'We've got your back'

Clinic cuts wait times for patients with back pain

Spine assessment clinic staff and client.
Spine Assessment Clinic physiotherapists Shelley Sargent (left) and Karen Malenchak (right) are responsible for evaluating patients like Michelle Henry (centre).
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Common causes of back pain

Winnipeg Health Region
Wave, November / December 2016

Michelle Henry started to experience back problems last November, after she slipped while walking on a sidewalk.

At the time, she didn’t think much of it. Her back just seemed a little stiff – that’s all.

But as the weeks went by, the stiffness progressed to mild discomfort and then to crippling pain.

“It started feeling like I had a grapefruit in my back,” says the 51-year-old administrative assistant with the Winnipeg School Division. “Soon I was so sore I could barely sleep.”

She started to miss work. And at times, her pain was so debilitating she couldn’t get out of bed or put on her clothes without help from her husband.

Eventually, Henry went to see her family physician, who referred her to an orthopedic spine surgeon.

Henry’s story may sound familiar to many. After all, thousands of Manitobans suffer from severe chronic back pain. And they often wait for long periods – sometimes up to a year – to see a spine surgeon, who will determine whether their problem requires surgery. 

But that’s where Henry’s story takes an interesting turn.

Rather than having to wait months or years for a spine surgeon to determine the best course of treatment, Henry’s file was diverted to a relatively new clinic funded by the Winnipeg Regional Health Authority to cut wait times and deliver care more efficiently.

Located at Health Sciences Centre Winnipeg, the Spine Assessment Clinic was conceived and developed by a group of health-care providers with years of experience in helping patients with back pain – Dr. Michael Johnson, an orthopedic spine surgeon; Neil Machutchon, Regional Director of Physiotherapy for the Winnipeg Regional Health Authority; Eva Karpyza, Regional  Manager for Outpatient Physiotherapy at HSC Winnipeg; and Lanette Siragusa, Director of the Winnipeg Regional Health Authority’s Surgery Program.

Johnson says the idea for the clinic sprang from the realization that many patients with severe chronic back pain were waiting too long for care, largely because of a bottleneck in the system.

As he explains, a patient with chronic back pain usually starts their quest for care by going to see their family doctor for help. Depending on the circumstances, the doctor will often refer the patient to an orthopedic surgeon or neurosurgeon specializing in spine procedures, who is expected to examine the individual to determine if they require surgery.

If surgery is not appropriate, the orthopedic surgeon may recommend the individual see a physiotherapist, who then works with the patient to develop a course of exercises to rehabilitate the back injury.

The problem is there are a lot of people who have chronic back pain, which means there are also a lot of people waiting to see a spine surgeon. Compounding the problem is the fact that many people on the wait list don’t need surgery and, as a result, really don’t need to see an orthopedic surgeon.

“I was overwhelmed with the volume of referrals, also recognizing that many didn’t need to see me,” says Johnson. In fact, he says he has a waiting list of more than 4,000 patients waiting for a consult, the majority of whom won’t need surgery and, therefore, don’t need to see a spine surgical specialist. The wait times for the four other surgeons performing complex back surgery in the city are much the same, he says.

Recognizing the scale of the problem, Johnson and his colleagues came up with a solution: a clinic staffed by specially trained physiotherapists who could properly evaluate a patient’s need for surgery and refer non-surgical patients for appropriate care without having to see an orthopedic surgeon, thereby cutting wait times.

And so, the Spine Assessment Clinic was launched as a pilot project in May 2015.

Under the pilot project, each of the participating spine surgeons took turns reviewing patient files referred to them by family physicians. Based on the information provided on the referral, as well as the results of the most recent imaging, patients were identified as candidates for the Spine Assessment Clinic. Physiotherapists Karen Malenchak and Shelley Sargent then reviewed the files and the patients were offered an opportunity for evaluation and discussion about appropriate treatment options.

As well as running the assessment clinic, both physiotherapists also work at the HSC Outpatient Physiotherapy Department and have plenty of experience working with people suffering with chronic back pain. As such, they were the perfect fit for this project as they were able to not only triage patients but also play a key role in the physical therapy management of those patients deemed non-surgical. As Johnson explains, the success of the clinic model depended on staff being able to not just tell a patient they didn’t need surgery, but to also provide them with a plan to deal with their pain non-operatively.

“Shelley and Karen worked with us for about a year and a half in our clinics,” says Johnson. Among other things, the physiotherapists learned how to perform a surgical screen and interpret MRIs. “And they taught me a lot about physical medicine and clinical application of those skills,” he says. “It was a symbiotic interaction that made us all better at our jobs.”

Malenchak says the concept of the clinic makes a lot of sense.

“It’s an opportunity for non-surgical patients who are referred to a specialist to be assessed and have treatment plans developed that will hopefully help them to recover functionally,” she says.

“If we didn’t see these people, it’s likely they could be waiting a long time for treatment – and with chronic spinal pain, the sooner the treatment interventions are initiated, the better.”

The clinic evaluates an average of 10 patients a day, with each assessment taking at least an hour, says Sargent. Most of the patients who visit the clinic will have back problems that range from a herniated disc to spinal stenosis. “If we think they’re surgical, then we refer them back to the surgeon for an appointment,” Malenchak says.

About 15 per cent of the patients seen at the clinic are referred back to a spine surgeon. The remaining 85 per cent of patients are evaluated and may be referred to a physiotherapist if deemed appropriate for active therapy.

Patient choice is a priority.  “If they want to come to HSC, they are offered physiotherapy treatment at our site,” says Sargent. “If they want to go somewhere else, we help them co-ordinate the referrals for different sites.”

Other treatment options can include a referral to the HSC Pain Clinic, where patients can receive injections of pain blockers or steroids to reduce inflammation. Again, patients are able to be seen within a few weeks rather than several months.

For patients like Henry, the quick access to care came as a relief.

Although she had been previously diagnosed with a herniated disc by a private physiotherapist, Henry says she still felt as though she had a more serious problem, possibly cancer.

Malenchak helped alleviate those anxieties. “She gave me so much relief,” says Henry.

Equally important, Malenchak referred Henry for an appointment with a physiotherapist at the Rehabilitation Hospital, a referral that meant the physiotherapy would be covered by Manitoba Health. Otherwise, she was facing waiting many months for a surgical consultation.

Surgery is, of course, the treatment of last resort for patients with back pain. Surgeons would rather see patients exhaust every avenue of alternative care to improve their condition because surgery can pose serious complications and risks. 

“The Winnipeg Spine Program belongs to a national database that keeps track of results as well as complications of surgical patients,” says Johnson. “Our post-surgical outcomes match or exceed those in the rest of the country, and our complications of spine surgery in Winnipeg are very good compared to national averages,” he says.

“In spite of our complication rates being low, a complication in spine surgery tends to be extremely harsh and can result in enormous disability for the patient,” says Johnson. “If a patient of mine ends up with a deep wound infection, that’s almost a year of repeat surgeries and intravenous antibiotics. It’s the potential for complications and the risks of surgery that validate the premise that patients should exhaust reasonable non-surgical options before proceeding with an operation.”

Fred Wiens was among the many patients pondering surgery. Injured as a child, he has suffered intense back pain for much of his life.

“If I would do something as simple as making a bed, I could feel like a knife went through my back,” says the 49-year-old IT worker who lives in Kleefeld, south of the city. “Sometimes, I wouldn’t be able to walk for a week.”

Like Henry, he had tried various avenues to get care to help him manage his pain with varying degrees of effectiveness. Then about a year ago, frustrated at his lack of success, he asked his family doctor for other options. The doctor referred him for an MRI and an expected consultation with a surgeon.

“I figured I was heading toward surgery to fix this,” he says, referring to a disc and vertebrae in his lower back that were slightly out of alignment.

Then, to his surprise, he got a letter informing him of his appointment at the Spine Assessment Clinic.

“At first I thought, ‘I’ve gone through this before and it didn’t really go anywhere,’” he says. Yet at the appointment – even in the waiting room – he knew this time would be different.

“My experience with the Spine Assessment Clinic was surprising, actually,” he says. “Even my experience with booking my appointment and meeting the administrative assistant Marie (Nubla) was really good.” She doesn’t just help organize patients’ visits and show them to the examination room. She soothingly treats each patient with respect, kindness and empathy, he says.

“There is all this pent-up anxiety and Marie sets them at ease in such a remarkable way,” he says, adding he observed her interaction with other patients in the waiting area. “She just communicated that, ‘You’re okay now. We’ll take care of you; you found the right place, and you’re good.’”

The rest of his experience was excellent.

He learned more about his condition, and that it could be improved without surgery. Then he was referred for physiotherapy, where he worked with Malenchak and other physiotherapists.

“It involved a lot of commitment like driving into the city a couple of days a week, but it was worth it because I’ve really been able to rehabilitate my back.”

The most important take-away for Wiens is that he now has control over his problem, whereas he had previously felt at the mercy of his condition.

“Personally, from an emotional and psychological perspective, it’s been hugely freeing,” says Wiens. “I have done a 180 in my outlook. On a scale of hopelessness to hope, I went from like a four to more like a seven. I know it’s still hard work and some days aren’t great, but I have more good days than bad now.”

For the time being, orthopedic surgeons remain the go-to health-care providers when a family physician refers a patient with back pain to a specialist.

Now that the pilot project has ended and the Spine Assessment Clinic is fully funded, the eventual goal is to have it serve as a first point of contact for all patients with severe chronic back pain.

“We’re not quite there, but we’re very close right now,” Johnson says.

That’s good news for the thousands of Manitobans dealing with bad backs – something to which Henry can attest. Her experience at the Spine Assessment Clinic was helpful and reassuring.

“I was so happy, I almost cried with relief,” Henry says. “It was an awesome experience – just for peace of mind alone.”

Joel Schlesinger is a Winnipeg writer.

Wave: November / December 2016

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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