A Significant Step Toward Greater DC-MD Collaboration
By Daniel Redwood, DC
Editor's note: The following is reprinted with permission from the Jan / Feb 2014 issue of Health Insights Today, an electronic publication of Cleveland Chiropractic College in Kansas City.
The first-ever joint meeting of University of Kansas Medical Center faculty members specializing in pain medicine, clinical and research faculty from Cleveland Chiropractic College, and practicing chiropractors from the Kansas Chiropractic Association (KCA), was held at CCC in early December 2013. It featured presentations by Kendall Payne, DC, president of the KCA, and Dawood Sayed, MD, of KU, in which these doctors described their successful collaboration on a patient with extreme facet-related pain and described the contribution each of their professions brings to the care of low back pain. Participants agreed to continue meeting on a regular basis, and to expand their reach to include primary care medical physicians and others.
Meetings such as this one are crucial to developing the kind of mutually respectful interprofessional relationships that form the foundation of truly integrative health care. Both educational and social in nature, they provide a promising reminder that the difficulties of the past need not be carried over into the future. When we hold the well-being of our patients as the highest priority, cooperation with other similarly motivated practitioners of all types logically and organically follows.
Chiropractic and Facet-Mediated Low Back Pain
Dr. Payne opened the evening with a description of chiropractic diagnostic and treatment approaches for low back pain patients, focusing specifically on facet-mediated pain. He emphasized the value of spinal adjustments and related therapies as front-line approaches to back pain and other musculoskeletal conditions. He described the anatomy and physiology of spinal facet joints, the importance of restoring joint mobility, and the usefulness of several complementary therapies.
Bringing this academic material to life, Dr. Payne then described the case of a patient whose acute, 10-on-a-scale-of-10 facet-related low back pain was so severe that the patient was unable to walk, but for whom his diagnostic workup indicated no signs of disc-based radiculopathy.
Unable to perform any manipulative or other manual procedures with the patient in this state, and recognizing that this extraordinarily severe facet-related pain required immediate help on an acute care basis, Dr. Payne called Dr. Sayed at KU Medical Center, explained his findings, and sent the patient directly to Dr. Sayed for treatment to relieve the pain. He did so knowing Dr. Sayed's goal would be to relieve the acute pain in order to make chiropractic care possible.
Medical Approaches for Extreme Facet-Mediated Pain
Dr. Sayed, who offered a highly informative introduction to "interventional" procedures, began by noting that chiropractors often see patients who have not been helped by medical procedures and that, conversely, MDs often see those for whom chiropractic has not offered relief. This is to be expected, he said, since no method helps all patients.
Before going into detail about interventional procedures, Dr. Sayed emphasized that he and his colleagues do not consider these invasive approaches to be front-line approaches; chiropractic, physical therapy, nonsteroidal anti-inflammatories, and other minimally invasive procedures should generally come first.
He described the use of facet blocks, which are commonly employed as a method for confirming whether the pain is caused by a facet problem. He followed this with what the chiropractors in attendance found to be a highly informative explanation of facet joint injections (with steroids) and radiofrequency ablation (in which a nerve is heated to decrease pain sensations), noting again that these more invasive interventional methods should be reserved for patients for whom front-line methods, including chiropractic, are not possible or where they have been tried and failed.
In general, Dr. Sayed stated, RF ablation should not be used unless patients have tried front-line approaches first and lived with chronic pain for at least six months.
Dr. Sayed described his work this way: "Facet mediated pain is one of the most commonly encountered disorders that physicians treating patients with spinal disorders will encounter in their practice. In addition to front line therapies such as medications, PT, and chiropractic treatment, one should consider interventional treatments such as facet injections and medial branch radiofrequency ablation. These therapies have proven success per the literature and an extremely low complication rate. Future studies and development of potential treatment algorithms combining interventional therapies and chiropractic medicine for facet mediated disorders have the potential to result in better results for patients than either treatment individually." [Italics added].
Charting a Way Forward
The December meeting at the Cleveland's Overland Park campus drew enthusiastic responses from key researchers at Cleveland and KU, boding well for future collaborative work.
Talal Khan, MD, who chairs the Department of Anesthesiology and Pain Medicine at the University of Kansas Medical Center and also serves as medical director for interventional pain medicine at the Marc Asher Comprehensive Spine Center at the University of Kansas Hospital, responded as follows:
"The delivery of quality health care depends upon care coordination amongst the different providers that care for patients. The escalating cost of healthcare in the United States is alarming and it is imperative that we get together and develop best practice models and algorithms based upon evidence to help our patients navigate the current complex care environment for the management of back pain. Our December meeting was the first of many to bring together medical and chiropractic practitioners to explore ways in which we can collaborate and exchange information for better care of patients suffering from back pain. I am very excited and optimistic about potential opportunities in the future where we can come together to challenge the status quo and improve care in the Greater Kansas City area and the region."
Mark Pfefer, RN, MS, DC, director of research at Cleveland Chiropractic College, was equally enthusiastic:
"I am excited to work together collaboratively with chiropractic and medical colleagues to improve patient care. Multidisciplinary practice and co-management will likely yield improvements in outcomes and lower costs for patients. I also look forward to development of collaborative research projects to improve diagnosis, develop effective clinical prediction rules, and to improve outcomes. We have an opportunity and a responsibility to develop improved interventions for the patients within our community and beyond."
It seems fitting to close with some parting words from the two presenters, starting with Dr. Payne of the KCA. After thanking those who set up the program – Dr. Clark Beckley, Sarah Hillard, Brendy Frasco and Lina Wilson – along with the college, the KCA and Dr. Sayed, Dr. Payne wrote:
"I felt the presentation went extremely well, but the real value of the evening for those in attendance was the opportunity to network and discuss ways we can begin collaborating on patient treatment. I have been in touch with all the doctors from KU Med since the meeting and we are looking for a time that we can start collaboratively treating patients as well as setting up future case studies and possibly even publishing some of these. In my opinion, this could not have gone better and I really look forward to working with Drs. Sayed, Braun, Khan, Williams and Nicol to establish best practices of a multidisciplinary treatment. This will be a first for the KCA and KU Medical Center."
Last but by no means least, from Dr. Sayed: "I felt that the meeting was an extreme success and the start of mutually beneficial collaboration between our Anesthesia Pain physicians at the University of Kansas and chiropractic physicians at Cleveland Chiropractic College. Both specialists have differing skill sets and practice styles with a lot to be learned from each other. Programs such as this lay the ground work for future collaborative efforts in research, development of treatment algorithms, and patient care."
May this be the first step on a long and fruitful journey.
Dr. Daniel Redwood is a professor at Cleveland Chiropractic College – Kansas City. He is the editor-in-chief of Health Insights Today, associate editor of Topics in Integrative Healthcare, and serves on the editorial board of the Journal of the American Chiropractic Association. Click here to visit his website and health-policy blog.