changing the culture of pain treatment · warwick • lincoln • providence • newport county •...
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Changing the Culture of Pain TreatmentRehabilitative Health Department
October 19, 2019
This symposium is supported by
funding from the Rhode Island
Executive Office of Health and
Human Services Healthcare
Workforce Transformation Program
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This activity has been planned and implemented in accordance with
the accreditation requirements and policies of the Accreditation
Council for Continuing Medical Education (ACCME) through the joint
providership of the Warren Alpert Medical School of Brown University
and the Community College of Rhode Island. The Warren Alpert
Medical School of Brown University is accredited by the ACCME to
provide continuing medical education for physicians.
This continuing nursing education activity was approved by the
Northeast Multistate Division, an accredited approver by the American
Nurses Credentialing Center’s Commission on Accreditation.
Accreditations
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• Physicians:
The Warren Alpert Medical School of Brown University designates this live activity for
a maximum of 3 AMA PRA Category 1 CreditsTM. Physicians should claim only the
credit commensurate with the extent of their participation in the activity.
• Physician Assistant/Nurse Practitioners/Physical Therapists/Occupational Therapists/Massage Therapists:
Participants will receive a Certificate of Attendance stating this program is
designated for 3 hours AMA PRA Category 1 CreditsTM. This credit is accepted by
the AAPA, AANP, RI Board of Physical Therapy, RI Board of Occupational Therapy
and RI Board of Massage Therapy.
• Nurses:
This continuing nursing education activity was approved by the Northeast
Multistate Division, an accredited approver by the American Nurses Credentialing
Center’s Commission on Accreditation, for 3.25 Contact Hours.
Continuing Education Credit Designation
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Conflict of Interest
In accordance with the standards set forth by the Accreditation
Council on Continuing Medical Education (ACCME) and the
American Nurses Credentialing Center (ANCC), planners and
presenters have been asked to disclose any relevant financial
relationships discussed in any educational presentation. Any
potential conflicts of interest have been resolved prior to this
presentation.
Warwick • Lincoln • Providence • Newport County • Westerly • Online
The following speakers has indicated that they have a relevant financial relationship to
disclose:
Matthew Smith, MD, EMHL
Major Stockholder: University Orthopedics, Inc.
Martine Delonnay, MD, ND
Consultant at BSD Sante PAP, Haiti, Owner of DELONNAY Holistics
The following speakers and/or planning committee members* have indicated that they
have no relevant financial relationships to disclose:
Faculty Disclosures
Karlo Berger, AOBTA, BCLMT* Regina Cobb, MSW, BCLMT, CMLD* Latisha Michel, CCHWVictoria Moutahir, BCLMT, MS*Jennifer Reynolds, DPT, TPSFrancis Sparadeo, PhDMaria Sullivan, BS*Julia Twining, MSN, RN, OCN
Mackenzie Johnson, MSN, RN*James McDonald, MD, MPH* Nancy Dooley, PhD, OTR/LEllen Flynn, MD, MTS Michael Gottfried, BA, MA, DC Jennifer Hurrell, PT, MS, DHScJennifer Jackson, DAOM, MSOM, LMT
Warwick • Lincoln • Providence • Newport County • Westerly • Online
• Recognize psychosocial risk factors for patients with pain.
• Evaluate outcomes of integrative therapy options to manage pain.
• Analyze patients’ biopsychosocial elements related to pain.
• Identify various treatment plans for pain management.
• Describe steps in the referral process for prescribing
non-pharmacologic pain management.
Learner Outcomes/Objectives
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Criteria for Successful Completion
Upon completion of the live educational activity, participants will
complete an evaluation stating whether the learning outcomes were
met and self-report intent to change practice.
Participants must be present the entire length of the live presentation to
earn contact hours.
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Donna Donilon, Ph.D., RN-BC
Executive Director
Healthcare Workforce Transformation Initiatives
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Suzanne Carr, Ph.D., RN
Interim Dean
Health and Rehabilitative Sciences
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Regina Cobb, MSW, BCLMT, CMLD
Program Director & Associate Professor
Massage Therapy Program
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Matthew Smith, MD, EMHL
Clinical Assistant Professor of Orthopedics
Warren Alpert Medical School of Brown University
Director of System Integration,
University Orthopedics, Inc. Chair,
Value Committee, North American Spine Society
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Jennifer Hurrell, PT, MS, DHSc
Professor
Rehabilitative Health Department
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30 Minute
Break
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Panel One
Acute Pain Management
Warwick • Lincoln • Providence • Newport County • Westerly • Online
• Board Certified, Licensed Massage Therapist since 1998
• Owner of Body Kneads, Inc. - founded in 1999
• Instructor since 2005, Continuing Education Provider
• Professional Organizations– Alliance for Massage Therapy Education
– National Certification Board for Therapeutic Massage and Bodywork
– American Massage Therapy Association Board Member
• Certifications– Orthopedic Massage
– Manual Lymphatic Drainage
– Oncology Massage
Victoria Moutahir, MS
I believe massage therapy is a preventative and proactive approach to healthcare
Warwick • Lincoln • Providence • Newport County • Westerly • Online
• Licensed Acupuncturist and Massage Therapist
• Earned Bachelor's Degree in Exercise Science from Sacred Heart University in 2001
• Earned an Associate Degree in Massage Therapy from CCRI in 2002
• Earned a Master Degree (MSOM) in 'Oriental Medicine' (Acupuncture and Herbal medicine) from Southwest Acupuncture College in 2011
• Traveled to and studied in Japan in 2011 and 2014 with Master Acupuncturists
Dr. Jennifer S Jackson, DAOM, LMTOcean Ki Acupuncture
Warwick • Lincoln • Providence • Newport County • Westerly • Online
• Occupational therapist for 28 years
• Practice has focused on the needs of people with serious and
persistent mental illness and on older adults facing multiple
challenges to their health and independence.
• After almost 20 years as a professor and director at New
England Tech, now is an Associate Professor in the
occupational therapy department at Worcester State
University.
• Holds master’s and doctoral degrees from New York University.
Nancy R. Dooley, Ph.D., OTR/L
Occupational Therapy
Ellen Flynn, M.D., MTS
Clinical Assistant Professor
Department of Psychiatry and
Human Behavior
Clinical Assistant Professor
Department of Medicine
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Julia Twining
MSN, RN, OCN
• Registered Nurse for 25 years with experience in Oncology (inpatient and outpatient), Orthopedics, and Hospice
• BSN and MSN, Rhode Island College
• Advanced Practice Manager at The Miriam Hospital assigned to the inpatient Oncology and Medical-Surgical unit and the Float Pool
• Reiki Master, 2016
• Started the Integrative Therapy Program at TMH in April, 2019. This program provides complementary therapies to patients admitted to the hospital. The focus of the program is to reduce pain, anxiety, and fatigue with patients.
• Adjunct nursing instructor for URI and RIC
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Karlo Berger, AOBTA, BCLMTProfessor
Therapeutic Massage Program
Adjunct Professor in CCRI’s Therapeutic Massage Program since 2009, with a focus on
instructing students in Japanese-style shiatsu massage, traditional Chinese medicine, and the
integration of eastern and western evidence-based clinical massage techniques.
Registered Instructor in shiatsu with the American Organization for Bodywork Therapies of Asia.
Has practiced shiatsu massage at Harvard University Health Services, Harvard Vanguard Medical
Associates, and Beth Israel Deaconess Medical Center, and currently maintains a private practice
in Providence specializing in pain management.
Graduate of Brown University and received his massage training at the Bristol School of Shiatsu
and the Boston Shiatsu School.
A founder and leader of various integrative healthcare initiatives, including the Boston-based
Integrative Medicine Alliance, the Rhode Island Birth Network, and the Integrative Medicine at
Brown clinical forums. Currently coordinates the Rhode Island Non-Opioid Pain Treatment
Coalition.
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Nicole is a 25-year-old African American woman with two children under
the age of five who sustained a third-degree ankle sprain in a motor
vehicle accident.
She was transported to a local hospital emergency department (ED)
where she was treated: her ankle was placed in a boot and she was
given crutches.
The treating clinician assessed the patient prior to prescribing pain
medication.
Case Study #1 – Nicole
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Nicole has a personal and family history of addiction, a history of mood
disorder, unipolar depression, and she smokes a pack of cigarettes a week.
In a minor car accident two years ago, she suffered a mild concussion when
her air bag deployed, hitting her in the face.
She and her young children live with her elderly maternal grandmother in
Providence while she attends college.
She works full-time at a department store.
Case Study #1 – Nicole
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Victoria Moutahir, MS
Licensed Massage Therapist
Owner of Body Kneads, Inc.
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RI Law and Regulation Statute, § 23-20.8-1 as of April 2019.
5) “Massage” means the systematic and scientific manipulation of the soft tissues of the body accomplished by
the use of digits, hands, forearms, elbows, knees, or feet, hand-held tool or other external apparatus. Massage
may include the use of topical applications.
(6)"Massage therapist" means a person engaged in the practice of massage and is licensed in accordance with
this chapter of the general laws of the state of Rhode Island.
(7)"Massage therapy” means the use of massage for therapeutic purposes, including, but not limited to: pain
management, stress reduction, promotion of relaxation and enhancement of general health and well-being.
Massage therapy includes, but is not limited to, evaluation of soft tissue and normal movement of the body to
develop an appropriate massage therapy session and the delivery of self-care and health maintenance
information.
Massage is recognized by the National Institutes of Health (NIH), and included in
nonpharmacological pain guidelines issued by The Joint Commission, as well as the
American College of Physicians (ACP) and the Federation of State Medical Boards. It is
recognized by the Department of Defense and the Veterans Health Administration as an
effective treatment for chronic pain, is included in DoD/VA pain management guidelines and
is a covered service in DoD/VHA facilities.
(https://www.amtamassage.org/uploads/cms/documents/mt_in_integrative_care_and_pain_
management.pdf, accessed 10/15/18)
THERAPEUTIC MASSAGE DEFINITION
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ANALYSIS OF NICOLE –
BIOPSYCHOSOCIAL FACTORS
Assumptions based on case information- Nicole has insurance and benefits from her full time job. Is willing to participate in treatment as she seems focused on bettering her self and her life.
During the intake, I want to know: When did the accident happen? What the treating physician prescribed for pain and what other meds
Nicole is taking.
Nicole’s stress level based on taking care of 2 young children, working full time, taking college courses,
? caring for elderly grandmother. How does she feel about the injury?
What kind of treatment did Nicole receive after the 1st accident? What does Nicole do for self care? Before the accidents and now.
Nicole’s availability of time and money (if treatments are not covered by insurance),
When was Nicole diagnosed with unipolar depression and mood disorder. Treatment prescribed?
Does Nicole have financial concerns if unable to work as this will affect payment of massage treatments.
Does Nicole have support from other family members, friends, community?
Is Nicole familiar with massage therapy and the benefits?
Assessment - range of motion, intensity of swelling, referring pain, past/current pathologies and treatments.
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Treatment Plan for NicoleAssumptions: Client is 6 weeks post injury and has medical clearance to receive massage. Client may be in a boot but can remove the boot for treatment. All necessary releases and HIPAA paperwork has been signed so all disciplines involved with recovery can talk with each other.
Treatment Plan:Start with 60 minute treatments that include Manual Lymphatic Drainage treatments to help decrease the swelling and light massage work on lower body (pelvic girdle to feet).
Client will receive 4 treatments no further than 1 week apart and on a different day than the other treatments are being administered.
Reassess client after 4 treatments and start to spread out treatments 10 days to 2 weeks. Begin focus on scar tissue work.
Continue massage therapy for at least 15 treatments gradually further apart and until client is able to come in for maintenance or progress of treatment stops.
Goals for Treatment:
• Decrease swelling.
• Increase blood flow to the area.
• Reduce scar tissue formation.
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Documentation for Massage TherapySample SOAP note:
10/19/19- 60min. tx.
Cl. reports being in a car accident on 9/1/19, has 3rd degree ankle sprain (R side) and is walking with the aid of a boot. Cl. also reports pain in her low back, legs, and neck since. Cl. did not see the car coming and was hit hard enough that she was pushed into the car in front of her. Cl. was taken from the scene on a stretcher and treated at ER for injury. Cl. had to take 3 weeks off from work. Cl. said her she was in a previous accident and suffered a mild concussion from airbag. Cl. reports having neck issues since that accident. Cl. has been working with PT since her accident as well.
LMT observed R hip and sh. appearing higher than L side and when cl. was prone, R hip and erector appeared incr. raised than L side. Prone: LMT focused on sacrum and pelvic girdle to address the sacroiliac joint. TP work on gluts into acetabulum, bilaterally, seemed to release the adhesions. Iliocostalis region, R side, felt tight and cl. reported referred pain into glut when LMT worked the area. Deep effl. and traction applied to area. LMT worked intercostals, bilaterally. Supine- LMT applied MLD work on legs and feet. Worked neck, sh. girdle and arms. All areas very tight and cl. reported it was tender to touch. Traction applied and seemed to relax the tissue, hyperemia to area. Upper traps tight esp. at base of neck, L side felt incr. adhesed. Specific work to c-spine revealed tenderness at base of neck. Forearms felt stringy, ? use of crutches. TP work, traction, and rocking applied to neck. Post tx, cl. reported feeling much better and she said her ankle movement was better. Cl. also said her hips wer less painful and she didn't feel the constant pulling. Cl. completed insurance paperwork and releases for billing. Cl. will return 10/26. VM
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Jennifer Jackson, DAOM, LMT
Acupuncturist, Licensed Massage Therapist
CrainoSacral Therapy Practitioner
Ocean Ki Acupuncture
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Acupuncture
BALANCE ~YIN YANG
QI
Blood
Stagnation/Deficiency/Excess
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Patient: Nicole
25 y.o. female
hx of: 3rd degree ankle sprain/mild concussion ( 2yrs
old)/depression, mood disorder
Intake
Assess the system(whole body)
• Assess the ankle
• Feel pulses, abdomen, meridians
• Check pulses, make diagnosis
Treatment
Includes whole system(body)
• Root tx,
• Branch tx
• Treat affected area
Follow Up
Take Home Treatment
• Give access and instructions to patient for mini at-home heat treatments.
• This will help reduce inflammation and pain
• Schedule a follow up appointment
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Nancy Dooley, Ph.D., OTR/L
Associate Professor, Occupational Therapy
Doctorate Program, Johnson & Wales
University Development Chairperson, Rhode Island
Occupational Therapy Association
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Occupational Therapy
Occupational therapists and occupational
therapy assistants help people of all ages do the
things they want to do and need to do through
the therapeutic use of everyday activities
(occupations).
American Occupational Therapy Association,
2018
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Model of Human Occupation
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• Maximize ability to function in life roles while the ankle heals
• If a knee walker is covered, it may provide increased independence
since crutches require 2 hands
• Discuss, demonstrate and practice using adaptive devices and
techniques to complete occupations
• Assess home environment including safety issues related to kids and
grandmother (as an outpatient would be thru pictures or interview)
• Problem solve on maintaining life roles to avoid depression, etc.
Occupational Therapy intervention plan
34
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How to Access Occupational Therapy
• In Rhode Island you do not need a doctor’s order for an
occupational therapy evaluation and creation of an intervention
plan
• The registered occupational therapist uses scientific evidence and
collaboration with the client to determine best plan
• BUT, if you want most insurers to pay for the occupational therapy
sessions, you do need a prescription.
• More information: American Occupational Therapy Association
www.aota.org
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Ellen Flynn, MD, MTS
Clinical Assistant Professor,
Department of Psychiatry, Department of Medicine
Warren Alpert Medical School of Brown University
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Mindfulness
Objectives
• Implications of Stress on Pain
• Mindfulness – what it is and isn’t
• What is the role of Mindfulness in Pain
Management?
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• Cardiovascular Effects
– Increased HR and Blood Pressure
• Systemic Effects:
– Increased release of glucose for energy
– Shut down of digestion/GI function
• Immune System Effects:
– Up-regulation of inflammatory response system
– Increased blood clotting
• Sexual Side Effects:
– Shuts down reproductive function
Flight, Fight or Freeze
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• Brain Shrink – Hippocampal Atrophy
• Altered Brain Function and Connectivity
• Dysfunctional cognitive looping leading to heightened
perception and privileging of negatively charged output
• Reduced executive function
YOUR BRAIN ON CHRONIC STRESS
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Stress
Mind & Body Dis-ease
Stress
Illness
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Mindfulness: Paying attention on purpose, in the
present moment, non-judgmentally
- Jon Kabat-Zinn
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Medicinal Effects of Mindfulness
• Enhances Parasympathetic Tone:
rest, relaxation, healing, and cellular maintenance
• Improved Regulation of Inflammatory System
• Decreased Sympathetic Activation
• Promotes Neurogenesis in Brain Regions Sensitive to
Serotonin Depletion
Creswell JD et al., Biol Psychiatry 2016; 80:53-61; Holzel BK et al, Psychiatry Res; 2011; 191:36-43
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Nicole: How might mindfulness apply?
• Decrease Sympathetic Activation
• Enhance her capacity not only to attend to painful sensations
but also promote flexibility of attention
• Increase her tool kit for working with difficult
physical/emotional
experiences – taking the pain out of pain
• Allow more effective reframing of the experience of pain
– not me, not mine, not who I am
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Thank you!
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Julia Twining, MSN, RN, OCN
Advanced Practice Manager
The Miriam Hospital
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Case Study 1:
Integrative
Therapy
Reiki and
Guided
Breathing
Exercises
Reiki could be very effective in managing her pain and
stress.
Reiki is an energy technique that uses gentle hands-on approach or no touch and visualization
techniques, with the goal of improving the flow of life
energy.
Practitioners are trained to detect and alleviate
problems of energy flow on the physical, emotional, and
spiritual level.
Reiki therapy is used to relieve pain, anxiety, and
stress. Reiki can also improve the symptoms of various health conditions.
Guided breathing exercises can also be helpful in managing periods of anxiety and stress.
Guided breathing exercise can be taught to Nicole and
she can do them on her own when needed.
Nursing
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Case Study 1:
Analysis
25 y.o. mother of 2, under the age of 5
History of mood disorder
Unipolar depression
Smoker, 1 PPW
History of mild concussion
Lives with elderly grandmother – who may be providing childcare for grandchildren
Works full time while attending college
Third-degree ankle sprain
• Now walking on crutches with boot
• Impacts her functional mobility and ability to work and go to school
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Case Study 1: Treatment plan
Reiki session 20-30 minutes each day.
There is a cumulative effect with Reiki and the benefits can increase with each intervention.
Reiki can help promote a sense of calm and a reduction in the perception of pain.
1
Teach Nicole guided breathing techniques she can use every day and when needed.
Breathing techniques will slow down her breathing when she is feeling anxious or stressed and during periods of pain and/or feeling overwhelmed. Slowed breathing will also relax her muscles and potentially decrease her pain.
2
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Situation: 25 year old African
American female who sustained a
third degree ankle sprain in a
MVA. Transported to ED and
treated, given a cast and
crutches to ambulate.
Background: Second MVA in 2
years. During the first MVA she
sustained a mild concussion from
the airbag deployment. She was
involved in a second MVA today,
she sustained a third degree
ankle sprain. Nicole has a history
of addiction (including family
history), mood disorder, unipolar.
Action: Start Reiki 20-30 minute
daily Reiki sessions and teach
guided breathing exercises to
decrease and manage pain
and anxiety.
Response: Anticipated response
would be decreased pain and
anxiety. Increased ability to
cope with stress and increased
functional mobility.
Patient: Pain assessment using
CAPA developed by the
University of Utah, see next slide.
Documentation Using SBAR-P
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Assessment to be done during a
conversation with Nicole about how her
pain is affecting her in these 5
categories below.
Comfort: Intolerable (during periods of
pain)/Comfortably manageable when
pain interventions are effective.
Change in Pain: Getting worse/better
Pain Control: Inadequate/Effective
Functioning: Can’t do anything
because of pain/Can do most things
Sleep: Awake most of the night/Awake
with occasional pain
Documentation of Pain Assessment Using CAPA
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15 Minute
Break
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Panel Two
Chronic Pain Management
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Jennifer Reynolds,
DPT, TPS• Doctor of Physical Therapy
• Advanced Certification in Pain
• Over 13 years experience in orthopedic and
pelvic physical therapy
• Presented internationally on Pain, Mindfulness
and Physical Therapy
• Annual Speaker at the Warren Alpert Medical
School of Brown University Comprehensive
Spine Conference
• Recognized by the International Spine and
Pain Institute for Exceptional Performance in
Therapeutic Pain Specialist certification
program
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Martine Delonnay, MD, ND
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• Community Health Worker at the Newport Health
Equity Zone (Newport HEZ)
• Founder of Ready Set Latch Go
• Certified Doula
• Certified Lactation Counselor
• Maternal Child Health Specialist
Rhode Island’s Health Equity Zone (HEZ) initiative is a place-based,
community-driven approach to eliminating health disparities. HEZ carry
out locally-tailored approaches to prevent chronic disease and improve
the socioeconomic and environmental conditions of neighborhoods.
Latisha Michel, CCHW
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Clinical Neuropsychologist/Health Psychologist
Private Practice
Career began at RIH/Brown University following a 2-year fellowship in
Behavioral Medicine and Neuropsychology
37-years assessing and treating Chronic Pain
Director of Rehabilitation Psychology at RIH (1982-1989)
Co-Director of the Interdisciplinary Spine Program at RIH 1994-2006
Chief Consultant at CODAC in the Pain and Addiction Program
Research Consultant to Calmar Pain Relief
Chief Trainer for the Massachusetts Rehab Commission on Substance
Use Disorders, Traumatic Brain Injury and Chronic Pain
Frank R. Sparadeo, Ph.D.
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Edward, a 52-year-old Amazon fulfillment center worker of Portuguese
decent, lives in Tiverton with his wife. He injured his back at home
getting ready for a move.
It is now 2 months later and he is in your office as a new patient. He
describes the pain at 7/10, aching in the center of the back without
radiation, and no numbness or weakness and no bowel or bladder
dysfunction.
The pain is worse with bending, cough, or straining with bowel
movements.
Case Study #2 - Edward
Warwick • Lincoln • Providence • Newport County • Westerly • Online
You have no chart, but the patient describes an initial treatment plan
by a prior provider consisting of ibuprofen, tizanidine, ice, heat,
stretching, and later physical therapy.
He was seen by a physiatrist after a magnetic resonance imaging (MRI)
showed multilevel disc disease without encroachment. An epidural
steroid injection under fluoroscopy did not help to alleviate his pain.
Edward is now unemployed and spends much of his day in bed due to
continued disabling pain, even though he's on
hydrocodone/acetaminophen 10/325 mg 6 pills a day. Edward has
been seen in the ER (x3); he had two prior surgeries and has adverse
childhood experiences.
Case Study #2 - Edward
Warwick • Lincoln • Providence • Newport County • Westerly • Online
The physical exam shows tight muscles in the low back with diffuse
tenderness and triggering of the pain down the right leg.
His range of motion is restricted by pain, with a negative neurologic
exam including a normal straight leg raise.
Provocative testing of the sacroiliac joint and piriformis muscle are
negative.
Case Study #2 - Edward
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Jennifer Reynolds, DPT, TPS
Reynold Physical Therapy – Owner, Physical
Therapist
Women's and Men's Rehabilitation –
Women's Medicine Collaborative,
Senior Physical Therapist
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Physical
Therapy phys·i·cal ther·a·py -
/ˈfizikəl ˈTHerəpē/ - of, or relating to the body
: therapeutic medical treatment of impairment,
injury, disease, or disorder
the treatment of disease, injury, or deformity by
physical methods such as manual techniques,
education, and exercise rather than by drugs or
surgery.
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Non-Specific Back Pain
• 90% of back pain
• Specific nociceptive source can NOT be identified
• Presumed MSK origin, no reliable tests to specify source
• MANY factors involved, often not just ONE
• Biophysical Factors – “tight muscles, tenderness with palpation, decrease in range of motion”
• Comorbidities – prior surgeries, adverse childhood event
• Social Factors – unemployed, cultural beliefs around pain
• Psychological Factors – beliefs, previous experience around pain, expectations, adverse childhood event
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Physical Therapy Intervention
• Any intervention, at any stage of healing/injury must involve calming/downregulation of the nervous system and teaching self efficacy of pain.
– Acute Phase of Injury – aggressive treatment of pain at this stage has been shown to reduce the likelihood of chronic pain, healthcare costs and the use of opioids
• Pain Neuroscience Education
• Therapeutic Exercise - Gentle, active movement
– Graded Exposure – teach patients it is safe to move
• “Sore but Safe”, “Touch it, Tease it, Nudge it”
• Neurodynamics – nerve gliding to encourage movement and blood flow along nerve
• Manual Therapy – joint mobilizations/manipulation as indicated
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DocumentationS: Pt. states he has 7/10 pain that is made worse with bending, coughing and straining.
0: Limited lumbar flexion and extension due to pain; Negative Straight Leg Raise; BilateralNeuromuscular Re-ed: PNE; walking program – starting with 5 mins(graded exposure, work within pain frame) passive sciatic nerve glides in supine with knee ext/flex, ankle DF/PF, seated active nerve glides with ankle DF/PF and cervical flex/ext as tolerated.
TE: lumbar rotations in hooklying x 20, SKTC x 20
A: Decreased likelihood of nerve root involvement secondary to negative SLR test, good LE strength and functional ability as well as imaging results. Pt. verbalized good understanding of PNE. Pt. able to tolerate initiation of AROM exercises and will continue exercises as part of HEP.
P: Continue with PNE, TE and NM re-ed 2-3x/week for 3-4 weeks. HEP: daily walking 5 mins a day, LTR and SKTC
Warwick • Lincoln • Providence • Newport County • Westerly • Online
References
• Hartvigsen et al. What low back pain is and why we need to pay
attention.2018;2356-2367. DOI:https://doi.org/10.1016/S0140-
6736(18)30480-X
• Bardin et al. Med J Aust. 2017 Apr 3;206(6):268-273
• Fronger at al. Health Serv Res. 2018 Dec;53(6):4629-4646. doi:
10.1111/1475-6773.12984. Epub 2018 May 23.
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Michael Gottfried, B.A.,
M.A., D.C.
Chiropractic Physician
Aquidneck Chiropractic
70
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Kinney et al. Spine Journal (2013): The likelihood of surgery for workers with back injuries
is 42.7%, if their first contact is with a surgeon. If their first contact is with a chiropractor, it’s
1.5%. This retrospective study was done at Dartmouth Medical College.
Wien et al. Rhode Island Medical Journal (August 2019) concluded that there has been an
increase in opioid prescriptions being given to pregnant women on RI Medicaid.
February 14, 2017 the American College of Physicians issued clinical guidelines that
recommended for acute and sub acute back pain patients non-drug therapies such as the
panel represents should be tried first.
“You must be the
change you want to
see in the world”
– Gandhi
“Not all of us can do
great things. But we
can do small things
with great love”
– Mother Theresa
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Edward’s Biopsychosocial Factors
1. 2 surgeries- back related?
2. 2 months of pain rated 7/10 with meds
3. Financial and emotional stress of unemployment
4. Moving stresses
5. Possible side effects of meds
6. Muscle tone loss- 2 months of being a “couch potato”
7. Adverse childhood experience?
8. Relationship stress
9. Possible inflammatory nutritional factors- Fried food, carbs, alcohol
and tobacco use as well as weight, blood pressure, and family
history are unknown.
Warwick • Lincoln • Providence • Newport County • Westerly • Online
• Chiropractic is the largest natural healing art in the US. Doctors of Chiropractic (DCs) recognize the body’s inherent wisdom to heal itself if free from inflammation, instability, stress imbalance, etc.
• The main focus of chiropractic is on the relationship of spinal structure and neuromuscular function. Four years of chiropractic college are devoted to learning the basic sciences and perfecting the art of knowing how, when, and where to make a corrective adjustment to free the body of imbalance by locating and managing subluxation (characterized by biomechanical changes, muscle imbalance, or altered nerve function).
• There are many different chiropractic techniques. I use mainly low force techniques. In particular Activator Method that delivers a measured/reproducible high speed/low force correction
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Martine Delonnay, N.D, M.D.
Founder and CEO of DELONNAY HOLISTICS
Naturopathic Physician, Sage Healing Collaborative
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Clinical Exam:
• History
– Nutrition/rehydration/alcohol (culture and education)
– Field of work: physical/mental/emotional aspect of work place
– Medication/supplements: risk factors/long term
improvement/interactions
– Past Medical History
– Family History
– ROS: Neurological/musculoskeletal/sleep/digestion/mouth
• PE: Neurologic/Musculoskeletal
Naturopathic Medicine - Integrative Therapy
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Analysis of Treatment plan
• CBC with differential, Cortisol level, DHEA, lactic acid
• Diet and lifestyle: Anti-inflammatory diet
• Supplementation: herbal/functional: bozwelia, tumeric, Ginger, S-
adenosyl-L-methionine (SAMe), CoQ10, B complex…
• Homeopathy: Constitutional and/or emergency: Rhus tox, Bryonia,
Arnica/Internal or topical
• Constitutional Hydrotherapy: To reduce body burden
• Cold Laser therapy
• Ozone therapy: Rectal Insufflation/Prolozone injection/Hemo.+--
• Neural therapy
• Hypnosis/Energy work/Cranio- Sacral: Addressing the Biopsychosocial
aspect
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Treatment Plan Summary
• Assessment of patient with a solid Medical history, lifestyle and
PE
• Evaluate the extent of Emotional impact on the body. Address
the biopsychosocial aspect of treatment and Adrenal
overwork.
• Choosing the best appropriate care based on degree of
invasiveness and patient’s comfort: understanding, cultural
accommodation, Financial capacity (Insurance coverage…)
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Patient Documentation
• S: CC: 52y/o m with chronic back pain started 2 months ago at home while preparing to move: 7/10. Dorsal region. No radiation, numbness, weakness, bladder nor bowel dysfunction. Worse with bending and straining
• O: Patient calm, oriented in 3 spheres. Mx tightness in the lower back, pain triggered in R leg. Restricted ROM. Neg: Neurologic exam, straight leg raise, SI joint, Piriformis
• A: 52 y/o m on disability has been seen multiple times in ER and by other providers. Imagery consistent only with discopathy without encroachment. Taking Hydrocodone/acetaminophen: 10/325 mg not helping. Patient feels misunderstood and is seeking alternative/integrative RX.
• Working Dx: Chronic back pain associated with significant psycho-social dysfunction (ICD-10 G89.4)
• P: Anti inflammatory lifestyle and diet, supplementation and other modalities.
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Latisha Michel, CCHW
Newport Health Equity Zone
Certified Community Health Worker
Founder of Ready, Set, Latch, Go,
Certified Doula,
Certified Lactation Counselor,
Maternal Child Health Specialist
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Community Health Workers are:
frontline, public health professionals who often have similar cultural
beliefs, who empower their community to advocate for themselves
and better navigate resources.
“We wish everyone in the system
understood only 10% of health happens
in the doctor’s office.”
Marti Rosenberg, State Innovation Model
http://chwari.org/
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Community Health Workers are:
Competent in nine areas:
1. Engagement Methods and Strategies
2. Individual and Community Assessment
3. Culturally Competent
4. Promote Health and Well-Being
5. Care Coordination and System Navigation
6. Public Health Concepts and Approaches
7. Advocacy and Community Capacity Building
8. Safety and Self-Care
9. Ethical Responsibilities and Professional Skills
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Edward is:
Having language issues? May need a translator
Having transportation issues? May need rides to doctor’s appointments & pharmacy
Having insurance issues? May need help navigating the system-health and unemployment paperwork
Having connection issues? May need access to a computer/ phone to make appointments
Having food access issues? May need to locate food pantries, discuss food stamps, other resources
Having mobility issues? Accommodations needed to improve
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Edward may benefit from:
Having language issues? Translator Services
Having transportation issues? Receiving a bus pass, Flex service or rideshare
Having insurance issues? Help navigating insurance system
Having connection issues? Having access to a working phone and computer
Having food access issues? Being informed of food stamps and helplocating food pantries and other resources
Having mobility issues? Using adaptive equipment that will help him better care for himself
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Edward’s healthcare providers should be
aware of Cultural Competency:
• Understand the values, attitudes, practices, structures, diet, and
behaviors of the people you are working with.
• Be aware of your own unconscious bias of: gender, sexual
orientation, marginalized or socially excluded groups, occupational
status, spiritual beliefs and practice
• Adapt to diversity
• Be an active listener
• Increase your understanding of barriers
• Acknowledge how past experiences affect present outcomes
• Eliminate prejudice
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Frank R. Sparadeo, Ph.D.
Instructor, Department of Rehabilitation
Counseling, Salve Regina University
Clinical Director, Pain Solution CODAC
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Behavioral Health
Integrative Therapy Approach
• Comprehensive Chronic Pain Evaluation that examines the degree of pain interference in life, the degree of pain impact, the beliefs of the patient (adaptive and maladaptive) and the coping skills of the patient (wellness-focused and illness-focused).
• Treatment planning taking into account physical, medical, social and emotional issues. Family and cultural issues also need to be considered.
• Application of Cognitive Behavior Therapy/Pain management
• Communication with other providers (P.T., M.D., Case management)
• Consider innovative approaches (e.g. Scrambler Therapy)
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Analysis• Medications: Hydrocodone + Tizanadine
– CNS and Respiratory depression, psychomotor impairment, hypotension
• Physical Therapy
– ROM, Strengthening, Fitness level, avoidance/behavior considerations
• Mental Status
– ?Hx of depression, ?PTSD, Type of job/affinity to his job, catastrophizing, solicitousness
• Pain Beliefs
– Medical cure, medications, avoid movement, rest, ER visits, control
• Wellness-focused coping vs. Illness-focused coping
– Presently poor Task persistence, pacing, exercise, meditating, movement, socializing
– High degree of illness-focused coping, poor wellness-focused coping.
– Poor coping self-statements
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Treatment Plan-biopsychosocial
Overall goal: Patient to return to work and normal activities
Objectives: Improve physical status (conditioning, ROM, etc.)
Understand the patient’s beliefs and make changes
Consider psych meds
Learn good body mechanics
Behavioral pain management techniques:
- Distraction, value-based activities, meditation
cognitive behavior therapy/ACT, family
involvement to reduce solicitousness.
Consider discontinuing medications and offer antidepressant
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Documentation
• Mental Status: low mood, tearfulness, catastrophizing, previous history of childhood trauma, slow cognitive abilities, helplessness, major lifestyle change. Depression is likely.
• Psychosocial: Wife and adult children taking care of the patient and increasing his dependency. No contact with friends or usual leisure activities that typically bring him joy and positive feelings
• Physical: Currently, sedentary with excessive resting. Only movement is with P.T.
• Medical: Currently using opiate analgesic meds and ER visits. Overuse and addiction is fast approaching. Seems to be developing greater pain sensitivity which is reinforced by ER visits.
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Questions &
Answers
Warwick • Lincoln • Providence • Newport County • Westerly • Online
Exhibitors
• Rhode Island Association of Naturopathic Medicine
• American Massage Therapy Association - Rhode Island Chapter
• Providence Community Acupuncture
• Chiropractic Society of Rhode Island
• Rhode Island Occupational Therapy Association
• Rhode Island Department of Health
• Rhode Island American Physical Therapy Association
Thank You