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Low Back Pain Treatment Program Emlyne St. HelenLesley CootsTerri PageVirginia Commonwealth UniversityLow Back Pain Treatment Program IntroductionLow back pain treatment is critical for patients to maintain optimal states of health. Low back pain is one of the most common injuries and causes of disability in the United States. Opioid medications are also a concern in healthcare today. The commonplace of prescribing opioid medications for pain treatment has led to an opioid epidemic, with deaths related to opioid medications increasing yearly throughout the United States. Most primary care physician offices do not have a low back pain treatment protocol in place to assist with avoiding the use of opioid medications for management. At the Daily Planet Health Services (DPHS) Center in Richmond, Virginia, there is currently no low back pain treatment protocol in place. The providers at this location do not prescribe opioid medications. However, they do care for a large population of patients who seek treatment for opioid addiction, whom also suffer from chronic low back pain. This low back pain treatment program plan will address the treatment of chronic low back pain following the American College of Physicians recommendations (Qaseem, Wilt, McLean, & Forciea., 2017) for patients enrolled in the office-based opioid treatment (OBOT) program at DPHS. Additionally, the program will focus on treatments that avoid the use of opioid medications. After the successful pilot program for patients in the OBOT program, the program can also be expanded to treat patients with acute and subacute low back pain at DPHS at a later date.Background and SignificanceOpioid abuse and related deaths have become public health issues of epidemic proportions. From 1999-2010, prescription opioid sales quadrupled with no correlation to the amount of pain patients were reporting (Centers for Disease Control and Prevention [CDC], 2017b). The loss of life from opioid drug overdose has continued to increase as more people have become addicted to opioid drugs. In fact, 66% of drug overdose deaths are now related to opioids (CDC, 2017b). According to Rudd, Aleshire, Zibbell, and Gladden (2016) opioid overdose death rates increased significantly, 14%, or 7.9 per 100,000 in 2013 to 9.0 per 100,000 in 2014. Death rates from opioid drugs continue to grow. In 2016, approximately 116 people died every day from opioid overdoses (The U.S. Department of Health & Human Services [HHS], 2017).The opioid crisis is also a significant problem in Virginia and within the city of Richmond. Virginia Governor Terry McAuliffe and State Health Commissioner Marissa J. Levine declared it a public health emergency in 2016 (Coy & Brewster, 2016). During that time, emergency department visits for opioid overdose had increased by 89% compared to previous year's statistics (Coy & Brewster, 2016). Since the declaration, opioid addiction and overdose within the state of Virginia and the city of Richmond have only continued to intensify. In February 2018, 36 patients (rate 16.1 per 100,000 residents) within Richmond City, and 593 patients (rate 7.0 per 100,000 residents) within the state of Virginia were seen in emergency departments for unintentional overdose by opioid or other unknown substance (Virginia Department of Health [VDH], 2018).According to the CDC (2017b), the drastic rise of prescription opioid sales caused the concomitant increase in opioid overdose deaths over the last 16 years. Therefore, a guideline was implemented for primary care practitioners treating chronic pain to improve pain management while also limiting the risk opioid abuse (CDC, 2017a). It is imperative for primary care physicians to be knowledgeable of drug-free alternative therapies for pain management and the tools available to make appropriate treatment decisions for their patients,.According to the World Health Organization (2018), low back pain is a pervasive problem and is the leading cause of disability worldwide. Approximately 80% of adults will experience low back pain at some point in their lives (National Institute of Neurological Disorders and Stroke [NINDS], 2017). In 2015, approximately 29.1% of adults age 18 and over reported experiencing low back pain within the last three months (CDC, 2016). In the United States, low back pain in adults is the fifth most common reason for all physician office visits, and medications are the most frequently recommended intervention for low back pain (Deyo, Mirza, & Martin, 2006). Up to 25% of patients with back pain seek help from a healthcare provider, with over half of these patients presenting to either a primary care doctor or another specialist such as a chiropractor (Scott, Moga, & Hartstall, 2010). Low back pain is also the most common cause of job-related disability in the United States (NINDS, 2017). In the case of chronic low back pain, 91% of patients consult a physician, and 25% see a specialist such as a chiropractor. Primary care physicians take on the first evaluation in 65% of low back pain cases and usually become the only provider for these patients. Most patients will likely visit more than one primary care provider for treatment (Scott et al., 2010).Due to the chronic nature of this condition, many patients are prescribed opioids for pain management, however, in recent years there has been a drive to decrease their use for pain management due to the opioid crisis. From 1996 through 2013, of the $30.1 trillion spent in the United States on personal health care, approximately $87.6 billion was spent on low back pain, making it the third highest amount in healthcare spending overall (Dieleman et al., 2016). Low back pain can also lead to fatigue, depression, stress, difficulty sleeping, decreased quality of life, and medication abuse (Brinzo, Crenshaw, Thomas, & Sapp, 2016). Current guidelines encourage providers to use non-narcotic, integrative treatments in the management of low back pain, whether acute, subacute or chronic.Characteristics of the Target PopulationDaily Planet Health Services (DPHS) provides a full range of health-related services to individuals and families experiencing, or at risk of homelessness in the Greater Richmond Area. DPHS serves a diverse population of coed patients from pediatrics to adulthood. Providers offer comprehensive health care and multiple services to young adult, middle-aged, older aged, and elderly adults living in the Central Virginia area. DPHS is affiliated with Virginia Commonwealth University Health Center, a nationally ranked hospital located in Richmond Virginia. DPHS operates two full-time health clinics, provides primary care at a local community mental health facility, and subcontracts services at a site in North Richmond. DPHS also manages a Medical Respite program, co-located with its Southside Health Center, and a Safe Haven transitional housing program serving homeless adults experiencing mental illness, substance use disorders, and AIDS/HIV (Daily Planet, 2017a). DPHS was chosen as the clinical practice setting due to the potential benefits for adult patients in the DPHS office-based opioid treatment (OBOT) program with chronic low back pain.Demographic characteristics of the patient population enrolled into the OBOT Program served by this specific practice setting vary among age, race, ethnicity, and socioeconomic background. Many patients in this treatment program are from Richmond city. Currently, a total of 42 patients are enrolled in the OBOT program at DPHS, with the capacity to accept up to 100 patients total. According to the contact person from DPHS, a significant portion of patients enrolled in the OBOT program suffer from chronic low back pain. However, specific percentages of patients are unknown at this time.Needs AssessmentGreenhalgh's Dissemination of Innovation Model's nine dimensions were applied to the DPHS to determine a need and fit for a new program to treat low back pain (Vinson, McCallum, Thornlow, & Champagne, 2011). Providers were surveyed to determine the needs of the practice regarding the treatment of low back pain, and the practice’s readiness to apply a new treatment protocol. The first dimension from Greenhalgh’s Model addresses the compatibility of the innovation with current processes in practice (Vinson et al., 2011). The Daily Planet does not have a treatment protocol in place for patients with low back pain. The majority of patients who present to DPHS with low back pain are patients who experience chronic low back pain. Currently, the providers use their discretion when treating patients with low back pain. Low back interventions used by providers include deep breathing exercises, heat/cold therapy, and massage interventions. Providers advise patients to use non-steroidal anti-inflammatory drugs (NSAIDS) and Tylenol as medications for treatment of low back pain. DPHS does not have access to provide external services such as acupuncture, yoga, physical therapy, spinal manipulation, or cognitive behavioral therapy to patients with chronic back pain. At DPHS, there is no relevant data regarding current practice patterns, since no treatment protocol is currently in place. Furthermore, providers do not utilize a stepwise approach such as the one used in the clinical practice guideline from the American College of Physicians (Qaseem et al., 2017). DPHS has multiple community partners, and patients are referred to these facilities for additional ancillary services. The size and capacity for change is the second dimension of Greenhalgh's Model (Vinson et al., 2011). DPHS has two locations, one location on West Grace Street and another on Belt Boulevard in south Richmond. Providers at both practices express willingness and desire to apply evidence-based practice guidelines to help patients with low back pain.The third dimension of Greenhalgh’s Model addresses system readiness (Vinson et al., 2011). DPHS is ready to make a change for low back pain patients. According to the medical director, there is a need for non-invasive treatments for acute, subacute, and chronic low back pain. The clinical treatment guideline for low back pain from the American College of Physicians is welcomed and being reviewed by the medical director. If deemed appropriate by the medical director, this program will be provided to the clinical providers, and nursing staff to implement for patients. The characteristics of the adopters are the fourth dimension of Greenhalgh's Model (Vinson et al., 2011). DPHS currently staffs 26 providers total, which is comprised of two physicians, six nurse practitioners, five behavioral health specialists, one physician's assistant, four dental providers, one health educator, one pharmacist, and six case managers. There are several medical assistants on site as well. The use of innovation and frequency of quality improvement projects at DPHS are currently unknown. The fifth dimension from Greenhalgh addresses assimilation of the system, and the sixth dimension from Greenhalgh discusses the implementation process (Vinson et al., 2011). According to the medical director, providers at DPHS will be able to apply the American College of Physicians treatment guideline for low back pain effectively. DPHS is a collaborative practice with invaluable resources and community partners. DPHS is linked with major hospital systems in the community such as VCU Health, HCA, and Bon Secours Health Systems. Clinical Psychologists are granted 20 hours of psychology services on site for patients. Social work, nursing, and medical students are offered clinical rotation hours during open enrollment as well. The seventh dimension from Greenhalgh addresses linkages within the organization (Vinson et al., 2011). According to the medical director, internal communication is established and supported by management. Staff meetings are held on-site monthly. Weekly huddles with team members and providers are vital to the health center’s success. Both meeting formats will help with ongoing evaluation and sustainability for this project.The outer context of the system is the eighth from Greenhalgh’s model (Vinson et al., 2011). It is currently unknown if providers are incentivized to provide evidence-based practice or if Centers for Medicare and Medicaid Services mandate them. The advancement coordinator at the Daily Planet will be meeting with the medical director and board members to present the program. This meeting will determine if buy-in will be obtained for the program from key stakeholders.The ninth dimension from Greenhalgh addresses communication and influence (Vinson et al., 2011). The medical director and advancement coordinator send an organizational communication on a weekly basis. Providers and other stakeholders are present to support program implementation.Mission / Goals / ObjectivesMission Statement To improve the health of patients with chronic low back pain (CLBP) in the OBOT program at DPHS by implementing a treatment protocol focusing on nonpharmacologic therapies for CLBP along with NSAIDS. Goals / ObjectivesThe goal/aim of this project is to lower the pain rating of patients with CLBP in the OBOT program at the DPHS, by providing evidence-based treatment using non-pharmacological therapies along with NSAIDS. The pain rating of the CLBP patients can be measured by administering the Oswestry Low Back Pain Disability Questionnaire before implementation of interventions and after completion of interventions (Fairbank & Pynsent, 2000). Another goal will be to increase the use of nonpharmacologic therapies such as a walking program, yoga, and water aerobics at the YMCA, as part of treatment for patients with low back pain at DPHS. The third goal will be to establish a referral system with Bon Secours and VCU Health Physical Therapy Clinics for those patients qualifying for the care card or Virginia coordinated care. Adherence to both of these initiatives can be measured with weekly telehealth check-ins. The fourth goal will be to ensure compliance with the OBOT program through monthly urine drug screening tests. This certifies patients are not obtaining opioids through other avenues. Lastly, provider awareness and knowledge of evidence-based practice (EBP) non-pharmacological low back pain treatments/guidelines will be assessed through a Pre-Questionnaire to accomplish these goals. An in-person educational session aimed at increasing awareness to current guidelines will then be given to the providers and nursing staff. Concluding the educational session, a Post-Questionnaire will be conducted to reassess provider knowledge via self-reported responses to correct treatments of CLBP o determine program effectiveness. Program DescriptionFrom the needs assessment, using Greenhalgh's Model, it was determined DPHS would benefit from the implementation of a clinical practice guideline/protocol to provide non-invasive treatments and interventions for adult patients in the OBOT program with CLBP.A literature search was conducted using databases PUBMED and CINAHL. Keywords used for the literature search were the following: low back pain, chronic pain, opioids, primary care, non-pharmacologic therapy, and low back pain interventions. Empirical literature from the American College of Physicians (ACP) exists to support the use of a low back pain treatment protocol. This specific treatment protocol from the American College of Physicians will be implemented at DPHS for the treatment chronic low back pain (Qaseem et al., 2017). If successful, this treatment protocol also includes modalities for the treatment of acute and subacute low back pain, which can both be implemented at a later date at DPHS. According to the American College of Physicians, the recommended first-line treatments for patients with chronic back pain are exercise, yoga, motor control exercise, multidisciplinary rehabilitation, cognitive behavioral therapy, or spinal manipulation. Pharmacologic treatment recommendations for chronic back pain are non-steroidal anti-inflammatory drugs (NSAIDs) as a first-choice agent, then Tramadol or Duloxetine as a second-choice agent (Qaseem et al., 2017). It is recommended that short-acting opioids should only be used for the short-term improvement of pain if all other treatment options are exhausted, and the benefits outweigh the risk to the patient. However, opioids will not be used in this specific treatment program. An educational session will be conducted with the providers and nursing staff at DPHS, to provide specific education regarding the treatment protocol recommended by the American College of Physicians. Education will also be provided to the staff about available community resources to help with the treatment of CLBP. Providers and staff will be administered a pre-education survey, and post-education survey to verify program plan education has been impactful (see Appendix G for the survey, see Appendix H for Answer Key). Clinical Vignette Surveys are based on hypothetical patient scenarios and will be used to examine the providers' recommendations for acute, subacute, and chronic for low back pain in a 25-year-old male patient receiving care at DPHS. Sources such as the clinical vignette are deemed a valid tool for measuring the quality of clinical practice (Veloski, Tai, Evan, & Nash, 2005).Four interventions will be provided directly to the patient. First, a pamphlet with available community resources for reducing low back pain will be mailed to all patients in the OBOT program with a concurrent ICD-10 diagnosis of chronic low back pain, encouraging them to contact DPHS if interested in enrolling in available activities (see Appendix D for Pamphlet). Further, an alliance will be created with the Richmond YMCA to offer a low-cost membership to the patients who have transportation for yoga, water aerobics, and strengthening exercises (see Appendix E for income-based rate scale worksheet). Next, for patients without transportation, a free pedometer will be provided along with educational materials for an at home walking program (see Appendix F for walking program). Last, physical Therapy Services can also be arranged for patients qualifying for the Virginia Coordinated Care Program at VCU Health System, or the Care Card with Bon Secours Health System. Both health systems have clinic locations in proximity to DPHS.Weekly telehealth communication will be arranged by nursing staff to perform check-ins on patients to verify compliance with program measures. The Oswestry Low Back Pain Disability Questionnaire will be administered pre-implementation, and post-intervention to measure improvements in low back pain among patients who choose to participate in the program (see Appendix C for Questionnaire). Urine drugs screening tests will also be administered on a monthly basis to certify compliance is being maintained in the OBOT program, and that patients are not obtaining opioids from other avenues. Resources and Budget Minimal resources will be needed for implementation of this program. Low-cost pedometers can be purchased in bulk online. The remainder of supplies are available online for free download and can be printed in a handout, or pamphlet/brochure format as needed from Staples. Nurses can spend two hours weekly for 12 weeks utilizing telehealth check-ins to ensure patient compliance with the program measures. Two hours will be budgeted for in-person training. A total budget of $1766.50 will be needed for program implementation. This program can be funded through a grant. See Appendix B for an in-depth look at supplies needed in attached budget.TimelineAn initial timeline was established by the program developers in the pre-planning stages with specific dates, time spans, and series of events in the planning, initiating, sustaining, and evaluating of this health project to stay on course for timely completion of the program project. See Appendix A for the projected timeline. The complete timeline for the implementation of this project will be from March 2018 through June 2018. The timeline serves as a guide and frame of reference for the program developers to complete any time sensitive requirements for the possibility of a grant.Program ImplementationAll available resources accessible to the management team, providers, medical care staff, as well as patients of DPHS were taken into account when developing the program. The financial resources available to the facility and the demographics of the patient population treated were also taken into consideration during program development. These findings led to the development of a cost-effective program, that will not significantly increase financial burden to DPHS and the patients it serves. The program developers will present the education session at DPHS. Education packets will be distributed to participants and will include the pamphlet, the clinical guideline (See Appendix I for clinical guideline) from ACP, and other available resources for patients. The session will be presented with the use of a PowerPoint presentation. The educational session will cover all non-pharmacological treatment modalities available in the community for low back pain such as yoga, water aerobics, weight training, walking, and physical therapy. The educational session with providers and medical care staff of DPHS will last approximately one to two hours. During the educational session, the pamphlet will be discussed in detail so that the medical staff can speak to patients about the information provided.The practice manager, providers, and medical care staff will be responsible for informing the patients of the new interventions for the treatment of low back pain. Pamphlets will be distributed or mailed to the patients to tell them of the program. Flyers will be placed in the building and at the receptionist desk to advertise the program (See Appendix J for flyer). The practice manager will also put up information about the program on the DPHS website.Providers will discuss treatment options with the patient and assist in formulating a treatment plan that will incorporate either yoga, water aerobics, and weight training, or walking as a form of exercise to improve low back pain. Providers will also discuss the use of physical therapy as another treatment option for low back pain and provide referral when necessary. Providers will address the need for monthly urine drug screening tests with patients to ensure compliance with the opioid treatment program.Care team members can assist with applications for YMCA membership, or provide the at home walking program and pedometer. The Oswestry low back disability questionnaire will be administered to all patients who indicate an interest in the program, by medical care staff before implementing the program. Throughout the 12-week program, the patients will be followed weekly, by medical care staff through telehealth conferencing. This will allow providers to assess compliance with program measures. At the end of the 12-week program, the Oswestry Questionnaire can be administered again to determine for improvement in low back pain. Compliance with program measures can be evaluated alongside the improvement in Oswestry disability scores.Barriers that may arise with the implementation of this program are low socio-economic status, transportation issues, lack of trust in medical providers, little motivation to complete the program, and lack of insight into healthy behaviors needed for health promotion. Clients that require extensive detoxification for the OBOT program may also not be appropriate candidates for this treatment protocol.Program EvaluationThe evaluation methods used will ensure successful implementation of this low back pain protocol. First, it will be essential to survey providers and staff before and after the educational session to verify that education provided has been beneficial to program implementation. Secondly, it will be crucial to perform monthly urine drug screens on patients using this protocol to certify that opioids are not being used from other avenues. Thirdly, low back pain can be measured pre-implementation, and post-intervention using the Oswestry low back pain disability questionnaire. This questionnaire is the most commonly used outcome measure worldwide for low back pain (Mehra, Baker, Disney, & Pynsent, 2008). Compliance with the YMCA exercise program or at home walking program can be assessed during weekly telehealth calls by nursing staff. If participating in the walking program, patients will keep a record of steps taken daily with pen and paper. If participating in the YMCA program, patients will keep a record of participation in classes or gym activities. These activities can be reported during phone calls, or during in-office visits. Physical therapy sessions can also be self-reported by patients during weekly telehealth check-ins. A run chart of participation in activities can be kept for each patient and used to compare with improvements in the Oswestry disability index scores. StrengthsThe project focuses on identifying areas to improve providers' understanding of low back pain guidelines. The final discussion of results will be shared with all practice providers and nursing staff. Data gathered through the use of a clinical vignette-based survey tool supports the rationale that implementation of effective guidelines is essential for safe, effective, and optimal clinical practices. Furthermore, through interviews, it will be determined if providers are up to date on current low back pain clinical guidelines. Participation incentives such as free pedometers will also be offered. Therefore, participation drop-out rate will hopefully be low.LimitationsA small convenience sample will be represented by providers across both clinical health sites, therefore, limiting generalizability. The project has the potential to improve with sustainability if also conducted at other healthcare facilities with the same target population such as urgent cares, community health centers, and family/general practices.ConclusionThis project serves as the groundwork program plan within the OBOT program patients with a possible future expansion of evidence-based standards of care to all patients suffering from low back pain at DPHS. This program focuses on educating providers on the low back pain guidelines and also provides methods for implementation into practice. This program seeks to implement resources available in the community to reduce CLBP with nonpharmacologic methods. Alliances will be created with the YMCA, Bon Secours Physical Therapy, and VCU Health Physical Therapy, to offer treatment modalities to patients in the OBOT program. If successful, this plan can be applied throughout the practice for all patients suffering from acute, subacute, or chronic back pain.References:Brinzo, J. A., Crenshaw, J. T., Thomas, L., & Sapp, A. (2016). The Effect of Yoga onDepression and Pain in Adult Patients with Chronic Low Back Pain: A SystematicReview Protocol. JBI Database of Systematic Reviews & Implementation Reports, 14(1),55-66. doi:10.11124/jbisrir-2016-2409Centers for Disease Control and Prevention (2017a). Guideline for Prescribing Opioids forChronic Pain. Retrieved from for Disease Control and Prevention (2016). Health, United States, 2016. Retrieved from for Disease Control and Prevention. (2017b). Opioid Overdose, Understanding theEpidemic. Retrieved from , B., & Brewster, M. (2016, November 21). Opioid Addiction Crisis Declared a PublicHealthEmergency in Virginia. Retrieved from /newsarticle?articleId=18348The Daily Planet Health Services (2017a). About Us. Retrieved from Daily Planet Health Services (2017b). 2016 Annual Report. Retrieved from, R.A., Mirza, S.K. & Martin, B.I. (2006). Back Pain Prevalence and Visit Rates: Estimatesfrom U.S. National Survey, Spine, 31(23), 2724-2727. Retrieved from , J.L., Baral, R., Birger, M., Bui, A.L., Bulchis, A., Chapin, A., . . . Murray, C.J.(2016).US Spending on Personal Health Care and Public Health 1996-2013. Journal of theAmerican Medical Association, 316(24), 2627-2646. doi: 10.1001/jama.2016.16885.Fairbank, J.C., & Pynsent, P.B. (2000). The Oswestry Disability Index. Spine, 25(22), 2940-2952. Mehra, A., Baker, D., Disney, S., & Pynsent, P.B. (2008). Oswestry Disability Index ScoringMade Easy. The Annals of The Royal College of Surgeons of England, 90(6), 497-499.doi: 10.1308/003588408X300984Michigan State University Rehab. (n.d.). Oswestry Low Back Pain Disability Questionnaire.Retrieved from Institute for Neurological Disorders and Stroke. (2017). Low Back Pain Fact Sheet.Retrieved from , A., Wilt, T.J., McLean, R.M., & Forciea, M.A. (2017). Noninvasive Treatments forAcute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from theAmerican College of Physicians. Annals of Internal Medicine, 166(7), 514-530. doi:10.7326/M16-2367Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, R. M. (2016). Increases in Drug and OpioidOverdose Deaths--United States, 2000-2014. MMWR: Morbidity & Mortality WeeklyReport, 64(50/51), 1378-1382. doi:10.15585/mmwr.mm6450a3Scott, N. A., Moga, C., & Harstall, C. (2010). Managing Low Back Pain in the Primary CareSetting; The Know-Do Gap. Pain Research Management,15(6), 392-400. Retrieved from, K. (2018). 12 Week Beginner Walking Program. Retrieved from States Department of Health and Human Services. (2017). About the Epidemic, The U.S.Opioid Epidemic. Retrieved from , J., Tai, S., Evan, A. S., & Nash, D. B. (2005). Clinical Vignette-Based Surveys: A toolfor Assessing Physician Practice Variation. American Journal of Medical Quality, 20,151-157.Vinson, M.H., McCallum, R., Thornlow, D.K., & Champagne, M.T. (2011). Design,Implementation, and Evaluation of Population-Specific Telehealth Nursing Services.Nursing Economics, 29(5), 265-272. Retrieved from Department of Health (2018, March 9). Emergency Department Visits for Overdose by Opioid, Unspecified Substance and Heroin Among Virginia Residents, February 2018.Retrieved from Health Organization (2018). Musculoskeletal Conditions Fact Sheet. Retrieved from Men’s Christian Association (2018). Membership Types, Income Based Rate ScaleWorksheet. Retrieved from ATimelineActivityResponsibilityStart DateEnd DateMeeting with team membersIdentify and design projectChoose clinical setting. Daily Planet Health Services (DPHS)TP, ES, LC03/01/18currentContact and arrange a meeting with Stakeholders, Office Manager, medical director of the DPHS- Describe project plansTP03/06/18 currentIdentify and assess educational needs of providers and medical staff on nonpharmacological management of chronic low back pain. Pre-testing.Schedule Educational session for providers and health staff- Venue-Daily planetTP, ES, LC4/10/18 currentMeet to develop educational material and Curriculum.TP, ES, LC4/17/18 currentDPHS Education Session: Supply educational material non-pharmacological treatment. Post-testingProvide information on YMCA- yoga, and water aerobics classes.Walking program- information on the rmation on PT with Bon Secours or VCUTP, ES, LC4/17/18 current Advancement Coordinator- contact YMCA- to inform of the program.SS4/17/18 current Design posters, pamphlet, and flyersDP, TP, ES, LC4/15/18 currentPut posters up at building and get flyers online on Daily planet websiteSS4/24/18 currentDistribute pamphlet orMail pamphlet to patientsProviders, Nursing staff, SS4/24/18 currentDescribe program, provide education and administer a questionnaire to the patient.Providers, nursing staff4/24/18 currentIntervention and evaluationProviders, nursing staff April-May2018 current Appendix BBudget Appendix COswestry Low Back Pain Disability Questionnaire(Michigan State University Rehab, n.d.)Appendix DPamphletAppendix EYMCA Form(YMCA Richmond, 2016) Appendix FAt Home Walking Program(Taylor, 2018)Appendix GPre-Education, Post-Education Survey (Veloski et al., 2005)Appendix HAnswer Key to Clinical Vignette-Based SurveysClinical Vignette 1: A 25-year-old male patient presents to DPHS for a physical exam. Overall, he is healthy and denies any new health problems. His most recent chief complaint is acute low back pain from lifting heavy objects at a new job. What non-pharmacological treatments/therapies, if any for low back pain may be used initially?ANSWER: According to the most current American College of Physicians (ACP), appropriate responses for the first vignette include the selection of external heat, massage, or acupuncture. If pharmacologic treatment is desired, providers should select nonsteroidal anti-inflammatory drugs (NSAIDS) or acetaminophen (Tylenol).Clinical Vignette 2: A 25-year-old male patient presents to DPHS for a physical exam. Within the past two years, he has experienced low back pain. He has previously tried Ibuprofen, stretching, and heat which have not been helpful. He recently took some Percocet that was left over from previous hand surgery to help with the pain. What, if any, low back pain therapies would you recommend?ANSWER: An appropriate response for the second vignette would be the initial selection of nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, yoga, water therapy such as aerobics (ACP). Clinical Vignette 3: A 25-year-old male patient presents to DPHS for a physical exam. He has a history of opioid use disorder. He has enrolled in DPHS OBOT Program. He has experienced chronic low back pain for the past five years. What low back pain interventions, if any, would you recommend at this visit? ANSWER: Providers and patients should consider pharmacologic treatment with NSAIDs as first-line therapy, or tramadol, or duloxetine as second line therapy (ACP). Nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, yoga, water therapy, progressive relaxation, cognitive behavioral therapy is also strong recommendations (ACP).(Veloski et al., 2005)Appendix IClinical Guideline Handout (Qaseem, et al., 2017)Appendix JFlyer ................
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