Effective Conservative Spine Care

#ThinkChiropractic

Low back pain (LBP) is a recurrent disorder that can occur anytime in a person’s life and 50% of people who experience LBP seek health care during an episode.[1] [2] At least 85% of those who do seek care are diagnosed as experiencing nonspecific/non-pathological LBP.[3] Effective management of LBP in the United States is challenging and therefore it is difficult to determine the best approach for each patient given the vast number of recommended conservative treatment options within our complex health care system.[4]

Researchers from Optum Health Care Solutions[5] in collaboration with researchers from the Jefferson School of Population Health[6] published an article in a 2013 edition of Population Health Management[7] titled, “Conservative Spine Care: Opportunities to Improve the Quality and Value of Care” that suggests the utilization of a “classification-based” model for the management of LBP which, in a clinical trial published September 29, 2011 in The Lancet, demonstrated practical potential for improving clinical outcomes and addressing incongruous utilization of services.[8] The STarT Back Screening Tool (SBST)[9] can be administered prior to initiating treatment and provides the portal of entry provider the opportunity to incorporate evidence-informed decision criteria and guidance regarding an appropriate conservative low back care pathway in which to place the patient.

The SBST approach changes the pattern of provider management and referral of LBP to coincide with primary care data that suggests approximately 55% of patients are at low risk of poor outcome (i.e. irrespective of treatment), 33% are at medium risk, and 12% are at high risk.[10] Using the SBST approach, low risk individuals usually benefit most from receiving reassurance and advice while treatment options for medium risk individuals are typically physiotherapy approaches to addressing pain and disability. However, providers who are skilled at cognitive-behavioral approaches in addition to physiotherapy interventions are best suited to render care to high risk individuals.[11]

When compared to current best practice, use of the SBST tool along with targeted treatments increased efficiency, improved clinical outcomes, and reduced health care costs. [4]

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[1] Dagenais S, Haldeman S. Evidence-Based Management of Low Back Pain. St Louis, MO: Mosby, Inc. (Elsevier); 2012:1–2.

[2] Kent PM, Keating JL. The epidemiology of low back pain in primary care. Chiropr Osteopat. 2005;13:13.

[3]Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344:363–370.

[4] Kosloff, Thomas M., David Elton, Stephanie A. Shulman, Janice L. Clarke, Alexis Skoufalos, and Amanda Solis. "Conservative Spine Care: Opportunities toImprove the Quality and Value of Care." Population Health Management. Mary Ann Liebert, Inc., 01 Dec. 2013. Web. 01 Feb. 2017.

[5] A health services and innovation company whose mission is to help make the health system work better for everyone.

[6] A college whose mission is to prepare leaders with global vision to examine the social determinants of health and to evaluate, develop and implement health policies and systems that will improve the health of populations and thereby enhance the quality of life.

[7] A journal that provides comprehensive, authoritative strategies for improving the systems and policies that affect health care quality, access, and outcomes, ultimately improving the health of an entire population. The Journal delivers essential research on a broad range of topics including the impact of social, cultural, economic, and environmental factors on health care systems and practices.

[8] Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary caremanagement for low back pain with current best practice (STarT Back): A randomisedcontrolled trial. Lancet. 2011;378(9802):1560–1571. https://www.youtube.com/watch?v=yVu6w_01p9k

[9] Developed by researchers at Keele University (United Kingdom) with funding from Arthritis Research UK

[10] Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: Identifying patient subgroups for initial treatment. Arthritis Rheum. 2008;59:632–641.

[11] Sowden G, Hill JC, Konstantinou K, et al. Targeted treatment in primary care for lowback pain: the treatment system and clinical training programmes used in theIMPaCT Back study (ISRCTN 55174281). Fam Pract. 2012;29:50–62.

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

Spine Health Program Overview

A compelling argument could be made that the most inefficient and ineffective area of health care is spine pain management. Nationally, direct costs of spine care have gone up six to eight times over the last 20 years accompanied by an even more dramatic increase in indirect costs (lost work days, decreased productivity). The bottom line: we are putting significantly more money into spine care, with worse outcomes.

The Spine Care Program offered by Lifetime Health Medical Group and Excellus BlueCross BlueShield is designed to address this issue. The program is based on a spine care pathway created by Spine Care Partners© and currently being implemented in hospital systems, ACOs and PCMHs as well as privately operated PCP and specialty groups.

The core of the program is an evidence-based, patient centered spine pathway based on a biopsychosocial model of care. Strong emphasis is put on patient choice, education and motivation in self-care. Educational websites, applications and specific self-care tools are being developed to support these patient directed efforts. Care is co-ordinated by a Primary Spine Practitioner (PSP), a licensed health care provider (i.e. physician, physical therapist, chiropractor, nurse practitioner). The PSP is trained in the pathway and necessary diagnostic, treatment and communication skill sets to effectively manage most cases by treating 85+% of spine patients and triage the rest to appropriate care.

PSPs are the hub of the diagnostic, management and treatment wheel. Relational care concepts create the infrastructure of the PSP/patient interactions, using validated psychosocial questionnaires and motivational interviewing techniques to more accurately access the ‘whole person’ impact of the spine condition and modify treatment and language used to motivate patients to fully participate in their own recovery and future management.

Another unique element of the program is the use of a multidisciplinary team of spine care providers to provide fast, effective quality patient care. The team seamlessly interacts to deliver a virtual value add, process driven model of spine care. Team members are identified through data, experience and peer recommendation. As “fast track” providers, they ensure pre-screened patients access to services within one-two business days, allowing quicker access to second level providers than can be acquired through a typical PCP/specialist interaction. This, in turn, allows ‘teachable moments’ between PSPs and PCPs, outline alternative and evidence based options to early or non-evidence based use of surgeons, injections, imaging and opioids. Evidence-supported shared decision making tools are discussed with patients with each pathway provider encountered. These concepts are supported by employer and community based public spine health initiatives, when possible.

Our spine program quality goals are aimed at better value through optimizing patient provider match, invoking process to the full spectrum of spine care (adding efficiencies via pathway adherence), and identifying psychosocial issues or early signs of perpetuating factors. We then align patient specific resources to address these early indicators of possible chronicity. We are early in our program, but our 'fast track' neurosurgeons enjoy the higher quality surgical patients they are seeing. We feel the timing of surgical intervention is often sub-optimal (too early, too late...) and these front end efficiencies help to right size the timing and the care.

Using data collection tools to examine episodes of care will allow us to monitor cost shifting and overall spine care costs. Strict outcome and patient satisfaction data will allow us to derive value measures to the individual practitioner or provider group level. Quality of life data and spinal registries are on the horizon.

We are evolving the program to a community-wide Spine Care Program to improve clinical outcomes (function, quality of life), the patient experience (patient satisfaction, patient directed outcome measures), and guide appropriate utilization of healthcare resources related to spine care (high value care).

For questions, research articles, or additional information, please contact: Brian Justice brian.justice@excellus.com