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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6032_Библиотеки_им_академика_М_И_Перельмана
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dynamic patient-provider interaction through the unique blending of multiple
disciplines (Figure 1). Committing to this process can be uncomfortable to
those cultured in the biomedical hierarchy of command and control
biomedical management.
The transdisciplinary care model requires dynamic interaction among a
variety of disciplines, thus enabling the exchange of information, knowledge,
expertise, and clinical skills necessary to team-based problem solving. This
approach is gaining traction in other healthcare milieus such as oncology and
nursing. Although more studies regarding its implementation are needed,
transdisciplinary care has been shown to contribute to both clinician
satisfaction and a favorable patient experience in a biopsychosocial
functional restoration program.
45
Structurally, a transdisciplinary model is inherently patient-centric,
heterarchical, and integrated. Through direct connection with any one
provider, the patient has connectivity to the entire system, as does each
provider (Figure 2). Although sensitive to best-evidence practice guidelines,
it allows clinicians to adapt to a patient’s needs. At the same time, however, a
transdisciplinary milieu is self-policing through interprovider accountability.
Importantly, this requires clear prospective group agreement regarding the
sometimes difficult process of conflict resolution.
Transdisciplinarity need not apply only to patient care; it can potentially
enhance clinical administration with positive effects for patients and
providers from initial contact to discharge and subsequent care. For example,
patients may freely make comments to nonprovider staff members that could
prove critical in ways that exceed the classic boundaries of patient-provider
interaction. A systemic approach recognizes the perceptions and input of all
individuals involved in the process of clinical care, including administrative
personnel such as receptionists and schedulers.
Figure 1
Illustration demonstrates the transdisciplinary
administrative, clinical, and surgical integration and
summation effects.
Figure 2
Illustration demonstrates optimal transdisciplinary team and
patient integration.
Foundations of a Transdisciplinary Team
The concept of transdisciplinarity has received considerable attention outside
the realm of spine care. One study stresses the Institute of Medicine’s
recommendation for healthcare teams as a key step toward improving the
quality of care and cogently characterizes the process and structural
differences between multidisciplinary, interdisciplinary, and transdisciplinary
functions. It is noted that “the multidisciplinary model involves vertical
communication from supervisor to subordinates, with each member
contributing an assessment after applying a discipline-specific skillset (with)
little discussion between team members (that) the interdisciplinary model
acknowledges the overlap in knowledge of (team) members and facilitates
horizontal communication at many points in the (evaluation and care process)
and that the transdisciplinary model of care takes collaboration to a still
higher level, incorporating ongoing cross-disciplinary education (and)
regulated overlapping roles.”
46
Best-evidence practice guidelines help to define key players in a
transdisciplinary approach to cervical spine disorders. Spine-specialized
neurologic and orthopaedic surgeons, physiatrists, physical and occupational
therapists, chiropractors, interventional pain specialists, psychologists, nurse
practitioners, physician’s assistants, and registered nurses contribute the most
fundamental elements of a clinical team; however, vocational rehabilitation,
social, and even lay community members can enhance care strategies in the
broader context of biopsychosocial spine care and disability management.
Viable transdisciplinary teams require healthcare providers to work across
historic boundaries and processes; without doing so, care coordination will
ultimately degrade. The chaordic approach to business management28 is
based on foundational principles that have been characterized as the Six
Lenses on Organization47 (Figure 3). Effective transdisciplinary teams are
created and sustained using these concepts. Without leadership dedicated to
these concepts, individual or discipline-specific agendas will invariably
undermine an integrated care milieu.
Transdisciplinarity in Biopsychosocial Care
The education of medical students in the biopsychosocial care model has
lagged substantially behind that of biomedical interventions.48 Given their
broad reach, effective transdisciplinary programs also require a commitment
to biopsychosocial patient care. Psychosocial factors are critical to the patient
experience and can be addressed at virtually every level of patient interaction.
Best-evidence advice that most imaging findings are benign and reassurance
that normal activity is not injurious will improve outcomes. When repeated
across multiple patient-provider interactions through transdisciplinary team
care, the effect of such advice is compounded and powerfully supports active
care strategies.
Depression, anxiety, catastrophizing, fear-avoidance behaviors, and other
psychosocial stressors have a well-established correlation with axial pain and
the progression to chronic pain and disability. Early risk recognition and
psychosocial interventions are facilitated in an environment of cross-trained
providers. Routine clinical interventions such as addressing fear-avoidance
behaviors during exercise and stability training, discussing emotional distress
at medical reassessments, or talking about passive treatment dependency
during chiropractic follow-ups can supplement structured mental health care.
The Benefits of Transdisciplinary Triage and Care Access
Accreditation and reimbursement are increasingly tied to access and patient
satisfaction. Balanced against value propositions, it is critically important to
optimize patient access to the providers or groups of providers who can most
effectively initiate and coordinate evidence-based spine care. Patient
preference also has been shown to affect satisfaction and outcome. More than
any single discipline, transdisciplinary care teams have greater flexibility to
meet the preferences and clinical needs of patients with neck disorders.
Figure 3
Illustration of the Six Lenses on Organization Chaordic
Design Process. Purpose is a clear statement that defines
and binds the community in worthy pursuit. Principles are clear,
commonly understood statements reflecting how participants conduct
themselves in pursuit of purpose. Participants are the group that
defines just, equitable, and effective relationships that all can trust to
achieve purpose in accordance with principles. Organizing concepts
are activities and process trusted as equitable, effective, and in
accordance with organizational purpose and principles. The
constitution is the codification of participant rights, obligations, and
relationships that forms an organizational entity. Practices are
activities, products, or services through which participants pursue the
organization’s purpose and create value.
A small percentage of patients with acute or first-episode cervical spine
disorders are likely to experience chronicity; therefore, early identification of
risk factors is critical. In a transdisciplinary model, screening for prospective
disability risks facilitates broader care coordination with employers and other
stakeholders.
49
Information technology can facilitate patient triage. Potentially serious
pathology, including red flags, psychosocial yellow flags, and patient
preferences, usually can be identified initially via a skilled telephone
interview (conducted by a registered nurse or equivalent professional) and/or
other preclinical mechanism. For patients with complex issues (for example,
serious comorbid health status, third-party liability claims, debilitating pain
with current work absence), preappointment telephone triage performed by a
nurse can inform clinical assessment while reducing both the amount of
waiting time before coming to the clinic and the length of the consultation
session.
Initial clinical evaluation by well-trained nonmedical spine specialists is
acceptable to patients.50 Evidence shows that most patients with acute neck
pain will respond favorably to basic care such as NSAIDs, muscle relaxant
medications, manual therapy, and postural and relaxation training. Early
access to providers of nonmedical spine care can reduce time to evaluation
and provide timely care. Nurse practitioners, physician assistants,
chiropractors, and physical therapists can hasten the identification of patients
with red flags that warrant early evaluation by a spine surgeon.
Transdisciplinary Clinical Assessment
The flexibility of the transdisciplinary model allows a range of clinical
assessments from targeted to comprehensive. Most patients present with axial
neck pain and stiffness in combination with dysfunctional stabilization
mechanics, postural faults, and lifestyle factors warranting functional
treatment and rehabilitation.
In the absence of red flag indicators or recent trauma, routine imaging
studies are not likely to inform treatment. Both standard and advanced
radiographs show a high prevalence of age-consistent degenerative findings,
which are poorly correlated with axial neck pain.51 However, treatment risk
and benefit considerations vary by discipline, and transdisciplinary
consideration should be given to imaging studies to address indications or
contraindications (for example, the appropriate level for an injection or
osteoporosis for spinal manipulation) or in the absence of projected
improvement after an initial course of care.
Best available scientific evidence generally does not support more than a
temporary effect with any stand-alone treatment, although treatment of pain
and stiffness can ease early rehabilitation and reactivation. Although
medication, interventional procedures, and manual therapy have specific
uses, unattended functional deficits such as motor control and stability
dysfunction or work exposures likely will result in recurrent or progressive
neck problems. In a transdisciplinary care setting, functionally oriented
physical and occupational therapy evaluations are critical to rehabilitation,
and include behavioral modification, targeted exercise (for motor control,
flexibility, and strength training), and positive lifestyle changes.
Standardized screening tools can inform clinical care.52 For example,
expert reassurance and guidance help modify behavioral barriers such as fear
avoidance or active endurance during routine follow-up care. However, in
more difficult cases, psychologic assessment should be considered based on
the input of a team member at any time during the patient’s clinical course.
Transdisciplinary Care Planning and Coordination
Synthesizing a treatment plan requires communication. In the
transdisciplinary setting, EMR systems afford virtual interprovider
communication, although real-time staff consultation should occur at the
discretion of any provider during the patient’s clinical course.
Based on discipline-specific training or experience, factors such as new
symptoms, findings, or patient noncompliance may become apparent to
certain clinicians before others, and the ability to confer and respond can be
critical. Variation between team members’ recommendations for treatment
and care must be addressed and resolved early and continuously. Because of
a lack of superiority of any single treatment approach, the transdisciplinary
model is well suited to communication and timing, and treatments can be
uniquely tailored to meet the evolving needs or preferences of patients.
Although further research is needed, concurrent treatments may be
complementary in the continuum of care. For example, neuromotor and
stabilization training can be limited by pain and stiffness, which can be
reduced through manual treatment and/or interventional pain procedures.
With transdisciplinary care emphasizing clinical interventions to support
functional rehabilitation, patients and providers must remain open to
alternative options in the absence of improvement, including cessation or
alteration of treatment.
In cases refractory to active care, referral to a chronic medical and
psychologic pain specialist may be necessary; however, evidence suggests
that integrated care in a biopsychosocial model shows promise in reducing
the incidence of disability from chronic pain and related work absence.
53
Transdisciplinary Clinical Care: Case Examples
These case examples are vignettes based on actual cases presenting to an
integrated academic spine center.
Case Example One
A 39-year-old woman employed as an oncology nurse reported a history of
neck pain and stiffness dating back to childhood. Team evaluation was
initiated at the recommendation of her primary care physician. Her work had
not required stressful lifting or patient transfer, and she had no history of
recent or remote neck or shoulder injury. Within 2 weeks preceding her
baseline visit to a primary care physician, radiating right arm pain suddenly
developed with distributed numbness from the right shoulder to the right
dorsal midline forearm and hand. The primary care physician prescribed
opioid analgesics and oral corticosteroids, without recommendation for
follow-up.
Within 1 week of the evaluation by her primary care physician, she
presented with improved symptoms, including decreased axial pain and
arm/hand numbness and tingling. Physiatric evaluation confirmed positional
aggravation of neck pain and right arm paresthesias without evidence of
ipsilateral peripheral neuropathy or neurologic deficit. Imaging was deferred,
and the patient was advised to continue taking the prescribed medications and
follow up with a physician assistant in 2 weeks. The patient was encouraged
to continue with her usual work and basic daily activities.
Within the next week, she presented for same-day physical therapy and
chiropractic evaluation after completing her course of oral steroids. In
addition to painful neck stiffness and poor deep neck flexor recruitment, the
physical therapy evaluation demonstrated dysfunctional axial, glenohumeral,
and scapulothoracic motor control, with grade 4/5 right elbow flexor and 3/5
serratus anterior weakness.
Chiropractic consultation confirmed the patient’s history of first-time arm
symptoms and an absence of any recent severe or atypical headache, vision
change, facial numbness, contralateral upper or lower extremity
pain/paresthesia or weakness, or incipient bowel or bladder dysfunction.
Obstetric history was para 3, gravida 3 with a history of antepartum low back
pain without symphalgia. The patient acknowledged a long-standing history
of nonlimiting, intermittent, and consistently mild episodes of low back pain.
Although able to continue basic daily activity and work (10-hour work days),
the patient reported worsening pain and a sense of global right arm heaviness.
Examination confirmed an otherwise healthy-appearing, alert, oriented,
and articulate middle-aged woman in modest distress. Sitting and standing
postures were slumped with the head/neck in anterior and slightly left lateral
weight bearing. Lumbar lordosis was exaggerated with poor lower abdominal
tone and dysfunctional axial stabilization mechanics. A costal breathing
pattern was present with asymmetric right scalene group and multilevel
segmental cervical/thoracic tenderness and low-grade cervical extensor
spasm.
Neck motions were limited to greater than 50% in extension and right
lateral bending because of immediate provocation of radiating arm pain and
paresthesias extending to the right dorsal forearm and hand, which was
consistent with a positive Spurling test result. Flexion was comparatively
well tolerated with adequate lordotic reversal. The Lhermitte sign was absent.
Anterior neck examination was remarkable for right supraclavicular fossa
tenderness and increased right arm pain and paresthesia on plexus
compression. No palpable cervical adenopathy was noted. Examination of the
right shoulder showed asymmetric shoulder internal rotation and extension
motion deficit without evidence of cuff impingement or labral compromise.
Right scapular dyskinesis was evident without gross scapular winging.
Comparative neurologic evaluation showed interim onset 3-4/5 right
biceps, triceps, and wrist flexor muscle weakness, decreased sensitivity to
pinprick in a right C6-C7 distribution, bilateral lower extremity hyperreflexia,
and bilateral Hoffman responses. Muscle bulk and tone of the arm and hands
was grossly normal. The Tinel sign was absent at the right elbow and wrist.
Finger escape, crossed adductor response, and clonus were negative, and gait
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