Efficient Spine Care in the United States

Back and/or neck pain are a prevalent issue in society today and it is estimated that 149 million work days are lost every year in the United States at a cost of $100-200 billion [i.e. lost wages and decreased productivity] due to low back pain alone.[1]^{,[2], [3]} The World Health Organization reports that currently the primary treatment for low back pain is analgesic medication and that the causes for its provocation are rarely addressed.[4] This ineffectual treatment protocol isn't necessarily the fault of the rendering primary care physician due to their “inadequate preparation for practice in the real world” with regards to musculoskeletal medicine.[5] In November 2014, DiGiovann, et al reported that North American medical schools have limited time devoted to musculoskeletal education and cite that only 30% to 40% of schools have required instruction in the musculoskeletal system.[6]^,[7],[8] This is unfathomable when the average total health expenditure per person with back and/or neck pain in the United States is 73% greater than for individuals in other countries.[9]^,[10] The time has come for a truly unbiased and integrative approach to the treatment of low back and neck pain a fact that has been evident within the medical community since 1999.[11]

In July 2011, Murphy et al published a commentary expressing the need for the implementation of a primary spine practitioner (PSP) to effectively triage patients experiencing spine related disorders (SRDs), conditions that include back pain, neck pain, many types of headache, radiculopathy, and other symptoms directly related to the spine. They state that the PSP “would function as the first contact for patients with SRDs, i.e. the first practitioner that a patient consults when he or she develops a spine problem and could also function as a resource for traditional PCPs (family practice physicians, general internal medicine physicians, pediatric, obstetrical/ gynecological physicians, primary care nurse practitioners or physician’s assistants) to refer patients who present with SRDs”. This implementation exhibits potential benefits to SRD patients (i.e. faster recovery, cost savings, iatrogenic[12] disability avoidance, increased productivity, decreased likelihood of becoming a chronic pain sufferer, high patient satisfaction, focus on prevention), our society ( i.e. knowledgeable care coordinator, SRDs as a public health initiative, improved worker productivity, less long term disability), and the overall healthcare system (i.e. controlling costs, unburdening traditional PCPs, more strategic specialist referrals, disruptive innovation, standardization of care, new evidence and technologies). [13]

Candidates for the role of PSP within our current system would be currently licensed healthcare providers (i.e. chiropractor, physician, physical therapist, nurse practitioner) who would receive additional training based on a spine care pathway which has already been implemented in hospital systems, accountable care organizations, patient centered medical homes,  and privately operated PCP and specialty groups.

The effectiveness of integrative care for SRDs has not only been clinically demonstrated but has been mandated by a renowned medical center’s health plan:

- A 2013 study of Washington state workers who had recently filed worker’s compensation claims due to back injury found a 41.2 percent decrease in lumbar spine surgeries when the claimant consulted a chiropractor first.[14]

- Priority Health a major health plan in Western Michigan found that when they required spine patients who were heading for a non-urgent surgical consultation to first consult a physiatrist, surgical referrals decreased 48 percent, spine surgeries decreased 25 percent, and surgical costs dropped 25.1 percent.[15]

- University of Pittsburgh Medical Center Health Plan requires that patients with chronic back pain undergo a minimum of three months of chiropractic and/or physical therapy before any spine surgery is approved.[16]

So why am I so adamant about this subject? In September 2013, Spine Care Partners in conjunction with Lifetime Health Medical Group and Excellus BlueCross BlueShield commenced the inaugural spine care pathway training which was conducted at Excellus’ corporate headquarters in Rochester, NY. Dr. Fralick and I had the honor of being part of that inaugural class and have experienced first-hand the benefits this evidence based and patient centered program exhibits. Everything the Murphy et al commentary envisioned, at least in regard to SRD patient benefits, has become a reality for the patients who have sought care in our office.

The desire for this integration on a community level became evident to us upon receiving a letter from Excellus Blue Cross/Blue Shield of Rochester dated 29 December 2014. In this letter they outlined a “Waived Copayment Pilot Program” whose purpose is to “help drive care to spine pathway trained practitioners so that the program’s value can be measured and compared to other modalities of treatment for back and neck pain”. This program will extend until 31 December 2015 and only include Excellus employees and their covered family members but underlines the fact that a major health insurer believes PSPs are credible portal of entry providers for patients who present with musculoskeletal conditions.

So I urge all of you who are reading this to share this information with your healthcare providers and encourage them to seek out these practitioners in your community and integrate them into their treatment plans for spine related disorders.   

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[1] Guo HR, Tanaka S, Halperin WE, Cameron LL. Back pain prevalence in US industry and estimates of lost workdays. Am J Public Health, 1999, 89(7):1029-1035.

[2] Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am, 2006, 88(suppl 2):21-24.

[3] Rubin DI. Epidemiology and risk factors for spine pain. Neurol Clin, 2007, 25(2):353-371

[4] Duthey, Beatrice, PhD. "Background Paper 6.24 - Low Back Pain." Priority Medicines for Europe and the World 2013 Update. Background Paper 6 - Priority Diseases and Reasons for Inclusion. BP 6.13 to 6.24 (part 2). World Health Organization, 15 Mar. 2013. Web. 11 Mar. 2015. <http://www.who.int/medicines/areas/priority_medicines/BP6_24LBP.pdf>.

[5] Association of American Medical Colleges. Medical School Objectives Project. Contemporary issues in medicine: musculoskeletal medicine education. Report VII. 2005.

[6] DiGiovann, Benedict F., , MD, Richard D. Southgate, , MD, Christopher J. Mooney, , MA, MPH, Jennifer Y. Chu, , MD, David R. Lambert, , MD, and Regis J. O’Keefe, , MD, PhD. "Factors Impacting Musculoskeletal Knowledge and Clinical Confidence in Graduating Medical Students."The Journal of Bone and Joint Surgery E185 96.21 (2014): n. pag. The Journal of Bone and Joint Surgery, Inc. The Journal of Bone and Joint Surgery, Inc.; STRIATUS Orthopaedic Communications, 05 Nov. 2014. Web. 17 Jan. 2015. <http://jbjs.org/content/96/21/e185>.

[7] DiCaprio MR, Covey A, Bernstein J. Curricular requirements for musculoskeletal medicine in American medical schools. J Bone Joint Surg Am. 2003 Mar;85(3):565-7.FREE Full Text

[8] Pinney SJ, Regan WD. Educating medical students about musculoskeletal problems. Are community needs reflected in the curricula of Canadian medical schools? J Bone Joint Surg Am. 2001 Sep;83(9):1317-20. Abstract/FREE Full Text

[9] Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingsworth W, Sullivan SD. Expenditures and

health status among adults with back and neck problems. JAMA, 2008;299(6):656-664.

[10] Rosner, Anthony. "Going About Spine Care the Wrong Way - Spine Care "bass-ackwards."" Dynamic

Chiropractic - News, Articles, Research & Information for Chiropractors. MPA Media, 01 Jan. 2014. Web.

10 June 2014. <http://www.lifeinmotionchiro.com/Educational%20Brochures/Going-About-Spine-Care-the-Wrong-Way.pdf>. Vol. 32, Issue 01

[11] Andersson GB, et al. A comparison of osteopathic spinal manipulation with standard carefor patients with low back pain. N Engl J Med 1999;341: 1426-1431

[12] of or relating to illness caused by medical examination or treatment.

[13] Murphy et al. The establishment of a primary spine care practitioner and its benefits to health care reform

in the United States. Chiropractic & Manual Therapies 2011, 19:17 http://chiromt.com/content/19/1/17

[14] Keeney B, Fulton-Kehoe D, Turner J. Wickizer TM, Chan KC, Franklin GM. Early predictors of spine

surgery after occupational back injury: results from a prospective study of workers in Washington

State. Spine, 2013;38(11):953-964.

[15] Fox J, Haig AJ, Todey B, Challa S.. The effect of required physiatrist consultation on surgery rates for back

pain. Spine, 2013;38(3):e178-e184.

[16] "DC Receives Federal Grant to Study Nonsurgical Alternatives to Surgery for Spinal Stenosis: Interview

With Michael Schneider, DC, PhD." Health Insights Today, March 2013.

Dangers of Forward Head Posture

Neutral posture is observed when a plumb line passes through the center of the ear, shoulder, hip, knee and just in front of the ankle (Illustration - LEFT). Forward Head Posture [FHP] is present when the head at rest is positioned in front of the center of the shoulder. The movement of this much weight (About ten pounds) in front of the plumb line causes a shift in the body's Center of Mass, or balance point.

The good news is that the human body has an exquisite self-balancing system to compensate for shifts of the Center of Mass. The bad news is that these compensatory changes can be quite extreme (Illustration - RIGHT ) and cause severe structural stresses and even changes in organ systems.

There is a predictable pattern of compensation as the body realigns the Center of Mass. This is called the Trinity of Forward Head Posture [FHP].

1. Head moves forward of the shoulders. This changes the body's center of mass and center of gravity, triggering a response in the body's balance system.
2. To counter-balance the mid and upper back drifts backward, the shoulders rotate inward.
3. In response to that movement, the pelvis tilts forward

Several major studies have concluded that FHP is a direct indicator of a person's overall health:

• Spinal pain, headache, mood, blood pressure, pulse, and lung capacity are among the functions most easily influenced by posture; however, many symptoms, including pain, may be moderated or eliminated by improved posture.¹
• Hyperkyphotic (hi-per-kie-fah-tick) posture [excessive curvature of the thoracic spine, commonly referred to as hunchback] predicts increased mortality. Interventions specifically targeted at improving hyperkyphotic posture could result in reduced mortality rates.²

What is Kyphosis?

• Researchers found that even mild forward head carriage is “detrimental” to a person’s “overall health”. They concluded that the farther the head/neck moved in front of the seventh (7^th) cervical vertebrae “all measures of health status showed significantly poorer scores” and that this forward translation increased a person’s pain and decreased their ability to function!³
• Researchers at the University of Leeds in the UK found a direct cellular connection between muscles in the neck and a part of the brainstem - called the nucleus tractus solitarius (NTS) - which plays a essential role in regulating heart rate and blood pressure. This finding quite possibly explains why an injury to the muscles of the neck (i.e. whiplash) can at times change a person’s blood pressure and heart rate. It stands to reason that repetitive use injury to these same muscles (i.e. slouched posture at your desk and/or computer, cell phone, tablet use) may very well adversely alter these vital signs too!

Poor Posture Alters Your Vital Signs

Major Effects of Forward Head Posture

- For every one inch the head sits forward of the shoulders, an additional 15-30 pounds of tension is placed on the muscles in the back of the neck.

The Physics of Forward Head Posture

- It has been estimated that a person with Forward Head Posture uses 30% more body energy to keep the body erect.

- As the body shifts, certain muscle groups get stretched and become weak, and other groups shorten, and become weak. This results in degenerative changes that twist and distort the spine and subsequently shorter stature.

 

<sup>There is nothing good about poor posture and regardless of the activity (work or play) posture affects your overall performance. At least 85% of the back/neck pain related issues that enter my office derive from improper posture. Poor bodily usage directly impacts the biological, psychological, and social aspects of our daily lives leaving us dysfunctional, exhausted, and in pain. Implementing proper body mechanics is simply a mindful adherence to good habits that must be practiced with moment to moment awareness.  

Even though poor posture is not self-correcting it can be reversed. A chiropractor near you utilizing manual therapy, therapeutic exercise, and lifestyle advice can help you overcome upper crossed syndrome [see image above] and return you to a neutral posture in no time</sup>

¹ Lennon J, Shealy N, Cady, RK, Matta W et al. Postural and Respiratory Modulation of Autonomic Function, Pain, and Health. American Journal of Pain Management. 1994;4 (1):36-3

² Journal of the American Geriatrics Society. Volume 52, Issue 10, pages 1662–1667, October 2004

³ Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976) 2005 Sep 15;30(18):2024-9.

⁴ The Journal of Neuroscience, 1 August 2007, 27(31):8324-8333

EXERCISE WALKING FOR BETTER BACK HEALTH

Taken from our 01 Aug 14 Spine-Health Powered Newsletter

People with ongoing or recurrent episodes of lower back pain should consider the benefits of walking as a low‐impact form of exercise.

Aerobic exercise has long been shown to reduce the incidence of low back pain. However, people with low back pain often find some forms of exercise too painful to continue, and therefore don't get the exercise they need to maintain good health. Exercise walking is one way to benefit from regular exercise while not aggravating the structures in the lower back.

BENEFITS OF EXERCISE WALKING

There are many inherent health benefits from a regular routine of exercise walking, such as:

 - Strengthens muscles in the feet, legs, hips, and torso - walking increases the stability of the spine and conditions the muscles that keep the body in the upright position.

 - Nourishes the spinal structures - walking for exercise facilitates strong circulation, pumping nutrients into soft tissues and draining toxins.

 - Improves flexibility and posture - exercise walking along with regular stretching allows greater range of motion; helps prevent awkward movements, and susceptibility of future injury.

 - Strengthens bones and reduces bone density loss - regular walking for exercise helps prevent osteoporosis and can aid in reducing osteoarthritis pain.

 - Helps with controlling weight- any regular exercise routine helps maintain a healthy weight, especially as one ages and metabolism slows.

EFFECTIVE EXERCISE WALKING TECHNIQUES

Using the following techniques will help improve the benefits of walking:

     1. Walk briskly, but as a general rule maintain enough breath to be able to carry on a conversation.

     2. Start out with a 5 minute walk and work up to walking for at least 30 minutes (about 2 miles) at least 3 to 4 times a week.

     3. Maintain good form while walking to get the optimum aerobic benefit with each step and help protect the back and avoid injury. These elements of form should be followed:

 - Head and shoulders: Keep the head up and centered between the shoulders, with eyes focused straight ahead at the horizon. Keep the shoulders relaxed but straight - avoid slouching forward.

 - Abdominal muscles: It is important to actively use the abdominal muscles to help support the trunk of the body and the spine. To do this, keep the stomach pulled in slightly and stand fully upright. Avoid leaning forward as you walk.

 - Hips: The majority of the forward motion should start with the hips. Each stride should feel natural - not too long or too short. Most people make the mistake of trying to take too long of stride.

 - Arms and hands: Arms should stay close to the body, with elbows bent at a 90 degree angle. While walking, the arms should keep in motion, swinging front to back in pace with the stride of the opposite leg. Remember to keep hands relaxed, lightly cupped with the palms inward and thumbs on top. Avoid clenching the hands or making tight fists.

 - Feet: With each step, land gently on the heel and midfoot, rolling smoothly to push off with the toes. Be mindful about using the balls of the feet and toes to push forward with each step.

DO I NEED WALKING SHOES?

Exercise walking, as with other forms of exercise, requires the right equipment for a safe and effective routine. Good walking shoes are an important investment; choosing the appropriate walking shoes is important to maximize the benefits of exercise walking.

Finding the proper walking shoe may take some time and a bit of money, but it is essential for achieving long and short term benefits. Shoes are the most important piece of equipment in walking.

Walking shoes provide a basic protection and mechanical support for the foundation structures of the body - the feet - which in turn help keep the entire body balanced and aligned. When there is a minute imbalance in the feet, the compensatory domino effect causes changes throughout the body.

Specifically, when the body's natural gait motion is off balance, the body counterbalances the problem by redistributing weight. This ultimately changes the natural posture and alignment of the spine, leading to muscle strain and back pain over time. Though the imbalance may seem minor, in the long run, the stresses added to the body can add up and cause unnecessary wear and tear.

The right walking shoes can help foster excellent balance and posture during exercise walking, while poorly fitted walking shoes can cause pain or increase susceptibility to injury. It is best to find a technical running shoe store that will watch the individual's walk and will provide a shoe that fits based on the individual's specific biomechanics (this service is not typically found in large chain stores).

Walking shoes should allow the feet to naturally roll slightly inward (pronation) and outward (supination) to help absorb the different forces acting on the body. For many people, either one or both feet under pronate (roll outward) or over pronate (roll inward), altering the balance and length of the leg during stance, as well as gait. Some shoes are designed to control over pronation, whereas others are designed to encourage pronation.

Therefore it is important to make sure that walking shoes match each individual's specific biomechanical pattern.

An additional side effect of pronation and supination is the change in the natural curvature of the arches of the feet.

The feet are the crucial elements of gait motion, and maintaining a smooth gait is critical to preserving good spinal health. To ensure the correct balance during exercise walking, one must limit over pronation and under pronation of the feet. Good walking shoes should provide this stability.

USING A TREADMILL

When using a treadmill for walking exercise, all of the above guidelines are still important, with the additional caution to avoid using the handrails as much as possible (unless they are needed to keep balanced).


Click here for more information about walking and guidelines for buying walking shoes: http://www.spine- health.com/wellness/exercise/walking-  shoes-exercise-walking

Chiropractic Care Boosts Surgery Avoidance

This PSA from the Foundation for Chiropractic Progress discusses how chiropractic care has enabled many people to avoid invasive surgical procedures. 

Back on the Job - Chiropractic Care

Thank You for your Trust and Support!!

Just wanted to take a moment and express my sincere thanks to all of my LinkedIn connections who have taken time out of their day to endorse my knowledge, skill, and ability with assessing and treating musculoskeletal pain and dysfunction. I am very humbled and honored to have your support. Have a great day!!

https://www.linkedin.com/in/drseanpkonraddc

Making The Case for Primary Spine Practitioner Care

Better Option to Back Surgery

“The American Association of Medical Colleges has identified musculoskeletal medicine as an area in which students receive inadequate preparation for practice in the real world.[1] North American medical schools have limited time devoted to musculoskeletal education. Only 30% to 40% of schools have required instruction in the musculoskeletal system.[2][3] Graduates entering practice experience the effects of this lack of instruction; one survey found that half of family physicians reported inadequate musculoskeletal training for clinical practice.[4]”[5]

These are not the words of an opinionated and/or biased chiropractor but those of clinical researchers at the University of Rochester School of Medicine and Dentistry. They admit that as of November 2014,[5] most primary care physicians graduating from medical school lack the confidence to assess and treat musculoskeletal complaints. This fact alone creates a substantial argument for the necessity of an integrative system of healthcare delivery that incorporates Primary Spine Practitioner (PSP) trained providers who possess the knowledge, skill, and ability to triage[6] patients with musculoskeletal complaints.

PSP trained providers [DC, PT, MD, NP, PA] can evaluate and manage the majority of patients with musculoskeletal conditions based upon best available evidence, and in a patient centered model of care. This portal of entry into the healthcare delivery system can then streamline the referral process for those patients who need a level of care beyond that of standard musculoskeletal treatment. Incorporating this type of provider would alleviate the burden of musculoskeletal complaints from primary care practices allowing medical doctors to focus on infectious disease and serious pathology, conditions they ARE TRAINED FOR.  

The desire for this integration became evident to us upon receiving a letter from Excellus Blue Cross/Blue Shield of Rochester dated 29 December 2014. In this letter they outlined a “Waived Copayment Pilot Program” whose purpose is to “help drive care to spine pathway trained practitioners so that the program’s value can be measured and compared to other modalities of treatment for back and neck pain”. This program will extend until 31 December 2015 and only include Excellus employees and their covered family members but underlines the fact that a major health insurer believes PSPs are credible portal of entry providers for patients who present with musculoskeletal conditions.

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[1] Association of American Medical Colleges. Medical School Objectives Project. Contemporary issues in medicine: musculoskeletal medicine education. Report VII. 2005.

[2] DiCaprio MR, Covey A, Bernstein J. Curricular requirements for musculoskeletal medicine in American medical schools. J Bone Joint Surg Am. 2003 Mar;85(3):565-7.FREE Full Text

[3] Pinney SJ, Regan WD. Educating medical students about musculoskeletal problems. Are community needs reflected in the curricula of Canadian medical schools? J Bone Joint Surg Am. 2001 Sep;83(9):1317-20.Abstract/FREE Full Text

[4] Sneiderman C. Orthopedic practice and training of family physicians: a survey of 302 North Carolina practitioners. J Fam Pract. 1977 Feb;4(2):267-50.Medline

[5] DiGiovann, Benedict F., , MD, Richard D. Southgate, , MD, Christopher J. Mooney, , MA, MPH, Jennifer Y. Chu, , MD, David R. Lambert, , MD, and Regis J. O’Keefe, , MD, PhD. "Factors Impacting Musculoskeletal Knowledge and Clinical Confidence in Graduating Medical Students."The Journal of Bone and Joint Surgery E185 96.21 (2014): n. pag. The Journal of Bone and Joint Surgery, Inc. The Journal of Bone and Joint Surgery, Inc.; STRIATUS Orthopaedic Communications, 05 Nov. 2014. Web. 17 Jan. 2015. <http://jbjs.org/content/96/21/e185>. 

Investigation performed at the Department of Orthopaedics and Rehabilitation, University of Rochester School of Medicine and Dentistry, Rochester, New York

[6] Process of organizing several patients for treatment. The process of deciding which people in a hospital department should get medical treatment first, according to how serious their condition is..

Link to the full article:

https://plus.google.com/114651765255995665833/posts/4PEFAr1kaDQ

Unlock Your Healing Potential with Chiropractic Care

Patient centered and evidence-based chiropractic clinic that assists patients in overcoming their back pain, neck pain, extremity pain or headaches. We educate, motivate, and empower patients via cost effective and clinically effective active care plans that induce high patient satisfaction.