28 low back pain panel russellnagarelee final -...

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Team-based care for low back pain: A panel discussion

Clifford Lee, L.Ac., Melissa Nagare, D.C., L.Ac. & Robb Russell, D.C. SCU Health System Southern California University of Health Sciences

Academy of Integrative Pain Management San Diego, California

October 21, 2017

Team-based care for low back pain

Melissa Nagare, D.C., L.Ac. Vice President and Chief Clinical Officer Robb Russell, D.C. Assistant Vice President and Clinical Chief of Staff Clifford Lee, L.Ac. Clinician SCU Health System Southern California University of Health Sciences Disclosures / Conflicts of Interest No financial or other conflicts to report


Learning Objectives 1. Address how fragmentation and misdirected care, inappropriate incentives

and inefficient communication lead to poor outcomes for low back pain

2. Explain how team-based, relationship-centered care can refine the approach to low back pain to produce optimal patient outcomes

3. Explain how integrative care options can be pragmatically incorporated in a care plan

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Usual care

•  Educational, practice and policy silos•  Supermarket approach to treatment •  Lack of coordination •  Perverse incentives


Emerging, team-based care options •  Interprofessional education and practice•  Evidence-informed / Experience-informed•  Team-based, relationship-centered care


The goal of integrating care should be the provision of comprehensive care that is safe and effective care, that is collaborative and interdisciplinary, and care that respects and joins effective interventions from all sources. Institute of Medicine: Committee on the Use of Complementary and Alternative Medicine by the American Public Board on Health Promotion and Disease Prevention. Institute of Medicine. Complementary and Alternative Medicine (CAM) in the United States. Washington D.C.: National Academy of Sciences Press, 2005

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Uncomplicated Acute LBP

•  31yearoldmale•  2½weeksofLBPw/radia;on•  3-5/10;almostconstant•  Non-trauma;conset•  NoRedFlags•  Moderatedisability(ODI-24)•  Noneurologicalfindings•  Nopriorsimilar•  +Findings-RSIJoint

Dysfunc;on/Painw/Flexion/MyofascialTenderPoints

•  Noclearpaingenerator





A relatively straightforward presentation. Now what? •  What is the most efficient way to proceed? •  Is imaging advisable? •  Are medications appropriate? •  What integrative approaches are warranted? •  What team-based care is relevant? •  What does the Keele STarT Back Screening

Tool add to decision-making?

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Uncomplicated Acute LBP •  Keele STarT Back Screening Tool (SBST)

•  5/2 Moderate risk of chronicity •  Reassurance

•  SCU / SBST / ACP •  Advice sheet (regarding LBP)

•  SCU / SBST •  Self-management

•  SCU / SBST / ACP •  Imaging is not recommended

•  SCU / ACP •  Medication (NSAIDs)

•  Patient preference per ACP •  Manual therapy (HVLA)

•  SCU / SBST / ACP •  Ergonomic and advice regarding ADL

•  Per practitioner experience •  Specific exercises

•  Extension bias per practitioner experience; SCU

Resolution with three visits in two weeks

Team-based care: Case 1

A 49-year old female referred by PCP for constant, 7-10/10 severity LBP with radiation to left buttock and leg. Concurrent diagnoses:

–  fibromyalgia, type 2 diabetes, Raynaud’s disease, hypertension, rheumatoid arthritis, scleroderma, restrictive lung disease, psoriasis

Functional challenges: –  Inability to drive, do housework, and go for a walk

Goals: –  Drive, do housework, go for walks, do DIY household craft projects

Initial SBST score: high-risk for poor clinical outcome


Team-based care: Case 1 Treatment:

–  6 chiropractic treatments over four weeks –  Chinese medicine treatment (acupuncture and herbs) added at 4 weeks

Outcomes after four weeks of integrative treatment: –  Pain scale 2-3/10 severity –  Improvements in her ability to drive, do housework, and walk –  Improved confidence and depression levels

SBST score: moderate risk for poor outcome The patient has required long-term supportive care but has achieved a higher level of self-efficacy and functional abilities.


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Team-based care: Case 3 Referral for Adjunct Treatment

•  67 yo male with progressive neck and low back pain and stiffness since radiation treatment in 2003 (throat cancer)

•  Consultation and examination through Spine Care (chiropractic), referred to AOM upon mutual decision between examiner and patient

•  With 10 months of treatment involving acupuncture, cupping and tui-na: •  Low back pain minimal or not even felt by patient. •  Neck pain/stiffness reduced by 60-75% with increased AROM (specifically, rotation). •  Patient referred for regular massage therapy (1x/2 weeks) and periodic AOM follow-up (1x/

month) •  Neck pain/stiffness has maintained at reduced levels.


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Questions? Comments? [email protected]

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28 low back pain panel russellnagarelee final -...

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