All right, on behalf of myself and my co-presenters, I'd like to welcome you all this afternoon. I have two co-presenters with me. So we've got a physical therapist, that's me. We've got a physician and a chiropractor talking about back pain. So to me, it sounds like a good first line of a joke, right? You know, a chiropractor, physical therapist, and a doctor walk into a treatment room. But Michael Dunn and I met and realized that we're really on the same page in terms of the management of back pain and how to prevent chronic disability. I don't think it's hard to be on the same page if you're reading the literature and you're trying to do what the literature suggests that you do, which is kind of how we all got to the same spot. So with that, we'll go to the next slide, and I'm going to let Michael introduce himself. Michael and Don are both virtual. Hello, I am Dr. Michael Erdell, and I work with a group of Occ Med physicians, Occupational and Environmental Health Network in Massachusetts. I also have an appointment at UConn Health in the Division of Occupational and Environmental Medicine. I've been at this for a number of years, both as a clinician and as someone who has looked at the literature, including being a reviewer for AHCPR, the Low Back Pain Guidelines, assisted with ECOM and ODG treatment guidelines. I am topic author for up-to-date Occupational Low Back Pain and Dynamed Plus Chronic Back Pain, for which I receive an honoraria. I served as the medical advisor and educator for Retain Connecticut, funded by the United States Department of Labor and ODEP. And for many of you who are interested in this issue of preventing unnecessary work disability, and if you're not familiar with the Retain Project, then I recommend that you go to the Retain website, because there's a whole trove of information. I've also been involved with a number of other ECOM activities and state activities. But at this point, I will turn this over to Don Murphy to introduce himself. Thanks, Mike. Yes. So, Dr. Donald Murphy. I'm a chiropractor by background, a primary spine practitioner by practice. I serve as the medical director of a primary spine care program here in Rhode Island for a large orthopedic group. Also I have a position in a company called Spine Care Partners that is in the business of implementing spine care pathways in various environments, and I'll talk about that a little bit today. My primary academic appointment is at the Medical School at Brown University here in Rhode Island. I also have an appointment at the University of Pittsburgh in the physical therapy department where I help to develop and I co-lead the certification course there where we certify physical therapists and chiropractors to serve as a primary spine practitioner, which is a relatively new role that my team, Spine Care Partners, is introducing to the health care system. And again, I'll talk about that a little bit as well. So what I'm excited about here today is that we're bringing together, you know, diverse but related minds, basically, and Dr. Erdell and Dr. Hoyle and myself. And so we hope that what we're going to be sharing for you brings in your mind together a way of looking and approaching patients with spine problems that I think is very useful going forward in the med space and in others. Thank you. And I'm David Hoyle. I'm a physical therapist by background. I work for Select Medical Corporation for their outpatient physical and occupational therapy division. In that capacity, I'm really in charge of trying to set the philosophy, provide training and tools for our physical and occupational therapists when it comes to managing workers' comp cases. And we'll talk a little bit about that. Select's got about 1,900 centers in 39 states, and there's probably an average of about two and a half clinicians at each of those sites. So we're going to talk a little bit about how to try to implement best practices into a healthcare system, and that's a pretty sizable one to try to change the practice patterns of clinicians. And I'm looking forward to sharing that with you. I'm also a board member of the Occupational Health Special Interest Group of the American Physical Therapy Association. I've written some guidelines for them. And I'm on an advisory board for the UConn Medical School Program in Public Health. So with that, Michael, I'm going to turn it back to you and let you take the beginning of the slides. Hey, can we get that next slide? And so some of the learning objectives today are to go over low back pain, disability risk factors and screening tools, talk about psychologically informed practice in the primary spine care model, and also to talk about a framework to identify and implement disability prevention strategies in multiple practice settings. And we'll have a little bit of time to do some question and answers. Can I get that next slide? And the first section, which I'm going to do, will be just the overview and the risk factors. Can I get that next slide? And the good thing is that I'm really talking to the choir here, because this is something that occupational medicine clinicians are very familiar with. But as a summary of why we really need to do this, I have a couple of slides. And this one is from the National Safety Council, looking at the estimate for fatal and nonfatal preventable injuries. And we have on the left some estimates on days lost or total 2019. We have 105 million days lost or injuries that occurred prior to 2019 and in 2019, with 70 million days lost just from 2019 injuries. On the right side, we have estimates of total cost, $171 billion, and it's really split between wage loss, medical payments, and administrative costs. And the NSC actually did a nice estimate that when you look at the cost of these preventable injuries, it comes down to each worker having to produce over $1,000 of goods and services just to pay that off. So this is something that really should be important for all stakeholders to try to mitigate. Can I get the next slide, Dave? This is a slide that looks at some trends for Social Security disability. And you see on the left the escalation in terms of individuals who transitioned to Social Security disability. From 1991 to its peak, there was an increase of about 270% of individuals who received Social Security disability. If you compare that to population growth, it was 20%, and that's really not a sustainable growth curve. When we look at what has contributed to this over time, if we go back to the 1980s, we see much more of a contribution of things like heart disease and cancer. It's not to say that musculoskeletal wasn't there, but if you look over time, musculoskeletal rises significantly. Mental health disorders rise significantly. So that currently musculoskeletal and mental health contribute about 62% of the Social Security disabilities, with low back pain being the primary driver of musculoskeletal. Can I get the next slide? When we start to think about this whole issue of work, there is a slide summarizing a publication from Waddell and Burton, and this was performed as part of the UK social welfare reform initiative. What the researchers did at the time was to look at the literature on a number of common health conditions and return to work to assess the impact on health and well-being of being employed. There's a little bit of a diagram on the upper right that looks at the worker and their strengths and their weaknesses. We look at the job and, again, the positive and the negative issues. So when we start to think about who goes back to work, if we have a worker who has either an illness or an injury and yet they are in an environment where they value work and their employer is willing to give them work that is safe and accommodated, consistent with their abilities, they end up going back to work. If we look at that worker and compare them to somebody who does not go back to work, there are adverse implications to that worker. The researchers looked at what is the impact of worklessness, and when they reviewed the literature, their estimate was that individuals who cease working, who could be working, have a 20% increased mortality. Now, there are other researchers who have said that may be higher, like 50%. But why do individuals die? They die because of cardiovascular disease, stroke, cancer, suicide. Individuals who cease working, they have worse general health. They have worse mental health. And in addition, there are other adverse impacts, including psychosocial, your social role, there are economic impacts. And so these are important messages when we talk to patients about why it's important to stay at work. Can I get the next slide? I put this slide up from Dr. Loisel's work because I think it's helpful as a framework to think about how we address this issue. So in the middle, we have a worker with a work disability. And the various stakeholders, because we have to think about, you know, how do we address each one of the stakeholders? So on the bottom, we have the worker. And the worker has their, you know, their physical condition, they have their perhaps personal coping issues, their expectations that can either be positive or negative in terms of their ability to go back to work. On the top half, we have the workplace system. So that's thinking about the job demands. It's thinking about whether there's modified duty. What is the supervisor like? And how involved is the supervisor in identification of return to work barriers and solutions? On the left, we have the healthcare system and the provider, and that's you. Do you practice evidence-based medicine? How well do you coordinate with other treaters? How well do you communicate with all stakeholders? And what is the messaging and the strategy in terms of return to work coordination? On the right, we have systems. The jurisdictions make a difference in terms of return to work. You know, some jurisdictions have utilization review, some don't. There are different guidelines that are utilized. There are community practice standards that all impact the eventual outcome. And, you know, the question is, well, where do you go with all of this? Well, you know, I have a couple of quotes there, that there is actually strong evidence that interventions that, especially interventions that are multi-domain, including healthcare provision, service coordination, work accommodation, can successfully reduce unnecessary work disability. So can I get that next slide? And so let's start to break this down a little bit further in terms of the, you know, particular factors. As I said, when we look at the worker, pain severity. So the individual has, you know, constant 10 or 11 out of 10 pain is a risk factor for becoming disabled. How the perception is about how their pain interferes with their ability to function. How severe do they perceive their activity limitations? As I said, mental health, whether it's anxiety or depression or PTSD and how well somebody does or doesn't cope. What is the worker's pain beliefs? Do they believe that they should be active or should return to work while they're in pain? Do they have fear avoidance? What are their expectations for care and are their expectations consistent with evidence base? What did they expect in terms of how well are they going to do and are they likely to recover? Or, you know, how do they perceive the fairness with which they are treated within systems? Other factors include, you know, family and social support. And then there are a few others, lifestyle issues, cigarette smoking, BMI, you know, having multiple musculoskeletal pain complaints and sleep disturbance are risk factors for poor outcomes. And I get that next slide. We also have to think about workplace systems. As I said, the ability to modify work is really key. There are several studies suggesting that having modified duty can reduce indemnity costs by perhaps 30 to 40%. What is the perception in terms of job control and job stress? You know, does somebody perceive that they get satisfaction from their job? You know, other issues include the workplace supervisor. You know, that workplace supervisor is a key. Is that workplace supervisor perceived by the injured worker to be someone who's caring, provides reassurance, is collaborative in terms of problem solving to address return to work barriers? It's going to be a big factor. Does the worker perceive that the coworkers are going to assist them as well? How, you know, physically demanding is work and what are the perceptions of the worker in terms of those work demands? All factors in terms of disability risks. Can I get the next slide? Then there's the health care system as well. And there are a number of studies now that have looked at care patterns and the concordance of care patterns with evidence-based medicine, whether you're looking at, you know, ACOM guidelines or ODG guidelines suggesting that greater concordance in general to guidelines is associated with improved outcomes. And there are some particular factors in that. Unnecessary specialty consults for benign conditions can result in increased in testing and interventions that are not going to be effective to address an injured worker's symptoms. MRI in particular for nonspecific low back pain. So certainly MRI is indicated for individuals who have red flags. We're thinking, do they have cancer? Do they have tumor? Do they have infection? Do they have a severe or progressive neurologic deficit? All indications for MR. However, MR for patients who have benign nonspecific back pain is associated with a lot of adverse impacts. And there are increases in diagnostics, increases in opioid prescribing, increases in surgery for benign conditions that lead to poor outcomes. There are a number of studies that have been conducted as well. There's a Washington study that looked at early unnecessary MRI for nonspecific back pain, suggesting six times the number of disability days and twice the risk of having work disability two years after the onset of symptoms. Opioids, we have seen the devastating impact of opioids on patients. Studies from Washington by Franklin suggested seven days of opioids are associated with twice the risk of disability at a year. Benzodiazepines similarly increase the risk of disability and are synergistic with respect to opioids. Lumbar fusion for degenerative conditions. Again, there are good indications for lumbar fusion for fractures and tumors and spinal instability. But for degenerative disease, we have treatments that are just as effective. Cognitive behavioral therapy and therapeutic exercise are just as effective with lower risk. When you look at outcome studies from Washington and Ohio, patients who undergo lumbar fusion for work-related conditions, two-thirds are disabled two years down the pike, and opioid prescribing goes up. Other disability risk factors. How do we communicate with patients? Bill Shaw has done some studies looking at the types of communications between the worker and the doctor. They tend to be more biomechanical in nature, whereas the key drivers of disability often are lifestyle, coping, et cetera, and often patients don't bring it up, doctors don't bring it up. This is an opportunity to explore those lifestyle issues that can favorably affect the course of return to work. The types of reassurance, offering reassurance that explains symptoms, explains that there's going to be a favorable prognosis. Pain does not equate with harm. Teaching patients about self-management are associated with improved outcomes. The recommendations we make with respect to return to work, the collaboration in problem solving involving the injured worker and the employer can be positive outcomes or negative outcomes. Can I get the next slide? Communication is really important for us to be successful. Other disability risk factors, looking at the worker's comp system, the timeliness of reporting, the timeliness of adjudicating claims so that if there are delays, then the injured worker doesn't get timely and effective care, and there is an association with increased disability days. Regulatory systems we talked about and jurisdictional systems we talked about. Again, that early appropriate return to work, studies that Bill Shaw has conducted on nonspecific back pain. Returning at day zero has much better outcomes than returning from zero to seven days or greater than seven days later. And again, the impact of worker's comp systems on perceived injustice and litigation are all very important in terms of the disability risks. Can I get the next slide? So the question comes up, what do we do about this? And we're going to talk about some potential solutions that are out there. Now, ACOM has recently published a new guideline on disability. And in the disability prevention section of that, they do talk about screening workers. While the guideline does acknowledge some of the limitations in terms of literature because of the methodologic variations of studies and the challenges in terms of interpreting some of the literature, the guideline has recommended at least screening for disability risk, especially when patients have a course that diverges from expected outcomes, when somebody fails to improve from evidence-based care, if you have medically unexplained symptoms or disability, because the screening can lead to implementing alternative strategies, especially behavioral types of approaches. So one of the screening tools that is available is the Oorabru Musculoskeletal Pain Questionnaire. The other is the Start Back tool. The Oorabru was initially developed as a 24-item. It subsequently has been modified to a short form, and what this does, and they both perform reasonably well. Talk about pain severity, impact of pain on work and sleep, and expectations for activity or working with pain, what the workers, the individual's expectation is with regard to persistence and eventual ability to go back to work. That's a mood issue, it's like anxiety and depression. And the nice thing about this tool, it's been used for back pain and other musculoskeletal conditions. It is available in a number of different languages. It's been used in primary care and work-related settings. And some study, a study that was conducted by Nicholas in Australia, looked at the Ouroboros score in terms of its ability to predict return to work for individuals by two to seven weeks. And risk scores that exceeded 48 to 50 were associated with longer times to return to work. So median return to work days, 26 individuals who scored below 50 had a median return to work of 10 days. So can I get the next slide? The other tool that's been commonly utilized is the Start Back tool. And there are some commonalities in terms of these two tools and some differences. The Ouroboros was developed in terms of looking at a potential risk. The Start Back tool was actually developed in terms of a stratification of intervention. And I'm gonna get to that in a couple of slides. But the tool asks about pain, bothersomeness, the impact on things like dressing and walking. Again, similarly, there are expectations for safe activity and recovery. Similarly, some questions about worry and enjoyment. And as I said, what happens with this, there are five questions that I felt to be psychosocial questions. And so this is scored, where individuals who score like three or less basically are treated with usual care. Individuals who score more than three are felt to be at medium risk and are treated with physical therapy. Individuals who score four or five or more, four to five, excuse me, on the psychosocial score are treated with physical therapy, but with a behavioral approach as well. And can I get the next slide? And I'll talk about some of the impacts on this slide of the work that's been done. So the Start Back tool has been looked at by Hill in a primary care setting. So again, thinking about that low, medium and high risk, basically usual care, physical therapy or physical therapy plus behavioral approach. And using that Start Back protocol, there was a positive impact overall in terms of disability, looking at things like Roland Morris, overall costs of care at 12 months and actually improved health outcomes, including a number of questionnaires like the SF. The Start Back tool has been used in the US in a couple of different trials, one by Shurkin, the MATCH trial, and Stevens, the TARGET trial. And unfortunately here, we have not had the same positive outcomes that were observed in the UK primary care trial. But when you look at the reason for that, it was really primarily due to provider and patient behavior so that there was non-adherence to the use of the tool and use of treatments like, again, MRI for nonspecific back pain and opioids were key contributors to a lack of improved outcomes. The ORBU, as I said, has been used in Australia by Nicholas, looking at its risk of disability with that cutoff score, as mentioned, the 45 to 50 being associated with higher risk of disability, greater disability days. And as the score went up, the risk of disability went up as well. There was a second part to the study that they conducted, and this was early screening of all injured workers with musculoskeletal conditions, including back pain and other disorders. And what happened is for the individuals who had high risks, so risk scores greater than 50, they were then treated with a psychological assessment and an assessment for return to work barriers. When the researchers looked at the outcomes at two years, using these additional interventions for high risk workers was associated with a 50% reduction of lost work days and a 30% reduction in costs. So can I get the next slide, please? So when we talk about patterns and then our next speakers are gonna talk a lot more about this. We think about the traditional model, which has been step care. So worker comes in, they get treated. Oh, how are you doing? Doing good or bad? Okay, what do we do next? Okay, what do we do next? The difference would start back as we start to think about this concept of stratified care. So prioritizing patients into low, medium and high risk and deciding about treatment approaches. As I said, PT for medium risk, PT and psychological approach for the high risk with the high psychosocial scores. And the other concept is really one of matched care where we look at the individual, look at all the risk factors and start to individualize the interventions based upon the needs of the workers. And what we are gonna be doing hopefully in this session is going to transition to our next speakers who will talk about how they implemented some of the strategies in different settings to decrease the risks of low back pain disability. One in healthcare systems, the other in sort of this multi-center rehabilitation type practices. So I will transition this over to Dr. Donald Murphy. Great, Dr. Adele, thank you very much. It was great. And so I'm just gonna take a moment and share my screens and I'll start taking the next step here. And we'll talk a little bit more about some of the specifics building on what Dr. Adele just presented. And I think that this will be helpful and useful to you in terms of framing around a couple of different ways in which we can approach bringing greater efficiency and effectiveness to spine, not just by providing high quality care, but also by applying it in an efficient and stratified way that can be made individualized to each individual patient. So, as we'll talk about, and I'm gonna touch on this very briefly because Dr. Adele just covered it in detail, that basically what we can call a healthcare system when it comes to spine is there's nothing systematic about it. So it's a mess. We're all over the map. And the patient is the one that's caught in the middle of this whole thing. And so what we're trying to do is bring order to that chaos. That is bring about a way in which we can all work together as a team in the best interest of the patient and bring those greater efficiencies that are so direly needed in the healthcare system. Now, one of the things with regard to this is that throughout the healthcare system, there are calls for bringing about more efficient, more effective ways of doing things in healthcare. And the Institute of Medicine has called for a retooling of the existing workforce when bringing about improvements. And so what they're talking about here and others are talking about this as well is coming up with better ways to do things and identifying professionals who already exist in the healthcare workplace and retool them to play new innovative roles going forward as we bring about improvements. And in our space, with regard to spine, that means the primary spine practitioner is a new role that a part of a team that has been moving in this direction and implementing this in various environments and primary spine care services as a service line or as a ways, a way by which we can provide upfront, front end care for patients with spine problems. So there's a couple of papers that I was a lead author on where we, again, introduced this new role, the primary spine practitioner and this most recent paper where we talked about, we originally introduced this 10 years ago, it was actually arose from the work of a guy named Dr. Scott Haldeman, you may heard of, he's a big name, a huge name in the spine world. And he's the one that originally introduced this idea of a primary spine practitioner, what we're now calling a primary spine practitioner. And so over the past 10 years or so, I've been part of a team that has been working towards implementing this new role in various environments and introducing primary spine care as a service line that is upfront, an organized upfront point of entry into the healthcare system, whereby we can maximize that first touch because what we have found and what has been demonstrated over and over again is that the quality of that interaction that the patient has when they first entered the healthcare system goes a long way towards determining down the road how things go for that patient. And so that's where we're putting this focus. So a really big important part of primary spine care is taking a psychologically informed approach. And so with regard to evaluating the patient, that means as Dr. Urdell has been talking about, assessing the risk of chronicity and assessing for psychological perpetuating factors, the Orobro and the SARPAC great tools for that, questionnaire based, but they don't replace the importance of relationship centered care. That is the best way to determine where the patients are at emotionally, psychologically, what their beliefs are is by getting to know the patient. And that means on a one-on-one basis between the practitioner and the patient, that's where the real action is in terms of understanding the psychological perpetuating factors and the beliefs that the patient may have that may serve to set them up for chronicity down the road, depending on what those beliefs are. But also important obviously is differential diagnosis. And one of the foundations of the approach that we take when we're training practitioners to play the role of primary spine practitioner is clinical reasoning and spine pain. I wrote a couple of books on this. And from a diagnostic standpoint, this is founded in three diagnostic questions. Number one, is this a red flag condition that may be going on? Number two, where's the pain coming from? And certainly in the majority of cases, we can't be 100% certain exactly where the pain is arising from, what tissue is the source of the pain, but we can identify signs and symptoms that suggest the presence of a particular source of the pain. And then important, the third question is, what are the perpetuating factors? What are the factors that serve to perpetuate an ongoing pain, disability, and suffering experience in each individual patient? And as Dr. Udell talked about, the importance of individualizing our approach to patients, the way in which we can individualize our approach is by identifying specific individual characteristics of the problem in each individual patient. From there, we can then identify those individualized treatment approaches that are most likely to positively impact the problem. So then applying, once we can make a diagnosis, we can answer those three questions and come up with reasonably accurate answers to those questions, then we can come up with a management strategy, again, that is most likely to have a positive impact. And when it comes to the primary spine practitioner, that means evidence-based approaches. There are a wide variety, including manual therapies and exercise and graded exposure and other things, but the foundation, the most important part of that approach has to be around patient education, providing them with self-care strategies and empowering the patient to take charge of their own problem. And importantly here is that all the approaches that the practitioner takes is done in what we call the CBT Act context. That is the practitioner, as they're going about the normal process of managing the patient and whatever specifics that may be carried out in any individual patient, that that interaction is informed by the principles of cognitive behavioral therapy and acceptance and commitment therapy, the two psychotherapeutic schools of thought that have been shown to be most effective in patients with spine problems. So when we're talking about applying the principles of CBT and Act, it's more contextual than it is literal, right? So there may be times in which we need to sit down with the patient and have a conversation about their beliefs and their cognitions and kind of go into a form of behavioral therapy type of thing. But for the most part, for most patients and in most situations, if we can contextualize those messages, then we can go about the process of quote, doing therapy unquote, without having to sit down and actually go through a formal conversation with the patient. So what kinds of messages are we referring to? Well, number one, the most important thing is for us as a practitioner to understand how the patient believes about this, what their thoughts are about this problem and what are their emotional responses and meet them right where they are. So the first step when it comes to applying a psychologically informed approach happens with us. How we approach the patient is the most important thing. Number two is providing a credible diagnosis. Study after study after study have found that one of the most important aspects to gaining the patient's confidence in us and in themselves is having a diagnosis explained to them. And there's some controversy around diagnosis. There are some people that think that you can't render a diagnosis in any individual patient. There are others that suggest, well, that you can identify individualized nuances about each individual patient that can tell you and help you to understand the characteristics of the pain and then explain that diagnosis to the patient. And I tend to be in that camp. So, but the most important thing here is that if we want to clearly build confidence in the patient, the patient's confidence in us as well as in themselves, then explaining a clear diagnosis is really important. Then important also is validating the patient. That is validating the patient's experience. And as we all experience, we see patients who have a cognition about this problem that is completely unrealistic, completely out of proportion with what's actually happening, that is not consistent with what we understand as to what's really happening in their spine. The important thing here is that we validate whatever their experience is, regardless of what we think of their experience. So step one, and that means acknowledge that whatever they're going through is very real and very important and is not a pathology. So strong emotional responses, even if we know the emotional responses to be inappropriate, ineffective, and unrealistic, they're understandable and normal. And that's one of the biggest things to understand about psychological perpetuating factors is that these are not pathologies. These are normal human experiences. These are normal human responses to a problem that arises in our lives. The reason why we place focus on them is because they can interfere with recovery. And that's why that's important. Then once we validate them, then we can provide realistic information that is perhaps more accurate, sharing with them the good news. And once we share with them the good news, then we can gently, kindly coax them to reconsider what they think is going on and what their beliefs are. Again, rather than shoving the accurate information down their throat, present the good news, and then asking them, what do you think about that? Coaxing out in them their own questioning of their beliefs. Getting the message across that, look, back pain, neck pain is a very painful and disabling problem. A temporarily disabling problem. Acknowledge that upfront. And again, meet them where they are. We all understand the concept of hurt does not equal harm, right? We all understand that, but that's counterintuitive to many patients. And so we have to make sure to be able to explain to the patient why. Why would hurt not equal harm? Because as far as the patient is concerned, boy, when I engage in a certain activity, I can feel the harm that goes on in my spine. I can feel that harm when I try to do some, to perform some kind of activity. So if we are going to help them to understand why hurt does not equal harm, it's important for us to explain the nature of pain, explain the realities of what pain is really all about. And nociplasticity is a particularly important mechanism of, that can contribute to chronic pain that it's really, really important for patients to understand. And another important message is movement promotes recovery, right? So this is, again, is something that we know inside and out, but it's counterintuitive to the patient because in their experience, in their mind, in their experience, when I engage in an activity that hurts my back, therefore that increases the damage. And so again, gently, kindly, getting those kinds of messages across about movement promoting recovery. But we can talk to them all we want. We can talk to them until we're blue in the face about how movement promotes recovery. But the best way to really get that across is by proving it to them through experience. And the best way we can prove to them through experience that movement promotes recovery is through self-care strategies. So giving them self-care strategies that they can self-apply, whereby they can experience approaches that involve movement and see the result of that, of repeating that movement over and over again where the condition starts to improve. That's an experiential experience that really reinforces in their mind that movement promotes recovery is not just a interesting concept, it actually is a real thing. Talking in terms of overcome and talking in terms of we, right? So from what I can see here, I think you can overcome this problem. And I really think that us, the two of us working together, boy, you will be successful in overcoming this thing, right? So if we talk in terms of overcome, and I'll talk about why that's important in a moment, but we talk in terms of we, that puts the patient in a position, number one, of empowerment, and number two, an understanding that I'm not alone in this, that we're a team together, working together in your best interest, helping you to get better. And then how do we prove that, that they have the ability to overcome this, approve it to them through experience via self-care strategies? Another important message is engaging the problem rather than avoiding the pain is the key to recovery. And again, this is something that we know, but it can be counterintuitive on the part of the patients. But what we do is we prove it to them through experience. How? Self-care strategies. That's why self-care strategies are so important. Not only are they effective from a treatment standpoint, they also empower the patient and also they help to reinforce the messages we're getting across to them by proving to them the points that we're making rather than just hoping that they are convinced based on our communications. Mindfulness is a big part of, especially of acceptance and commitment therapy. But the important things about mindfulness is that it starts with us. So if we can enter into the encounter with the patient, being mindful ourselves, we present to them an example of what it's like to be mindful, what it's like to be present. And that naturally gets across to the patient. Helping them to get in touch with their most deeply held values. And again, what really helps us to be able to do that is us explore our most deeply held values and then serve as an example of what that's like. Then we're in a better position to help the patient explore their core values. Help the patient to become an objective observer of the pain. And this is really powerful in terms of this part of mindfulness. Helping them to step away from themselves, step away from their beliefs and cognitions about this and just observe themselves, observe their pain and observe their reactions to the pain. How can we do that? We can do that through our examination, right? So an important part of our examination is what I call the pain provocation exam, where we do certain tests that seek to reproduce the patient's pain. So by doing that, if we frame that in the right way, if we frame that and we communicate that to the patient in a certain way, we can help them to learn how to become an objective observer of their own pain experience without having to sit down and have a conversation about it. Just by the nature in which we go about performing a normal examination that we would do anyway. And of course, self-care strategies is a big way to help them to become an objective observer of their own pain experience. Acceptance is huge, but acceptance is very, very commonly misunderstood. Number one, acceptance starts with us. Accepting the patient just as they are. And that means us being an objective observer of our reactions to the patient and to see if there are areas in which, or the ways in which we're just not accepting the patient. We're not willing to accept them as they are and forgive ourselves for being human and then turn that around and accept them as they are. Acceptance is the acquisition of helping the patient to accept the pain as it is now. And the big thing about that is that a lot of patients, when we talk about accepting the pain, a lot of patients will say something along the lines of, okay, so you're telling me I have to accept the fact that I'm gonna be in pain the rest of my life. No, acceptance is not about the rest of your life. Acceptance is about right now, in this moment, which of course is the only, that is your life, this moment. That's the only thing, the only moment that ever exists. So helping them to just get into this moment right now and accepting the pain as it is. And then helping them to commit to living their life according to their most deeply held values. But be sure to remember that there's gonna be a certain amount of ambivalence with regard to that. Okay, I mentioned earlier about talking in terms of overcome versus relief, right? So overcoming the problem. So helping them to relieve some pain, there's a lot of things we can do to release their pain that can provide them with relief, that can reduce the intensity of the nociception. And that's fine, that's a good thing to be able to do. But be careful about putting that as our primary focus, because if we focus primarily on getting relief, that puts the pain in charge. Whereas talking in terms of overcoming this problem puts the patient in charge. Talking about and focusing primarily on relief is temporary. We can relieve patient's pain in the majority of cases, but that's a temporary situation, right? Pain comes back, that's the nature of pain. The pain is a part of life. Whereas overcoming the problem is more enduring. So that means overcoming the problem means getting my life back independent of whether there's the presence of pain or the absence of pain in any given moment. That's what overcoming is about. And that's enduring. Nocyplasticity, or a lot of people would use the term central sensitization or any kind of a state in the nervous system, where the patient is having an enhanced experience of pain, that makes the problem seem more severe than it really is. And that's good news, right? So sharing the good news with patients is really big when we're talking about educating them as to the nature of pain. Work is therapy. One of my mantras that with patients in my classes and otherwise is you don't get better in order to go back to work. You go back to work in order to get better. And that's a really, really important message to get across that return to work is part of therapy. And again, I mentioned before, maintaining their focus, helping them to maintain their focus on living a life that's in accordance with their most deeply held values. So the primary spine care pathways that I've been part of a team implementing in various environments works in a lot of different ways, depending on the environments in which it's placed. So it can be placed in a primary care environment. It can be placed in a secondary care, a specialty care environment. It can be placed in a workers' comp environment. So just a very brief example of how it can apply in a workers' comp environment is where you have a occupational medicine personnel, primary care personnel, working side-by-side with a primary spine practitioner. And a primary spine practitioner usually means a specially trained physical therapist or chiropractor. And so the workers' comp population enters the healthcare system and they can see either an oc-med doc or their primary care practitioner, or they can see the primary spine practitioner and they work side-by-side in the best interest of the patient, depending on what the needs are of each individual patient. In some of those patients, behavioral health is an important component of primary spine care, sometimes acupuncture, depending on the specifics, depending on the diagnosis, depending on the needs of the patient, et cetera. And in our experience, the vast majority of patients, we would say about 85% or so of patients with spine problems can be managed purely on the primary spine care level. But a sizable minority of patients, and when we're talking about back pain, we're talking about lots and lots of patients, large, large numbers of patients. And so even the minority of those patients is a huge number. And so a lot of them are in need of care in a secondary level. And that may mean specially processes for diagnostic clarity, or it can be for more invasive or intensive treatments, depending on the situation with each patient. And in our pathway, relational coordination holds the thing together. So I won't go into a lot of details about relational coordination, but you may have heard of this. It's a systematic way by which we can enhance the ability of professionals in all areas to work together in a seamless way as a team in the best interest of each patient. And the primary spine practitioner and primary spine care can be applied in secondary care as well, where you have the specially trained physical therapist or chiropractor, the primary spine practitioner working side by side. Usually in this case, it would be with a PM&R doc. You know, the PM&R doc in place seeing the more complex patients, the PSP in place seeing the more relatively straightforward patients. But again, working side by side as a team, and then of course, coordinating referral for whatever other services may be needed with relational coordination, holding the whole thing together. Okay, so an important aspect that we talk about when I'm training primary spine practitioners and when I'm functioning as a primary spine practitioner in a integrated system is guiding the patient across the full cycle. So that means the patient first arriving with a pain, disability and suffering experience and guiding them across the full cycle towards resolution. And so for the primary spine practitioner as we talked about before, there are a number of different evidence-based approaches that can be applied. The most important focus being on self-care and education all done in a CBT Act context. And in a lot of patients that we see, we can manage the patient across the full cycle without the need for other professional services in many cases. However, a sizable number of those patients do need other professional services. And so the primary spine practitioner is trained to help to coordinate referral for other professional services depending on the needs of the patient, depending on the diagnosis, depending on what's happening in each situation and following up with the patient after they've received those other professional services to make a determination as to, okay, where are we at now? Where are we on the cycle? And what do we need to do now to accelerate you towards resolution as quickly as possible? Okay, so I wanted to present to you just some of the preliminary results that we've looked at. We've done a number of studies most of which have been published and I don't have time to present all of the data we've gathered, but I thought I might share with you some data that we've gathered that I think you'd find useful in terms of the clinical results, the clinical outcomes that we've seen, as well as the cost savings, et cetera, that our experience is that can be realized by applying an integrated and organized systematic pathway approach to managing patients. So this was one study that was presented a few years ago at the North American Spine Society. It was published in Spine Journal in 2016. This was a hospital-based primary spine care clinic that was in place in a large hospital in Chicago. We looked at 217 patients with low back pain. There was an average of six sessions with the primary spine practitioner. We only documented the early results. This is just three weeks in. So again, there's a lot more that need to be looked at here, but again, I thought it might be interesting to at least share what we found so far. And this was a mixed patient population. Some were workers comp and some were indemnity. And we looked at the disability. We used the Roland Morris questionnaire and we found it over three weeks, a 51% reduction in Roland Morris score across that series of patients and a mean reduction in pain intensity of 48%. And we also, we used the Start Back tool, but it was interesting. We not only used that as a stratifier upfront, we also were curious as to look at, in three weeks, have them recomplete the Start Back questionnaire and see if there's any changes there. And what we found was that the patients who at intake, when they first came in, were designated by the Start Back tool as high risk. By three weeks, a third of them had dropped from high risk to moderate risk. And more than half dropped from high risk to low risk at three weeks. And so this was really important because what we found here was that, number one, the risk profile improved in these patients. And also that the Start Back identifies risk, high risk, moderate risk, low risk, but those are not fixed characteristics. Those are not fixed things that they can change over time based on what we're doing with the patient. Of those who were designated as moderate risk at intake on the first visit, 73% of them dropped from moderate to low. And the smallest group were already diagnosed, already designated as low risk at intake, and 95% of them, almost all of them, remained low in three weeks' time. So this was a study we looked at, a controlled observational study, where we looked at two groups of primary care practitioners within an ACO, one of which was trained to function in the pathway. And the pathway that I'm talking about here was implemented in their community, within their system. The other was a group of, a similar group of primary care, but they were not trained and they were not functioning within the pathway. So what we found was that we saw a significant per member per month decreased in costs across all spine care, but particularly when it came to spine surgery and opioid. So in other words, the rate and thus the cost of spine surgery was lower in the pathway trained and pathway functioning group within the ACO, compared to the control, which was not involved with the pathway. And the same thing with opioids. So there's a lower rate of prescription of opioid and thus lower costs related to that. So I think this is early and there's a lot more work that we need to do to look at this, but we're finding is that by putting in place an organized and systematic pathway that you can see improvements that can occur. So there are different environments in which we've implemented this pathway, private practice in hospital systems, in large orthopedic or neurosurgical systems. So the pathway can be applied and made available or made that to fit into a lot of different environments that are out there. The most important thing in my mind with regard to improving the way in which we take care of patients is make the patient the hero of the story, right? If we can make the patient the hero of the story, boy, we're light years ahead in terms of our ability to empower them and help them to rapidly move towards resolution of the problem as quickly as possible. And now we're humans, right? So naturally, like all human beings, we want to be the hero of the story, right? It's natural. So one thing that we can do that would be really powerful is to, as we're entering the interaction with the patient, if we notice ourselves wanting to be the hero of the story, step back, watch ourselves do that, going through the process of wanting to be the hero of the story, forgive ourselves for being human, and then turn it around and make the patient hero of the story. Wow, that's so powerful. It's such a powerful thing to do for our patients. And really, as I said, puts us light years ahead in terms of our ability to maximally help this patient overcome the problem as quickly as possible. All right, well, thank you very much, gentlemen. So from here, what I want to do is talk about how we tried to institute this into our own system. We want to get back to the slides. Guys, can you flip that or he has to do something? I stopped sharing. There we go. I think we're good. So, no, let's do this. Sorry about this. Got that? Everybody's got it, right? All right, so I want to talk about how we decided to implement this where I work in a large multi-site practice. Want to go through some of the training and support that we've given, and also talk a little bit about what we're seeing in terms of some trends. And where Don was really talking about the Start Back tool, I'm going to talk a little bit more about the Arabro, and I'll explain why. My abbreviation for Arabro is a little bit different than the one that Mike put up there, and the reason for that is there's actually three different versions of the Arabro out there, and so I'm using a slightly different version. So, one of the things in physical therapy, and I think this really comes from occupational medicine, although I've been to some occupational medicine talks where they've credited physical therapy with this, is really starting to look at things from a flag perspective, which we've had a lot of discussion about, right? Red flags, everybody knows. Yellow flags are sort of the person's beliefs, feelings, coping strategies that may be maladaptive. And then we've got some black and blue flags, having to do with system problems, as well as, like, the interaction between the work environment and the particular worker. So, this article came out looking at screening for yellow flags, and was this needed from a physical therapy perspective? And the author said, following, really, the Start Back tool model, that there's going to be people out there that just need standard physical therapy. That's what the Start Back tool showed. And then it showed that there was a group out there that needed a specially trained therapist who could really help the person go through and get over some of the psychosocial barriers that actually came into play. And then this author's saying, in addition to that psychologically-informed physical therapy, or PIPT, there's probably cases where people need a referral, that they have more going on psychologically than what the physical therapist can maintain. We're not trying to make physical therapists into psychologists by any means. We're just trying to use the special tools that physical therapists have that might help them through this process. And then there are people that need immediate relief, so some of you may, immediate referral, some of you may be familiar with the concept of psychological first aid that's being taught out there. Who's really at high risk for, you know, harm to themselves or others, and let's get them some help right away. So, through this article, they really kind of laid out all these different steps in terms of what you would need to do to try to implement this within an organization, and I'm not gonna read them to you because I'm gonna go through them a little bit one at a time. So the first thing was purpose. What did I want to try to achieve here? Well, we want to improve outcomes, we want to support our clinicians. Believe it or not, 16% of our business is work comp. And when I go to our average clinician in our clinic, I go, don't you love seeing a patient who's covered under work comp? And they go, I hate that, right? Give me the 18-year-old ACL injury that wants to go back to sport, that's highly motivated. Those people do incredibly well, generally speaking, right? Give me the work comp patient with all of these other things coming in that are changing their psychosocial beliefs and loss of control and everything else, and they don't want to see these patients. So that's part of my goal is to give them the support so that they're comfortable doing this, right? We want to improve the value to the payers. Wanted to have a competitive advantage, right? We are a business. And we wanted to save the world, right? Well, who doesn't? And so this article just talks about psychologically informed practice in general, which Don did a really nice job going through kind of the concept. And we all need to just start to think about this biopsychosocial model and what psychologically informed practice means for our own practice. So it's gonna be different for a physical therapist than for a physician. Perhaps it's different for a chiropractor or an OT, but we need to just start to identify and figure out ways to help these people through some of these psychological barriers to recovery. So we're definitely not trying to make a whole new group of mental health practitioners. We're just trying to make practitioners that are more aware of their influence on the individual, what their own beliefs and thoughts impart to the individual. All right, what's the patient population? People that are referred to outpatient physical therapy covered under worker's comp. And the purpose of this discussion, we're gonna talk about low back pain. And we just picked the Arabro and implemented this as a tool back in 2017. Why the Arabro? Well, could use the Start Back tool, but actually the first thing the Start Back tool says in terms of decision making is, should this person go to physical therapy? Well, they're already in physical therapy, right? So I don't need to answer that question, sort of a foregone conclusion. The other thing is that the Start Back tool, although there's been some more work done on it since, they tried to validate it in other body parts and it wasn't valid. And in physical therapy, we don't just see back pain. So I wanted one tool that could go across all areas of the body because this concept, although certainly important in back pain, certainly relates to things like tennis elbow, right? And so we wanted something that was a little bit more robust in terms of its validation in different populations. And then what we did was we trained people on what this tool meant and sort of the Start Back tool philosophy. Some people are gonna be low risk. They're gonna do fine. Get out of their way, right? Some people have some physical impairments that that's your skillset. Help them deal with that. Some people also have some psychological overlay to their problem, which isn't abnormal. The studies in PT show that from a musculoskeletal injury, work comp, people coming into physical therapy, a high percentage of them would score positive on something like the Beck Depression Index. But within six or seven visits, most of them get better. And if they don't get better, it doesn't matter what else changes, they don't go back to work. And so we wanted to look at that. So today, and I'm gonna show you some results, but we've administered the Orebro almost a half a million times to more, I'm sorry, we've administered the Orebro more than a million times to almost a half a million people. Pretty significant. All right, and so how did we do this? Well, we knew it needed to be integrated. Not too integrated, but integrated. I had IT come to me one day and say, if you want this, we can get this on everybody. We'll just keep sending them emails until they fill it out. I'm like, well, that's not great. I want the clinician to actually come and say, it's not there, I need it, right? If you take it and you make it so that it's just automated to that extent, I won't be able to know which clinicians are using it and which ones aren't. It'll just always be there. So we have an online automatic collection tool for all of our outcomes, which then can sync to other data within our company. It can be administered at home, meaning we send the person a link, they do their whole registration and come to PT online, and it automatically recognizes that they've got back pain and that they're under workers' comp, and it administers them a modified Oswestry Disability Index, now called the Modified Disability Questionnaire, and it also administers to them the OMSQ-12, as well as a medication questionnaire. And then what we did was we instituted into our medical record where they could actually put this, so that we knew they were looking at it, it was getting entered into the chart, it was being communicated to you as an occupational medicine professional, that you could look and you could see what the risk stratification was on the individual that maybe you referred to one of our clinics. And then what we did was we came up with dashboard reporting in its mess, and what the heck does all that mean? But each subgroup of this are trends in our collection within a certain market, and we put somebody in charge of trying to drive compliance within the market. And so currently, on admission, not just back pain, but every work comp patient that's admitted to one of our clinics, we have about an 87% compliance rate with getting that data up front, which is pretty darn good. And here's some early results. So this is 21,000 patients plus back in probably 2018, and this is what we were seeing. So similar trends to what Don was showing on the Start Back tool, 39% of our patients under work comp are coming in high risk for chronic disability and poor return to work outcomes. What I did was, not a statistician, I'm a physical therapist, but have a couple of degrees, so I played around a little bit, and I took people, kind of like Don did, that I had matched scores for down the road when we discharged them. And so of the 21,000, I had about 15,000 that I actually had outcome data on. So my person in outcomes always says to me a lot, you have a lot of income, not a lot of outcome. And having an initial number without a final number really doesn't do you much good. But in this case, 70% is pretty darn good. And the data matched along with the full pool, right? I mean, we're still at 39% high risk, et cetera. This is what we saw in terms of utilization. We saw in the high risk group, we used 11.7 visits. In the medium risk group, we used 11.4 visits. And in the low risk group, we used 9.6 visits. So fairly consistent across the board, but obviously, kind of trends out the way you thought it would trend. Functional change. So this is looking at the oswestry by the initial risk group. So the group that started high risk actually came in with a very high level of disability. The medium risk group came in with slightly lower disability and the low risk group came in with lower disability. And then they all kind of made around a 10 point change. Right, 10, 12 points. Everybody got about 12 points better. So the people that came in worse, left worse. People that came in better, left better. Which kind of brings the question, it's the chicken and the egg thing. Which is driving which? Do the psychosocial factors drive the recovery or did the recovery drive the psychosocial factors? Could be either. But when we actually look at, this is the high risk only group and we break it down, and we look at the change, just like Don did on the start back tool, the people that started high risk and ended low risk made more improvement than any other group. They went from a 50, yeah. They went from a 56 on the Oswestry down to a 34 and they had, or I'm sorry, down to a 17 and they had a 30 point improvement. So this is actual functional change by entire risk group. We went backwards. There we go. This is what I really like. So this compares risk and change on risk to change in Oswestry. And so what you have on the left is you have the people that came in high risk on the Orebro and they left us at high risk on the Orebro. They used about the same number of visits as the people on the right who came in high risk and went low risk. The further you are below that line, the more improvement you got on the Oswestry. So what you see on the left is it's random. Some people got a little better. Some people got a bunch worse. Nobody got all better because if they got all better, they'd be on that bottom line. The people that started high risk and went low risk, a lot of people actually left with zero self-perceived disability on the Oswestry. And again, we can go back and I see the head shaking. One thing could be driving the other thing. We're not sure whether it's the psychosocial factors that are driving the lack of recovery or the lack of recovery that's keeping the psychosocial risk factors high. But I would call to your attention an article that came out last month on disc herniations and pain in the European Journal of Pain that looked at radiculopathy with lumbar disc herniations. And they did some really cool stuff that's way over my head. They looked at the size of the disc herniation in MRI. They looked for certain factors that represented inflammation, et cetera. So they looked at a lot of things that we would think of from a biomedical standpoint. But they also looked at pain processing on functional MRI. And they looked at catastrophizing on the pain catastrophizing scale. And the only thing that was really predictive of the person's pain wasn't any of the biomedical factors. It was pain catastrophizing was number one. If they didn't think they were going to get better, they didn't get better. If they thought they were going to get better, they didn't. I'm sorry. If they didn't think they were going to get better, they had a lot of pain. If they thought they were going to get better, they didn't have a lot of pain. So again, in terms of just trying to change all this, we took all this information. And then we tried to put it in practice. So we've trained about 1,800 physical therapists. We've done some training specific to low back pain in terms of similar to what we're talking about today, but in a little bit more detail to try to get our clinicians to think a little bit more from a biopsychosocial model and a little bit more from a psychologically informed approach. And now what we're doing is really trying to build them tools. Because this is not easy for them. They were really brought up and trained on more of a biomedical model and really starting to think about out of the box types of treatments. We find they need more support than what we thought they were going to need. So one of the things we did was we took the Orebro and we actually made a flow chart looking at the specific questions. If the person scores high on these questions, they're pain dominant. We need to get them some pain relief in order to get them moving. If they're high on these questions, they're catastrophizing. They don't think they're going to get better. We need to get them through that and show them, have them experience that they can do things so that they'll start to get better. And then there's a group that has problems with mood, depression. And we sort of already talked about early on that exercise is one of the best treatments for depression. So how do you get people going so that their mood improves just through exercise? And so we're creating all these interesting things that our clinicians can use based on the specific questions within the Orebro. So for somebody who's pain dominant, let's build you your own pain management toolkit. Let's give you two lists of things, things that you could do immediately that are going to have an immediate benefit, things that might work over a little bit of time to help you control your pain. Simple things. Pick two. You want a patch. You want to rub some gel on you. You want some tape on that. Those kinds of things. And then things that take a little bit more work. Do you want to learn a little bit more about pain, which has been shown to decrease pain, if you understand it? Do you want to get more on a walking program? Do you want to do deep paced breathing exercises in those times of stress? And then what we're doing is coming up with sheets on each one of those to help our clinicians educate the individuals. The other thing we have in play is what we call our utilization mentorship program, which actually assigns the ODG benchmark to every case that comes into a clinic. And if they exceed that ODG benchmark, the clinician gets an email saying, hey, this thing may not be going the way we want. Can you give us some more information? And so they go in and they do a self audit. And then a peer goes in and actually audits the audit and raises their hand and says, I'd like to try to help you on this. Somebody with a little bit special training. And so this is the result of one of those. And you can read it. But this is a really interesting case where this poor gentleman sat in a chair that broke and hurt his back. And he came to therapy and he started doing OK. And then all of a sudden, his daughter tragically died. And he went south. His recovery, he got worse rather than better. And he'd been seen for quite a while. And I got involved with the case. And just in talking to the therapist, she had all this information she wasn't using. And it came out that they were actually doing this 5K jog a number of months away in memory of this guy's daughter. And so I said, look, let's capitalize on that. Let's use that to get him to move. Because right now, the only place he's going is therapy. And otherwise, he's sitting home. And he's not doing anything. And so we actually got him to download Map My Walk. Anybody use Map My Bike, Map My Run, Map My Walk My Dog? There is one. And so we got him to download Map My Walk. And we talked to him. And in those terms that Don was talking about, how can we motivate this guy to start to be more active and get a little bit back into social environments, et cetera? And so we gave him the analogy of training for a marathon with a goal of walking in this 4K and not having it take him 20 or 5K without it taking him 20 hours to do it, which at the time we started this, he was walking 1.0 miles per hour for three minutes on a treadmill. That was all he was tolerating. And so this is the email back from the clinician just thanking me for kind of getting involved. So we really have a comprehensive system in play. I think we're still building more things. And we're looking at results and trying to figure out how to support our patients and our clinicians kind of on this journey for a different way of thinking. Michael, I'm going to turn it over back to you. You know, two super discussions about how to potentially implement some of this screening. And so can I get the next slide? I want to try to take all of the things that we've discussed in terms of the evidence base and the potential utilization in different practices and leave you with a thought process of how you may potentially take this information and implement it in your practice settings. So can I get the next slide? So, you know, one of the takeaways is, you know, think about you and your Achmed setting. And there are similarities in terms of primary care. One takeaway is it's really important to think about the use of evidence-based practice. There are a number of studies, we didn't discuss them, but that demonstrate, in general, that care consistent with ACOM and ODG guidelines improves outcomes. In particular, avoid interventional treatments and other treatments that are associated with either a lack of benefit or harm that can potentially exceed the benefit. In particular, you know, opioids, in particular, lumbar fusion for degenerative diseases. Think about the implementation of universal disability risk screening and risk stratification. We all recognize that the literature has some inconsistencies, and yet there are reasonable studies, you know, Hill and Primary Care UK, Start Back, and the Australian studies and Workers' Comp, early screening with Uribru, first 15 days, identification of at-risk individuals, implementing a strategy to decrease the risk of disability. What if you say, jeez, there's no way in my practice setting, in my hospital or group setting or whatever it is, I'm going to be able to utilize them. Although, for the years I was in practice, I used two tools, with the Uribru and the Oswestry, because they gave me a lot of information that I could use to implement effective treatments. If you're not going to use them, think about implementing some questions in your conversations with your patients that'll help you get to identify some of these at-risk scenarios. Ask patients, you know, what are your expectations with respect to treatment? What are your expectations with respect to recovery? What are your expectations with respect to return to work? Ask your patient, what is your mood? Ask your patient, perhaps, do you have any concerns regarding return to work? What kind of tasks or activities at work are going to be problematic for you? Do you have the ability to vary your work? Do you think that you're going to get help from your supervisor or your coworkers? And you can get a lot of that information from that type of conversation. Be patient-centered. We've heard from, you know, Don and Dave about meeting the patient where they're at, using motivational techniques and therapeutic alliances and motivational interviewing and therapeutic alliances. If you look at the literature, are associated with increased patient active participation, better goal setting, better goal achievement, and better self-management for patients. Really important about the education for patients and expectations and that cognitive reassurance and that empowerment of the patient, and as Don said, making them the hero of the story is really important. Can I get the next slide? Be cautious in terms of making referrals. So make appropriate referrals. We talked about in the Start Back strategy, medium risk using evidence-based chiropractic or physical therapy, high risk using that rehabilitation with a behavioral approach. Think about your return to work planning and your coordination. We talked about the use of functional outcomes assessments like the Oswestry and Roland Morris. Stress the need for graded activity prescriptions. You're going to walk five minutes today and 10 minutes next day and 15 minutes the following day. Again, promotion of early appropriate return to work, utilizing modified duty when needed so that we can decrease risks for patients on return to work, timely communication with other treaters, with the employer, identification of return to work barriers, collaborative problem solving, recommendations from the patient, recommendations from the supervisor, how we overcome the barrier to return to work. Again, maximizing the collaboration of multiple domains and when there are other treaters, that interdisciplinary collaboration where everybody is on the same wavelength and everybody has the same information about the benefits of being able to return to safe and accommodating work. Use of participatory ergonomics, matching the worker ability with the work demands, using multifaceted approaches, collaboration between the worker and the employer. Can I get the next slide, please? Making sure working within your healthcare system to establish critical clinical care pathways, train primary care spine practitioners. Again, integrate evidence-based care and screening into systems, including think about putting them into your EMR. If you're going to be using secondary care providers, make sure that they are trained similarly on the identification of risks for disability and the mitigation of those risks as well. Implement an active CQI and mentorship program so that you address the outliers that are in the systems. Can I get the next slide, please? And we need an awful lot of work in society about like they did in UK and Australia, promoting the information on health and wellness benefits of safe and accommodating work and public education on back pain to sort of de-stigmatize back pain and have the public be less afraid of back pain as well. So I think that is the last slide that I have. We all want to thank you for attending the session today. We put up our email addresses in the event that anyone out there has some questions for us. I apologize that we are at the 5.30 mark. Sorry that we ran a little bit late, but we really appreciate all of you attending today. I'll turn this back to you, Dave. Thank you very much. I can stick around and answer some questions for a while. In 30 seconds, there are two questions online. One is having to do with getting MRIs to place people in work categories. Wouldn't be my suggestion. I think there's other things that would be a better predictor of the ability to tolerate that work, maybe like a resilience survey might be better than actually doing an MRI. And the other question is, how can I get education to my local PT so they can kind of take this practice? The American Physical Therapy Association has a pretty robust, very well done, evidence-based clinical practice guideline set. One of the most recent ones that came out should be really important to this group. It actually has to do with working with people with work impairments and what works from a physical therapy perspective. And both the low back pain guideline that came out in 2021 and the newer work impairment guideline that came out just recently, both very much go along with this approach. So thank you very much. Thank you.

back pain management

chronic disability prevention

evidence-based practices

collaboration among healthcare professionals

occupational low back pain

spine problems

disability risk factors

psychologically informed practice

screening tools

cognitive behavioral therapy

patient education

movement promotion

return to work facilitation