ON Spinal Chat

Delivering Optimal Care to Patients with Arthritis

Episode Summary

This episode will provide you with practical research and insights on proven approaches to effectively assess, diagnose and treat patients with spinal stenosis and other forms of arthritis. Hear 'world expert in spinal stenosis' Dr. Carlo Ammendolia outline how he delivers optimal treatment to his patients and subtle variations between demographics. He offers tips and resources on how to assess a patient's physical, functional and psychosocial issues to help you strengthen your skills in these areas. As part of an interprofessional clinic at Mount Sinai Hospital in Toronto, Dr. Ammendolia shares examples of his collaborations with physicians as part of a patient's circle of care team. And be sure to check the show notes for links to ‘must read’ arthritis research and resources discussed throughout this podcast. (29:09 minutes)

Episode Notes

Topics Covered:

Key Links to References/Resources Discussed:

OCA Circle It Arthritis Campaign Links:

About Dr. Carlo Ammendolia:

Dr. Ammendolia is the Director of the Spine Clinic and the Spinal Stenosis Program at the Rebecca MacDonald Centre for Arthritis and Autoimmune Disease at Mount Sinai Hospital in Toronto. 

He received his MSc degree in Clinical Epidemiology and Health Care Research and his Ph.D. in Clinical Evaluative Sciences from the University of Toronto and his Chiropractic degree from the Canadian Memorial Chiropractic College (CMCC) in Toronto. 

Dr. Ammendolia is an Assistant Professor in the Institute of Health Policy, Management, and Evaluation, the Department of Surgery, and the Institute of Medical Sciences at the University of Toronto. 

In 2012 and 2017, Dr. Ammendolia was the recipient of the Professorship in Spine Award from the Department of Surgery in the Faculty of Medicine.  Dr. Ammendolia has been in clinical practice for over 39 years and now combines clinical practice, research, and teaching in the areas of non-operative treatment of mechanical, degenerative, and inflammatory spinal disorders with a special interest in degenerative spinal stenosis. 

In 2021. He was given the distinction of “world expert” in spinal stenosis by Expertscape based on his publication in this area in the past 10 years. ​

Episode Transcription

Episode 45: Delivering Optimal Care to Patients with Arthritis

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Introduction:

Welcome to ON Spinal Chat, where we explore what O-C-A is doing or supporting to help enhance your patient care, grow your practice or advance the chiropractic profession. 

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I’m Leslie from the Ontario Chiropractic Association. This fall 2021 we launched a comprehensive Circle It Arthritis Campaign to tell patients with arthritis and their MDs across Ontario about the value of including a chiropractor in their circle of care. 

To complement this campaign, we spoke with one of our own chiropractors – Dr. Carlo Ammendolia – who was recently given the distinction of ‘world expert’ in spinal stenosis by Expertscape.

Dr. Ammendolia is Director of the Spine Clinic and the Spinal Stenosis Program at the Rebecca MacDonald Centre for Arthritis and Autoimmune Disease at Mount Sinai Hospital in Toronto, where he also runs a spinal stenosis boot camp for patients. He’s been in clinical practice for more than 39 years and combines this work with research and teaching at the University of Toronto. 

Dr. Ammendolia joins us today to share his approach to assessing, diagnosing and treating arthritis and how it varies between different demographics. 

We’ll chat about his experience working with physicians, an example with widespread impact and how you can become a key part of your patients’ care teams. 

And be sure to check the show notes for links to ‘must read’ arthritis research and resources discussed throughout this episode.

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Main Interview:

Leslie:

Thank you, Dr. Ammendolia, for taking the time to meet with us today. To start off, why should we be focusing on arthritis?

Dr. Carlo Ammendolia:

Arthritis is a big problem in our community for lots of reasons. Number one, the aging population, and so we're seeing many, many people coming into our clinics who are older and suffering from arthritis. The second thing is sedentary lifestyles, whether it be COVID or just lifestyles in general. This also increases the risk of arthritic problems. And obesity. Obesity is a huge problem, an epidemic in our community, and also is a high-risk factor for arthritis.

All in all, these things are risk factors that are growing in prevalence, and as a result, we're seeing a large explosion in the number of people with arthritis. One in five Canadians have arthritis and this is growing rapidly. So as clinicians, we need to be aware that this is increasing and develop our tools and skillset to be able to handle the patients who come into our clinics suffering from various types of arthritis.

Leslie:

Okay. Is there any updated research that further underscores this that you might want to flag?

Dr. Carlo Ammendolia:

There is a recent update on the status of arthritis in Canada (for the Arthritis Society). A lot of things that came out of that particular report are of interest. Number one is in terms of having access around professionals who have skillsets around arthritis is a problem, the growing prevalence, and the lack of a cure for arthritis. So the new research really aligns well from what chiropractors are doing for many years, and that is keeping our patients active, reducing sedentary lifestyles, reducing weight, and increasing activity levels.

In the area that I'm most interested in, in spinal stenosis, for example, just a month ago, there was a guideline published in the British Medical Association Journal, the BMJ, which is highly prestigious, that suggests that for the very first time, that a non-operative and a non-pharmacological approach should be the first-line treatment for something like degenerative spinal stenosis, which is a type of arthritis. That's exciting because it aligns with what we do and it provides credence to what we do as chiropractors.

Every chiro should know this, because this condition, spinal stenosis, is a growing problem because of the aging population. We're expecting millions of people in the next 15 years to have this problem. Then you need to know that the evidence suggests that right now, first-line treatments should be manual therapy, education, exercise, and delivered using a cognitive-behavioral approach. That's what's being recommended to physicians for their patients who have this condition. And that's the skillset that chiropractors have.

This is exciting because back in 1994 when the guidelines came out that spinal manipulation was an effective treatment for back pain, that was a watershed moment for chiropractic. I believe this is a watershed moment for spinal stenosis because the approach that should be taken aligns with what we do as chiropractors. Chiropractors should know about that, physicians should know about that, and patients need to know about that. 

Then a couple of months ago, there was a clinical practice guideline that was published on the management of degenerative spinal stenosis. Again, it echoed the recommendations from the BMJ papers. 

Also, the research helps to guide our treatment programs and our treatment tools. So, for chiropractic, arthritis is in our wheelhouse, and we have the tools and now the evidence supporting what we do.

Leslie:

That's definitely great news. Could you please share with OCA members and other chiropractors who are listening what your approach is to assessing, diagnosing, and treating your patients with arthritis?

Dr. Carlo Ammendolia:

Sure. Although we do see quite a number of patients who have ankylosing spondylitis, which is more of an inflammatory type of arthritis, the most common type of arthritis is osteoarthritis, which is the one that we often see. For the patient who comes in with osteoarthritis of the knee, the hip, the back, the shoulder, the foot, the approaches are quite similar in that the first thing you want to do is to assess clinically what's physically impacting the patient's function.

Then following that, how does it impact the person's overall function? So we look at the physical, we look at the functional and then something that we often forget is the psychosocial. We will screen for yellow flags, catastrophizing fear, avoidance behaviors. These are strong predictors of improvement in patients with arthritis, and so we want to screen for that. So good consultation at the very beginning to assess the type of arthritis stats the patient has, how is it impacting the patient physically?

How is it impacting the patient functionally? Then record that particularly around limitations. All our patients will be asked, how is this condition impacting your life? "Well, I can't walk. I can't sit. I can't play golf. I can't play tennis. I can't play with my grandchildren." These are things that we will document. Then finally, screening for underlying psychosocial barriers, like catastrophizing pain, avoidance behavior, that suggests that people who have pain will avoid doing activities and that perpetuates their problem.

Once we've got all that data, then we match that information with the right treatment. I think what's really important in arthritis and pretty well everything we treat, we shouldn't be treating, for example, all low back pain the same. We shouldn't be treating all patients with arthritis the same. We need to tailor our program based on those criteria that I just mentioned: the physical, the psychosocial, and the functional, and then match the right treatment with those parameters. That's our approach in the clinic.

When you're seeing physical limitations where the person can't bend, they can't move their arm, they can't lift their shoulder, we will address those with certain therapy techniques. Then the functional is where patients may not able to walk and play tennis, and then we'll try to establish goals and objectives and try to achieve functional restoration. Finally, we would look at some of the psychosocial issues and intervene at that level. Of course, if they're suffering from severe depression or severe anxiety, then we might need to collaborate with other professionals.

But things like pain avoidance behavior and catastrophizing, we can often provide interventions to deal with those underlying barriers using various techniques like cognitive behavioral approach or motivational interviewing.

Leslie:

Okay. As you've mentioned, the psychosocial is often missed. Could you highlight any barriers where chiropractors should pay more attention?

Dr. Carlo Ammendolia:

Sure. I think the first and the most important thing is to validate the patient's concerns. They'll say to you, "Anytime I go to exercise, or I do an activity, I feel more pain and therefore I'm not going to do it. So, I'm not going to do your exercise because it causes more pain." Instead of saying, "No, no, you need to do them." You would first say, "Yes, I understand your concern. I know that you're having more pain because of the exercise."

Validating the patient's concern is the first step when you're dealing with underlying psychosocial things. Don't try to confront the patient with their beliefs, even though the beliefs may be incorrect. But first and foremost is to validate. 

And then second, say something like, "We know that you're having more pain, but this is common. In fact, 60% of our patients who are on our programs are worse before they get better. This is very common and that's because you're deconditioned and because you've been sitting most of the time because of your pain.

As a result, when we get you exercising earlier on, you're going to feel more pain. But if you stick through our program, our research suggests that 85% of our patients do significantly better." That would be an approach where you validate, you provide data, and you provide encouragement, you provide support, you provide compassion and empathy. Those are the key ingredients when you're dealing with underlying psychosocial things.

And whether it be a depressed mood or whether it be negative expectations or whether it be pain catastrophizing or avoiding activities because of their fear, these are the similar approaches we take to try to change those attitudes, change those beliefs around myths that are incorrect.

Leslie:

Is there something that you can highlight that might be slightly different from what you might be doing with a patient who just comes in with low back pain or something else?

Dr. Carlo Ammendolia:

Yeah. With a patient who has arthritis, for example, someone who might have inflammatory arthritis like ankylosing spondylitis, psoriatic arthritis, or lupus, these are an inflammatory type of arthritis and the approach would be much, much different than someone who comes in with osteoarthritis, given that it's an inflammatory condition and the patients are more likely to have a flare-up when they're doing exercises. I think one needs to be more careful folk when dealing with an inflammatory type of arthritis.

Now, having said that, there are patients who have inflammatory arthritis that have chronic and not acute symptoms. Like patients who have ankylosing spondylitis for many years, they have very stiff spines, and they have morning stiffness. For them, there might be some flare-up in their condition, but generally not as much, or just as much as people who have osteoarthritis. Well, I think it's important to know the underlying type of arthritis because it does impact the way you're going to treat them.

And also age is important. It affects all ages of course, but it does impact older patients more readily, and they're more people with older age that have arthritis than younger people. We do approach it slightly differently in that when you're dealing with older people who have arthritis, you're really looking more the long-term in terms of building up reserves for muscles around knees and hips and backs. We do know that, for example, the definition of aging is the progressive use of reserves to maintain function.

And I'll tell this to all my older patients. And if I'm talking to doctors, I'll say it's the progressive use of reserves to maintain homeostasis. So we need to build strength for patients in terms of back strengthening exercises for lower back, problems in osteoarthritis or knee or hip or hands or shoulders. It's strength training to build up those reserves, so even though they're aging, they build up sufficient reserves that it doesn't impact their function very drastically and they age slowly as opposed to drastically.

People who are out of shape and patients who don't have much reserves, they tend to age very, very quickly and their arthritis impacts their lives more dramatically than someone who's fitter, stronger, and more flexible. Although those are important in younger people who've had an injury and caused osteoarthritis, I think with older people, we can see a more rapid decline in their overall health because they don't tend to be as active and that will be more devastating for their health from a cardiovascular perspective, increase the risk for heart attacks and strokes and Alzheimer's disease and a lot of other degenerative conditions that we see in older people.

Whereas the younger people, they tend to be at less risk of that because they're young. So yes, we treat them somewhat differently and more to do with preventative and trying to reduce the acceleration of their arthritis and slow down their functional decline.

Leslie:

What about someone who's 75 plus less or elderly? Are there any differences in their treatment?

Dr. Carlo Ammendolia:

The approach is the same whether you're 90 or 75 or 65. You just change the intensity of the program and you match it to the physical abilities of the individual. I've seen 65-year-old patients who are less fit than my 90-year-olds and vice versa. It's really based on the patient's physical abilities. You'd be amazed of what we do with our 100-year-old patients and our 90-year-old patients. We get them moving around and we get them stretched out and we get them doing exercises, we get them cycling every day for 30 minutes. So the intensity might be different.

Your manual therapy techniques might be a little gentler than usual. The techniques are the same, but the force that you're going to use is going to be less of course. I have lots of stories to tell you of people who visit our clinic and watching us treat our older patients, how at the end of that session will look at us and say, "Well, I'm amazed of what that patient was able to do." Because we underestimate often what these seniors can do. And we tend to push them a bit, of course within reason and with sensibility. But don't wear white gloves when you're treating these older patients because they can do a lot more than you think they can do.

Leslie:

Are there different modalities for older or younger?

Dr. Carlo Ammendolia:

No. We use the same modalities. For example, we have our complete program for spinal stenosis and patients might do their exercises twice a day and their repeats might be five repeats of 10 seconds. And we might have our older patients start off doing two repeats and do it once a day and then gradually build it up to twice a day. We might move a little bit slower with the older patient because they're more likely to have a reaction to exercise too quickly given that they're more sedentary.

I'm going to use the word “fragile” really in quotation marks because that's not a kind of word that I often use in my clinic. I'm very positive and I will use words like superman or superwoman to describe my patients to provide them with positive imagery and positive motivation. But yeah, modifying the program to suit the patient's physical and functional abilities. But again, the principles and the underlying fundamentals are the same.

Leslie:

Okay. Is there any special advice that you would give to other chiropractors when they are assessing, diagnosing, or treating a younger person?

Dr. Carlo Ammendolia:

Yeah. There are two main reasons that younger people might get arthritis. Number one would be genetics; they have a predisposition for whether it'd be osteoarthritis or rheumatoid arthritis or whatever the case may be. Genetics and family history play a role. The second one primarily in the realm of osteoarthritis is usually related to injuries of falls and accidents that cause arthritis to form at a premature age.

In terms of the approaches, they're the same as they would be older adults depending on where the arthritis is, if you're dealing with a spinal arthritis or a knee or a hip arthritis and you want them to reduce weight, you want them to get fit, you want them to keep active, you want to keep strong, and you want to use particular modalities to help them reduce pain to maintain function. I think the principles of being old or being young are the same. However, the underlying causes will be different. So being aware of them; it's important.

For example, in spinal arthritis, something that I know a little bit more about, a condition known as spinal stenosis, we might see it in a young person (even though) it's really an old person's disease - but I've seen it in people as young as 30 years old. So what I'm getting at is that if the syndrome, which is referred to as neurogenic claudication, is what you see in a 30-year-old, don't write it off as something that can't be because of it possibly can be.

Another word of wisdom, if you will, is that even though they're younger, they still may have an underlying arthritic condition that's actually given rise to their symptomatology even though it's unexpected. So be aware of that.

Leslie:

Okay. Thank you. Can you tell me about a scenario in treating a patient where you worked with a physician as part of the patient's circle of care and what was this like for the patient?

Dr. Carlo Ammendolia:

I'm unique and fortunate in that in my clinic at the hospital, most of our patients are referred by physicians. So right from day one, we have a collaborative approach with patients. Most patients have a referral note with imaging and information about the underlying health conditions that we may want to be aware of and also the concern that physicians may have regarding that patient.

Then we have the opportunity to communicate back and forth on questions we might have or sometimes to do with medications and medications that we may feel are not necessarily appropriate, even though we're not the experts in medication. Oftentimes, I find that certain medications are being prescribed for patients that are, number one, not effective for the condition coming in, and number two, they're impacting their cognitive function for example, which impacts their likelihood of having a fall. So communicating with them, I've done that a number of times.

And I can give you an example. There was a situation in the emergency department when a patient came in with an acute sciatica and the emergency doc sent me an email because he received a systematic review that was published in the Canadian Medical Association Journal. And all physicians get this journal. This particular systematic review suggested that pregabalin, the neuropathic, is not effective for sciatica. So he sent me an email (that) says, "What do you think of this article, Carlo? Because we here in emerge always prescribe this for our sciatic patients.”

So I emailed them back with three other articles that said the same thing. I sent him systematic reviews and clinical practice guidelines saying that these drugs don't help patients with sciatica. Then he emailed me back and CC'd all the doctors in the emergency department saying "Hey, guys, look at this. This evidence suggests that we should not be prescribing this drug to these patients who come in with sciatica." 

That kind of experience is about the relationship that I have with the docs and we're able to speak the same language and able to discuss evidence and try to help each other in terms of best clinical practice and best practices.

Leslie:

That's a great example. Did you see any impact as a result of the communications that the physician shared?

Dr. Carlo Ammendolia:

Well, we see many patients from the ER who have sciatic pain being the number one thing, and acute low back pain. So normally patients will be coming to the ER and they will send them to us to help them with their pain and get them educated on what to do. In the past, we would see that they were all prescribed Lyrica or pregabalin. Now we see less of that.

So there is definitely some change in attitudes and beliefs around that medication and patients are prescribed less of that medication now. It was nice to see that we were part of that changing practice behavior. I'm sure that would work the other way around when there are evidence going the other way as well in terms of changing our practice based on evidence.

Leslie:

Could you tell me a little bit more about one of the scenarios where you treated a patient and then collaborated with their physician to monitor and manage their care?

Dr. Carlo Ammendolia:

There are lots of examples. The thing about the conditions that we treat in a clinic, they're very chronic conditions that don't tend to have a cure. The tendency is that there is always going to be some ongoing collaboration with other health care practitioners because the condition doesn't go away, and the patient continues to seek the care. So there's always ongoing collaboration. 

In terms of imaging, for example, we would often get an email from a doctor saying, "So and so still having these symptoms, should we get an MRI? Or should we do a special test? Or do they need an ultrasound? Or they need this and that?" 

We're fortunate in our hospital because we're considered the experts and the family physicians will often contact us, and with their patients, asking us for what we think the next step would be. 

That would be another example of the ongoing collaboration with physicians in terms of we're seeing the same patient and we want to make sure they get the best care. And often, imaging is overrated in these conditions like arthritis, because arthritis that we see in the spine, for example, doesn't really correlate very well with patient symptoms.

They're really not very good for prognostic purposes in terms of predicting who's going to go well, who's not going to go well. And as long as there aren't any red flags suggestive of some serious disease going on like a cancer or infection, then imaging is often not very useful. So that's the kind of thing I would communicate to the physicians and say, "Yeah, I don't think right now imaging is really good."

Leslie:

Okay. And how do patients respond to this? What's their experience like and what kind of reaction have you seen with this go through?

Dr. Carlo Ammendolia:

Well, yeah, I think patients love it. And why not? I mean, they're getting collaborative care and we do know that collaborative care is better than single care. I'm not the expert in medication and they're getting expert advice on medications. I'm the expert around non-pharmacological and non-operative. So they're getting the best of both worlds and the people are talking to each other. There are many different collaborative models, but the most common is that person gets referred and that's it.

You might get a note going back and forth, but it's nice to have more collaborative where doctors are emailing each other and talking about the patient and thinking about next steps and some of the barriers. I think that's the best type of collaborative care, is when the practitioners are talking to each other about the patient and trying to do what's best for them. 

We don't have it on every patient, but we do have it on a number of patients and it's actually growing, so that's encouraging.

The reason it's growing too, I think, is because we do train family physicians in our clinics. We get physicians early in their training and teach them the importance of collaboration and what chiropractors can do for patients with arthritis and other musculoskeletal conditions.

Leslie:

For other chiropractors who don't have these relationships, but want to establish them, can you give them any advice?

Dr. Carlo Ammendolia:

We had a visitor into our clinic on Monday and he is a new graduate from the states and that was one of his questions because they come in and say, "Well, I like what you do here. I'd like to do the same thing. How do I go about doing it?" So one of the things I told him, and then I recommend to all our chiropractors out in the field, is that when you do have a patient that's in front of you and they do have a family doctor, then ask the patient if it's okay for you to write a little note to the family doctor about what we're doing for you for your condition.

That would be a great way to open up the door of communications with the physician. I find this very, very effective. If your note is done professionally and is done with keen knowledge and skill, which chiropractors have, then the physician will likely say, "Yeah, this guy knows what he's doing." And number one, he will encourage the patient to continue on. And number two, he may develop a relationship with that chiropractor and send patients and vice versa.

Another way is lunch and learns. I've done this many times on behalf of other chiropractors, going to clinics like the Albany Clinic. We plan to do one at Health Sherbourne clinic in the next few months. I plan to do the one there on behalf of the chiros there. These doctors come and have lunch and they listen to a speaker. There's no reason why you can't be one of those speakers and talk about arthritis or talk about sciatica or talk about back pain or talk about neck pain and then get the other physicians to ask questions on your talk and open those lines of communication. 

There are many ways, but I think those are two ways that I would suggest are pretty easy ways to get started.

Leslie:

Great. Thank you. Now, we've talked about this a little bit before, but just wondering if you have any advice to help chiropractors provide optimal care for patients with arthritis.

Dr. Carlo Ammendolia:

One of the things that I find when I'm teaching about spinal stenosis and neck pain and back pain, whether it's arthritic related or not, is the importance of the psychosocial and the importance of how you interact with your patient because we do know now, and particularly in arthritis, those psychosocial factors are really strongly predictive of success. I think we need to do a good job on, number one, identifying the underlying psychosocial.

And again, these are the main ones: catastrophizing, pain avoidance behavior, depressed mood, anxiety. We're not psychologists and we're not psychiatrists, but we do have the skillset to deal with mild forms of these conditions without having to refer them up. You can easily learn how to do things like a cognitive-behavioral approach and motivational interviewing, skillsets that I learned on my own and that I use every day in the clinic. 

Number two is really communicating with your patient because we do know now that there's this whole world, what we call contextual factors.

That is how you talk to your patient, how you relate, how you touch your patient, verbal or nonverbal communications. These are very strong, and predictors of outcomes and we know now through the research that these contextual factors can often be even stronger than your intervention. So learn how to show compassion, learn how to show empathy, learn how to validate patients' concerns, how to put them at ease, and then change the way they think because how they think really will determine how they will treat their back pain or neck pain or osteoarthritis.

Changing attitudes, changing beliefs, mitigating negative expectations, these are things that we often don't think about as chiropractors. We think about the manipulation, the adjustment, the exercise, the nutrition, which are all important, but as the evidence grows, we're seeing how much these contextual factors play a really strong role in predicting your outcomes. So given that they're modifiable, you should be able to go in there and make those changes. It's not easy to make the changes, but these are the kinds of things that we need to look at when we're treating our patients with arthritis.

Leslie:

Okay. Now, with the psychosocial, you've said that you've learned a lot of cognitive therapy and other techniques. Is there any resources or any area that you might suggest a chiropractor might start to learn and develop their skills in this area?

Dr. Carlo Ammendolia:

Yeah. There's a number of books out now on motivational interviewing. I have a colleague of mine, Dr. Mike Schneider, from the University of Pittsburgh. I've attended some of his courses on motivational interviewing. Then also go to PubMed and just plug in motivational interviewing or cognitive-behavioral approach. There are many papers you can learn tips on how to do it. It's not rocket science, but it does take practice in learning those techniques.

We're now developing a bootcamp app and we're implementing these kinds of strategies inside the app, so motivational interviewing techniques as well as cognitive-behavioral change techniques, alongside our physical intervention, our exercises and our self-management strategies. But because we are learning more and more how these psychosocial (issues) impact our outcomes, that we're incorporating that kind of approach even in the app that we're building for patients who have spinal stenosis.

It's an area that's expanding in terms of our knowledge and our understanding and I think chiropractors are taking advantage it, because generally speaking, chiropractors have a very good rapport with their patients.

This should just take it one step further in developing that trust and using these skillsets to change negative attitudes and negative beliefs and pain avoidance behaviors that can significantly impact patient outcomes.

Leslie:

Okay. Now you've talked about the end result being the patient outcomes, but I'm wondering, do these affect compliance somewhere in the middle as well?

Dr. Carlo Ammendolia:

Absolutely. And we're very proud in our clinic that we have a very high compliance rate. 

We attribute it to many factors, maybe because we have a self-selected group in terms of people who know that it's about the bootcamp, they know it's hard work, and they come knowing that that's what they're going to get. 

Having said that, one of our big key factors, I believe, is that we motivate our patients, and we give them feedback on how well they're doing. And just a little tip I could give to the chiros out there, that every single visit that a patient comes into your clinic, find a positive.

Ideally, a positive clinical finding, the range of motion, their tenderness, their straight leg raise. Those are the easy ones. But in the very chance that you can't find something physical, even saying something, "Your hair looks great today," Or "Are those new glasses today." We think of these as little things, but we do know... Again, the evidence is growing. This is evidence speaking. 

There was a paper that was published in The Lancet in 2018 around back pain and back pain could be caused by arthritis. But this whole paper was devoted in terms of the importance of a positive attitude and positive health when you're dealing with patients with back pain and how you message that to your patients is really, really important. 

By finding things positive to relay back to your patients, it increases their self-esteem and gets them to continue on what you tell them to do. Showing them feedback is really key. 

And we use speedometers for our patients who have difficulty walking and they're asked to look at their speedometers and do a walk test every week for us. We use that as a very powerful way to demonstrate their walking ability has changed, their distance has improved, and this becomes a powerful reinforcement that their exercises are really helping them and they continue on. 

So we have a very good compliance rate and we attribute it to our approach, but also patients coming to our clinic know that it's not going to be easy and doctors would tell them. It's called a bootcamp program, so they know that they're in for some work.

Leslie:

Now, is there anything that we haven't addressed that you think is important for OCA members and other chiropractors to know about arthritis and treating patients with arthritis?

Dr. Carlo Ammendolia:

Just like you don't treat all your low back pain patients the same, don't treat all your arthritis patients the same. Tailor your treatment to the condition at hand looking at the physical, the psychosocial, and the functional. And try to match your treatments based on what you find clinically. These are key tips on maximizing your outcomes. And then do a thorough history or thorough assessment, document what you find, and then sit down and think about to approach this patient based on the things you find.

Try not to get into a rut because it's easy to do that where every back pain patient comes in or every arthritic knee or every arthritic hip that comes in you treat them all the same. You're not like they're going to get good outcomes if you treat them all the same. So tailor your program, personalize your approach, and you'll have better outcomes.

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Outro:

Thank you Dr. Ammendolia for sharing your expertise in spinal stenosis and other types of arthritis to help OCA members enhance their patient care of these conditions – as they continue to rise.

Thanks also for taking a deep dive in how to best assess a patient’s psychosocial issues, as well as their physical and functional, with tips and resources Ontario chiropractors can apply to strengthen their skill in these areas. 

We’ll be taking a break in December so you can enjoy your holiday season but we’ll be back with a new podcast on January 15th. 

I hope you’ll join us.

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