Multi-discipinary Care – How Does it Work in Clinical Practice?

I am going to begin this article by explaining that multi-disciplinary care is most often inaccurately used in common parlance. The term implies that several health care practitioners are managing an individual patient at the same time. While this type of care can be found at teaching hospitals – where I have worked  for many years – it is extremely rare to find in the Independent Health Care System. In this system – when it is at its best – what you will find is more accurately described as inter-disciplinary care. As the term implies, individual patients may be treated by different practitioners – as required and in a cohesive manner – but care will be administered by one practitioner at a time.

In a recent article I reviewed why it can be so very difficult to accurately diagnose different lower back pain conditions even while carrying  out thorough and high quality assessment procedures including MRI scans. That is why we have the wide array of health disciplines at our clinic. Each discipline has something unique to offer and when working in a cohesive manner better results and patient satisfaction are obtained.

As regards the diagnosis and management of lower back pain we have chiropractors, osteopaths, physiotherapists, general practitioners, consultant rheumatologists, consultant surgeons, medical acupuncture and stress management. Pretty impressive for a non-hospital based Independent Clinic – but necessary.

A Typical Treatment Course

Patients are of course given the choice of whom they wish to see and this has been demonstrated to give better results. If however, patients have no preference they will usually be referred to Dr Alan Jordan, Chiropractor, Phd a founder of the clinic who has many years of experience in the diagnosis and management of lower back pain and has published extensively in international peer reviewed journals. Perhaps most importantly, he has worked at leading Spine Centres in Europe and has a wealth of experience in coordinating appropriate care.

The initial task is to arrive at a proper “working” diagnosis and to determine the most appropriate course of care. It may or may not be chiropractic care. In a sense his job is like that of a GP of back pain. Make the appropriate diagnosis and initiate the best treatment. An additional advantage of initiating treatment with chiropractic care is that it has been scientifically proven that it works quickly – very quickly. Although not all patients respond favourably to chiropractic care it only takes a few (2-3) treatments in order to determine if this is the correct treatment pathway to chose. Many patients will also be seen by our General Practitioner if prescription medication is required.

Patients undergoing chiropractic care will most often be referred to physiotherapy as their condition settles. Our expert physiotherapists have a state of the art gym in which they carry out active exercise based treatment. This combination is the most common pathway that we use at the Broadgate Spine & Joint Clinic for patients who have not specifically requested an appointment with one of our other practitioners.

If however, Dr Jordan feels that additional investigations are necessary, we have the opportunity to refer to other disciplines of progress is lacking or indeed if additional investigations are required. This would most often by our Consultant Rheumatologist if there is a suspicion of inflammatory disease such as an active arthritis or to our Consultant Spinal Surgeon is there is a suspicion of for example, a frank disc herniation. This will usually involve additional investigations such as blood work, MRI scans etc.

Conclusions

The team at the Broadgate Spine & Joint Clinic are uniquely equipped to diagnose and manage lower back pain patients. We have the largest array of health disciplines of any Independent Clinic in London. All of our experienced clinicians work in a cohesive manner and our sole aim is to get patients better – as quickly as possible – and to ensure that preventative measures are undertaken in order to limit the risk of recurring symptoms.

Dr Alan Jordan

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Non-Specific Lower Back Pain – What is that?

Patients are often confused or disappointed when they are told that they are experiencing “non-specific” lower back pain because they understandably do not know what it means. In fairness, it is a generic diagnosis which means;

  • Their condition is not serious
  • We are confident that their pain is not caused by an inflammatory condition, a tumour or otherwise
  • We are not – nor can we be – exactly certain as to what tissues are causing their pain.

How can this be?

The illustration below shows just how complex a structure the spine and its individual segments are.

heart

Each and every one of these differing tissues can result and/or contribute towards pain.

Most back injuries will involve several tissues being injured and it is therefore impossible for clinicians to provide a pure and proper diagnosis as the pain experienced by the patient will not distinguish between the differing tissues. For example, joint pain will feel like disc pain and so forth. Once again, injured joints will impact the muscles and joint capsules which will then result in a mixture of pain which neither the clinicians or the patient can accurately classify. Therefore, the term “non-specific” lower back pain.

To add to the confusion

Even with a thorough case history and physical examination + MRI scans we are not always able to identify the source of pain. Below are MRI scans of the lower back.

 

fig1fig2

Figure one illustrates a healthy spine with well-defined discs which are adequately filled with fluid and all disc heights are well maintained. Figure two illustrates a disc herniation which is clearly visible as is the fact that the lower discs no longer have any fluid in them.

Clear Enough?

One would naturally think that the patient scans of Figure 2 – which are clear enough – would lead one to believe that this patient has a disc herniation and is likely in need of surgery. Even this is not a certainty and many patients will MRI scans similar to Figure 2 are not experiencing any pain at all.

These are termed “silent” disc herniations.

Working Diagnosis

The vast majority of patients – at least from honest clinicians – will be told that they have non-specific lower back pain because we cannot provide them with an anatomically secure diagnosis which identifies the precise tissue that is causing the pain. We then work with a “working diagnosis” and initiate treatment while monitoring regularly monitoring results their symptoms.

If progress is unsatisfactory we can request further investigations or refer to another clinician.

Conclusion

This article has attempted to explain why diagnosing lower back pain is not as straight forward as one might think. We are fortunate that at our clinic we have a very broad array of clinicians who work in a cohesive manner – and we often seek advice from our colleagues.

Dr Alan Jordan, Chiropractor, Phd

Director, Broadgate Spine & Joint Clinic

 

 

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Low Back Pain – Proper Diagnosis and Management

Low back pain is so common – over 80% of the population will experience it at some point – that terming it a disease does not really make much sense. Everyone has experienced the common cold and we all get over it within a short period of time and although we clearly feel ill for a few days, no one considers it be a disease.

Low back pain – harmless?

An acute episode of lower back pain will usually subside within a few days to a week and rest, moderated activities and “over the counter” medication will usually be sufficient. Patients will intuitively know if their symptoms are “turning the corner” after a few days. If they are not, patients should consider consulting an authorised health care professional. This may come as a surprise to readers, but the most documented preventative results are obtained by 1st class and comprehensive care. High quality care is so very important in order to prevent reoccurrence and chronicity.

Proper Evidence based care – what does this involve?

  • A thorough case history
  • A thorough physical examination
  • Patient choice and empowerment
  • Providing treatment that the scientific literature has demonstrated to be safe, effective and cost effective.

Case History

The case history – or patient interview – is crucial in that experienced clinicians can arrive at a good working diagnosis simply by interviewing the patient. A thorough symptom description including exactly where the pain is, its intensity and duration, how they came about, aggravating and relieving activities, previous episodes, general health status and so forth all form the parameters of the interview. The clinician develops an “index of suspicion” during the interview and this will to a large extent determine where the focus of the physical examination should be.

The Physical Examination

There are of course standardised examination procedures that most authorised clinicians carry out. Range and quality of movement, the testing of reflexes, sensitivity and muscle strength are standards. Careful palpation of the area involved is also standard. Rashes, multi-joint pain, fever and general illness will necessitate referral a medical consultant. At our clinic we are fortunate to have the broadest team of practitioners of any private clinic in London.

Patient Choice – Empowerment

It has been demonstrated in numerous studies that patients should have a good understanding of their condition and that when choice is relevant – for example chiropractic or physiotherapy treatment for non-inflammatory low back pain – that they should be able to make an informed choice. They should be properly informed as to what to expect as regards symptom improvement, how long this should reasonably take and so forth.

Treatment

A solid and well evidenced treatment course for lower back pain involves spinal manipulation, pain relieving medication, information and concluding exercise/ergonomic instruction. This course of treatment is the most common at our clinic. If there is any suspicion of inflammatory disease – such as active arthritis or connective tissue disease – patients will be referred to our consultant rheumatologit. If findings indicate that a surgical or neurological evaluation should be undertaken this can also take place at our clinic. Gait analysis, acupuncture and massage are also available. On occasion, when stress levels appear to be high – not unusual in the City of London – we refer patients to our in-house stress experts.

Conclusion

Although usually benign and self-limiting lower back pain does not always “go away”. Up to 10% of patients still suffer from their initial episode of acute pain 1 year on and many will experience recurring symptoms with physical exertion. The best treatment is multi-disciplinary and comprehensive. No individual health discipline can manage the myriad of conditions related to lower back pain and being part of a cohesive team will usually result in better and long lasting results.

Dr Alan Jordan, Chiropractor

Clinic Director

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Treating Modic Patients – A Case Study

At the Broadgate Spine & Joint Clinic we have the largest number of MAST Certified Clinicians of any clinic in the UK. We are seeing an increasing number of patients who come to our clinic in order to determine whether they are candidates for antibiotic therapy.

At Broadgate, we scrutinise our patients extremely thoroughly prior to initiating treatment. This involves identifying specific characteristics from their case history, their physical examination, and of course MRI confirmed Modic changes. The essential clinical findings related to arriving at the diagnosis of Modic has been reviewed elsewhere in this journal. All of our MRI scans are interpreted by MAST Certified Radiologists with whom we work closely.

As one would expect, the more thorough and certain clinicians are of a diagnosis, the greater the likelihood of attaining better results.

Patients suffering with longstanding disabilities and severe lower back pain who have tried every imaginable therapy are desperate to seek a solution to their problem. As our clinic is well known we have been receiving patients from all over the country who are desperate to find out whether or not they have Modic changes that could be responsible for their troubles. We also receive MRI scans via the postal service from many countries asking us to interpret their MRI scans.

However, a diagnosis must be arrived at in which the case history, the physical findings and the MRI scans must “add up” to a clear picture of Modic prior to prescribing antibiotics for a period of 3 months. AS we knew before this all began, we would be receiving patients who are indeed experiencing severe difficulties who do not demonstrate signs of Modic and must sadly inform them that we cannot offer them any meaningful treatment. This is a far from pleasant task.

A Case Study

As discussed elsewhere in this journal the average patient requires 6-8 weeks of antibiotics before they experience any improvement and that even after 3 months of antibiotics they will continue to improve for the remainder of the following year. In other words, this is a long process which makes perfect biological sense. However, as back specialists know, not everyone “fits” into the statistical averages that the large clinical trials demonstrate.

Approximately 6 weeks ago we interviewed and examined a young (mid-thirties) personal trainer who had undergone surgery for a disc herniation about 1 year ago. Initially, her results were excellent but some months thereafter a “new” pain developed deep in her lower spine that was constant, kept her awake at night, and only permitted her to work 1 day per week. After a day at the gym she had to remain in bed for three days in order to recover – not at all sustainable. Her case history and examination ticked all of the boxes, and as a post-surgical patient we knew that she was amongst those that are most likely to develop Modic changes. We anxiously awaited the results of the MRI scans. When they came back positive for Modic changes we were all delighted.

We began antibiotic treatment 6 weeks ago and she returned to the clinic for a follow-up consultation. At the initial consultation she cried out of frustration – at the follow-up consultation she cried out of joy. She had NO pain and no physical limitations. We were all astonished and delighted at the same time. It is cases like this that can make practice such an utter joy.

At Broadgate we record patient pain levels, disabilities, nr of hours with pain per day and all of the other outcome measures that were used in the groundbreaking clinical trial carried out by Dr Hanne Albert. The Case Study outlined above is one of the cases that clinicians dream about but clearly reflect the exception rather than the rule. So far, our results appear to reflect those of Dr Albert but these are early days for our clinic and proper follow-up data takes a year to obtain. We will publish the data when the time arrives.

Needless to say, we are more than pleased with our results to date, are happy with the work that we are doing and the skills that we have obtained by becoming MAST Certified Clinicians. We now have a treatment to offer a significant number of patients who had nowhere else to go just a few months ago.

Dr Alan Jordan, Chiropractor

Board Member, MAST Medical Society

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MAST Certified Clinicians

MAST Certified Clinicians have undertaken an educational programme to teach them techniques in diagnosing and managing patients that show signs of Modic changes on MRI scans.

In previous articles, we have already seen that Modic changes have been linked to lower back pain, and that MAST antibiotic treatment has been show to be effective in many cases.

With the founding of the MAST Medical Academy, there is now a formal training programme and certification for healthcare professionals to learn and demonstrate their knowledge of MAST and medic changes. Those having completed the course include spine surgeons, orthopaedic surgeons, pain consultants, GPs, physiotherapists, rheumatologists, osteopaths and chiropractors.

To help our patients make informed choices, we have full details of what it means to be MAST certified here, including information on what is included in the curriculum and what different types of Mast Certified Clinicians can do for patients.

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What is the MAST Medical Academy?

Recently there has been a lot of coverage around Modic changes in the vertebrae, which research has indicated as being linked with lower back pain. Modic Antibiotic Spine Therapy (MAST) has been demonstrated to have a positive correlation with reduction in that back pain.

To help the public make informed choices about practitioners claiming to offer MAST, the MAST Medical Academy was set up by researchers from the University of Southern Denmark and two professionals from The Broadgate Spine Centre.

The goals of the Academy focus on ethical and responsible dissemination of information about MAST / Modic changes, and to provide education to other healthcare professionals leading to certification in diagnosis and treatment.

A full review is included in our journal, here.

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Modic Changes Explained

In this blog post I will provide a brief summary of Modic changes, which are named after Dr Michael Modic who first described them 25 years ago.

Modic Changes are physical changes to the vertebra of the spine, which have been associated with lower back pain.

Both infection and mechanical causes have been shown to create Modic Changes, and recent research shows that antibiotic treatment has been effective in a significant percentage of patients.

There are three types of Modic Changes, which in simple terms we can describe with reference to their appearance on an MRI scan and the lower back pain that they have been associated with

Type 1 typically sees the formation of micro fractures in the thread of the vertebra, that contain fluid rather than healthy bone marrow. Research has shown that lower back pain is frequently felt in patients that also show signs of Modic Changes.

As Modic Changes progress to Type 2, that fluid forms in to yellow fat and is more visible on MRI scans. However, research of Type 2 cases shows less of a correlation with lower back pain relative to type 1 cases, although objectively speaking the correlation is still high.

Research has not shown a correlation between Modic Changes type 3 and lower back pain.

Most patients showing signs of Modic Changes have type 1 for several years, moving to type 2 and sometimes Modic Changes type 3.

For a more detailed explanation and for links to research in to Modic Changes, read my journal article here.

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Miracle Back Pain Cure?

Conventional treatments for chronic lower back pain do not demonstrate impressive results. This fact is not disputed. However, a breakthrough treatment, pioneered by Dr Hanne Albert, using antibiotics to treat chronic lower back pain, has reported remarkable success in clinical trials.

The recently published research, demonstrates how patients suffering with Modic changes which have been identified by MRI scans, has clinically significant reduction in their symptoms when treated with antibiotics.

In the study, “outcome” measures were used to access the improvement of the treated participants vs the control group who were administered a placebo. The participants reported on their ability to tackle common daily activities and household tasks and to measure their level of discomfort according to the Roland Morris Disability Questionnaire.

The term miracle should not be used lightly, and while it is early days yet, it is clear that while this treatment provides significant relief from symptoms in 60-70% of patients, the condition still persists and requires on-going management.

However, to patients who prior to treatment had scarcely been able to leave their bed but are now able to freely engage in household chores and even return to work, the treatment may indeed seem miraculous!

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Breakthrough in Modic Changes

A recent breakthrough by colleagues of mine at the University of Southern Denmark has cast new light on a condition afflicting tens of thousands of people, suffering from lower back pain. Having monitored the progress of this research, I am delighted to be a part of this esteemed group of scientists and play such an important role in the diagnosis and treatment of patients suffering with Modic changes.

Modic changes are a swelling in the vertebral body, on top and below the disc. They can only be identified using MRI scans. The inflammation is secondary to an infection in the disc. The latest research, through biopsies, has identified the bacteria causing the infection. This indicates that the correct treatment is long term antibiotics resulting in outstanding clinical outcomes. These are particularly astonishing when compared to any and all other treatments for chronic low back pain.

In response to this discovery, MAST Medical Academy, has been formed distribute information about the treatment of Modic changes to the general public and the medical community. The two representatives of this Academy in the UK are Dr Alan Jordan (Myself), of Broadgate, and Mr Peter Hamlyn of Broadgate and The Spine Surgery London.

More information is available at www.mastmedical.com.

If you have been diagnosed with Modic changes or are suffering from chronic lower back pain, we at the Broadgate Spine and Joint Centre will be able to give you more information or a course of treatment if required. Please get in touch with us on 020 7638 4330.

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Risk Factors for Developing Neck Pain

Neck pain is the most common complaint seen at our clinic. This is not surprising due to the fact that City workers most often sit at their desks for long periods of time in constrained postures. The work environment in the City can be rather stressful and coupled with the amount of “static” work that the neck and shoulder muscles carry out this should be of no surprise to anyone. Continue reading

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