Back 2 Health An Innovative Approach to Managing Low Back Pain

Katie Krenz, MSc, CSEP-CEP Jillian Corfe, MA, R.Psych

Sarah-Joy Haggstrom, BHSc (Hon.)

Presenter Disclosure Presenter: Jillian Corfe Sarah-Joy Haggstrom Katie Krenz Relationships that may introduce potential bias and/or conflict of interest:

-No relationships to declare.

Why ? Back 2 Health

“Patients see me looking for a cure… talking about what works for

LBP takes time and is often not what they want to hear”

–SCPCN Physician

Current treatments available • CPC– at capacity • Spinal Specialists • Meds

What we know helps… • Multidisciplinary approaches • Self management • Activity

• “Top” guidelines • What helps vs. what people have access to

Back 2 Health Program

1. Building capacity in primary care to

assess and manage low back pain

2. Providing timely access to team

based care

3. Promoting self management

strategies through education and

home practice

Overarching goal of Back 2 Health is to improve patient outcomes through:

Key Components

Physician Education:

• Promote use of standardized tools for assessment

• Facilitate small interactive skill development groups

• Identify more appropriate care pathways

• Reduce diagnostic imaging referrals – choosing wisely

Key Components The Keele STarT Back Screening Tool1

Thinking about the last 2 weeks tick your response to the following questions: Disagree Agree 0 1

1 My back pain has spread down my leg(s) at some time in the last 2 weeks □ □

2 I have had pain in the shoulder or neck at some time in the last 2 weeks □ □

3 I have only walked short distances because of my back pain □ □

4 In the last 2 weeks, I have dressed more slowly than usual because of back pain □ □

5 It’s not really safe for a person with a condition like mine to be physically active □ □

6 Worrying thoughts have been going through my mind a lot of the time □ □

7 I feel that my back pain is terrible and it’s never going to get any better □ □

8 In general I have not enjoyed all the things I used to enjoy □ □

Not at all Slightly Moderately Very much Extremely

□ □ □ □ □

0 0 0 1 1

Overall, how bothersome has your back pain been in the last 2 weeks?

1. © Keele University 01/08/07 Funded by Arthritis Research UK

Patient Care Pathway

Screening Tool ( STarT Back )

Patient Referral

High Risk

Medium Risk

Low Risk

Specialist Referral

Mental Health

Patient Navigator

Interview

• Confirm screening result • Change in symptoms since screening • Program description • Communicate plan back to FP

Back 2 Health Pain

Orientation

Brain 2 Back Back 2 Your Life

Back 2 Body Back 2 Movement

Patient Education Modules

Session 1 – Back 2 Health Orientation

Session 2 – Brain 2 Back

Session 3 – Back 2 Your Life

Session 4 – Back 2 Body

Session 5 – Back 2 Motion

Session 6 – Back 2 Practice

ORIENTATION

BRAIN 2 BACK

BACK 2 YOUR LIFE

BACK 2 BODY

BACK 2 MOVEMENT

BACK 2 PRACTICE

Session 1 – Back 2 Health Orientation Purpose: To provide an overview of the fundamentals of low back pain and how it can be managed

Objectives: • Expand knowledge regarding low back pain anatomy

and pathology

• Understand the role of muscles

• Learn about your personal pain

• Understand self-management of pain

• Encourage engaging in appropriate self-care activities

• Patient Self Efficacy Questionnaire

Weak, Tight

Muscles

Physical Deconditioning

Withdrawal From Social

Activities

Anxiety Depression

Anger

Limited Activities

Tissue Change

Seek Doctors, Specialists

Rest, Passive Coping

Pain Centered Life

Function Centered Life

Increased Activity

Physical Reconditioning

Improved Social

Functioning

Improved Mood

Use Self-Management

Skills

Tissue Change

Self-Management Rehabilitation Medical Management

Treatment Sun

SELF MANAGEMENT

Stretching/Yoga

Manual Physical Therapy

Massage

Body Mechanics

1. Self-monitoring* 2. Pacing* 3. Relaxation* 4. Self-talk* 5. Communication* +2…. 1. Flare-up/Coping plan* 2. Exercise and Activity

5 BIG Skills (+2)

*CPC Self-Management Group Handbook (2014)

Workbook

Session 2 – Brain 2 Back Connector Purpose: Develop self-management skills for managing pain to improve day to day life

Objectives: • Identify personal thoughts and beliefs about low back

pain and how this impacts your pain

• Overview of Central Sensitization of Pain and Gate

Control Theory

• Review and explore psychological factors that impact

our perception of pain

• Learn the “Big 5 Skills” of self -management

BIOPSYCHOSOCIAL MODEL OF PERSISTENT PAIN

Increase in disease causing loss of fitness, depression, and social issues= more pain

Back pain: Initially a painful sensation from injury or illness

Worry about the cause of pain and the future consequences

Avoidance of movement and activities in fear of making pain worse

If I’m not making things worse, then why does it hurt so much?

Psychological Factors that Impact Pain

1) How and what we think about pain 2) Catastrophizing or assuming the worst 3) Hurt vs. Harm 4) Negative affect/mood 5) Answer-seeking 6) Pain self efficacy

CBT: Process and Tools

Thought Log

Self Management Process: Tying it all together 1) Behavioural Activation 2) Pacing for pain (find your baseline for safe

activity!) 3) Cognitive skills training- 3C’s 4) Relaxation Skills training (remember the

connection between stress and pain flare ups) 5) Restructuring and balancing out our unhelpful

thoughts 6) Relapse prevention and problem solving (practice,

practice, practice!)

Session 3 – Back 2 Your Life Purpose:

Increase understanding of posture and ergonomics,

and how to improve the environment around us

Objectives:

• Answer questions about Brain2Back

• Define and increase knowledge of basic ergonomics

• Identify principals of efficient static and dynamic

postures

• Develop strategies to reduce awkward and static

postures

Ergonomics isn’t just a work thing! Think “physics & leverage” around the home…

Washing dishes, pots & pans Carrying and loading groceries Picking up and carrying kids Walking the dog Yard work ◦Raking, shoveling, sweeping ◦Lawn mowing, snow removal ◦Wheel barrels

Seated posture…Do you…

OR

Session 3 – Back 2 Your Life

What is one thing you can modify: either your behavior or physical environment to improve your body’s ability to sustain this position? How will you implement this change? How will you communicate this to your friends/family/colleagues? How will you communicate to yourself when you start to feel your discomfort rise?

Session 4 – Back 2 Body Purpose:

To provide an overview of how muscles cause pain

Objectives:

• Expand knowledge specific to myofascial pain

• Identify trigger points

• Trigger point management techniques

• Learn and practice exercises that may be helpful for

low back pain

• Encourage engaging in appropriate self-care

activities

Session 4 – Back 2 Body

Stretching

Acupressure

Physical Modalities

Strengthening/Balancing

Clinician Treatments

Pressure • Acupressure • Foam Rolling • Massage

Stretching

Session 4 – Back 2 Body Applying some of what you have learned about myofascial pain, select either acupressure or stretching and complete it 1-2x per day for the next week. Which strategy will you select? How has this strategy affected your pain? How has this changed over time? How has your range of motion been affected? In the future, will you incorporate these strategies into your flare-up plan? How will you know when to use them?

Session 5 – Back2Movement Purpose:

To explore how to introduce movement back into their life and explore

exercises that improve stability in the core capsule

Objectives:

• Increase knowledge of anatomy and soft tissue involvement in

stability and mobility

• Expose participants to exercises that improve core coordination,

endurance and strength

• Develop coping/flare up plan

1.Find your baseline 2.Push yourself in moderation 3.Choose an activity you want to do 4.Try for every day 5.Be persistent and patient

Movement Guidelines

Action Plan

• Red light: Pain is high – Breaking up rest time

• Yellow light: Pain is tolerable – Stretches/Myofascial

• Green light: Pain is low – Core stability

• Specific • Measurable • Attainable • Rewarding • Time-Oriented • Sabotage

SMARTS Goals

Back 2 Practice • Application day

– 30 minute core/stretch program – 30 minute mindful training

• Follow up and problem solving

What they leave with? • Knowledge • Skills • Confidence • A plan

Patient Comments “What’s the best thing that could happen if you use the

information you learned in the program?”

• “The pain can become more manageable”

• “[I can] reduce my everyday pain”

• “[I can] recover fast from pain”

• “[I know] that I’m not alone and the back pain is real”

• “[I can] feel better without the use of professionals ($$$)”

• “The language used was very understandable”

• “The delivery was humorous”

• “The open dialogue and sharing with the other participants”

• “The interaction between all of us in the class, learn from everyone”

• “Informative”

Patient Comments “What did you like best about the program?”

Evaluation

Data Collected • Referral Information

• Attendance Rates

• Patient Outcomes (Initial, 5 weeks & 3 months)

• Content Feedback (Patient and Provider)

• Program Satisfaction (Patient and Referring Physician)

Referral Information

Attendance Rates Enrollment

• 62% of referrals enrolled (29 out of 47) • Patients with the following characteristics

were more likely to enroll: • Lower STarT Back Tool scores • Less severe pain • Less family physician visits in the last year

Attendance Rates Attrition

70% Completion Rate

Patient Outcomes 1. Pain Numeric Rating Scale

2. Patient Health Questionnaire-2

3. Pain Self-Efficacy Questionnaire

4. Rolland-Morris Disability Questionnaire

5. Patient-Specific Functional Scale

Pain Numeric Rating Scale

Changes in score of ≥2 are significant

0 1 2 3 4 5 6 7 8 9 10

No Moderate Worst pain pain possible pain

Pain Numeric Rating Scale 5 weeks results (n=6)

Pain Numeric Rating Scale 3 months results (n=7)

Patient Health Questionnaire-2

• Used to screen patients for depression

• Patients with scores of 3 or more should be further evaluated

Patient Health Questionnaire-2 5 weeks results (n=11)

Patient Health Questionnaire-2 3 months results (n=7)

Pain Self-Efficacy Questionnaire Please rate how confident you are that you can do the following things at present, despite the pain. To indicate your answer circle one of the numbers on the scale under each item, where 0 = not at all confident and 6 = completely confident.

For example:

0 1 2 3 4 5 6

Not at all Completely Confident confident

Remember, this questionnaire is not asking whether or not you have been doing these things, but rather how confident you are that you can do them at present, despite the pain.

1. I can enjoy things, despite the pain.

0 1 2 3 4 5 6 Not at all Completely

Confident confident

Pain Self-Efficacy Questionnaire • Assesses the confidence people have in

performing activities while in pain

• 10 questions

• Changes in total score of ≥7 are significant

Pain Self-Efficacy Questionnaire 5 weeks results (n=11)

Pain Self-Efficacy Questionnaire 5 weeks results (n=11)

Pain Self-Efficacy Questionnaire 3 months results (n=7)

Pain Self-Efficacy Questionnaire 3 months results (n=7)

Rolland-Morris Disability Questionnaire When your back hurts, you may find it difficult to do some of the things you normally do.

This list contains sentences that people have used to describe themselves when they have back pain.

When you read them, you may find that some stand out because they describe you today.

As you read the list, think of yourself today. When you read a sentence that describes you today, put a

tick against it. If the sentence does not describe you, then leave the space blank and go on to the next

one. Remember, only tick the sentence if you are sure it describes you today.

1. I stay at home most of the time because of my back.

2. I change position frequently to try and get my back comfortable.

• Assesses the level of back-related disability

• 24 questions

• Changes in total score of ≥5 are significant

Rolland-Morris Disability Questionnaire

Rolland-Morris Disability Questionnaire 5 weeks results (n=6)

Rolland-Morris Disability Questionnaire 3 months results (n=7)

Patient-Specific Functional Scale Patient-specific activity scoring scheme (Point to one number):

0 1 2 3 4 5 6 7 8 9 10

Unable to perform activity

Able to perform activity at the same level as before injury or problem

(Date and Score)

Activity Initial 5 weeks 3 months 1. 2. 3. 4. 5. Additional Additional

• Assesses the ability of patients to perform activities that matter to them

• Average Score = Total Score/# of Activities

• Changes in average score of ≥2 are significant

Patient-Specific Functional Scale

Patient-Specific Functional Scale 5 weeks results (n=5)

Patient-Specific Functional Scale 3 months results (n=7)

Content Feedback Patients who attended the pilots recommended: 1. Shorter sessions

2. Afternoon sessions

3. More practical exercises and individual application

4. More handouts of the material presented

Program Satisfaction - Patients • Overall, patients were satisfied with the program:

• Patients particularly enjoyed the facilitators and the way the information was presented

• Class discussions were very valuable

• Patients liked the small, relaxed atmosphere

• Areas for Improvement • More practical exercises and handouts

• More one-on-one attention

• More information and discussion on the brain-pain relationship

Program Satisfaction – Referring Physicians

• Patient feedback was positive

• The program is meeting a need for patients

• Self-referral is preferred

• Physicians would like more communication from the Back 2

Health team

Program challenges and changes

Challenges and Changes 1. Referrals Self-Referral 2. Acute pain Persistent pain 3. 2 hour session 1.5 hour session 4. Session content, ‘room’ within the sessions for

conversation lecture/application, group size 5. Evaluation tools Added PSF 6. Attrition interview, numbers and engagement

Referrals • Interview process • Dropped some referral data based on

population change

Evaluation changes • Eliminated the Pain Numeric Rating Scale

0 1 2 3 4 5 6 7 8 9 10

No Moderate Worst pain pain possible pain

Target population • SCPCN young demographic • Program originally made for acute back pain

– However….we found it was too early on pt likely best suited for rehab

– Transitioned to acute-early chronic/persistent – Accepting of long term chronic depending on

outlook

Critical Pieces • Mentorship from Dr. Virani and Diane

Roylance • Multidisciplinary team: Medical Director,

Program Manager, Therapist, Kinesiologist, Program Evaluator, Admin team

Future Program • B2H became operationalized after two pilots

in September 2017 • Self-referral only?

Thank you!

Key Components Pain Diagram1 Please shade the following diagrams to identify each area where you are experiencing pain today. Also indicate on the scale below the level of pain you are experiencing today

1. http://www.homesteadschools.com/nursing/courses/ManagementCancerPain/AttachmentB.htm

Referrals - Gender

Referrals - Age

Attendance - Attrition

Attendance - Attrition