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My name is Max Buxton, and I am a family physician in the Ottawa Valley. Like many other primary care providers, I have at times felt overwhelmed by patients seeking help for depression and anxiety. The problem is not uniquely rural, but the lack of services available to rural patients provides an additional barrier to addressing the problem.
A relatively new service that I have found very helpful, and that my patients have come to appreciate is BounceBack.
BounceBack provides cognitive behaviour therapy through an online program, with the help of a coach who contacts your patient directly via phone or email, and guides them through a series of CBT exercises.
The program is funded by the Ontario Ministry of Health and requires a referral from a registered nurse practitioner or family physician.
Feedback from my patients to date has been universally positive, and it has given me something to offer people who may have no access to a psychiatrist, no coverage for psychologic services, and limited ability to travel.
The referral process is simple. Forms can be downloaded from bouncebackontario.ca, along with a brief screening questionnaire for the patient to complete. The referral can be faxed, emailed or submitted directly through some EMR’s. BounceBack has helped my patients with anxiety and mild to moderate depression. Maybe it can help your patients too.
By Dr. Aly Abdulla,
BSC, MD, LMCC, CCFPC, DipSportMed CASEM, FCFCP, CTH (ISTM), CCPE, Masters Cert Phys Leader
Medical Director The Kingsway Health Centre
FHO Lead Manotick Rideau River South BAPH
Assistant Professor The University of Ottawa Faculty of Medicine
Clinical Instructor The University of Ottawa Faculty of Nursing
Ottawa West LHIN Subregional Clinical Lead
I am a family doctor in Manotick in a 20 doctor Family Health Organization (FHO). I am also a sports medicine doctor so I receive many referrals for various musculoskeletal issues. The most common referral is for chronic low back pain (LBP). These patients don’t seem to get better with conventional therapy or after so many weeks. There is a consideration for an MRI and a neurosurgeon consult but the wait list is too long so they decide to send the patient to me. Many doctors (and patients) find this challenging.
But there is another option:
The ISAECS Interprofessional Spine Assessment and Education Program is a great resource in our community to manage these cases. In addition, they provide a robust educational program online (for patients and doctors) at your convenience to improve outcomes. Here are some highlights:
- Is your pain back or leg dominant?
- Is the pain constant or intermittent?
- What position makes it worse/better (flexion or extension)?
- What have you tried and failed?
- How disabled are you?
- The use of red flags (NIFTI guide for critical pathology),
- yellow flags or STarT Back (for risk of chronicity) and
- the Opioid Risk Tool (to prevent addiction).
The biggest benefit is the patient self-management and the CORE back tool home exercises.
The ISAEC program provides optimisation of conservative management including exercise prescription, education and advice, support and appropriate referral if needed.
Article reviewed: Timing of the decline in physical activity in childhood and adolescence: Gateshead Millennium Cohort Study
Mohammed Abdulaziz Farooq,1,2 Kathryn N Parkinson,3 Ashley J Adamson,3,4
Mark S Pearce,3 Jessica K Reilly,4 Adrienne R Hughes,1 Xanne Janssen,1
Laura Basterfield,4 John J Reilly1
It has been well shown in research and preached in our world community that physical activity is an essential component to well being. Studies show a clear dose-response relationship between increased levels of physical activity and associated health benefits. Canadian guidelines for physical activity including those for children and adolescents encourage participation in a variety of physical activities that support their natural development and promote their well-being. The Canadian guidelines for physical activity note that health benefits will be felt by children and adolescents who do at least 60 minutes of moderate to vigorous physical activity (MCPA) on a daily basis. General consensus in previous studies has suggested that as we grow up, physical activity levels decline. In particular, it is a common belief amongst those involved in healthcare that in adolescent years this decline was the most drastic and important to target. It was also believed that this decline was more serious in girls than in boys. This article assessed the validity of these perceptions by reviewing the literature on this topic and by performing a longitudinal cohort study to assess physical activity decline over time from age 7 to 15.
On review of the evidence, the authors concluded that there was insufficient proof that both total volume physical activity and MVPA declines with the onset of adolescence nor to prove that this decline is more marked in girls than boys. The main reasons for this were a lack of objective measurements in the previously done research, the amount of follow-up and the lack of present-day applicability of the studies, which were mainly done before the year 2000.
The longitudinal cohort study included 545 individuals from the Gateshead Millennium Study over 8 years of follow-up, from North-East England. The cohort was studied at ages 7, 9, 12 and 15 years of age to assess the progression of their physical activity in terms of habitual total volume of physical activity and MVPA. To do this, they used an Actigraph accelerometer to get objective measures over 5–7 day intervals at each year of collection. The analysis of the cohort was done by looking at a trajectory of physical activity to be able to assess whether there was a significant drop in adolescence. As well this trajectory method of analysis allowed the authors to identify subgroups within the cohort who may have had different changes in physical activity over time.
Four trajectories of change in terms of total volume of physical activity and four trajectories as well for MVPA were identified for boys. There was one trajectory of change in the total volume of physical activity and three trajectories of change in MVPA for girls. All of these trajectories showed a decline from age 7 to the age of 15 years old in all the participants. There was no evidence of a steep decline starting in adolescence for both total volumes of physical activity and for MVPA.
This study showed that in all forms of objective data that were used as measurements showed declines in physical activity from as early as age 7. These measures are commonly used in similar studies. In recent years, since the beginning of this study, there have been other studies that fit the conclusion of these findings. These other studies either did not include childhood or failed to prove the previously held belief that physical activity begins to decline at adolescence more rapidly and declines more rapidly in girls than boys.
The strengths of this study were its longitudinal design, the size of the cohort, the objective nature of its results and the fact that it represents a contemporary sample of children. The fact that this study was located only in the North-East of England makes it possible that different results may be found in a different cohort living in a different part of the world with different physical activity policies and perspectives.
In conclusion, the present study contradicts the currently held belief that there is a significant decline in physical activity in adolescence as opposed to earlier in a child’s life. The main implication of these findings is that current policy is not founded in evidence-based findings. Thus, there is a need for future research and change in public health policy with a greater emphasis on the child rather than adolescent physical activity, and on both for boys and girls. Specifically, healthcare professionals including primary care physicians may need to consider their focus on promoting physical activity in early childhood for both sexes.
Dr. Mickey Moroz M.D.C.M. CCFP
Sport and Exercise Medicine Fellow, University of Ottawa
Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (CAC SEM), Dip Sport & Exercise Med
The Province has rolled out new mental health resources that are proving to be very valuable in the Primary Care Sector. Many mental health problems present first in the primary care setting and Big White Wall and Bounce Back are evidence-based resources that will help support primary care patients on their path to recovery.
Big White Wall is a guided self-help peer community that supports the recovery of individuals with moderate depression and/or anxiety. The resource utilizes highly trained “Wall Guides” to moderate your patient’s experience and has demonstrated significant improvements for patients who have used the resource. While many publically funded resources have significant wait lists, this resource is immediately available to anyone with an Ontario postal code simply by signing up for the resource. Big White Wall is accessed directly by patients at https://www.bigwhitewall.com/v2/Home.aspx
Bounce Back is a coaching Intervention that is available through a Primary Care Practitioner’s referral. Developed in the U.K. and established in York Region two years ago, the program has been used by more than 80% of the physicians in the York region. Bounce Back will contact your patient within five days of referral and will deliver an intervention of telephone coaching sessions supported by workbooks developed for the patient’s specific goals. Your patient’s Telephone Coach will set up a schedule of sessions and will assess your patient’s risk and improvement at each session. Bounce Back will also link back to you to ensure the intervention is complementary to other treatment you may be providing.
You may access Bounce Back by visiting the website at http://ontario.cmha.ca/bounce-back-ontario/
Helping patients manage their pain is complex. To support primary care providers as they navigate this challenging landscape, partners across Ontario have come together to provide a one-stop spot for family physicians, nurse practitioners and other primary care clinicians to find resources to help manage their patients’ pain.
A range of supports – from guidelines on appropriate opioid use to CME-accredited webinars on topics like chronic pain – are included. Plus, access direct links to medical mentors who can provide timely advice and guidance on challenging care issues.
Resources are updated regularly and can be found at: http://www.hqontario.ca/Quality-Improvement/Guides-Tools-and-Practice-Reports/Primary-Care/Partnered-Supports-for-Helping-Patients-Manage-Pain
For more information about this coordinated approach to provide clinicians in Ontario with pain management resources contact: http://www.hqontario.ca/
Kien V. Trinh, Dion Diep, Hannah Robson
Clinical Journal of Sport Medicine, Volume 28, No. 4, July 2018
Currently, many sporting organizations including the International Olympic Committee (IOC) prohibit the use of any substance that has an ergogenic (performance enhancing) effect, poses a risk to the use of the user’s health and safety, or violates the spirit of sport. The legalization of marijuana in Canada is tentatively set for October 2018, which may increase the use and normalization of the drug. Thus, it is vital that primary care physicians remain up to date regarding the rules and regulations surrounding marijuana use, as well as its effects on users. Much of the literature points to marijuana being more of an ergolytic drug, where it impairs rather than improves one’s physical performance, stamina, or recovery. Despite patient beliefs that that marijuana use can improve their performance, it’s ergogenic potential remains poorly understood. The purpose of this study was to determine the effects of marijuana on athletic performance.
This systematic review included any primary study of any design of any clinically or laboratory-relevant outcomes on athletic performance. Studies included both male and female participants of any athletic background, between the ages of 18 and 65 with no other comorbid conditions. All studies used marijuana cigarettes for the intervention group and all studies utilized a control group (participants that were not given marijuana cigarettes). Vital signs, pulmonary measures, physical work capacity, grip strength, and exercise duration were chosen to be relevant outcomes. After identifying and screening 929 citation postings, only 3 trials met the inclusion criteria.
The effects of marijuana on heart rate, blood pressure and exercise duration remains unclear. Low-quality evidence exists for marijuana having an ergogenic on effect on exercise by inducing bronchodilation and increasing FEV1 after exercise compared to inactive controls. There was no significant difference in grip strength between treatment, sham and inactive control groups. Additionally, there is low-quality evidence that suggests marijuana use is associated with decreased physical work capacity compared with sham and inactive control groups.
There are several limitations to this study. Firstly, there were only 3 trials (one observational, one crossover, and one crossover randomized control trial) that met the inclusion criteria. When comparing these 3 trials, clear heterogeneity is noted between study type, intervention, and outcomes. Thus, no meta-analyses were performed. Furthermore, despite various available forms of consumption (e.g. edible, vaporization, tinctures, oils), all studies only assessed smoked marijuana as their treatment. There is a clear paucity of current research on marijuana and its effects on athletic performance. The banning of substances in competition is a highly debated and ever-changing field. With its legalization in Canada looming, further research is warranted on marijuana and its effect on athletic performance to help investigate and justify current and future doping policy.
Sean Mindra, MD, CCFP
PGY3 – Sport and Exercise Medicine, University of Ottawa
Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine
Please note that due to unforeseen circumstances, the Lung Cancer Screening and Smoking Reduction and Cessation conference planned at the Renfrew Groves Park Lodge GEM Hall on Thursday, February 22, 2018 is being postponed. Please stay tuned for a new date and time to be announced.
Champlain Regional Cancer Program Presents: Lung Cancer Screening – An Interactive Learning Event
POSTPONED: Thursday, February 22, 2018 6:00 pm—8:00 pm
(Buffet Diner and Registration will start at 5:30 pm)
Groves Park Lodge GEM Hall 470 Raglan Street North Renfrew, On. K7V 1P5
Register online Now!
For more information contact: firstname.lastname@example.org
or dial: 613-798-5555 x 15811
This program has been accredited by the College of Family Physicians of Canada and the Ontario Chapter for Mainpro+ credits.
Please share poster: Lung CME Poster2
Don’t have to see it to believe it – The Effect of Magnetic Resonance Imaging Scans on Knee Arthroscopy
Don’t have to see it to believe it:
The Effect of Magnetic Resonance Imaging Scans on Knee Arthroscopy: Randomized Controlled Trial Arthroscopy. 2007 Nov;23(11):1167-1173.e1
Multiple pathologies of the knee cannot be picked up on x-ray and ultrasound. Increasing prevalence of MRI has led to increased use. We as physicians may not see the bill for these investigations but they are still a considerable expense for our system. Due to long wait times, the National Health Service (UK) has started to perform MRIs to try and reduce the number of patients that will actually require surgery while in the US, they are questioning whether MRI will actually add value.
A randomized control trial was performed using 252 patients on a waiting list for knee arthroscopy. All patients had an MRI of their knee performed. They were then randomized into two groups; one had their MRIs read by their surgeons prior to surgery and the other did not. Even though the group whose MRIs were read had a diagnosis change in 47% of cases, compared to 1% in the control group, ultimately, the rate of surgery was the same.
Important to highlight that this is American data and they may be more likely to proceed with arthroscopy than their Canadian colleagues. Important to note that a diagnosis change occurred in 47% meaning information from MRI was still of value.
Take away message to consider: Don’t wait for an MRI report to refer to orthopaedics because it is unlikely to change the management plan in patients you suspect will require arthroscopy but still order the MRI as it can provide valuable information for operative planning.
Anthony Caragianis, PGY3
Advisor Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med
The Champlain Regional Cancer Program is pleased to share with you our evening Education Opportunity in January for Primary Care Providers. Please see poster and feel free to send to anyone in your organization.
Breast Imaging Update 2018
Featuring Dr. Jean Seely and Dr. Erin Cordeiro
Wednesday, January 24, 2018
The Ottawa Hospital – General Campus
Critical Care Wing Room 5225
Register online Now!
For more information contact Champlain Primary Care at 613-798-5555 x 15811 or email@example.com
CME Certified Fall Prevention module
In a cross Canada review, there were few certified Fall Prevention programs targeted towards Primary Care physicians and their healthcare professional teams. Dr. Frank Molnar, Geriatrician, and his team have changed that! The Champlain Fall Prevention Steering Committee, Dr. Molnar and the Regional Geriatric Program of Eastern Ontario have worked together to deliver an interactive Fall Prevention module which utilizes the Champlain Fall Prevention tools. This online group learning program meets the certification criteria of the College of Family Physicians of Canada and has been certified by the University of Ottawa’s Office of Continuing Professional Development for up to 2 MainPro+ credits.
The sequential modules focus on education, client self-screening using the Staying Independent Checklist, and delivery of the appropriate and evidence-based follow up assessment and diagnosis to determine the root cause of the fall. Selecting the right intervention and referral is also covered in the module.
A complement to this CME program includes access for non-registered health care workers to an online PSW Fall Prevention module. It can be useful for volunteers, receptionists and other non-registered team members as it provides information to enable them to act as a coach and guide for their older clients and to understand the importance of self-screening and the use of the Staying Independent Checklist as part of the Champlain Fall Prevention Algorithm.
These two modules are components of the Fall Prevention education framework to reinforce the delivery of the best practices in Fall Prevention across the continuum. Work is now being undertaken to provide other registered healthcare professionals with similar support,
All of these resources and the link to sign up for the CME module can be found through the www.stopfalls.ca website