research review Corner Continued from page 16 • The type of provider seen was the strongest predictor of exercise pre- scription – PTs were more likely to provide supervision, exercise in gen- eral, and stretching specifically. • Patients who were female, more edu- cated, on workers’ compensation, were employed in the last year, or had seen a PT or chiropractor were more likely to receive exercise pre- scription. (Variables that were almost significant included younger age, pri- vate insurance, no narcotic use, and higher physical therapy visits.) • Those who were on Medicare (this was an American study), were in poorer general health, or reported greater disability were less likely to be prescribed exercise. • A higher number of visits to a chiro- practor raised the likelihood of exer- cise prescription. • 86 per cent used more than one ad- ditional treatment – heat/cold and electrotherapy were most common for back pain, while heat/cold and manipulation were most common for neck pain CONCLUSIONS AND PrACTICAL APPLICATION: Overall, this study suggests that exercise is being underutilized in clinical practice in the management of chronic neck and low back pain. We should all take this study as a call to action – get your patients ac- tive! One of the only successful treat- ments for chronic neck and low back pain, exercise, was prescribed less than 50 per cent of the time in this large population-based study. Paradoxically, CHA Education Continued from page 14 The art of management is a very im- portant and critical skill for owners and clinic managers to develop. Also, by utiliz- ing these management tools, you can cul- tivate an atmosphere of objectivity, which reduces staff’s perceptions of “unfairness” or “favouritism”. (Perception issues, within the manager-staff relationship, are often the number 1 complaint within teams.) 20 • CANADIAN CHIROPRACTOR | APRIL 2009 the type of practitioner was more influ- ential than any patient-related factors in the prescription of exercise – the au- thors say “who you see is what you get”. Prudent clinicians should focus on the patient when prescribing exercise, regardless of his/her profession. It may be expected that PTs are most likely to prescribe exercise, but it should be noted that roughly one-third of their patients, in this study, did not receive ex- ercise. Less than half of patients consult- ing a physician received exercise, either from the doctor or from a subsequent referral to a PT or chiropractor. Chiropractors were somewhere in the middle, prescribing exercise at a reason- able rate (roughly 33 per cent), and more frequently as patients saw them more. This may reflect a common practice pattern of attempting to reduce pain levels before instituting exercise and rehabilitation. In general, common barriers to ex- ercise prescription could be provider knowledge and confidence. For those who do not have this background, adding a team member to your office who does can be a great asset, and based on existing literature, can improve care outcomes. STUDy METHODS: Data was analyzed from a population- based survey of health care and treat- ment use in a population of chronic low back and neck pain patients4 . The goals of the study were: 1. to assess the extent and details of exer- cise prescription by medical doctors, physical therapists, and chiropractors 2. to identify sociodemographic and work-related factors related to ex- ercise prescription 3. to determine the level of supervision provided for exercise programs 4. to evaluate the extent to which other INTErDEPENDENCE BETWEEN LEADErSHIP AND MANAGEMENT Management without leadership be- comes about trying to change our staff – making them do differently or better – and viewing them as independent of, or unattached to, the big picture in the practice. When strategies to grow people are about controlling other people, we are less likely to assist them in any kind of transformational change. Our staff mem- bers are not independent entities in our conservative treatments are used in conjunction with exercise A cross-sectional, telephone-assisted survey was conducted on a sample of pa- tients in North Carolina. 4,451 adults from 3,276 households reported a history of back or neck pain in the past few years. One adult from each household was selected, and 86 per cent completed the survey, re- sulting in 2,723 subjects. It should be noted that respondents and non-respondents to the survey were similar in age and race, but respondents were more likely to be male. 873 subjects had chronic LBP (with or without leg pain) or neck pain that was chronic (defined as at least three months’ duration, or more than 24 activity- limiting episodes in the previous year). Questions regarding exercise prescription were adequately specific, including informa- tion on type of exercise (posture, stretching, strengthening etc.), practitioner, amount of supervision, and exercise parameters. STUDy STrENGTHS/WEAkNESSES: The primary weakness of this study is the use of patient recall in the data collec- tion. For example, in pre-trial piloting, some patients were unclear what “range of motion” exercises were. Further, it is possible that patient responses were sub- ject to a social desirability bias. This study does provide some valu- able insight into the practice patterns surrounding exercise prescription. Fu- ture research should incorporate cohort study designs and alternative data sourc- es, such as provider reports or claims data, while further exploring provider and patient characteristics that are as- sociated with exercise prescription, and barriers to prescription and adherence. • For article with references, please go to www.canadianchiropractor.ca practice. They are a reflection of us. When we link leadership and man- agement into an interdependent rela- tionship, the power to change ourselves, and bring about transformation in oth- ers’ performance within our practice, in- creases exponentially. My favourite quotation by Ralph Waldo Emerson sums this up beautifully: “It is one of the most beautiful compen- sations in life – we can never help another without helping ourselves.” • www.canadianchiropractor.ca
Chiropractic + Naturopathic Doctor April 2009: Page 20
