The Physiotherapy & Rehab...The Physiotherapy & Rehab Teleconsult Service for Chronic Pain, Update &...

10/16/2019

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The Physiotherapy & Rehab Teleconsult Service for Chronic Pain,

Update & Insights.

AHS Chronic Pain Centre, CalgaryShort Snappers 2.0

Kate Gerry, B.Sc. PT, BPE(ODPU)

October, 2019

The PT & Rehab Teleconsult Service for Chronic Pain,Inspiration:

• Resources are finite, need to use wisely

• Are all the people on the waitlist appropriate referrals?

• How to prevent the development of chronic pain?

• What support is available to PT/HCP, to help manage complex patients?

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The PT & Rehab Teleconsult Service for Chronic Pain:

1. What we offer

2. Who we are

3. Update4. How to

access service

The PT & Rehab Teleconsult Service for Chronic Pain,Inspiration & Background:

• Original Premise:• First service in Canada offering PT to PT telephone consultation for chronic pain care

• support PTs managing chronic pain patients

• Other influencing factors:• Opioid crisis & need for info RE: non-pharmalogical strategies

• Update:• Now available to all health care professionals/students across AB in public & private practice

• More Choice: Callers may request to book a consultation with a CPC PT, OT or KIN

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The PT & Rehab Teleconsult Service for Chronic Pain,

Dual Purpose: To help support best practice while investigating the needs of healthcare professionals:

• By offering confidential telephone consultations to discuss ideas & provide clinical support

• By collecting data:

•brief questions: role + public/private, # yrs practice, int’l training

•Follow-up surveymonkey: 8 questions, average time 3min.(11/17)


Examples of consultation topics:

• Clinical guidance : Rx plans & trouble shooting

• Navigation & wayfinding of services/resources

• Networking & interdisciplinary referrals in community

• ID of patients at risk for developing chronic pain

• Support early management

• How/when to refer in community & CPC

• Non-pharm options

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Who We Are:

• Team of 6 clinicians: 3 PT, 2 OT, 1 KIN

• We 1:1 assess/treat, work with NMSK/HA/Pelvic teams

• We teach education & exercise groups

The PT & Rehab Teleconsult Service for Chronic Pain,What We do:

• Gather qualitative & demographic data:

• who uses the service?

• FAQ?

• Common themes?

• where are the gaps in knowledge & in the health care system?

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Call Summary: Demographics.

• Total number of health professionals who have accessed service: 19

• Total number of calls: 17 (2 calls PT/OT duo)

• Private: 32%, Public: 68%

Call Summary: Demographics• Profession of Caller:

• PT 47%

• RN 10.5%,

• KIN 16%,

• MD 10.5%,

• NP 0%

• Years of Practice: • 0-5: 10%,

• 5-10: 16%,

• 10-20: 42%,

• 20+ : 21%,

• Unknown: 11%

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Call Summary: Nature of Inquiries (can be > 1/call):

• Clinical guidance:16/17

• Way finding of services: 3/17

• Early flags/prevention: 2/17

• Other: 2/17• How to encourage earlier referral to physiotherapy post-surgery

• Program development/networking/learning opportunities

• Referrals: 1/17

Call Summary: Location type/zone• Type of Community:

• City: 47%

• Town: 29%

• Specialized Municipality: 24%

• AHS Zone: • Calgary: 41%

• Edmonton: 24%

• North: 18%

• Central: 12%

• South: 5%

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What do HCP need most to help optimize care for patients with chronic pain? (summary from survey)

• A supportive environment

• Can't expect one person or discipline to tackle these difficult cases on their own

• Access to a toolkit, resources recommendations, help to develop plan of action

• Access to resources and specialists + high quality, easily available patient resources

• Self management, brief guidelines/algorithms for Rx

• Access to case studies/scenarios with screening and intervention tools built in

• Interdisciplinary team to improve goal setting & focused Rx for improved health outcomes

• Tools to help improve collaboration will reduce the waitlists i.e. interdisciplinary meetings, group sessions, improved health information sharing/management

Update CPC

• Approximate waitlist: 8 mon. until Initial MD or NP Ax (improved from 2 yrs ago, up to 24 mon)

• Earlier access available via initial allied health Axs

• Online lectures(10) available to public at any time

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The AHS PT & Rehab Teleconsult Service for Chronic Pain,How to Access the Service:

To book CALL: 403-943-9900

Informalberta.ca/keyword: teleconsult

/physiotherapy and rehabilitation chronic pain tele-consult service

10/15/2019

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MDT With or Without Steroid Injection for Chronic Lumbar Radiculopathy.

Feasibility project: RCT

Audrey Long Bonavista Physical Therapy, Calgary

U of A : Geoff Bostick, Eric Parent, Linda Woodhouse U of C ; Geoff Schneider, Dr. Arun Gupta U of A and U of C Ethics Review Boards

132 – 53 Centralizers

= 79 surgical candidates

17 (22%) had surgery

Background: 2014 Cohort Study Van Helvoirt et al

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Objectives: Is it feasible?

Can we replicate these methods in Canada?

Replicate their methods

Randomized to Two evidence-based treatments

1. MDT –Mechanical Diagnosis and Treatment +/- TESI

OR

2. TESI – Transforaminal Epidural Steroid Injection

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1. MDT assessment

MDT assessment over 2 visits.Classify patients as: Non-centralizers + TESI (Van Helvoirt study)

Centralizers

References for Radicular Pain: Svensson et al, 2013, 2014, Albert and Manniche, 2012, Skytte et al., 2005, Murphy D, 2009, Rasmussen et al., 2005, Broetz D, 2010, Broetz D, 2003, Donelson et al., 2012, Petersen T, 2011

Centralization:

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2. Guided Transforaminal Epidural Steroid Injections (TESI)

Literature shows short term benefit in some individuals

Best candidates?

Long term effects?

References: Pinto 2012,Akuthota, 2013, Ghahreman et al., 2010, Manchikanti et al., 2012, Cohen et al., 2012

Current Status - RecruitmentN=25

Randomized

N=20

• 5 excluded• (n=1 transportation, n=3

diagnosis, n=1 legal)

N=18 baseline

• N= 8 MDT+/- TESI; • 1 drop-out

• N=10 TESI; • 1 drop-out

Follow-up ongoing

2 dropouts (arm preference)

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Duration-back pain

MDT+/- TESI

25% < 1yr12.5% 1-5 yrs..25.0% 5-10 yrs.37.5% > 10 yrs.

TESI

20% < 1yr40% 1-5 yrs.20% 5-10 yrs.20% > 10yrs

Baseline data

Back Pain - Duration

MDT +/- TESI TESI

Gender (% male) 63% male 50% male

Duration - leg pain 37.5% < 3 mos.

12.5% 3-6 mos.

50% 6-12 mos.

0% > 1 yr.

0% < 3 mos.

20% 3-6 mos.

30% 6-12 mos.

50% > 1 yr.

Leg Pain Duration

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Leg pain intensity, RMDQ, FABQ-PA

MDT +/- TESI TESI

Usual leg pain intensity 6.6 (1.4) 7.0 (2.1)

RMDQ /24 15.6 (6.0) 18.1 (3.5)

FABQ-PA 13.5 (5.2) 15.9 (5.0)

Early Results – leg pain intensity

0

1

2

3

4

5

6

7

8

9

10

Baseline leg pain 6-wks leg pain 3-mos leg pain

MDT 1

MDT 2

0

1

2

3

4

5

6

7

8

9

10

Baseline leg pain 6-wks leg pain 3-mos leg pain

CTRL 1

CTRL 2

CTRL 3

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Early Results – disability

0

5

10

15

20

Baseline RMDQ 6-wks RMDQ 3-mos RMDQ

MDT 1

MDT 2

0

5

10

15

20

Baseline RMDQ 6-wks RMDQ 3-mos RMDQ

CTRL 1

CTRL 2

CTRL 3

Early Results – fear-avoidance (physical activity)

0

5

10

15

20

25

Baseline FABQ-PA

6-wks FABQ-PA 3-mos FABQ-PA

MDT 1

MDT 2

0

5

10

15

20

25

Baseline FABQ-PA

6-wks FABQ-PA 3-mos FABQ-PA

CTRL 1

CTRL 2

CTRL 3

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FeasibilityBarriers/challenges: Privacy Laws, no access to info of patients on waist lists (target) ‘Instability’ in the referral source(s) PT clinician-led research is new to universities Managing patient preferences

Facilitators: hire a project manager to oversee: recruiting staff, data completion, eye on follow-up, on-site liaison, etc.

Relationship building with invested stakeholders

Lessons Learned

Privacy Laws leave patients stranded on wait lists

Passive Recruiting Strategies too slow, not realistic (e.g., posters, newsletters)

Real World Silos: Clinicians keen to help but …… (PTs, Chiropractors, Surgeons, Physiatrists, GPs, PCNs, ERs)

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Acknowledgments

Funding

CRIF – Canadian Research Innovations Fund

IMDTRF – International Mechanical Diagnosis and Treatment Research Foundation

81/145

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Can PTs screen for Psychosocial Factors in Patients with Low Back Pain?An AHS Research Challenge Project

October 19, 2019

October 19, 2019

• Karin Eldred, MSc RS, BScPT

PTII Jasper, Team Lead Research Challenge

• Jason Daoust, MScPT, BSc

PT Team Lead for North Zone

• Krista Shore, MScPT, BSc

PTII Hinton

• Geoff Bostick, PT, PhD

Academic Advisor

Our Team

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October 19, 2019

• AHS sponsored

• Driven by front line care providers

• Competitive selection process

• 2nd cohort = 12 Teams across AHS

• Support small scale clinical research projects - e.g. pilot/feasibility studies

AHS Research Challenge

October 15, 2019

Background – Clinical Qs

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October 19, 2019

• Why do some people transition from acute to chronic pain?

• Are PTs able and willing to screen for other (non-anatomical) risk factors for the development of chronic pain and disability?

• What are the best methods for screening?

Background – Clinical Qs

October 19, 2019

AHS ContextRehab Model of Care

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October 19, 2019

AHS ContextRehabilitation Strategic PlanStrategy #3: Optimize patient outcomesin the community.

October 19, 2019

• Back pain is prevalent.

• Aligns with Bone & Joint SCN

- Spine Access Alberta

- MSK assessment

AHS Context

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October 19, 2019

What are the barriers and facilitators to physiotherapist identification of psychosocial factors for delayed recovery in outpatients with low back pain in the North Zone of Alberta Health Services?

1) Examine the feasibility of implementing a process that aims to identify relevant psychosocial factors in outpatients with LBP by AHS physiotherapists.

2) Identify barriers and facilitators for broader implementation from physiotherapist perspectives.

Research Question

October 19, 2019

• Recruitment of AHS North Zone PTs

• PTs administered StarTBack Tool (SBT) to new outpatients with LBP

• 3 month period of data collection

• PTs interviewed re: their experience using the SBT

• Quantitative analysis of SBT

• Qualitative analysis of PT interviews

Methods

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October 19, 2019

The STarT Back

Screening Tool

Methods

1. Referred leg pain2. Comorbidity, pain elsewhere3. .4. .5. Fear avoidance6. Anxiety7. Catastrophizing8. Depression9. Overall Impact

disability

October 19, 2019

• 11 PT participants collected SBT from 47 patients

Results - Quantitative

4

7

36

8.5

14.9

76.6

0 10 20 30 40 50 60 70 80 90

LOW RISK

MEDIUM RISK

HIGH RISK

Patient Risk for Chronicity with Low Back Pain

% n

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October 19, 2019

Theme 1: Barriers to Implementation a) North Zone Physiotherapist participants are confident in their ability to identify patients at high risk of disability without using a screening tool.

“I assess it through a thorough client interview.” PT10

“You can kind of get a feel for people” PT04

“I think a lot of physios probably have the mindset – I don’t need a tool to tell me if this person’s going to have a delayed recovery… because I’m so good at reading people.” PT03

Results - Qualitative

October 19, 2019

Theme 1: Barriers to Implementation b) More education is needed about the tool before broader implementation.

“I could use more education on the SBT… when you first try to implement change it’s hard” (PT03)


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October 19, 2019

Theme 2: Facilitators to Implementation a) Acknowledgement of potential utility of the tool.

“…it would have made my assessment easier and more efficient, I didn’t have to dig as much in my subjective interview” PT04


October 19, 2019

Theme 2: Facilitators to Implementationb) Ease of Use.

“Administering it was very easy… it’s very simple to score” (PT03)

“Patients can just fill out when they register to see the physiotherapist” (PT02)


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October 19, 2019

• Theme 3: Normalization of high LBP-related disability in the North Zone

PT participants were not surprised by the finding of 77% high risk.

“There’s just been lots of fear around back pain, and around recovery. And I just think based on people’s background and their previous encounters with injuries… it doesn’t surprise me that it would be that high.” (PT04)


October 19, 2019

• How should PTs screen patients for psychosocial risk factors?– Interview versus standardized tool

• Are PTs prepared to address these risk factors?– Training/education, scope of practice,

available community supports

Practice Implications: Clinicians

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October 19, 2019

Implications - AHS

October 19, 2019

• AHS North Zone sites may need to rethink how LBP is delivered based on large prevalence of high risk.

- Standardized screening

- Msk / LBP care pathways

Implications - AHS

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October 19, 2019

• Knowledge Translation– Presentations to AHS staff and management

– Conferences

– Publications

• Broader Implementation– Through-out AHS North Zone PT Departments

– Provide training about the tool, implementation and management recommendations based on score

• Another study? – Address barriers and facilitators to implementation

– Implement stratified care based on SBT score

Next Steps

October 19, 2019

• AHS – time and financial support

• North Zone PT and patient participants

• Geoff Bostick, PhD

• Katie Churchill, Senior Practice Lead, AHS

• Doug Gross, PhD

• Andrews Tawiah, Interviewer

• Kim Forster, Research Assistant

• Deborah Lafleur, Transcriptionist

Thanks

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Questions?

October 19, 2019

[email protected] – 780-852-6610



October 15, 2019

Clinical Assessment Of Psychosocial Yellow Flags

http://www.topalbertadoctors.org/cpgs/?sid=65&cpg_cats=90

Evidence-Informed Primary Care Management Of Low Back Pain

http://www.topalbertadoctors.org/download/1885/LBPguideline.pdf?_20190115003555

Graduate Certificate in Pain Management - Faculty of Rehabilitation Medicine - University of Alberta

https://www.ualberta.ca/rehabilitation/professional-development/certificate-programs/certificate-in-pain-management

Resources - 1

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October 15, 2019

Pain Science Division Mentorship Program – Canadian Physiotherapy Association

https://physiotherapy.ca/divisions/pain-science

PTAlberta chronic pain tool kit:

https://www.physiotherapyalberta.ca/files/chronic_pain_toolkit.pdf

Keele STarTBack Tool

https://www.keele.ac.uk/sbst/startbacktool/

– https://www.keele.ac.uk/sbst/startbacktool/

Resources - 2

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“Keep Your Move In The Tube™”Breaking Down the Restricted Walls of Movement

Post‐Sternotomy

Foothills Medical CentreCalgary, Alberta

October 19, 2019

Lauren Park MScPT, Christopher Coltman RN, Heather Agren RN, Susan Colwell RN, Dr. Kathryn King‐Shier

Disclosures

• None

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Cardiac Surgery• > 1million cases of open‐heart surgery per year, worldwide

•Median sternotomy is the access of choice

• Post‐operative instructions referred to as “sternal precautions”

• WEIGHT and TIME based restrictions• Adopted on the belief that movement compromised healing

• Thought to prevent wound complications

Challenges with Sternal Precautions• No standard definition, inconsistent practice

• Protective vs. restrictive?• May impede recovery• Hinders optimal healing• Increases muscle atrophy

• Reinforces fear of activity

• Decreases quality of life

• Delays or prevents return to work

• May prevent return home increased health services burden

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Evidence Based Practice?

No direct evidence linking activity level or arm movement to

increased risk of sternal complications

Coughing exerted the largestmean total force on the sternotomy at 60lbs.Confirms a lack of consistent

practice amongst physiotherapists in Canada

Sneezing equates to 90lbs force on the

sternum

So are we saying it’s ok to lift 60‐90lbs?

Keep Your Move in the Tube™ • Focuses on lever arm reduction enabling patients to perform previously contraindicated movements

• No specific time requirement to remain in the “tube”

• PAIN is their guide

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FMC Study ‐ Purpose

To adopt Keep Your Move in the Tube™ (KYMITT) as standard

practice for median sternotomy patients at FMC and to compare return to function, pain, wound healing and health services use in patients who use standard sternal precautions or KYMITT.





Design and Methods• “Before and after” cohort design

• Sternal precautions group n=100

• KYMITT group n=100

• Data was collected over a period of 12weeks, beginning on post‐op day 3

Inclusion Criteria Exclusion Criteria

• Cardiac surgery via median sternotomy

• Non‐English speaking/reading

• > 18 years • Cognitive impairment or unlikely to complete data collection process

• No telephone access

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Outcomes Pain and discomfort

Wound healing

Pain medication

use

Antibiotic use

* Time to moving out of the tube

Health services use

Return to function

Group Characteristics Standard Sternal

PrecautionsKYMITT p

Male 77% 77% ‐

Age (mean) 66 65 0.577

BMI (mean) 29.00 29.50 0.523

Surgery Type

CABG 67% 72% 0.357

Valve 10% 11% ‐

CABG + Valve 8% 7% ‐

Other 15% 10% ‐

Donor Graft Site

Right IMA 12% 12% ‐

Left IMA 52% 66% 0.044

Saphenous 65% 65% ‐

Other 21% 11% 0.054

Sternal Wound Closure

Staples 11% 2% 0.010

Sutures 86% 97% 0.005

Missing 3% 1% 0.531

Previous Sternotomy 2% 8% 0.052

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Results

Functional Status Scores Using HAQ

Standard Sternal Precautions

(Mean (SD))

KYMITT

(Mean (SD))p

HAQ 2 weeks 1.97 (0.55) 1.68 (0.63) 0.003

HAQ 4 weeks 1.46 (0.63) 1.15 (0.60) 0.001

HAQ 6 weeks 0.88 (0.59) 0.66 (0.63) 0.021

HAQ 12 weeks 0.23 (0.34) 0.30 (0.49) 0.276

• Return to Function (Health Assessment Questionnaire HAQ)

• Statistically significant difference at 2, 4 and 6‐weeks

• KYMITT group had less functional impairment than the standard sternal precautions group

• Statistically significant AND clinically meaningful!

Results

Mean Pain Scores Over Time

Day 5 Week 2 Week 4 Week 6 Week 12

Standard Sternal

Precautions3.44 (2.30)

2.55

(2.09)

1.47

(1.58)

1.04

(1.50)0.20 (0.68)

KYMITT 3.24 (2.13)2.49

(2.19)

1.86

(2.11)

1.00

(1.52)0.48 (1.10)

• Pain

• Statistically significant improvement in pain scores over time for BOTH groups

• There were no significant differences in pain scores between groups over time

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Results

Wound Healing Difficulty

Standard Sternal

Precautions (%)

KYMITT

(%)p

2‐weeks 13 10 0.47

4‐weeks 12 10 0.67

6‐weeks 9 3 0.07

12‐weeks 0 0 ‐

• Wound Healing• 3 sternal wound healing factors ‐ drainage, stability and incision approximation

• There were no statistically significant differences in wound healing problemsthough KYMITT patients had fewer wound healing problems than standard sternal precautions patients overall

Take Home Messages…

• NO harm caused using KYMITT

• Early functional improvement likely meaningful to patients

• Potential for a more efficient journey through health system?

• Stay tuned for a comprehensive analysis of data!

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Questions?Contact Information:

[email protected]

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