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Is The Primary Care Team Missing A Key Player?

Primary care providers are typically patients' first point of contact with the health care system for neck and back pain, but patients are rarely satisfied with the results. Here Cameron Brown, D.C., discusses how the primary care team can begin to address neck and back pain.

By Cameron Brown, D.C.

Policy reform is well underway in primary care, with important initiatives like the patient-centered medical home (PCMH) slowly taking root throughout the country. The PCMH aims to address the needs of the whole patient by using a multidisciplinary team of health care professionals each uniquely positioned to address a different subset of those needs. Inclusion of social workers, dietitians, behavioral health specialists and pharmacists, for example, reflects our health care system’s recognition that chronic disease, obesity, mental health and social determinants of health should all take top priority in health care, and that not all issues that impact health require a strictly biomedical solution.
These health issues also demonstrate that the global burden of disease is no longer defined by mortality; it is defined by morbidity. What’s making us sick is no longer necessarily killing us, only disabling us along the way.
There is perhaps no better example of this shift in disease burden than the current spine pain pandemic. Spine related disorders – primarily low back and neck pain – are among the most common physical conditions affecting an individual’s ability to work and carry out activities of daily living. Back pain is the number one physical condition for which patients in the U.S. visit their doctor.
Recent estimates of total annual costs attributable to low back pain in the US have been projected at $600 billion or more. Low back pain is one of the top five reasons patients see their primary care physician, with approximately ten percent of the US population reporting functional limitations due to severe low back pain.
Primary care clinicians are critical to spine care. They see up to 65 percent or more of patients with low back pain as first contact providers. The behavior of these clinicians is therefore paramount to effectively and efficiently managing spine pain. Unfortunately, a 2009 Consumer Reports survey indicated that of all providers – primary care, medical specialists, physical therapists, chiropractors and acupuncturists – primary care physicians received the lowest patient satisfaction scores for management of back pain.
Primary care clinicians, however, are not the only providers traditionally involved in the spine care pathway. Chiropractic physicians, orthopedic surgeons, neurosurgeons, physiatrists, osteopathic physicians, physical therapists, psychologists, massage therapists, kinesiologists, naprapaths, and acupuncturists are also involved. This has resulted in a spine care supermarket, with current spine pain patients facing upwards of 60 different pharmaceutical options, 20 different exercise programs, 100 different manual therapy techniques, 26 passive modalities, 9 psychological techniques, 20 possible injections, countless devices, and a vast array of surgical procedures.
Yet despite the aforementioned hemorrhaging costs and a supermarket of options available to both patients and providers, we have seen negligible improvements with regards to the quality of care across all professions.
The twenty-fifth anniversary of Gordon Waddell’s seminal paper on the biopsychosocial model of low back pain was the recent focus of the Twelfth International Forum for Primary Care Research on Low Back Pain. The forum, however, was unable to make any firm conclusions regarding the model’s utility due to a lack of utilization and implementation in both clinical practice and research.
Although current practice and payment structures were cited as one of the primary reasons for this lack of utilization, the report goes on to state two crucial points:
“Even in the occupational health context of the United States, where there is sufficient payment and other incentives based on outcome evaluations, providers retreat to the ‘safe’ biological arena when faced with psychosocial problems.
“Also, training for most of the professions that treat back pain remains biomedically focused and grounded in profession-specific tradition
rather than on contemporary evidence.”
If sufficient payment and properly incentivized outcome evaluations have not rendered change, it appears health care reform on its own will not solve the spine pain crisis. In addition to this, and based on the latter statement, it seems new and improved training programs must be established, grounded in contemporary evidence, and centered on a biopsychosocial model of care.
It is therefore the marriage between both policy reform and newly adopted training programs that will yield optimal economic and clinical outcomes within the world of spine care.
In order to aid, and in turn partner with new initiatives such as the PCMH, newly adopted spine care training programs must be quick to follow suit. And I’d assert that primary spine care specialists should become commonplace members of the multidisciplinary primary care team.
One training program already underway is for the Primary Spine Practitioner. With primary care clinicians becoming increasingly burdened with more responsibility and less time, in addition to the projected gap in availability due to health care reform, a Primary Spine Practitioner could play an essential role on the primary care team and in the health care system as a whole.
The 100-hour Primary Spine Practitioner Course, which combines live training and distance learning targeting Doctors of Chiropractic and Doctors of Physical Therapy, is intended to build upon their existing knowledge and skill-set so they can fill the role of Primary Spine Practitioner.
Two recent articles published online in Becker’s Spine Review do an excellent job of explaining how one would effectively and efficiently amalgamate this model with that of the patient-centered medical home; and also how this model has been viewed from a payer’s perspective. A third publication describes the results of this model at work within a hospital setting, resulting in relatively low costs, high patient satisfaction, and an overall value-driven multidimensional spine care pathway.
It is my hope that someday in the near future, the primary care community will work hand in hand with primary spine practitioners engaged in a spine continuum of care pathway in order to bring about value-based spine care reform.
For more information: Primary Spine Practitioner and Spine Care Partners.

Cameron Brown, D.C., completed his clinical training under the mentorship of Dr. Donald Murphy, Clinical Director of The Rhode Island Spine Center and Clinical Faculty at Brown University’s Alpert Medical School. He has been trained as a Primary Spine Practitioner and has published articles in both the lay press and academic communities. He currently practices out of Harvard Vanguard’s Cambridge MA location. You can contact him at

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