changing the culture of pain treatment · warwick • lincoln • providence • newport county •...

Changing the Culture of Pain TreatmentRehabilitative Health Department

October 19, 2019

This symposium is supported by

funding from the Rhode Island

Executive Office of Health and

Human Services Healthcare

Workforce Transformation Program

Warwick • Lincoln • Providence • Newport County • Westerly • Online

This activity has been planned and implemented in accordance with

the accreditation requirements and policies of the Accreditation

Council for Continuing Medical Education (ACCME) through the joint

providership of the Warren Alpert Medical School of Brown University

and the Community College of Rhode Island. The Warren Alpert

Medical School of Brown University is accredited by the ACCME to

provide continuing medical education for physicians.

This continuing nursing education activity was approved by the

Northeast Multistate Division, an accredited approver by the American

Nurses Credentialing Center’s Commission on Accreditation.

Accreditations


• Physicians:

The Warren Alpert Medical School of Brown University designates this live activity for

a maximum of 3 AMA PRA Category 1 CreditsTM. Physicians should claim only the

credit commensurate with the extent of their participation in the activity.

• Physician Assistant/Nurse Practitioners/Physical Therapists/Occupational Therapists/Massage Therapists:

Participants will receive a Certificate of Attendance stating this program is

designated for 3 hours AMA PRA Category 1 CreditsTM. This credit is accepted by

the AAPA, AANP, RI Board of Physical Therapy, RI Board of Occupational Therapy

and RI Board of Massage Therapy.

• Nurses:

This continuing nursing education activity was approved by the Northeast

Multistate Division, an accredited approver by the American Nurses Credentialing

Center’s Commission on Accreditation, for 3.25 Contact Hours.

Continuing Education Credit Designation


Conflict of Interest

In accordance with the standards set forth by the Accreditation

Council on Continuing Medical Education (ACCME) and the

American Nurses Credentialing Center (ANCC), planners and

presenters have been asked to disclose any relevant financial

relationships discussed in any educational presentation. Any

potential conflicts of interest have been resolved prior to this

presentation.


The following speakers has indicated that they have a relevant financial relationship to

disclose:

Matthew Smith, MD, EMHL

Major Stockholder: University Orthopedics, Inc.

Martine Delonnay, MD, ND

Consultant at BSD Sante PAP, Haiti, Owner of DELONNAY Holistics

The following speakers and/or planning committee members* have indicated that they

have no relevant financial relationships to disclose:

Faculty Disclosures

Karlo Berger, AOBTA, BCLMT* Regina Cobb, MSW, BCLMT, CMLD* Latisha Michel, CCHWVictoria Moutahir, BCLMT, MS*Jennifer Reynolds, DPT, TPSFrancis Sparadeo, PhDMaria Sullivan, BS*Julia Twining, MSN, RN, OCN

Mackenzie Johnson, MSN, RN*James McDonald, MD, MPH* Nancy Dooley, PhD, OTR/LEllen Flynn, MD, MTS Michael Gottfried, BA, MA, DC Jennifer Hurrell, PT, MS, DHScJennifer Jackson, DAOM, MSOM, LMT


• Recognize psychosocial risk factors for patients with pain.

• Evaluate outcomes of integrative therapy options to manage pain.

• Analyze patients’ biopsychosocial elements related to pain.

• Identify various treatment plans for pain management.

• Describe steps in the referral process for prescribing

non-pharmacologic pain management.

Learner Outcomes/Objectives


Criteria for Successful Completion

Upon completion of the live educational activity, participants will

complete an evaluation stating whether the learning outcomes were

met and self-report intent to change practice.

Participants must be present the entire length of the live presentation to

earn contact hours.


Donna Donilon, Ph.D., RN-BC

Executive Director

Healthcare Workforce Transformation Initiatives


Suzanne Carr, Ph.D., RN

Interim Dean

Health and Rehabilitative Sciences


Regina Cobb, MSW, BCLMT, CMLD

Program Director & Associate Professor

Massage Therapy Program


Matthew Smith, MD, EMHL

Clinical Assistant Professor of Orthopedics

Warren Alpert Medical School of Brown University

Director of System Integration,

University Orthopedics, Inc. Chair,

Value Committee, North American Spine Society


Jennifer Hurrell, PT, MS, DHSc

Professor

Rehabilitative Health Department


30 Minute

Break


Panel One

Acute Pain Management


• Board Certified, Licensed Massage Therapist since 1998

• Owner of Body Kneads, Inc. - founded in 1999

• Instructor since 2005, Continuing Education Provider

• Professional Organizations– Alliance for Massage Therapy Education

– National Certification Board for Therapeutic Massage and Bodywork

– American Massage Therapy Association Board Member

• Certifications– Orthopedic Massage

– Manual Lymphatic Drainage

– Oncology Massage

Victoria Moutahir, MS

I believe massage therapy is a preventative and proactive approach to healthcare


• Licensed Acupuncturist and Massage Therapist

• Earned Bachelor's Degree in Exercise Science from Sacred Heart University in 2001

• Earned an Associate Degree in Massage Therapy from CCRI in 2002

• Earned a Master Degree (MSOM) in 'Oriental Medicine' (Acupuncture and Herbal medicine) from Southwest Acupuncture College in 2011

• Traveled to and studied in Japan in 2011 and 2014 with Master Acupuncturists

Dr. Jennifer S Jackson, DAOM, LMTOcean Ki Acupuncture


• Occupational therapist for 28 years

• Practice has focused on the needs of people with serious and

persistent mental illness and on older adults facing multiple

challenges to their health and independence.

• After almost 20 years as a professor and director at New

England Tech, now is an Associate Professor in the

occupational therapy department at Worcester State

University.

• Holds master’s and doctoral degrees from New York University.

Nancy R. Dooley, Ph.D., OTR/L

Occupational Therapy

Ellen Flynn, M.D., MTS

Clinical Assistant Professor

Department of Psychiatry and

Human Behavior

Clinical Assistant Professor

Department of Medicine


Julia Twining

MSN, RN, OCN

• Registered Nurse for 25 years with experience in Oncology (inpatient and outpatient), Orthopedics, and Hospice

• BSN and MSN, Rhode Island College

• Advanced Practice Manager at The Miriam Hospital assigned to the inpatient Oncology and Medical-Surgical unit and the Float Pool

• Reiki Master, 2016

• Started the Integrative Therapy Program at TMH in April, 2019. This program provides complementary therapies to patients admitted to the hospital. The focus of the program is to reduce pain, anxiety, and fatigue with patients.

• Adjunct nursing instructor for URI and RIC


Karlo Berger, AOBTA, BCLMTProfessor

Therapeutic Massage Program

Adjunct Professor in CCRI’s Therapeutic Massage Program since 2009, with a focus on

instructing students in Japanese-style shiatsu massage, traditional Chinese medicine, and the

integration of eastern and western evidence-based clinical massage techniques.

Registered Instructor in shiatsu with the American Organization for Bodywork Therapies of Asia.

Has practiced shiatsu massage at Harvard University Health Services, Harvard Vanguard Medical

Associates, and Beth Israel Deaconess Medical Center, and currently maintains a private practice

in Providence specializing in pain management.

Graduate of Brown University and received his massage training at the Bristol School of Shiatsu

and the Boston Shiatsu School.

A founder and leader of various integrative healthcare initiatives, including the Boston-based

Integrative Medicine Alliance, the Rhode Island Birth Network, and the Integrative Medicine at

Brown clinical forums. Currently coordinates the Rhode Island Non-Opioid Pain Treatment

Coalition.


Nicole is a 25-year-old African American woman with two children under

the age of five who sustained a third-degree ankle sprain in a motor

vehicle accident.

She was transported to a local hospital emergency department (ED)

where she was treated: her ankle was placed in a boot and she was

given crutches.

The treating clinician assessed the patient prior to prescribing pain

medication.

Case Study #1 – Nicole


Nicole has a personal and family history of addiction, a history of mood

disorder, unipolar depression, and she smokes a pack of cigarettes a week.

In a minor car accident two years ago, she suffered a mild concussion when

her air bag deployed, hitting her in the face.

She and her young children live with her elderly maternal grandmother in

Providence while she attends college.

She works full-time at a department store.

Case Study #1 – Nicole


Victoria Moutahir, MS

Licensed Massage Therapist

Owner of Body Kneads, Inc.


RI Law and Regulation Statute, § 23-20.8-1 as of April 2019.

5) “Massage” means the systematic and scientific manipulation of the soft tissues of the body accomplished by

the use of digits, hands, forearms, elbows, knees, or feet, hand-held tool or other external apparatus. Massage

may include the use of topical applications.

(6)"Massage therapist" means a person engaged in the practice of massage and is licensed in accordance with

this chapter of the general laws of the state of Rhode Island.

(7)"Massage therapy” means the use of massage for therapeutic purposes, including, but not limited to: pain

management, stress reduction, promotion of relaxation and enhancement of general health and well-being.

Massage therapy includes, but is not limited to, evaluation of soft tissue and normal movement of the body to

develop an appropriate massage therapy session and the delivery of self-care and health maintenance

information.

Massage is recognized by the National Institutes of Health (NIH), and included in

nonpharmacological pain guidelines issued by The Joint Commission, as well as the

American College of Physicians (ACP) and the Federation of State Medical Boards. It is

recognized by the Department of Defense and the Veterans Health Administration as an

effective treatment for chronic pain, is included in DoD/VA pain management guidelines and

is a covered service in DoD/VHA facilities.

(https://www.amtamassage.org/uploads/cms/documents/mt_in_integrative_care_and_pain_

management.pdf, accessed 10/15/18)

THERAPEUTIC MASSAGE DEFINITION


ANALYSIS OF NICOLE –

BIOPSYCHOSOCIAL FACTORS

Assumptions based on case information- Nicole has insurance and benefits from her full time job. Is willing to participate in treatment as she seems focused on bettering her self and her life.

During the intake, I want to know: When did the accident happen? What the treating physician prescribed for pain and what other meds

Nicole is taking.

Nicole’s stress level based on taking care of 2 young children, working full time, taking college courses,

? caring for elderly grandmother. How does she feel about the injury?

What kind of treatment did Nicole receive after the 1st accident? What does Nicole do for self care? Before the accidents and now.

Nicole’s availability of time and money (if treatments are not covered by insurance),

When was Nicole diagnosed with unipolar depression and mood disorder. Treatment prescribed?

Does Nicole have financial concerns if unable to work as this will affect payment of massage treatments.

Does Nicole have support from other family members, friends, community?

Is Nicole familiar with massage therapy and the benefits?

Assessment - range of motion, intensity of swelling, referring pain, past/current pathologies and treatments.


Treatment Plan for NicoleAssumptions: Client is 6 weeks post injury and has medical clearance to receive massage. Client may be in a boot but can remove the boot for treatment. All necessary releases and HIPAA paperwork has been signed so all disciplines involved with recovery can talk with each other.

Treatment Plan:Start with 60 minute treatments that include Manual Lymphatic Drainage treatments to help decrease the swelling and light massage work on lower body (pelvic girdle to feet).

Client will receive 4 treatments no further than 1 week apart and on a different day than the other treatments are being administered.

Reassess client after 4 treatments and start to spread out treatments 10 days to 2 weeks. Begin focus on scar tissue work.

Continue massage therapy for at least 15 treatments gradually further apart and until client is able to come in for maintenance or progress of treatment stops.

Goals for Treatment:

• Decrease swelling.

• Increase blood flow to the area.

• Reduce scar tissue formation.


Documentation for Massage TherapySample SOAP note:

10/19/19- 60min. tx.

Cl. reports being in a car accident on 9/1/19, has 3rd degree ankle sprain (R side) and is walking with the aid of a boot. Cl. also reports pain in her low back, legs, and neck since. Cl. did not see the car coming and was hit hard enough that she was pushed into the car in front of her. Cl. was taken from the scene on a stretcher and treated at ER for injury. Cl. had to take 3 weeks off from work. Cl. said her she was in a previous accident and suffered a mild concussion from airbag. Cl. reports having neck issues since that accident. Cl. has been working with PT since her accident as well.

LMT observed R hip and sh. appearing higher than L side and when cl. was prone, R hip and erector appeared incr. raised than L side. Prone: LMT focused on sacrum and pelvic girdle to address the sacroiliac joint. TP work on gluts into acetabulum, bilaterally, seemed to release the adhesions. Iliocostalis region, R side, felt tight and cl. reported referred pain into glut when LMT worked the area. Deep effl. and traction applied to area. LMT worked intercostals, bilaterally. Supine- LMT applied MLD work on legs and feet. Worked neck, sh. girdle and arms. All areas very tight and cl. reported it was tender to touch. Traction applied and seemed to relax the tissue, hyperemia to area. Upper traps tight esp. at base of neck, L side felt incr. adhesed. Specific work to c-spine revealed tenderness at base of neck. Forearms felt stringy, ? use of crutches. TP work, traction, and rocking applied to neck. Post tx, cl. reported feeling much better and she said her ankle movement was better. Cl. also said her hips wer less painful and she didn't feel the constant pulling. Cl. completed insurance paperwork and releases for billing. Cl. will return 10/26. VM


Jennifer Jackson, DAOM, LMT

Acupuncturist, Licensed Massage Therapist

CrainoSacral Therapy Practitioner

Ocean Ki Acupuncture


Acupuncture

BALANCE ~YIN YANG

QI

Blood

Stagnation/Deficiency/Excess


Patient: Nicole

25 y.o. female

hx of: 3rd degree ankle sprain/mild concussion ( 2yrs

old)/depression, mood disorder

Intake

Assess the system(whole body)

• Assess the ankle

• Feel pulses, abdomen, meridians

• Check pulses, make diagnosis

Treatment

Includes whole system(body)

• Root tx,

• Branch tx

• Treat affected area

Follow Up

Take Home Treatment

• Give access and instructions to patient for mini at-home heat treatments.

• This will help reduce inflammation and pain

• Schedule a follow up appointment


Nancy Dooley, Ph.D., OTR/L

Associate Professor, Occupational Therapy

Doctorate Program, Johnson & Wales

University Development Chairperson, Rhode Island

Occupational Therapy Association


Occupational Therapy

Occupational therapists and occupational

therapy assistants help people of all ages do the

things they want to do and need to do through

the therapeutic use of everyday activities

(occupations).

American Occupational Therapy Association,

2018


Model of Human Occupation


• Maximize ability to function in life roles while the ankle heals

• If a knee walker is covered, it may provide increased independence

since crutches require 2 hands

• Discuss, demonstrate and practice using adaptive devices and

techniques to complete occupations

• Assess home environment including safety issues related to kids and

grandmother (as an outpatient would be thru pictures or interview)

• Problem solve on maintaining life roles to avoid depression, etc.

Occupational Therapy intervention plan

34


How to Access Occupational Therapy

• In Rhode Island you do not need a doctor’s order for an

occupational therapy evaluation and creation of an intervention

plan

• The registered occupational therapist uses scientific evidence and

collaboration with the client to determine best plan

• BUT, if you want most insurers to pay for the occupational therapy

sessions, you do need a prescription.

• More information: American Occupational Therapy Association

www.aota.org


Ellen Flynn, MD, MTS

Clinical Assistant Professor,

Department of Psychiatry, Department of Medicine

Warren Alpert Medical School of Brown University


Mindfulness

Objectives

• Implications of Stress on Pain

• Mindfulness – what it is and isn’t

• What is the role of Mindfulness in Pain

Management?


• Cardiovascular Effects

– Increased HR and Blood Pressure

• Systemic Effects:

– Increased release of glucose for energy

– Shut down of digestion/GI function

• Immune System Effects:

– Up-regulation of inflammatory response system

– Increased blood clotting

• Sexual Side Effects:

– Shuts down reproductive function

Flight, Fight or Freeze


• Brain Shrink – Hippocampal Atrophy

• Altered Brain Function and Connectivity

• Dysfunctional cognitive looping leading to heightened

perception and privileging of negatively charged output

• Reduced executive function

YOUR BRAIN ON CHRONIC STRESS


Stress

Mind & Body Dis-ease

Stress

Illness


Mindfulness: Paying attention on purpose, in the

present moment, non-judgmentally

- Jon Kabat-Zinn


Medicinal Effects of Mindfulness

• Enhances Parasympathetic Tone:

rest, relaxation, healing, and cellular maintenance

• Improved Regulation of Inflammatory System

• Decreased Sympathetic Activation

• Promotes Neurogenesis in Brain Regions Sensitive to

Serotonin Depletion

Creswell JD et al., Biol Psychiatry 2016; 80:53-61; Holzel BK et al, Psychiatry Res; 2011; 191:36-43


Nicole: How might mindfulness apply?

• Decrease Sympathetic Activation

• Enhance her capacity not only to attend to painful sensations

but also promote flexibility of attention

• Increase her tool kit for working with difficult

physical/emotional

experiences – taking the pain out of pain

• Allow more effective reframing of the experience of pain

– not me, not mine, not who I am


Thank you!


Julia Twining, MSN, RN, OCN

Advanced Practice Manager

The Miriam Hospital


Case Study 1:

Integrative

Therapy

Reiki and

Guided

Breathing

Exercises

Reiki could be very effective in managing her pain and

stress.

Reiki is an energy technique that uses gentle hands-on approach or no touch and visualization

techniques, with the goal of improving the flow of life

energy.

Practitioners are trained to detect and alleviate

problems of energy flow on the physical, emotional, and

spiritual level.

Reiki therapy is used to relieve pain, anxiety, and

stress. Reiki can also improve the symptoms of various health conditions.

Guided breathing exercises can also be helpful in managing periods of anxiety and stress.

Guided breathing exercise can be taught to Nicole and

she can do them on her own when needed.

Nursing


Case Study 1:

Analysis

25 y.o. mother of 2, under the age of 5

History of mood disorder

Unipolar depression

Smoker, 1 PPW

History of mild concussion

Lives with elderly grandmother – who may be providing childcare for grandchildren

Works full time while attending college

Third-degree ankle sprain

• Now walking on crutches with boot

• Impacts her functional mobility and ability to work and go to school


Case Study 1: Treatment plan

Reiki session 20-30 minutes each day.

There is a cumulative effect with Reiki and the benefits can increase with each intervention.

Reiki can help promote a sense of calm and a reduction in the perception of pain.

1

Teach Nicole guided breathing techniques she can use every day and when needed.

Breathing techniques will slow down her breathing when she is feeling anxious or stressed and during periods of pain and/or feeling overwhelmed. Slowed breathing will also relax her muscles and potentially decrease her pain.

2


Situation: 25 year old African

American female who sustained a

third degree ankle sprain in a

MVA. Transported to ED and

treated, given a cast and

crutches to ambulate.

Background: Second MVA in 2

years. During the first MVA she

sustained a mild concussion from

the airbag deployment. She was

involved in a second MVA today,

she sustained a third degree

ankle sprain. Nicole has a history

of addiction (including family

history), mood disorder, unipolar.

Action: Start Reiki 20-30 minute

daily Reiki sessions and teach

guided breathing exercises to

decrease and manage pain

and anxiety.

Response: Anticipated response

would be decreased pain and

anxiety. Increased ability to

cope with stress and increased

functional mobility.

Patient: Pain assessment using

CAPA developed by the

University of Utah, see next slide.

Documentation Using SBAR-P


Assessment to be done during a

conversation with Nicole about how her

pain is affecting her in these 5

categories below.

Comfort: Intolerable (during periods of

pain)/Comfortably manageable when

pain interventions are effective.

Change in Pain: Getting worse/better

Pain Control: Inadequate/Effective

Functioning: Can’t do anything

because of pain/Can do most things

Sleep: Awake most of the night/Awake

with occasional pain

Documentation of Pain Assessment Using CAPA


15 Minute

Break


Panel Two

Chronic Pain Management


Jennifer Reynolds,

DPT, TPS• Doctor of Physical Therapy

• Advanced Certification in Pain

• Over 13 years experience in orthopedic and

pelvic physical therapy

• Presented internationally on Pain, Mindfulness

and Physical Therapy

• Annual Speaker at the Warren Alpert Medical

School of Brown University Comprehensive

Spine Conference

• Recognized by the International Spine and

Pain Institute for Exceptional Performance in

Therapeutic Pain Specialist certification

program


Martine Delonnay, MD, ND


• Community Health Worker at the Newport Health

Equity Zone (Newport HEZ)

• Founder of Ready Set Latch Go

• Certified Doula

• Certified Lactation Counselor

• Maternal Child Health Specialist

Rhode Island’s Health Equity Zone (HEZ) initiative is a place-based,

community-driven approach to eliminating health disparities. HEZ carry

out locally-tailored approaches to prevent chronic disease and improve

the socioeconomic and environmental conditions of neighborhoods.

Latisha Michel, CCHW


Clinical Neuropsychologist/Health Psychologist

Private Practice

Career began at RIH/Brown University following a 2-year fellowship in

Behavioral Medicine and Neuropsychology

37-years assessing and treating Chronic Pain

Director of Rehabilitation Psychology at RIH (1982-1989)

Co-Director of the Interdisciplinary Spine Program at RIH 1994-2006

Chief Consultant at CODAC in the Pain and Addiction Program

Research Consultant to Calmar Pain Relief

Chief Trainer for the Massachusetts Rehab Commission on Substance

Use Disorders, Traumatic Brain Injury and Chronic Pain

Frank R. Sparadeo, Ph.D.


Edward, a 52-year-old Amazon fulfillment center worker of Portuguese

decent, lives in Tiverton with his wife. He injured his back at home

getting ready for a move.

It is now 2 months later and he is in your office as a new patient. He

describes the pain at 7/10, aching in the center of the back without

radiation, and no numbness or weakness and no bowel or bladder

dysfunction.

The pain is worse with bending, cough, or straining with bowel

movements.

Case Study #2 - Edward


You have no chart, but the patient describes an initial treatment plan

by a prior provider consisting of ibuprofen, tizanidine, ice, heat,

stretching, and later physical therapy.

He was seen by a physiatrist after a magnetic resonance imaging (MRI)

showed multilevel disc disease without encroachment. An epidural

steroid injection under fluoroscopy did not help to alleviate his pain.

Edward is now unemployed and spends much of his day in bed due to

continued disabling pain, even though he's on

hydrocodone/acetaminophen 10/325 mg 6 pills a day. Edward has

been seen in the ER (x3); he had two prior surgeries and has adverse

childhood experiences.



The physical exam shows tight muscles in the low back with diffuse

tenderness and triggering of the pain down the right leg.

His range of motion is restricted by pain, with a negative neurologic

exam including a normal straight leg raise.

Provocative testing of the sacroiliac joint and piriformis muscle are

negative.



Jennifer Reynolds, DPT, TPS

Reynold Physical Therapy – Owner, Physical

Therapist

Women's and Men's Rehabilitation –

Women's Medicine Collaborative,

Senior Physical Therapist


Physical

Therapy phys·i·cal ther·a·py -

/ˈfizikəl ˈTHerəpē/ - of, or relating to the body

: therapeutic medical treatment of impairment,

injury, disease, or disorder

the treatment of disease, injury, or deformity by

physical methods such as manual techniques,

education, and exercise rather than by drugs or

surgery.


Non-Specific Back Pain

• 90% of back pain

• Specific nociceptive source can NOT be identified

• Presumed MSK origin, no reliable tests to specify source

• MANY factors involved, often not just ONE

• Biophysical Factors – “tight muscles, tenderness with palpation, decrease in range of motion”

• Comorbidities – prior surgeries, adverse childhood event

• Social Factors – unemployed, cultural beliefs around pain

• Psychological Factors – beliefs, previous experience around pain, expectations, adverse childhood event


Physical Therapy Intervention

• Any intervention, at any stage of healing/injury must involve calming/downregulation of the nervous system and teaching self efficacy of pain.

– Acute Phase of Injury – aggressive treatment of pain at this stage has been shown to reduce the likelihood of chronic pain, healthcare costs and the use of opioids

• Pain Neuroscience Education

• Therapeutic Exercise - Gentle, active movement

– Graded Exposure – teach patients it is safe to move

• “Sore but Safe”, “Touch it, Tease it, Nudge it”

• Neurodynamics – nerve gliding to encourage movement and blood flow along nerve

• Manual Therapy – joint mobilizations/manipulation as indicated


DocumentationS: Pt. states he has 7/10 pain that is made worse with bending, coughing and straining.

0: Limited lumbar flexion and extension due to pain; Negative Straight Leg Raise; BilateralNeuromuscular Re-ed: PNE; walking program – starting with 5 mins(graded exposure, work within pain frame) passive sciatic nerve glides in supine with knee ext/flex, ankle DF/PF, seated active nerve glides with ankle DF/PF and cervical flex/ext as tolerated.

TE: lumbar rotations in hooklying x 20, SKTC x 20

A: Decreased likelihood of nerve root involvement secondary to negative SLR test, good LE strength and functional ability as well as imaging results. Pt. verbalized good understanding of PNE. Pt. able to tolerate initiation of AROM exercises and will continue exercises as part of HEP.

P: Continue with PNE, TE and NM re-ed 2-3x/week for 3-4 weeks. HEP: daily walking 5 mins a day, LTR and SKTC


References

• Hartvigsen et al. What low back pain is and why we need to pay

attention.2018;2356-2367. DOI:https://doi.org/10.1016/S0140-

6736(18)30480-X

• Bardin et al. Med J Aust. 2017 Apr 3;206(6):268-273

• Fronger at al. Health Serv Res. 2018 Dec;53(6):4629-4646. doi:

10.1111/1475-6773.12984. Epub 2018 May 23.


Michael Gottfried, B.A.,

M.A., D.C.

Chiropractic Physician

Aquidneck Chiropractic


Kinney et al. Spine Journal (2013): The likelihood of surgery for workers with back injuries

is 42.7%, if their first contact is with a surgeon. If their first contact is with a chiropractor, it’s

1.5%. This retrospective study was done at Dartmouth Medical College.

Wien et al. Rhode Island Medical Journal (August 2019) concluded that there has been an

increase in opioid prescriptions being given to pregnant women on RI Medicaid.

February 14, 2017 the American College of Physicians issued clinical guidelines that

recommended for acute and sub acute back pain patients non-drug therapies such as the

panel represents should be tried first.

“You must be the

change you want to

see in the world”

– Gandhi

“Not all of us can do

great things. But we

can do small things

with great love”

– Mother Theresa


Edward’s Biopsychosocial Factors

1. 2 surgeries- back related?

2. 2 months of pain rated 7/10 with meds

3. Financial and emotional stress of unemployment

4. Moving stresses

5. Possible side effects of meds

6. Muscle tone loss- 2 months of being a “couch potato”

7. Adverse childhood experience?

8. Relationship stress

9. Possible inflammatory nutritional factors- Fried food, carbs, alcohol

and tobacco use as well as weight, blood pressure, and family

history are unknown.


• Chiropractic is the largest natural healing art in the US. Doctors of Chiropractic (DCs) recognize the body’s inherent wisdom to heal itself if free from inflammation, instability, stress imbalance, etc.

• The main focus of chiropractic is on the relationship of spinal structure and neuromuscular function. Four years of chiropractic college are devoted to learning the basic sciences and perfecting the art of knowing how, when, and where to make a corrective adjustment to free the body of imbalance by locating and managing subluxation (characterized by biomechanical changes, muscle imbalance, or altered nerve function).

• There are many different chiropractic techniques. I use mainly low force techniques. In particular Activator Method that delivers a measured/reproducible high speed/low force correction


Martine Delonnay, N.D, M.D.

Founder and CEO of DELONNAY HOLISTICS

Naturopathic Physician, Sage Healing Collaborative


Clinical Exam:

• History

– Nutrition/rehydration/alcohol (culture and education)

– Field of work: physical/mental/emotional aspect of work place

– Medication/supplements: risk factors/long term

improvement/interactions

– Past Medical History

– Family History

– ROS: Neurological/musculoskeletal/sleep/digestion/mouth

• PE: Neurologic/Musculoskeletal

Naturopathic Medicine - Integrative Therapy


Analysis of Treatment plan

• CBC with differential, Cortisol level, DHEA, lactic acid

• Diet and lifestyle: Anti-inflammatory diet

• Supplementation: herbal/functional: bozwelia, tumeric, Ginger, S-

adenosyl-L-methionine (SAMe), CoQ10, B complex…

• Homeopathy: Constitutional and/or emergency: Rhus tox, Bryonia,

Arnica/Internal or topical

• Constitutional Hydrotherapy: To reduce body burden

• Cold Laser therapy

• Ozone therapy: Rectal Insufflation/Prolozone injection/Hemo.+--

• Neural therapy

• Hypnosis/Energy work/Cranio- Sacral: Addressing the Biopsychosocial

aspect


Treatment Plan Summary

• Assessment of patient with a solid Medical history, lifestyle and

PE

• Evaluate the extent of Emotional impact on the body. Address

the biopsychosocial aspect of treatment and Adrenal

overwork.

• Choosing the best appropriate care based on degree of

invasiveness and patient’s comfort: understanding, cultural

accommodation, Financial capacity (Insurance coverage…)


Patient Documentation

• S: CC: 52y/o m with chronic back pain started 2 months ago at home while preparing to move: 7/10. Dorsal region. No radiation, numbness, weakness, bladder nor bowel dysfunction. Worse with bending and straining

• O: Patient calm, oriented in 3 spheres. Mx tightness in the lower back, pain triggered in R leg. Restricted ROM. Neg: Neurologic exam, straight leg raise, SI joint, Piriformis

• A: 52 y/o m on disability has been seen multiple times in ER and by other providers. Imagery consistent only with discopathy without encroachment. Taking Hydrocodone/acetaminophen: 10/325 mg not helping. Patient feels misunderstood and is seeking alternative/integrative RX.

• Working Dx: Chronic back pain associated with significant psycho-social dysfunction (ICD-10 G89.4)

• P: Anti inflammatory lifestyle and diet, supplementation and other modalities.


Latisha Michel, CCHW

Newport Health Equity Zone

Certified Community Health Worker

Founder of Ready, Set, Latch, Go,

Certified Doula,

Certified Lactation Counselor,

Maternal Child Health Specialist


Community Health Workers are:

frontline, public health professionals who often have similar cultural

beliefs, who empower their community to advocate for themselves

and better navigate resources.

“We wish everyone in the system

understood only 10% of health happens

in the doctor’s office.”

Marti Rosenberg, State Innovation Model

http://chwari.org/

[email protected]


Community Health Workers are:

Competent in nine areas:

1. Engagement Methods and Strategies

2. Individual and Community Assessment

3. Culturally Competent

4. Promote Health and Well-Being

5. Care Coordination and System Navigation

6. Public Health Concepts and Approaches

7. Advocacy and Community Capacity Building

8. Safety and Self-Care

9. Ethical Responsibilities and Professional Skills


Edward is:

Having language issues? May need a translator

Having transportation issues? May need rides to doctor’s appointments & pharmacy

Having insurance issues? May need help navigating the system-health and unemployment paperwork

Having connection issues? May need access to a computer/ phone to make appointments

Having food access issues? May need to locate food pantries, discuss food stamps, other resources

Having mobility issues? Accommodations needed to improve


Edward may benefit from:

Having language issues? Translator Services

Having transportation issues? Receiving a bus pass, Flex service or rideshare

Having insurance issues? Help navigating insurance system

Having connection issues? Having access to a working phone and computer

Having food access issues? Being informed of food stamps and helplocating food pantries and other resources

Having mobility issues? Using adaptive equipment that will help him better care for himself


Edward’s healthcare providers should be

aware of Cultural Competency:

• Understand the values, attitudes, practices, structures, diet, and

behaviors of the people you are working with.

• Be aware of your own unconscious bias of: gender, sexual

orientation, marginalized or socially excluded groups, occupational

status, spiritual beliefs and practice

• Adapt to diversity

• Be an active listener

• Increase your understanding of barriers

• Acknowledge how past experiences affect present outcomes

• Eliminate prejudice


Frank R. Sparadeo, Ph.D.

Instructor, Department of Rehabilitation

Counseling, Salve Regina University

Clinical Director, Pain Solution CODAC


Behavioral Health

Integrative Therapy Approach

• Comprehensive Chronic Pain Evaluation that examines the degree of pain interference in life, the degree of pain impact, the beliefs of the patient (adaptive and maladaptive) and the coping skills of the patient (wellness-focused and illness-focused).

• Treatment planning taking into account physical, medical, social and emotional issues. Family and cultural issues also need to be considered.

• Application of Cognitive Behavior Therapy/Pain management

• Communication with other providers (P.T., M.D., Case management)

• Consider innovative approaches (e.g. Scrambler Therapy)


Analysis• Medications: Hydrocodone + Tizanadine

– CNS and Respiratory depression, psychomotor impairment, hypotension

• Physical Therapy

– ROM, Strengthening, Fitness level, avoidance/behavior considerations

• Mental Status

– ?Hx of depression, ?PTSD, Type of job/affinity to his job, catastrophizing, solicitousness

• Pain Beliefs

– Medical cure, medications, avoid movement, rest, ER visits, control

• Wellness-focused coping vs. Illness-focused coping

– Presently poor Task persistence, pacing, exercise, meditating, movement, socializing

– High degree of illness-focused coping, poor wellness-focused coping.

– Poor coping self-statements


Treatment Plan-biopsychosocial

Overall goal: Patient to return to work and normal activities

Objectives: Improve physical status (conditioning, ROM, etc.)

Understand the patient’s beliefs and make changes

Consider psych meds

Learn good body mechanics

Behavioral pain management techniques:

- Distraction, value-based activities, meditation

cognitive behavior therapy/ACT, family

involvement to reduce solicitousness.

Consider discontinuing medications and offer antidepressant


Documentation

• Mental Status: low mood, tearfulness, catastrophizing, previous history of childhood trauma, slow cognitive abilities, helplessness, major lifestyle change. Depression is likely.

• Psychosocial: Wife and adult children taking care of the patient and increasing his dependency. No contact with friends or usual leisure activities that typically bring him joy and positive feelings

• Physical: Currently, sedentary with excessive resting. Only movement is with P.T.

• Medical: Currently using opiate analgesic meds and ER visits. Overuse and addiction is fast approaching. Seems to be developing greater pain sensitivity which is reinforced by ER visits.


Questions &

Answers


Exhibitors

• Rhode Island Association of Naturopathic Medicine

• American Massage Therapy Association - Rhode Island Chapter

• Providence Community Acupuncture

• Chiropractic Society of Rhode Island

• Rhode Island Occupational Therapy Association

• Rhode Island Department of Health

• Rhode Island American Physical Therapy Association

Thank You

changing the culture of pain treatment · warwick • lincoln • providence • newport county •...

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