Chiropractic + Naturopathic Doctor • February 2019 • MSK Experts

The ISAEC program allows chiropractors to improve fragmented care for back pain patients

While back pain is rarely a life-threatening condition, as chiropractors you know it can significantly impact your patient’s quality of life. With more than an estimated 540 million people across all ages and socio- economic statuses suffering from back pain worldwide, health-care professionals need a better way to manage this often debilitating condition. Through the ISAEC (Inter-professional Spine Assessment and Education Clinics) program, Toronto-based spine surgeon Dr. Raj Rampersaud and his team have done just that.

Rampersaud and his team have created a multidisciplinary approach to evaluate, stratify, and treat patients living with back pain. The program’s approach, and inclusion of chiropractors in an advanced practice provider (APP) role, is not only helping patients be seen and evaluated quickly, it’s also resulted in a reduction of unnecessary tests (such as MRIs), improved patient quality of life, and ensured that those who actually need to see a surgeon are able to receive a consult in a timely manner.

In Ontario, specially trained chiropractors and physiotherapists take a central role in the program, evaluating the cause of back pain in patients, and teaching them how to manage pain. These APP leads are currently split about 50/50 between physiotherapists and chiropractors. Administered through Local Health Integration Networks, or LHINs, rapid assessment clinics are opening up throughout the province after the success of the sixyear pilot program.

Dr. Andrew Bidos, a chiropractor involved with ISAEC since its inception, says it has been good to see the changes in the way the province is managing MSK conditions.

“What was happening a lot of the time prior to the ISAEC model of care, is that the patients didn’t receive the care they required,” he said. “Traditionally, managing lower back pain is very siloed, and depending on who [the patient] sees, they’ll get very conflicting advice on how to manage it. So there was no standardized format in assessing or managing low back patients.

“Essentially what we did with the ISAEC model of care is that we took all of the available evidence and started stratifying patients based on their presenting condition. And then we also risk-stratified them utilizing specialized questionnaires, so it allowed us to actually suggest targeted interventions for these patients. By stratifying, you can provide targeted treatments, targeted interventions, targeted advice and education to help these patients better manage their condition.”

The first step for a patient to access care through the ISAEC program is to be referred to one of the rapid assessment clinics by their primary care provider – either their family doctor or a nurse practitioner who has received training on the program. The person then visits an APP (either a DC or a physiotherapist). Once their back pain is evaluated, depending on the findings, the patient can be given self-management exercises to help with the pain, referred to other supports, or sent for surgical assessment. Prior to the program, patients were waiting up to six months for MRI scans, and then another 18 months to see a spinal surgeon, only to be told that surgery couldn’t fix their pain. Now, patients are seen at a clinic in an average of 12 days, and about 90 per cent of them require no further treatment beyond their customized exercise plan from the APP. Those who do need to see a surgeon are able to have an evaluation in as little as two weeks, and MRI use has decreased 30 per cent.

The program has seen such success in Ontario, that other provinces are running their own pilots with the program. In New Brunswick, Dr. Neil Manson is the orthopedic surgeon leading the ISAEC-NB project over the past year. He says that despite a few subtle changes due to the setup of the province’s health care system, they’ve kept Rampersaud’s ISAEC model mostly the same.

One of the major differences in the NB program is that, unfortunately, chiropractors are not involved in assessments – only physiotherapists, given the funding model within the province. This has also meant that evaluations and treatment take place within hospital. Chiropractors were part of a lengthy consultation process when getting the pilot off the ground, and Manson is quick to highlight their role.

“We couldn’t have done it without the multidisciplinary perspective, because there would have been huge holes,” he said. “When we look at [professionals] of all different specialties – the physio, the chiro, the massage therapist – they’re managing this way more than the surgeons are, so it would be foolish not to have them as part of the mix.”

The project is ongoing in Saint John and Moncton, which captures a large percentage of the population, but Manson admits scaling the model across the province to rural areas is where the challenge lies. The Ontario model was tested in Toronto, Hamilton, and Thunder Bay in order to address delivery issues in varying regions.

“The numbers are small, but the results are pretty impactful,” said Manson. “Almost all the patients [we’ve seen through the program] have self-reported improvements in their back pain, and are confident that their back pain is not cancer; that they can work through an exercise program to improve their back pain, that they can continue to work, that they don’t need to see a spine surgeon, and they don’t need an MRI.”

He notes that out of 146 patients, only eight were flagged as needing further assessment by a spinal surgeon, meaning the other 138 didn’t have to wait an extended length of time to see someone to tell them they didn’t need an operation, and they simply have mechanical back pain - a huge win for all involved.

Ontario chiropractors have found the program lets them leverage their skillset in a more thorough manner. Dr. Henry Candelaria has been involved with the ISAEC program since its inception – first as an APP and now as a practice lead for the Mississauga, Ont., LHIN. He notes that a chiropractor’s ability to assess and diagnose causes of back pain allows patients to better navigate available treatment options within the health care system.

“We’re known more for our manual skills than our diagnostic skills, and I don’t think that’s fair, given the level and degree of training that we go through in our chiropractic college,” he said.

“I think the program plays a significant role in providing a different avenue by which a patient can get an expedited diagnosis and then, if need, expedited access to somebody that can help them manage their pain, manage their condition and then, if needed, escalate their care to the appropriate person.”

Bidos says that what ISAEC has done well is highlighted the value that chiropractors can bring to the health-care system.

“We have expertise in MSK, and I think that this is something that the profession needs to focus on. That we’re not just spine experts, we have general orthopedic expertise that the health care system can tap into, and can use to help improve access in conjunction with the broader health care system. I think that we’re well equipped to be a part of these advanced practice roles, to be part of the broader medical system, and to come under the fold of the medical system in Ontario.”

For its part, the Ontario Ministry of Health and Long- Term Care (MOHLTC) says the current government is reviewing all programs and services to ensure Ontarians are receiving the care they need to stay healthy.

“The ISAEC pilot demonstrated the value of an innovative integrated care approach to help patients with low back pain where a variety of providers were involved. Active and co-ordinated participation by all providers and patients is the key component of this program,” said David Jensen, a media relations coordinator for the MOHLTC.

As for the future of the program and the role that chiropractors will take, the Ministry is expanding a hip and knee program using principles of the ISAEC model of care, and chiropractors will no doubt take a leading role again in the evaluation and stratification of patients. Candelaria says that although there is currently no funded rehab or manual therapy in the program, there are talks about incorporating that in the future.

“Another piece that we’re working on currently is a piece with accelerated referral to a rheumatology service that provides quick access for patients who are suspected to have inflammatory sources of back pain.”

Bidos says that the government has been a great partner for improving care and management of low-back pain, and that he hopes the program can expand its stream of treatment options beyond just surgical.

“We’re improving fragmented care. Chiropractors are now seen as a legitimate choice as MSK practitioners who can work within a hospital system, as well as a global medical system.”