Multilevel approach Michael’s Hospital in Toronto is considered a pioneer in this area, where chiropractic has been successfully integrated in its primary care setting. The Ontario Primary Care Low-Back Pain (PCLBP) pilot project, for the last two years, has seen the pilot sites reporting better outcomes for patients. Ninety-percent of patients seen at the Windsor-Essex PCLBP pilot site are chronic low-back pain patients, ac-cording to Dr. Dean Tapak, one of the chiropractors in-volved in the project. Patients are reporting significant reduction in their pain levels over the course of their re-spective treatment plans – many of them saying they have since either reduced or completely stopped taking their pain medications. “We learned that patients, when placed in multidiscipli-nary settings – where you have specialists in different areas all coming together, sharing patient files, discussing pa-tient’s management – it’s just that much better for the patient’s overall health and well-being,” Tapak says. www.canadianchiropractor.ca There are other factors beyond spinal manipulation and chiropractic care, however, that should be considered when managing chronic pain patients. “Chronic pain is a multifactorial problem,” Burnie ex-plains. “There may be organic problems – muscles, nerves, joints. There’s also other factors (like) societal issues.” Peo-ple can have different responses to pain, and tolerance levels may vary. There are also psychological issues that must be considered when assessing pain patients. Effective pain management must involve a biopsychoso-cial approach to assessment and treatment. When a patient is in pain, the health-care provider does not only look at the physical or peripheral areas of dysfunction, but also assesses the psychological factors, especially if the patient is exhib-iting symptoms of depression, anxiety or stress. Looking for signs of central sensitization is one way to assess for any psychological risk factors. When a patient cries out in pain even from the slightest palpation from a chiro-practor, that’s usually a sign of central sensitization, notes Dr. Chris Carter, a chiropractor from Kelowna, B.C. Carter has a particular interest in pain management and has taken a master of science in pain management at the University of Sydney Medical School in Australia. “We have to assess – are there issues going on in the brain that are amplifying the person’s pain experience?” Carter says, a CMCC graduate who spent 10 years in private prac-tice in Perth, Australia, before moving back to B.C., over a year ago. Research has shown that when central sensitization occurs and patients transition from acute to low-back pain, the risk for underlying depression, anxiety or stress is higher. Research has also revealed that for patients who have pre-existing depression and/or anxiety and then develop acute low-back pain, their condition is more likely to evolve into chronic pain, Carter notes. Detecting high levels of affective disorders – stress, depres-sion or anxiety – in patients with acute or chronic pain upon assessment should prompt chiropractors to make a referral to the family doctor for further psychosocial screening. “Patients that are in the mild or moderate category of pain intensity or disability… they can be given conservative care, but you’re (also) monitoring for any psychosocial risk factors or maladaptive cognition that you discovered in your exam-ination,” Carter suggests. Maldaptive cognition includes fear avoidance and “catastrophization,” where people tend to overanalyze their pain and always think about the worst-case scenario. Minding the psychosocial aspect is crucial to effective pain management. When patients talk about their pain with their health-care provider and they’re tearful, seemingly frus-trated, overwhelmed or having suicidal thoughts, that’s a red flag that a mental health specialist should be brought into the care protocol, says Karen Overholt, a social worker at Essex County Nurse Practitioner-led Clinic. In her line of work, Overholt sees a “strong connection” between chronic pain and mental health. “If we’re not feeling well on a daily basis, we start to deal with negative thinking. Some of the main facets of depres-sion and anxiety are negative thinking habits,” she explains. April 2017 Canadian Chiropractor 19
Chiropractic + Naturopathic Doctor April 2017: Page 19
