Annette Weller, MD Next to the common cold, LBP is the 3 rd most - - PowerPoint PPT Presentation

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Annette Weller, MD Next to the common cold, LBP is the 3 rd most - - PowerPoint PPT Presentation

Nov 05, 2023 125 likes •366 views

Annette Weller, MD Next to the common cold, LBP is the 3 rd most common reason for physician office visits 1 Leading cause of disability under 45yo. 2 >26 million Americans between the ages of 20-64 experience frequent back pain 2 25% US Adults

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Annette Weller, MD

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Next to the common cold, LBP is the 3rd most common reason for physician office visits1 Leading cause of disability under 45yo.2 >26 million Americans between the ages of 20-64 experience frequent back pain2 25% US Adults have back pain lasting >1 day in the past 3 months3 1/3 with persistent pain 1yr after acute LBP Cost >$100,000,000,000/year4

  • 2/3 of which are lost wages & productivity

( 1CDC National Ambulatory Medical Care Survey 2010;

2National Centers for Health Statistics, 2006; 3Deyo et al, SPINE

2006; 4Bureau of Labor Statistics 2008;)

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Improved clinical outcomes & pt satisfaction through collaborative treatment Reduce progression to chronic pain Diminish burden on PCPs Reduce $ of care for back pain (Trillium RFP)

  • ED visits
  • Imaging
  • Surgical Interventions
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Nonsurgical first (unless red flags) Physiatry led / multi-disciplinary team Address Bio Psycho Social Model Shared decision making Patient focused/Patient friendly

  • Patient navigator
  • One-stop shopping

Outcome data collection

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Nonsurgical, Board Certified MD Physical Medicine

Neuro-Musculoskeletal Training

 Neurology  Non-surgical Orthopedic  Rheumatology

Rehab Medicine Focus on improving function Experience with multidisciplinary teams

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Bio-psycho-social model

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Nerve “Diskogenic” Muscles Facet joints Ligaments Bones Role of H&P

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False positive rates high for disk herniation or other abnormalities 63% Asymptomatic have abnormal disks on lumbar MRI (Jensen et al, N Engl J Med 1994) 86% ♂ / 89% ♀ cervical discs abnormal >60yo

(Matsumoto et al. J Bone Joint Surg [Br] 1998)

Use concordant w/ pt pain pattern & neurologic deficit

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MRI Complementary

  • Evidence of nerve injury
  • High specificity
  • ID radiculopathy when

normal MRI May differentiate peripheral nerve/root involvement ID other neurologic conditions that mimic radiculopathy

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Depression

  • pHQ9 Scale
  • Waddell signs

Anxiety/stress Pain avoidance behavior “Catastrophising”

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Job Dissatisfaction Job Modifications Distress (MMPI) Enabled behavior for secondary gain Family Support / Influence to forced life- style changes

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3,020 workers – 279 with low back pain Predictors:

  • Job dissatisfaction

“Hardly ever enjoyed work” were 2.5x more likely to report back injury

  • MMPI Hysteria scale, highest 20% were 2.0x

more likely to report back injury “Non-physical factors significantly impact the reporting of back injuries and may also affect patients’ response to medical treatment.”

(Bigos et al. Clin Orthop Relat Res., 1992, A Longitudinal prospective study of industrial back injury reporting )

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Bio

  • H&P
  • Imaging
  • Nerve Conduction Studies/Electromyography
  • Red flags/surgical indications

Psycho

  • Addressing non-organic findings
  • Pain and its emotional component

Social

  • Job & workplace satisfaction
  • Family dynamics
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Medications Physical therapy “Movement is good” Address psych-social issues Nutritional counseling and smoking cessation Education Shared decision making Goal: Improve function/movement with less pain

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Focused H&P to ID:

  • Non-specific LBP
  • LBP associated with radiculopathy or spinal

stenosis

  • LBP with another spinal cause

Appropriate use of Diagnostic Imaging Pt education with evidence based information

  • Encourage pt to remain active
  • Provide information @ effective self care options

Medications with proven benefit

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Goals:

  • Improved pt outcomes & increased pt satisfaction
  • Reduced progression to chronic pain
  • Reduced PCP burden
  • Decreased cost

Evidence from Priority Health Early anecdotes / case studies

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Fox J, et al. Spine 2013, The effect of required physiatrist lt ti t f b k i

 Priority Health Insurance required pts w/ non-

urgent spine surgical consultations to first have physiatrist consult (2007 – 2010)

  • Imaging studies ⇩18%
  • Referrals to surgeons more highly directed

(surgeon referrals ⇩48% resulting in surgical procedures only ⇩29%)

  • Pt satisfaction ⇧ through more involvement

and fewer surgeries

  • First year total spine care cost ⇩12.1% ($14M)

(Avg surgical cost ⇧8% reflecting increased ratio of fusions to total spine surgeries)

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Core staffing of:

  • Physiatrist
  • Therapist
  • Care Coordinator

Aligned Medical & Surgical Consultants Diagnostic Services Use of evidence based guidelines Pt/care provider shared decision making Collection & reporting of clinical outcomes

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31yo ♂, chronic LBP, sciatica 2 mo hx of LBP, L flank & abdominal pn with multiple ER visits MRI:

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79yo ♀, chronic LBP & prior disk injuries 1mo hx R post leg ache & R lateral hip/groin pn w/standing & walking PCPOrthoSpine Center Imaging:

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31yo ♀, LB and left leg pain x 6 mo Exam with intact strength/sensation, positive SLR on left Imaging:

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Annette Weller, MD mprehensive Spine Center