An Integrative Protocol for Lower Back Pain

Katia TwyfordOsteopath

Louise GodfreyYoga Therapist

Dr Suzanne Grant, Chinese Herbalist & Acupuncturist

Post Doctoral Research Fellow, UWS

LBP is the most common condition for which people use CAM 1

1. Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. December 2008.

Workshop planWhat is integrative health careWhy we might treat using an integrative health care protocolCommence with a case studyHow would we construct IHC protocol for LBP

Create a patient profileCreate a treatment planAssess progress

Chinese medicine treatment for LBPOsteopathic treatment for LBPYoga therapy for LBP

What is Integrative health care?

“An inter-disciplinary, non-hierarchical blending of both CAM and conventional medicine that provides a seamless

continuum of decision-making and patient-centred care and support. It employs a collaborative team approach guided by

consensus building, mutual respect and a shared vision of

health care that permits each practitioner and the patient to contribute…to treat the whole person, to assist the innate

healing properties of each person..”

Boon et al Integrative healthcare: arriving at a working definition Altern Ther Health Med 2004; 10:48-56

Why integrative health care?

Patients are increasingly using integrative health care to manage their health and prevent illness.Chronic disease is not being adequately treated by single modalitiesSome patients are seeking alternatives to pharmacological treatment that have unpleasant side effectsPatients perceive CAM combined with biomedicine is better than either alone

Case presentationChris, 46 yr old male, outdoors enthusiast, who injured his back 2 years ago while doing martial arts. He is suffering from intermittent but ongoing lower back pain. He reluctantly takes pain killers from time to time. He was diagnosed with a disc herniation at L4 and L5.

Case presentation cont’dHe admits to getting cold easily and his muscles cramp. His stools were loose, and he often had to get up at night to urinate. He drinks coffee and cold fruit juice and little else for breakfast, and is always “on the go”. He craves sweet foods. New symptoms include poor sleep and depression.

Integrative health care Protocol for Lower Back PainPatient

wants to see GP

Who is the gatekeeper

?

Commence individual treatment

with specific practitioner

Create a patient profile

[2]

Consider referring back to the IHC process where appropriate

Not suited for IHC

Yes – patient suited to IHC and chooses this path

Patient wants to see CAM therapist

Patient has a lower back pain & does

not know who to see

Patient referred to therapist or

GP for known health

condition

Patient has ‘symptoms’

but not health condition unclear

Clinical presentation – create patient profile

Health history (description of pain, response to previous treatments, comorbidities and medications)Examination (vitals, orthopedic exam)Imaging (x-ray, ultrasound if warranted)Psychosocial measuresPreferencesExpectations of improvement with each modality (5 point scale)Previous experience of other treatments

Preferences and

expectations

Integrative health care Protocol for Lower Back PainPatient

wants to see GP

Who is the gatekeeper

?

Commence individual treatment

with specific practitioner

Create a patient profile

[2]

Patient-Practitioner(s) decide on a

treatment plan

Consider referring back to the IHC process where appropriate

Not suited for IHC

Yes – patient suited to IHC and chooses this path

Patient wants to see CAM therapist

Patient has a lower back pain & does

not know who to see

Patient referred to therapist or

GP for known health

condition

Patient has ‘symptoms’

but not health condition unclear

Eg. LBP. What are the comorbidities? If overweight, consider nutritionist involvement; if depressed consider assessment of severity, consider osteopathic appraisal for the level of musculoskeletal involvement.

Some improvement

No improvementHow is this assessed? What happens here? Review treatment plan.

Decision making session with patient bringing in evidence, cost and time, the patient’s preferences, expectations and values

1. Patient assessed by nominated therapists and initial treatment

2. Case conference (via email, phone or in person) with patient

3. Treatment Plan: with an agreed revision date. For example, 3 months osteopathy & one course of acupuncture, commence yoga classes and consider some other mind body therapy

Review with appropriate validated

instruments at agreed

timeframe for review

Determining treatment plan

Recommendations for treatment based on evidence-informed practice model:

Clinical presentationExpressed values and expectationsBest available scientific evidenceTeam’s clinical experience

Best available evidence

www.nccam.nih.gov/health/

How do you know if it’s working?

Patient feels better!Assessment tools can be administered in the waiting room after the consult, they can be administered by the practitioner or therapistConsider utilising measurement tools at baseline eg MYMOP and Roland Morris questionnaire

Available at http://sites.pcmd.ac.uk/mymop/

http://sites.pcmd.ac.uk/mymop/

www.outcomesdatabase.org

Back to our case study…So one protocol may be a course of acupuncture, combined with an therapeutic exercise such as yoga or tai chi and some Chinese herbs….

Chinese medicine treatmentDiagnosis of the dominant pattern(s):

Aetiology: The depleting behaviours of coffee, cold juices, repeated outdoor exposure have depleted his qi and yang, and allowed cold and damp to penetrate his back. Yang typically depletes as we age.Diagnosis: Yang deficiency is associated with back pain, cold hands and feet, night-time urination, needing coffeeThere are also some elements of Qi deficiency too – loose stools, muscle cramping, craving sweets

TreatmentDiet:

Stop coffee, fruit juice Eat warm cooked foods to build qi and yang.

Herbs:Shen Tong Zhu Yu Tang for meridian circulation then Shen Ling Bai Zhu San for the qi

Acupuncture: Ashi points, selected huataojiaoji points (.5 cun lateral to the lower border of the spinous processes of T1-L5)Bilateral SJ5 waiguan, GB41 zulingqi, UB 22 pishu, BL23 shenshu and Ki3 taixi

What else is needed?A way to deal with stress other than coffee and being “on the go” all the timeSelf care for preventionThis may come in the form of:

A concurrent exercise therapy to prevent recurrenceFurther dietary advice and planning from a nutritionist???

Osteopathic "lecture notes# 2Igor A. Litvinov

YOGA

24

YOGA THERAPY

25

HOW YOGA IS USEFUL IN THE MANAGEMENT OF PAINPAIN IMPACTS YOGA’S RESPONSE

PHYSICAL IMMOBILITY

ENERGY LOW

MIND AGITATED

ATTITUDE DESTRUCTIVE

EMOTIONS UNSTABLE

SLEEP DISTURBED

MOBILITY

BALANCED

CALM

CONSTRUCTIVE

STABLE

CONTINUOUS DEEP

SLEEP26

APPROACHINDIVIDUALIZED

MULTI-DIMENSIONAL

SELF-EMPOWERING

INTEGRATIVE

27

CASE STUDY 1September 2009• 57 year old female• Retired school teacher• Married/no childrenHealth History• Nervous breakdown 1995• Depression since 1995• Scoliosis of the spine since childhood• Cancer melanoma/right leg• Migraines• Debilitating back pain from 1985 car accident

28

CASE STUDY 1September 2009Current HealthFrequent chest infectionsDepressionChronic lower back painLeft wrist/thumb arthritisSinus/recurring CandidaFamily Medical HistoryAsthma/obesity/arthritis/high

BP/diabetes/cardiac/otherMother - Asthma

29

CASE STUDY 1September 2009Appetite-Good Energy levels-Moderate Sleep onset - goodSleep Continuity - disturbed, wakes for 1-2

hoursMenstrual cycle – post menopausalBowel movement – good/regularFitness- regular walking, weekly yoga

30

CASE STUDY 1September 2009

MedicationsAnti-depressant (Zoloft) since 1995 100mgDaily Rivotrol for anxietyValium for back pain when neededNaturopathic care for chest infectionsTherapiesOsteopathyWeekly yoga classGoalTo reduce stress and anxiety, increase

movement and to “stay in the present moment”

31

CASE STUDY 1ObservationsVery low moodScoliosis of the spine Weakness in the backFatiguedRepeating old behavioural patternsShort term goalReducing back painStabilizing emotionsStrengthening respiratory systemLong term goalLifting depressionChanging old patterns

32

Case study 1

33

Case study 1Final OutcomeCompletely off medication for depression

since November 2011Rectified scoliosis of the spine 2011Back pain improvement and ceased in first

practiceRespiratory system strengthened in 2010

34