Low back pain is best managed using a holistic approach that includes providing education, self-management strategies, and psychosocial support when needed. However, there is often poor uptake and lack of consistency in implementing these recommendations.
Ontario Health had a chance to interview Dr. Eugene Wai, Orthopaedic Surgeon and Head of the Combined Adult Spinal Surgery Program at the Ottawa Hospital, to talk about his experiences treating patients with low back pain from the frontline and his advice on how to ensure patients are receiving the highest quality care possible.
Can you describe your practice?
The Combined Adult Spinal Surgery Program provides spinal surgical care for a range of spinal conditions and is supported by a team of surgeons.
We also offer the ISAEC Program, which is a provincial program that provides patients with rapid standardized assessments and customized self-management plans to help them manage their low back pain. Our hospital works with community partners such as physiotherapists and chiropractors as part of the ISAEC program to help treat and manage low back pain.
What type of patients do you typically see?
As a spine surgeon, I see patients who usually have had chronic low back pain for six months or longer. The cause is usually non-specific and likely related to factors such as lack of physical activity, obesity, and poor nutrition. These factors can accelerate degeneration of structural elements in the body, inflammation, and muscle deconditioning.
A small percentage of patients are appropriate for surgery, so most are managed using education and self-management tools. I conduct e-consultations with primary care providers to support them in co-managing their patients. When we consult, the major focus is identifying potential gaps in patients’ low back pain care and helping primary care providers address these gaps.
What kind of gaps in care do you often see?
The Low Back Pain Quality Standard provides guidance on what quality care looks like. From my perspective, there used to be a strong emphasis on using analgesia to help patients manage low back pain, but the quality standard moves away from that and provides a much more holistic approach that includes an emphasis on patient education, self-management strategies, maintaining physical activity, and providing psychosocial support.
When working with primary care providers, there are often two common gaps in care: Encouraging and supporting patients’ physical activity and providing psychosocial information and support. These are definitely challenging to address and my suggestion to primary care providers is to do an environmental scan to find out what resources are out there (such as community organizations, online tools, and ministry funded programs).
Once you’ve gathered this information, you can vet what’s appropriate to use, tailor these resources to the needs of your patients, and incorporate them into your daily practice. These tools for Implementation is a good place to start.
How has your practice changed due to the pandemic?
We’re definitely providing much more virtual care and there are pros and cons to this. On one hand, patients appreciate not having to come into the hospital and exposing themselves to risk. We can successfully take a history, review patients’ pain and strength levels, and discuss how they are coping virtually. We’re able to guide patients to do assessments (such as a single leg heal raise, a gait test etc.) and they can often give us good information based on a subjective assessment of their condition.
On the other hand, sometimes patients expect that there won’t be wait times with virtual visits, but delays do happen (for example longer than anticipated appointment times and technical/internet issues). Another downside is that some things are difficult to assess virtually. For example, there is a risk of missing myelopathy, cancers, fractures, or infections. If we have concerns, we’ll bring patients in for further assessment.
We’ve learned that having patients do a virtual visit test-run with admin staff is helpful to make the actual visit more efficient.
What advice do you have for primary care providers who work with patients with low back pain?
The best advice I can give is to empathize with your patients. There are no easy answers. Tools like the Low Back Pain Quality Standard provides guidance on what to do and what not to do, but it doesn’t take away a patient’s pain. Patients may be expecting a solution, but sometimes, there may not be one and you can’t dismiss patients because of this. Patients need reassurance and acknowledgement that it’s not easy to live with pain.
My second-best advice is to engage patients in a general fitness program consistent with the Public Health Agency of Canada’s physical activity guidelines. Give patients encouragement to stay active and modify activities to make it possible to do so. Research available online physical activity supports so that patients can receive coaching and encouragement. Again, these tools for Implementation is a good place to start.
You may also be interested in: