pain best practice Screening for rapidly progressive neurological deficit and red flags Psychosocial risk stratification Back pain subgroups with matched treatment Multiple service options

9 Physical therapist services 1:1 clinic-based PT Persistent pain services Pain education class STEP Telehealth pilot Long-term self-management maintenance program

10 Physical Therapy Pathway Patient with back pain Entry to PT services Rapidly progressing neurological deficits: send to emergency department Red flags: refer for medical follow-up Radiculopathy: consult with neurology or physiatry; consider MRI STarT Back Screening Tool PT as needed Low Risk Medium Risk High Risk Education, reassurance, medication (PCP) Possible PT Same as low risk + Best practice PT Same as medium risk + Biopsychosocially-minded care + MD & Behavioral Health If improved, discharge Improving but goals not yet met, reassess POC/continue If not improving in 4-8 weeks, refer back to MD

11 Back pain best practice Psychosocial risk stratification

12 STarT Back Screening Tool Thinking about the past two weeks, mark your response to the following questions: Disagree Agree My back pain has spread down my leg(s) in the past two weeks I have had pain in the shoulder or neck at some time in the last two weeks I have only walked short distances because of my back pain In the last two weeks, I have dressed more slowly than usual because of back pain It s not really safe for a person with a condition like mine to be physically active Worrying thoughts have been going through my mind a lot of the time I feel that my back pain is terrible and it s never going to get any better In general, I have not enjoyed the things I used to enjoy Overall, how bothersome has your back pain been in the last two weeks? Not at all Slightly Moderately Very much Extremely Total score (all 9): Psych subscore (questions 5-9): Keele University 1/8/2007. Funded by Arthritis Research UK.

13 Psychosocial complexity stratification High complexity High risk

14 Treatment tailored to high psychosocial complexity Focus on cognitive, emotional, and behavioral responses Multidisciplinary care, including behavioral health Gradual return to activity Tools for self-management

15 Back pain best practice Back pain subgroups

16 Back pain subgroups Evidence-based classification Matched treatment

17 Identifying back pain subgroups

18 Matched Treatment Physical Therapy Low Back Pain Clinical Practice Guidelines Matching Treatment to Back Pain Subgroup Subgroup Clinical Picture Key Matched Treatments Low back pain with movement coordination impairments Hypermobility and/or weakness is the main problem Needs strengthening, conditioning Low back pain with mobility deficits Acute low back pain with related lower extremity pain (somatic referral) Stiffness is the main problem May be deconditioned Non-radicular referral to the LE(s). Often similar to the movement coordination impairments (hypermobile/weak) group Needs stretching and mobilization May need strengthening & cardio May respond to McKenzie/MDT (repeated exercise) May need strengthening Low back pain with radiating pain Radicular referral to the LE(s) Screen for red flags/progressive neurological deficits Be aware of neural mobility protect in acute phase, mobilize in chronic phase Low back pain with related cognitive or affective tendencies Chronic low back pain with related generalized pain Pain and psychosocial issues are the main problem Treat objective impairments as well as addressing psychosocial and pain education needs Gentle cardiovascular exercise Multidisciplinary care

19 Back pain best practice Persistent pain services

20 Persistent Pain Services All therapists in Rehab Services have basic pain training Pain specialists Other services

21 Pain Education Class Free for current Rehab Services patients One-time, two hour class Understanding pain helps calm pain Current understanding of pain neurophysiology Self-management strategies and resources Understanding pain reduces pain there is hope

22 Oregon Pain Management Commission Pain Care Resources

23 Back pain best practice STEP

24 STEP: Spine Therapy Exercise Program Supervised exercise therapy for people with back and neck pain Failed previous therapies, including surgery, injections, PT, etc. Need a strength and conditioning program to enable them to perform their daily and work activities Number of treatments varies between 4 and 12, based on psychosocial complexity (STarT score) Goal is to establish a long-term, independent resistive exercise program

25 How do I know whether to refer to PT or to STEP? Typical PT back pain patient Patient with persistent pain Ready for supervised exercise Failed previous therapies Not sure? PT referral; PT will get the patient to the appropriate specialist/ program PT referral STEP referral STEP referral PT referral; PT will get the patient to the appropriate specialist/ program

26 Back pain best practice Long-term self management

27 Long-term exercise program Strong evidence that exercise alone or in combination with education reduces the frequency, duration, and severity of future episodes of back pain Building and maintaining capacity Physical activity is not associated with back pain flare-ups, but sitting, stress, and depression are Pradeep S, Rainville J, de Schepper E, Martha J, Harigan C, Huner DJ. Do physical activites trigger flare-ups during an acute low back pain episode? A longitudinal case-crossover feasibility study. Spine 2018:43(6); Steffens D, Maher CG, Pereira LSM, Stevens ML, Oliveira VC, Chapple M, Teixeira-Salmela LF, Hancock MJ. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. doi: /jamainternmed Published online January 11, 2016.

28 Back pain best practice Working together for optimal outcomes

29 Working together for optimal patient outcomes Patient

30 Working together for optimal patient outcomes Talking about to patients about their back pain Talking about imaging What to expect in PT Realistic expectations Fostering hope

31 Talking about imaging Early imaging Evidence shows that early imaging is not helpful for most people with back pain and that simple guidelines indicate when it s appropriate Persistent symptoms Guidelines often indicate that imaging is appropriate Cultural beliefs about imaging have repercussions

32 Talking about imaging

33 Talking about imaging

34 Working together for optimal patient outcomes Establishing realistic expectations You have had this for a long time. It s not going to go away immediately, but you will learn exercises and strategies to take better care of your condition. You will probably be able to move better and do more before your pain goes down. It will be important to continue with what you learn even after you start to feel better.

35 Working together for optimal patient outcomes Fostering hope Reinforcing idea that back pain is normal Imaging doesn t tell the whole story The body has great potential to heal People can learn the tools they need to manage their condition better Regular exercise helps prevent back pain

36 Take home messages 1. A message of hope is important and builds selfefficacy Imaging results don t mean you can t get better With a little work, you can learn to manage this better 2. PT offers a wide variety of services Evidence-based treatment Pain education 3. Long-term exercise and self-management

37 Questions?

38 Thank You!

39 References Back Boot Camp breaking down back pain. Accessed on 4/17/18. Brinjikji W et al. Systematic literarture review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol 2015:36: Childs JD, Flynn TW, Wainner RS. Low back pain: do the right thing and do it now. J Orthop Sports Phys Ther 2012;42(4): Chou R, Qaseem A, Owens DK, Shekelle P. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154: Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ. Low back pain clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther 2012;42(4):A1-A57. Downie A et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ 2013;347:f7095 doi: /bmj.f7095 Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther 2011;41(11): , Epub 3 June doi: /jospt Fritz JM, Brennan GP, Hunter SJ. Physical therapy or advanced imaging as first management strategy following a new consultation for low back pain in primary care: associations with future health care utilization and charges. Health Services Research 2015 Mar 16. doi: / Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral to patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine 2012;37(25): Fritz, JM, Cleland JA, Childs JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther 2007;37(6): Hadler N, Meira E, Hilton S. I am a placebo: and interview with Dr Nortin Handler MD. Pain Science and Sensibility Podcast. 12/28/17. Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378(9802): doi: /s (11) Karran EL, Hillier SL, Yau Y, McAuley JH, Moseley GL. A quasi-randomised, controlled, feasibility trial of GLITtER (Green Light Imaging Interpretation to Enhance Recovery) a psychoeducational intervention for adults with low back pain attending secondary care. PeerJ 2018:e Karlen EK. Implementation of evidence-informed physical therapy and chiropractic care improves value for patients. SpineLine 2015;Jan-Feb: Keele STarT Back Screening Tool Matched Treatments. Available at: Accessed on April 9, Pradeep S, Rainville J, de Schepper E, Martha J, Harigan C, Huner DJ. Do physical activites trigger flare-ups during an acute low back pain episode? A longitudinal case-crossover feasibility study. Spine 2018:43(6); Sackett, DL, Rosenberg, WM. On the need for evidence-based medicine. Journal of Public Health 1995;17: Srinivas SV, Deyo RA, Berger ZD. Application of less is more to low back pain. Arch Intern Med. 2012;172: Published online June 4, DOI: /archinternmend Stevans JM, Bise CG, McGee JC, Miller DL, Rockar P, Delitto A. Evidence-based practice implementation: case report of the evolution of a quality improvement program in a multicenter physical therapy organization. Phys Ther 2015;95: