AS CHIROPRACTORS, WE BELIEVE
that chiropractic care should be the first choice for patients experiencing neck or back pain. We also know that some patients inevitably pursue surgical options with or without our input. In the absence of red flags, such as cauda equina syndrome, surgery should rarely be scheduled for patients who haven’t exhausted conservative options first. In such cases, pre and post operative chiropractic intervention could naturally be an ideal route for patients’ continuity of care.
As a profession, we need to accept that currently, the general public often seeks the advice of a primary care physician or even a spine surgeon first to determine course of care. I have witnessed this since joining a spine surgery practice with a strong national footprint. This gives me the unique perspective to consult with a large share of the 80 to 90 percent of the population that we statistically never see in stand-alone chiropractic clinics.
The zeitgeist in health care today promotes integrated, patient-centric, best practice and outcomes based approaches. ACA publications over the past year or so address these topics. In contrast, let’s take a moment to consider how patients often think when they are suffering with pain. Chronic pain is intimately tied to brain functions that can govern behavior and decision-making. It can influence expectations, attention and comprehension.
Some may devote a lot of time and money into multiple types of care and procedures in a quest to find relief. Others might consider more aggressive or invasive options for treatment when symptoms are extreme. In short, patients may exclude less invasive or aggressive options such as chiropractic care and opt for surgery earlier in their continuum of care. Most chiropractic physicians are not immune to finding out that a surgeon has instructed a patient to avoid chiropractic care or that a patient was referred to a physical therapist after surgery, even if the doctor of chiropractic's (DC) clinic is equipped to deliver post-surgical care modalities. In some cases, you may have been the referring doctor.
In both surgical and chiropractic capacities, there’s an inevitable percentage of patients who will have less-than-ideal outcomes with offered treatments. If we can accept this truth and move past our differences toward a multidisciplinary cooperation and collaboration, we all stand to benefit. Modern medicine is so specialized and compartmentalized that we often fail to understand or see how an integrated approach in the interest of our patients should ultimately foster a better appreciation for our different areas of expertise. The key is building a partnership with surgeons and/or surgical facilities that are like-minded.
Consider this: If patients are ultimately willing to explore surgery as a viable option for their pain, don’t we owe it to ourselves and our patients to become more knowledgeable in these techniques and the diagnostic studies that are used to make surgical determinations?
This was the question I was pondering while completing my training in 2012 at the surgical center where I currently work. My position allowed for additional training, experience and confidence in reading MRI images (with a good amount of post-surgical spine imaging as well). I developed a better understanding of interventional diagnostic studies and the different minimally invasive vs. open back surgery techniques available. The caliber and complexity of spine cases presenting to the surgical center were not typical of what I saw during my chiropractic training and more than 12 years of clinical experience in private practice. Concurrently, it became apparent that no detailed post-graduate seminar programs were available to learn more about minimally invasive spine surgery and case management for the DC. Like most DCs, I learned to simply “treat above and below the surgical site,” or as some say, “surround the dragon.”
In late 2012, a medical physician who was training me in the surgical center passed on a quote from Miles Kington (a British journalist and musician): “Knowledge is knowing that a tomato is a fruit; wisdom is not putting it in a fruit salad.” He was talking to a patient about the complex world of spine care and varied treatment options leading up to surgery. Even with surgery, there are many different surgical options available. It is challenging to stay up-to-date, as well as navigate through all of the information for a physician, let alone a patient.
That is when the light bulb clicked. Could a postgraduate training program on this subject be developed for DCs so they could both market and safely manage pre-and post-surgical spines? Was this an uncharted territory with an incredible opportunity to provide for my peers? I felt that this was a new and creative way to help advance the chiropractic profession, help patients we already serve and gain access to the ones who haven’t yet considered chiropractic care.
1) Chiropractors will become better clinicians.
2) They could refer to surgeons who are willing to refer back for post-surgical care.
3) There would be better continuity of care via interdisciplinary collaborative cooperation.
4) Surgeons gain comfort knowing patients are co-managed by a chiropractor, who is trained to safely care for a post-surgical patient.
5) Medical facilities can refer to chiropractic physicians neck and back pain sufferers who aren’t candidates for surgery and haven’t tried chiropractic care.
In addition, patients referred for minimally invasive outpatient spine surgery (compared with traditional hospital-based open back surgery) can enjoy the benefits of:
• Outpatient procedures
• Smaller, muscle-sparing incisions
• Maximum preservation of structure and function
• Lower infection risk
• Less bleeding
• Quicker return to work and activities
• Higher patient satisfaction scores
In early 2013, the concept was given the green light from the leadership of Laser Spine Institute, headquartered in Tampa, Fl. During 2013 and into 2014, Laser Spine Institute’s leadership team worked with American Chiropractic Association (ACA) leadership to create a landmark collaborative partnership and jointly develop the training program. The president of ACA at that time, Keith Overland, DC, asked that the ACA Rehab Council leadership also be invited to codevelop and deliver the content of this certificate program.
A one-of-a-kind, comprehensive, 12-hour continuing education program was crafted and ready for introduction to the chiropractic profession after almost a year of conference calls, site visits and information sharing among ACA, ACA Rehab Council leadership (e.g., Jerrold Simon, DC, and George Petruska, DC) and the Laser Spine Institute. The course is named Post-Surgical Spine Rehabilitation (PSSR). And the program is now PACE certified through the Federation of Chiropractic Licensing Boards and ACA for CE acceptance in 40 states (and soon to be 41, with Missouri pending), as well as Puerto Rico.
The first class was delivered successfully in February 2015 in Tampa, Fl., with the second in March in Scottsdale, Ariz. Classes were also held in Cleveland in May and Wayne, Pa. in June. Upcoming courses are scheduled to take place in Cincinnati, Oklahoma City and St. Louis in 2015. To date, all of the courses have been held at established Laser Spine Institute surgery centers. This allows chiropractic physicians the unique opportunity to tour the surgical centers and get a firsthand view of the process patients go through with outpatient spine surgery. Students in each class to date have had the opportunity to meet and speak with the physicians and surgeons at Laser Spine Institute facilities to help facilitate interdisciplinary communication and relationship building.
Communicating With MDs
Chiropractors are encouraged to pursue this training program even if located in remote areas. The content presented will help practicing DCs better communicate with local medical providers and surgeons by improving the understanding and rationale for allopathic diagnostic and treatment options for neck-and back-related disorders. It will aid DCs in developing comfort in the recognition of clinical thresholds where surgical consideration is appropriate and what surgical options are available. Perhaps most satisfying: DCs will be given a blueprint on how to develop care and rehabilitation protocols for patients who undergo more modern minimally invasive spine surgery procedures.
Material that is covered in the program includes:
• Diagnostic studies and clinical recognition of surgical candidacy;
• Allopathic and surgical interventions commonly (and less commonly) provided;
• Clearing post-surgical patients medically for the DC to safely rehabilitate (also referred to as medical clearance);
• Rehabilitation theory and principles; and
• Functional testing and hands-on rehabilitation training.
At the conclusion of the program, DCs are given the option to take an exam to earn a certificate, signifying the completion of training in post-surgical spine rehabilitation.
With a willingness to refer and co-manage patients when appropriate with reputable physiatrists, surgeons or orthopedic specialists in your area for evaluation and treatment, it’s likely you’ll develop a higher level of knowledge, wisdom, respect and trust in your local community. You may be amazed at the insight you could develop to better establish yourself as the cultural authority for spine care with your staff, local providers, peers and ultimately patients.
For more information or to register for an upcoming PSSR program, please visit www.acatoday.org/pssr
Anthony Gross, DC, CCSP, FIAMA, left private practice in 2012 to become the consult physician for Laser Spine Institute
in Scottsdale, Ariz. Dr. Gross is co-instructor for ACA’s PSSR program. He graduated from New York Chiropractic College in 1999. He is past president of the Arizona Association of Chiropractic and a certified chiropractic sports physician. He was the SACA president and national legislative chair for SACA while at NYCC.