GSCI Researchers and Cross Lake Clinicians present at Chiropractic Rounds webinar in Saskatchewan

Last month, researchers of the Global Spine Care Initiative and clinicians at the new World Spine Care clinic in Cross Lake, Manitoba, were honored to present a webinar for the Chiropractic Rounds offered by the Chiropractors’ Association of Saskatchewan. Dr. Mark Labrecque hosted the webinar and invited Dr. André Bussières, the GSCI implementation project lead, to conduct the rounds.

The presentation was titled "Reducing barriers to conservative spine care to minimize opioid exposure in the Northern Indigenous Community of Pimicikamak, MB, Canada: A Global Spine Care Initiative and World Spine Care Canada Implementation Project." The research team highlighted the objectives, methods, initial findings, challenges, and future steps of the project. Funding is made possible through a grant from the Health Canada Substance Use and Addiction Program, the Canadian Chiropractic Association, the Canadian Chiropractic Research Foundation, and the Skoll Foundation. The goal of the project is to develop and implement a model of spine care that can reduce opioid usage and improve health outcomes in underserved communities. The discussion also covers cultural context issues, implementation research, community engagement, and capacity building.

Dr. Scott Haldeman, founder and president of World Spine Care, who was born in Canada, began the meeting with an acknowledgment of the Indigenous peoples of North America and later gave an overview of the Global Spine Care Initiative.

Dr. Jean Moss, CEO and president of World Spine Care Canada, introduced the charity and gave a background on its origins, mission and vision, and current clinical projects. Dr. Bussières then introduced the research project and methods.

Dr. Jennifer Ward, an Indigenous chiropractor practicing on the Opaskwayak reserve and Ph.D. student at the University of Manitoba, shared the initial results of the research project, which involved a chart review, community health survey, and qualitative interviews with stakeholders and members of the Pimicikamak band.

Dr. Steven Passmore, co-project lead and professor of Kinesiology at the University of Manitoba, further discussed the findings of the community health survey, which evaluated the presence of spine pain in the community, current approaches by healthcare providers and community members to address spine pain, and their preferences for treatment.

Nicole Robak, Ph.D. student and senior research assistant at the University of Manitoba, continued the presentation with the results of interviews with leaders and clinicians.

Jacqueline Ladwig, a Ph.D. candidate at the University of Manitoba, described a Community Movement Program she developed to encourage inclusive movement based on traditional dance. The program involves group classes held in the community and online video instruction.

Dr. Patricia Tavares, Director of Clinics for World Spine Care, detailed the GSCI triaging system that helps determine a classification based on symptom severity and recommends appropriate intervention or referral.

Dr. Melissa Atkinson-Graham, a chiropractor and anthropologist now residing in Cross Lake, provided an overview of the spine care service offered to members of the community.

Dr. Deborah Kopansky-Giles then reflected on the challenges & opportunities the team has experienced while conducting the research project and combining Western traditions and Indigenous ways of knowing.

Dr. André Bussières then closed the presentation by explaining the anticipated outcomes of the research project.

The panel then addressed questions from the ~100 attendees before the meeting concluded.

Dr. Mark Labrecque generously made the webinar recording available to World Spine Care. Watch the video above or on the World Spine Care YouTube channel.

Show Transcript

André Bussières: It's really my pleasure to be, um, able to present today and along with my colleagues on a project that we've been working on for a number of years now that's very exciting. And it's called, or entitled, Reducing Barriers to Conservative Spine Care to Minimize Opioid Exposure in Northern Indigenous Community of Pimicikamak, Manitoba.

This is the World Spine Care Canada and Global Spine Care Initiative implementation project, and as you can see, there are quite a number of team members that we are fortunate to be working with. We have no conflict of interest to declare, and we will. provide the acknowledgement for the funding received toward the end of the presentation.

I will first ask Dr. Scott Haldeman to provide the land acknowledgement. Scott?

Scott Haldeman: Thanks, Andre. We would like to acknowledge that people are joining us from all across the lands of Turtle Island. We respectively acknowledge that the Saskatchewan Health Authority, where these chiropractic rounds are taking place, are located in Treaty 2, 4, 5, 6, 8, and 10, and are the traditional territories of the Anishinaabeg, Cree, Oji-Cree, Assiniboine, Dene, Saulteaux, Dakota, Nakota, and Lakota Sioux, the Blackfoot people, and the Metis Nation.

We would also like to specifically acknowledge the Cree in Treaty 5 on which these lands, uh, lands, these, this research was conducted. The University of Manitoba, where our data is housed, is in Treaty 1 territory, the traditional lands of the Cree, Oji Cree, Dakota, and Dene peoples, and the homeland of the Red River Métis.

We give thanks to the indigenous people who continue to protect the land, water, and resources. We recognize that systemic racism and contemporary colonization contributes to the current inequities experienced by Indigenous people in Canada. And with great humility, we dedicate ourselves to work towards reconciliation.

Although I now reside in California. I was born in Treaty 4 Territory in the city of Regina, Saskatchewan. My grandmother was the first chiropractor in Canada and practiced in Herbert, Saskatchewan, and my father also practiced in, uh, Regina, Saskatchewan.

Andre.

André Bussières: Thank you so much, Scott. And thank you to everyone for attending and making time out of your busy schedule. I will be introducing a group of 10 people who are presenting on behalf of the entire team today. This is a bit of a tag show, so, um, please bear with us. We'll be, I'll be chairing and making sure the slides are moving forward.

Um, so first, the background will be presented by Jean Moss for World Spine Care and World Spine Care Canada. We will then hear from Scott for the Global Spine Care Initiative. I'll be covering the methods that are used to do this research and a resource section will be provided for the baseline data for the chart review by Jennifer Warren, followed by community health survey that Steve will talk about.

A glimpse at the interviews we've conducted with leaders and clinicians at Cross Lake. Nursing Station. We will also hear from Jackie, who will provide some information on the community movement program that was designed. Patricia will cover the GSCI triaging system that is being used for the new clinical service that Melissa and Jennifer are delivering.

And we will hear from Deborah to provide some insight and opportunities and challenges with regard to this project. So without further ado, Jean, if you'd like to take this away.

Jean Moss: It is lovely to be back in Saskatchewan. It's been a long time and I miss seeing many of my friends from Saskatchewan. You may not have heard of World Spine Care, but I know you've heard of Scott. And, uh, this all started when Scott and his wife Joan were on a visit to Botswana and South Africa, which is where Scott grew up.

And, uh, it became very clear to them that there was a desperate need for underserved areas of the world to have access to evidence based spine care without financial barriers. Underserved areas are often remote and rural with a population heavily dependent on manual labor. But not always. If you look around in the area in which you practice, whether it be city or rural, you will probably also find areas that are underserviced.

And maybe you can do something about that. Um, Scott and Joan worked hard talking to government and local health professionals, and in 2008, World Spine Care opened its first clinic in Shoshong, Botswana, which is a very small, uh, rural village. The second clinic opened shortly afterwards at Mahalapye District Hospital.

Mahalapye is a larger town and it has a well established hospital. Botswana was a good site for the first clinics because it has a democratic elected government, little corruption, a universal health system, and it's relatively safe to send volunteers to. In 2011, World Spine Care Canada was formed and a clinic was opened in Moca in the Dominican Republic.

You might ask why the Dominican Republic? Well, we already had contacts there because UQTR and CMCC had been sending students there for a number of years, um, for short to enhance, for short periods of time to enhance their clinical experience. And then in 2015, uh, we were approached by Adam Wilkey from England, and he was interested in creating a World Spine Care Europe.

And with the help of Margareta Nordin, who I'm sure many of you have heard of, uh, she was one of our founding members. A clinic was established at the Mahatma Gandhi University in Mumbai, India. They also look after a clinic in, uh, Accra, Ghana. We are now three organizations, um, Incorporated within our own jurisdictions as not for profit charitable organizations with a common vision and mission and we work together very collaboratively.

Our mission is to work with local and national governments to develop clinics that are evidence based and follow the clinical protocol developed by the Global Spine Care Initiative, the GSCI. which is the research arm of World Spine Care. Our organizational values are to provide consistent care without financial barriers in a su in a sustainable environment sensitive to the local culture.

Also to educate the local community and local healthcare workers to give preventative advice to patients. And finally, obviously if Scott's involved, there's research going to be in there somewhere. Our organization is run by volunteers, other than a couple of part time individuals who are very important to us.

The clinics are also managed by volunteers. And those volunteers, um, will volunteer for a full year, which is a, just a huge commitment. Uh, we have gone a little, uh, yeah, here we go. No, we've gone too far. Can you go back one slide, please? Oh, okay, the slides have got out of order. Okay, that's fine. Uh, what we have here is the clinics, the two clinics, uh, that are run by World Spine Care Canada.

And on your left is the, is the third clinic in Botswana. It's in the capital city of Haperone. And the two people here are, um, Mfudzi, Chim, Chihima Bakwe, and his assistant, Okun Betse. Um, and also we have the clinic in the Dominican, um, and, uh, you can see it's within, uh, another clinic, another charity that is run, that provides physiotherapy care.

These are our first two clinics. The one here on the right is the one in Shoshong. This is the building or mobile temporary building that the government supplied for us. And here you have Joan, Scott, Mufudzi, and the current volunteer. who is Michael Pretorius. And then we have a picture of the Mahalapye Hospital with Michael and his assistant there as well.

And this is the new nursing station in Cross Lake. And Cross Lake is where this research project is taking place. As soon as this nursing station is completed, we will be moving into that station with the chiropractic office. And up until now, we are in temporary, a temporary location. Um, but that will be changing, we hope, soon.

Um, and just before we move on, there's a couple of things I just want to say. Um, World Spine Care is an organization. It's very small, uh, but I think you can see from the research we've done that it hits way beyond its weight. It is run by volunteers. Very little, uh, help that's actually paid for. Thank you.

And there are two truths. One is that we're always looking for volunteers. The other is that we're completely dependent on donations and we're always deeply appreciated. Every penny of support that we get. I now pass you to Scott.

Scott Haldeman: Thanks, Jean. I'm going to pop through these slides really fast and try and explain why we're here. Why is it important for us to be in Cross Lake, and how did we get here, and what is it all about? Uh, so let's start. Why back and neck pain? Why related disorders associated with it? low back pain now, for those who don't, haven't seen this already, is the number one cause of disability worldwide.

And neck pain is the number four, cause, leading cause of disability worldwide, with some variation, depending on year to year. The problem is that disability disproportionately impacts women. The elderly, rural communities, the lower income community, quintile of the population in lower income countries, according to the World Bank on Disability.

The question then is why are we talking about opioid prescription and disorders, which is part of this, the research study, uh, almost 23, 000 Canadians died over a five year period, according to, to, um, Health Canada, and in 2018, uh, the Community Health Survey showed that twelve point seven percent of Canadians over the age of 15 reported using prescription or non prescription pain medication containing opioids in the past year.

Opioids, by themselves, is the number one, is prescribed primarily, uh, for low back pain. Low back pain is the number one indicator for prescribing opioids with 50 percent of users. And neck pain is number four, 17 percent of users, at least in the United States. If we look at burden of spinal of disease, all diseases in the, uh, in Canada, and this is from the Institute of Health Metrics and Evaluation number two is low back pain, number three is musculoskeletal, and number four is drug use disorder. Neck pain is also in this high, in this list. Uh, and so now we talk about why do we have a Global Spine Care Initiative and what is it? This was an initiative by World Spine Care that we established to develop an evaluation of an innovative integrative model of care to improve the management of spinal disorders with the goal of reducing all of this disability and burden disease we've described.

It was done by 68 spine care experts from 24 countries and published in 19, uh, 15 articles in a, in a journal in the European Spine Journal. The methodology was a literature review on all the literature on assessment, non invasive management, invasive management, psychosocial management, public health, and interventions for serious red flag disease.

And then we did a, uh, consensus, three round consensus Delphi study. At the end, we gave the recommendations and developed a model of care. Anybody who wants to look at these more fully should, uh, read the, uh, go to the World Spine Care site and you will get it. Uh, they're open access, and, uh, Pat will discuss this in further, uh, in her presentation.

The question then, is there any basis for the hypothesis that non pharmaceutical spine care can impact opioid disease? In other words, are we just drawing this out of the blue, or is there some basis for this? Well, I've been fortunate to be involved in a series of research projects, and there are a number of other papers.

Here's four of them. There's a non pharmaceutical spine care has been shown to be associated with less opioid prescription and less adverse drug events, increased satisfaction of care and reduced costs. And you can check these articles and get some of the data. It has not been shown that spinal manipulation or non pharmaceutical care actually prevents it. That's what we're trying to look at, but it is associated with this less impact of, um, opioid prescription.

So why Cross Lake? Well, Health Canada has shown in their report in October 2020 that Indigenous people in Canada and the U. S. experience higher incidents of pain and pain related disability than the non Industrial population.

An age standardized rate of opioid poisoning, hospitalization of First Nations individuals living in reserve is 5.6 times higher than the rate among non Indigenous population. This led to the question which we're going to discuss here. Is it possible to minimize opioid prescription and usage by reducing barriers to an evidence based spine model of care in an underserved community?

This is the basis for our Cross Lake First Nations study. Thanks, Andre.

André Bussières: Thank you so much, Scott. So it's my pleasure to introduce the methods by which we're aiming to address some of the questions, and, um, some of you might be familiar with the Medical Research Council Framework on Implementation and Evaluation.

Essentially, our work is mostly in the center where there's a core element, where we need to consider context, obviously, and culture. We have, um, based from the work that Scott and others have done, developed a program theory, in other words, a model of spine care along with triaging and care pathways that we're looking to implement and see ready, you know, whether it is, um, possible and to implement within a community that is remote and, um, Whether there's an important need for spine care.

To do so, we have first engaged with the community over a two year period, identified key uncertainties or potential challenges, and further refined the intervention, and of course, cost needs to be considered. So this This model is what we're following basically to sit our study within and test the feasibility and measure some of the outcomes.

Our main objectives for this Phase 2 study are to evaluate the readiness to implement the GSCI model of spine care in the Northern Community of Cross Lake Manitoba from the perspective of the stakeholders. First, we're looking to confirm the nature and the extent of the spinal pain impact on individual within the community.

We are also concerned whether it is possible to culturally adapt a model of care based on the implementation of barriers and facilitators that we're identifying, looking to measure perceived value of the implementing the model of care and estimating the extent to which stakeholders will support and engage throughout the entire study.

This is also linked to the third phase of this program, which is to evaluate the feasibility to implement the model within the community. We're therefore measuring potential for integration into the community based care program that includes basically two main services. One is the clinical service– that only started recently in October, on October 5th– as well as a community movement program that Jackie will describe later. And of course, we want to measure the potential impact of the individual receiving care and the community at large. To do so, we're using a mixed method approach, meaning that there's qualitative and quantitative assessment using a participatory approach where stakeholders, clinicians, leaders in the community and the people extremely important in guiding the research.

This is a stepwise approach to prepare implementation and assess current spine care status, identify potential theoretical pairs and facilitators, to uptake and to plan and design tailored implementation solution we will be able to test in the future studies. For this particular study, we're looking to include adults that are over the age of 18 with spine symptoms or concerns that live in Cross Lake and will include, therefore, community leaders, clinicians, and residents.

We're using a number of different tools to be able to capture the information, including a chart review Cross Lake Nursing Station before and after the implementation. A community health survey will give you results of today, adoption questionnaires looking at the acceptability, appropriateness, and feasibility of the model of spine care in this community, as well as a qualitative interviews and focus group of clinicians, leaders, and residents.

This framework provides an insight into the structure of the study. First, using the GSCI model of spine care classification system and care pathways, thinking of implementation strategies that would be used to improve or increase the likelihood of uptake of the model of spine care within the community, using a range of strategies that will target Decision makers, de engagement, extremely important, and this is ongoing.

Local clinicians and community health workers, where we're providing insight into the program. We've had webinars and, um, as well as on site training. We've designed some tools to be able for patients to questions and determine whether they need to see care. The community movement program I mentioned and several outcomes are being measured.

Implementation outcomes such as feasibility, acceptability, Service outcome, number of patients seen, number of new patients, and number of treatment delivered, looking as well as client outcomes or patient outcomes of pain, function, disability, and quality of life, and really to determine whether it's adequate to use these type of tools to be able to measure pain.

And Jennifer will talk to us more about this later.

So Jennifer will now walk us through the initial phase of the results. Jen?

Jennifer Ward: All right. Thank you, Andre. And, um, thank you all for being here tonight. It's great to see such a, um, so many faces that, uh, are on the chat, are on the, uh, photos to see all the people that are present that are here. So thank you for attending.

Um, we're going to go through now the three components of the, um, first part of the study that we've been doing. So I'll speak about the chart review that is being done at the nursing station. Um, that started in November. 2022, and we finished it in April 2023. Um, Steve will go on to talk about the Community Health Survey, and then we will also, Nicole will present the qualitative interviews.

And I just want to point out that those, uh, faces and those photos are not, uh, patients or clients. Those are us and our team. So, uh, We didn't, uh, so we have permission from everybody, everybody to present those photos here. You're going to see a lot of photos throughout the presentation, just to really give you a sense of the, uh, participation and in participatory action research it's really important to speak with all the stakeholders involved. And so you'll see lots of photos through the presentation. So it'll give you a feeling of, uh, of being in Cross Lake or being in Pimicikamak. Um, so when you're working with Indigenous people, positionality is very important, and so I include this slide here so you know who I am and where I come from.

I'm Indigenous, I'm Mi'kmaq from New Brunswick, and I've lived and worked in Treaty Territory, uh, number 5 at Opaskiak Cree Nation for the past 20 years, and then I've been involved in this project, um, since about 2021. So today we'll talk about the, uh, the chart review, and I just want to point out at the beginning that these are preliminary findings that we have done the research, but like I said, that we're going to be, we're in the process of communicating with the community to really understand and put these findings in a cultural context so that we We can say for certain that this is our understanding of what is going on.

So these are preliminary findings. We're still in that consultation phase, so bear with us, but we'll get to that point. So the study aim was to describe the current care provided to adults who are presenting at the nursing station with MSK problems. And so in Manitoba, an adult is 18 and plus. The methods that we used was a retrospective chart review, and we looked at adults that were presenting to the Cross Lake Nursing Station in the past year, and then we had to contact those patients, um, and get consent to look into their chart.

So we were able to provide, we were able to get them to provide consent for that. And then, I looked through all of the charts. I looked through about a hundred charts to be able to get, uh, the 41 that we actually were, was able to get all the data extracted. And then we used a 14 instrument data extraction form that was on a iPad.

And then I was able to like go through all of the pieces in the chart and sometimes that involve like flipping back and forth and trying to. um, go back and forth from the MRI information or the x ray. And then we came up with the list of results here. This is a very busy slide, so in the next couple of slides I'm going to summarize it.

But you can see here from this slide that all of the categories that we looked at are on the left and then a summary of the results are in the column beside it. Um, so some of the key findings from all of the results are part of the analysis and, uh, What we found was that the leadership and physicians in Cross Lake have made amazing policy changes to limit the amount of opioids that are being prescribed to patients in Cross Lake and to patients with MSK, so they make up 21.9%. Some of the research that we see, the national average is about 29%, and so that's quite, uh, relatively low compared to what we're seeing in other communities, which is great. And they really made a concerted effort to implement these policies in the nursing station. And then what we also saw was that almost half of all the MSK patients were receiving appropriate advice regarding education and self care.

So this is really great to see. Uh, we know from guidelines that in the management of MSK pain, uh, education and self care is very important. So almost half We're, uh, half of the files did reflect that, but there are still half that didn't. So we're hoping that while we're there, we can kind of make an impact on the amount of exercises.

I know with my patients, they always ask, uh, I always say that they're getting homework. So I think we'll be able to help with that. Um, so of all the patients presenting with MSK, 63.4 percent had low back pain. And 63.4 percent were also acute and onset. So these are definitely areas that chiropractors have been showing that we can have a tremendous impact on acute onset low back pain.

And then some of the, uh, the not so great parts of the chart review was The findings that we found were that, that's why there's kind of like a sad face there, MSK patients underwent an excessive diagnostic imaging. So 63.4, I think Andre might have got the numbers steady at 63.4. I think there's another number in the backslide, um, that showed that, uh, 41 percent of those had, um, x rays that were done in house.

So that number might, uh, that number is a little bit high, but it is reflective of the fact that they do have an x ray machine on site, and that, um, they, and they use it. And so, uh, sometimes that's all the option they have. Uh, we did find that physicians are limited in their referral options for local non pharmacological treatments.

And so... When you talk to the physician, they wanna, you know, and you're trying to tell them or encourage them to use non-pharmacological treatments. It's, uh, really difficult when there's no other options available for them. So they prescribe medications to about 75% of the patients who did present with Ms.

K, and then they also had to refer out 26.8% of those patients to other specialists, whether that's a, a massage therapist or a physiotherapist, um, or some other type of like ortho or neuro. Um, and all of these would be outside of the community for the most part. And then there was also a small majority of the patients, so 53.7%, they only went to the nursing station once, and a lot of the uh, feedback that we're getting from patients was that, Yeah, I went there, but, um, they just wanted to give me Tylenol, so I didn't go back. Um, so, those are the patients that we're trying to capture for the clinical portion of it. And then we also seen that the other half, 46.3%, did return for subsequent treatments. Now, the average of that one was about two. There was one person who came in 24 times, but that was like acute chronic disc, um, stenosis types of, uh, type of condition. And so for the most part, we're seeing a little over half for each of those.

Now, we also saw that, the, when we talk to patients and we ask them like, Hey, what's your intensity of pain on a scale? Zero is no pain and 10 is the worst. a lot of that, is not being collected in the nursing station. The intensity of pain in the Indigenous community is is quite poorly understood by Western practitioners, and it's so it's currently not being captured in the charts. I think it was like 84 percent of the charts had no pain intensity questions.

And the reason for that is that a lot of the outcome measures that we're using are culturally inappropriate and that, we're hoping that more research will come out that allows us to capture pain intensity better, so that the practitioners in Cross Lake would benefit from that and understanding, Indigenous pain.

And so then the next steps, what, what is that? Um, so this is our pre, um, implement. This is before we started the clinic, so this is our study from before, and then we're going to do a second chart review, and that'll be planned in the new year, and that'll be able to compare the pre and post data for the new clinical service at Cross Lake.

And so stay tuned for those results, and we're looking forward while all in, and thank you for, um, joining tonight. I'm going to turn it over to Steve, and then Steve is going to talk about the Community Health Survey.

Steven Passmore: Thanks, Dr. Ward. Um. The Community Health Survey is really designed to, uh, complement and, and our understanding of what's happening in the community. So, uh, what Jennifer just presented on, uh, was data that came from actual clinic charts at the nursing station. And what I'll be speaking about is, uh, the Community Health Survey that was done with individuals in their homes.

So, uh, our, our assistant, uh, Muriel, as well as Jennifer, went to many homes and spoke with many people and drank many cups of tea and had great conversations and laughter with the, uh, the folks that they interviewed. And, and so today I'll share the, the results from that.

So the three big questions that we had that emerged from the Community Health Survey were, is there spine pain in the community? And if so, what are people doing about it? And what would people like to be able to do about it?

So 130 surveys were conducted, and the characteristics of our respondents were that they were majority female. We saw people across the full range of adult lifespan from 21 to 85 years, with a mean of 48.4 years, with a standard deviation of 14.3. So our question was, is there spine pain in the community? And this is what the survey results indicated. In the past four weeks, in terms of acute pain, three quarters of the people that we spoke to had low back pain. And in terms of neck pain in the past four weeks, over half of the people that we spoke to had low back pain.

had neck pain. And these weren't necessarily people that were identified as patients ahead of time. This was a random sample from the community. The pain that these folks had in terms of their neck pain, as well as their low back pain, led to activity limitations in the majority of cases in both instances, which exceeded a day.

Most of the pain came from insidious onset, while only about a third came from another sort of injury. We also saw a lot of chronic pain in the community. And chronic pain was defined as pain that had been taking place for longer than three months. And again, three quarters of respondents reported low back pain, while more than half reported neck pain.

And then when it came to actually being clinically diagnosed, diagnosed by a health care provider in the community, those numbers appear much smaller when we look to see folks who had been experiencing pain for six months or longer. But, there was depression or anxiety from their pain in about a third of cases, and about a fifth of cases, uh, came from an arthritis of some sort. So, is there spine pain in the community? Yes. Both neck and low back pain, both acute and chronic pain, and it's limiting the activities that people can do.

So, what are people doing about it? In terms of non pharmacological care, uh, at least, uh, 88.5 percent of people, so the vast majority, are doing some home self care at some point in the past three months, and this includes keeping moving with exercise and sports, uh, heat, ice, or rest, uh, seeking massage, or, uh, stretching and strengthening.

So lots of people pursuing these at home options. Uh, much less people saw a traditional healer. Um, but the vast majority of people chose to do something non pharmaceutical about their pain.

In terms of pharmaceutical care, a majority of people were prescribed a medication in the past three months, and there's a full spectrum of medications that were prescribed, the majority of which were acetaminophen, uh, relaxants, and then we can see opioids at about 13.9 percent of the population.

In terms of non prescription pharmaceutical care, over the counter medication was preferred by a lot of participants, about 73.1 percent. Cannabis was used by just over a third of the population and, uh, unprescribed opioids in about a fifth of the population. And in terms of illicit drug use, uh, it's not being utilized by about 89.2 percent of the population that we surveyed. So that was a reassuring finding.

So, what are people doing about it? Well, this summarizes what we saw in the last slide. The vast majority are exploring aspects of self health, home self care. A slight majority are using massage and prescription medications, and a smaller percentage are using another means of coping.

So, what would people like to be able to do about pain in the spine in their community? Well, this list gives you, uh, from highest to lowest, the options, uh, that were responded to. In terms of, if someone in the community had low back pain or neck pain, in the next month, what would they like to do?

The vast majority of people would like some sort of an at home treatment that they could manage on their own. Next, we had over the counter medications. And third, we had see an allied healthcare provider. Followed by about a third of people wanted to see a nurse or a physician. about a quarter of people wanting to see a traditional healer, and, uh, much fewer people choosing, uh, another option.

So, this summarizes what people would like to do about it. The majority of people are interested in home treatments or over the counter medications. The allied health provider is the clinician of choice that people would like to see. And there are a few people that are interested in some other means of coping.

And that's it for me, and I will throw things over to Nicole.

Nicole Robak: Thank you. So, I'm Nicole. I'll be presenting some of the results of the interviews conducted on the clinicians and leaders of Cross Lake. And I want to begin by adding to the methods that Andre spoke about, specifically how we use the theoretical domain framework.

Of the 14 domains that make up the TDF, we built upon three to better suit this community. Some adaptations include culture as a subdomain under knowledge. perceptions of health professionals within the social professional role and identity domain, and context within the environmental domain. So these domains are then grouped into themes which covered the community, the state of healthcare, and perspectives about the program.

To start, it's important to understand the past and present community as described by the leaders.

The reserve was made by government choice, but the treaty was established by community choice, and was chosen through ceremony based off of accessibility to fish, specifically sturgeon. Cross Lake is composed of many islands, so to move between those islands, movement was a necessity.

They shared that the old treaty grounds was where people would gather and share knowledge. These gatherings were described as happy times and healing. Spiritual connection was emphasized during those times, and was afforded by the incorporation of silence into everyday life. But, as Leader 4 put it, There's a bit of an economic change over the years.

Too much, too fast. It's like a cultural shock. The change that occurred brought many good things, like the hydro dam, roads, increased housing and access to technology. At the same time, these changes decreased the need to be mobile, increased the uptake of processed foods, the expansion disconnected community members, and also disconnected those members from connecting spiritually.

Pain, unfortunately, was a byproduct of these changes experienced in the community. Regarding the pain experienced by community, the leaders and clinicians shared concerns over the state of health care, clinicians shared the importance of addressing the mind body connection when treating pain, and leaders expanded by including the spiritual and emotional element.

However, there are difficulties with addressing all realms of being, the most predominant one being access. As Leader 3 put it, It's not community based and it's not accessible, most of it's not portable, so it really affects their lifestyle. Our people want to get better, but everything's out there, not here.

It's always about the medicine. Clinicians express how they feel restricted by the minimal treatment options. Specialists more educated in musculoskeletal injuries, like chiropractors, physiotherapists, or massage therapists, are outside the community. The most accessible option is medication, but new clinical guidelines recommend against prescribing opiates for pain relief, especially in chronic pain cases.

To further illustrate the difficulties, the demands of the nursing station make it difficult to address every patient's immediate and less immediate needs. Both clinicians and leaders desire more time to discuss pain relief options during treatments. Some patients take their care into their own hands by seeking pain relief through substances, but others have sought non pharmaceutical options. The introduction of the new care pathway is a non pharmaceutical approach and was met with overwhelming optimism for both leaders and clinicians. Pain relief was at the forefront. Leaders shared their affinity to chiropractic services because if this service was available in the community, then that means more accessibility to treatment options.

Those seeking pain relief through any means now have the opportunity to choose a non pharmaceutical approach. as opposed to only a pharmaceutical one. The toolbox of the clinicians would expand and in turn increase their confidence. Additionally, the patient doctor relationship would strengthen because patients would feel like their pain concerns are being addressed.

To facilitate the new program, the need for consistent advertisement, education, and communication were highlighted. Community based in person events were emphasized to allow for misconceptions surrounding chiropractic care to be demystified and to help build trust and connection. In person approaches also align culturally.

Suggestions like sharing circles were recommended for sharing testimonials. Education not only will be important for community members, but for clinicians as well. Education will help them fully understand chiropractic care, so they can confidently make their recommendation to their patients.

I'd like to conclude with this quote from one clinician, who describes how the new program could improve multiple aspects of life. It reads, I think having chiropractic services is just another thing that will really benefit people in this community. Why I say that is that I compare it similar to the massage therapy program we've had here in Cross Lake for quite some time.

It's been amazing to see the benefits for people in this community. Many of those people have come off medications, so I just think that having something like this is another tool in our drawer. To say for patient X, I understand you have some trouble with your back or your neck. This is something I think we can offer to you that would be beneficial immensely to your overall well being.

Thank you, and on to Jacquie, I believe.

Jacqueline Ladwig: All right, thank you so much. So my name is Jacquie. I am a PhD candidate at the University of Manitoba. And, uh, my background is actually in dance, so I don't have a clinical, uh, or a chiropractic background, although I see a chiropractor on a regular basis. Um, and, um, yeah, so my research is around dance and disability and inclusion and also more development.

So for this study, my role is to develop a community movement program and to implement that in the community and then to assess the feasibility of that. So you can see from this slide, the program that I developed is based on a program that I conduct currently in Winnipeg, which is based on some other existing programs in the country as well.

We do a range of different types of activities in that program. And we did a hybrid delivery for this particular program as well. Um, and it was, so essentially it was a Pre existing programs, sort of a prescribed program that we brought into the community. Um, yes, and then to assess that, we did both self reported and observed assessments that were specific to balance, um, as well as physical function as well.

So, uh, we launched the program in May. We had held an open house in the community. We had 14 people who came to attend, which was a great, uh, showing for the open house. Uh, nine of those people, uh, completed consent forms to participate. Um, and, uh, at the end of the day, we had seven people who participated in more than one class, um, throughout the first seven weeks.

However, the attendance was It was quite sporadic, so it was sort of our typical sort of intervention approach, like you'd come twice a week, it's an hour and a half, um, it was in the evening, um, and that presented some challenges, and the time of year also presented some challenges as well. Um, there were some forest fires that happened in the area, um, that forced people to evacuate from the community, um, and that sort of slowed the momentum of the program as well.

of those, uh, who were, who had consented, um, predominantly female individuals and quite a broad age range from 21 to 65, um, years of age. So I'm not going to go over any of the assessment outcomes because we only did one assessment time point, um, for the group, but I will talk about sort of our next, uh, steps, uh, for this project.

So what we've done, we've paused the program after... Seven weeks, because that was the start of summer and, um, attendance had completely trickled off to literally nothing at that point. Um, so we thought we'll pause it and let's reassess, because clearly we weren't, um, we weren't achieving our goal of having people attend on a consistent basis.

Um, and so what we're doing is, um, We're reassessing and we decided, you know, let's look at how, how can we sort of decolonize this program, um, and, and incorporate the community's perspective more into the development of the program. So it's something that is, that piques their, their interest directly. Um, so in an effort to do that, our goal is to, we'll do, take a co design approach.

We'll be, we'll, we will be gathering insights. From the people who participated in the program through focus groups, um, to get their ideas on their goals, um, what outcomes and what movement activities are, um, are interesting to them. Um, and then we're also going to do from those focus groups, we'll show that information back to those folks, and then do a co-design.

So do some sessions where you work together. to develop a program that, um, works for them. Okay. Um, so we have started this process. We started the focus groups back in August. And so we've done three focus groups with about five participants and they participated in that initial, um, first iteration of the movement program.

And they shared, um, across the groups after the individuals that actually shared their interest. in more of an intergenerational approach, so something that's more family based so people can bring their children and the, you know, grandparents can come and everyone can come together to participate in something.

Um, also incorporating some more culturally appropriate activities. Um, so there's a, there's two, uh, huge festivals that happen in the community where they do, um, uh, different activities from their culture and sort of carry on those traditions from one generation to the next. So incorporating some of those, those activities, um, into the program, uh, so that they can do some of those things between the, the two different festival times.

There's a winter festival and there's a summer festival. Um, so it's, you know, incorporating those things so they can make that a year long. Um, uh, practice as opposed to just twice a year. Um, they also shared an interest in finding ways to access indoor spaces for both walking and physical activity. So we know that, um, some, one of the barriers to physical activity in Indigenous communities is a lack of transportation, as well as a lack of indoor and outdoor facilities.

Um, and also, uh, as well as limitations to, uh, their physical function as well. Um, so right now there's very few places to walk. You know, um... When I was in the community with Millis the last time, we went for a walk on the side of the road. So there's literally just a shoulder of the road and there's about a 45 degree grade.

So very difficult to walk. Um, certainly if you have any sort of physical, physical limitations, you're not going to be getting up to do any walking, um, on the side of the road. Um, and then also they talked about having safe ways to be active outdoors. Um, there are lots of dogs in the community that are just. running free. Um, and so having places where they can feel, feel that they're safe to be able to go out and, and be active out of doors without having to be concerned about personal safety.

So our next steps, our next visit to the community, we'll be completing the focus groups. We're going to do a couple of more of those, and then we'll also be initiating that co design of the movement program with key community members.

Thank you very much.

André Bussières: Invite Patricia to provide us some insight on the CSGI triaging system.

Patricia Tavares: Um, hi. Uh, so, um, let me share with you some of the foundational steps of the Global Spine Care Initiative model of spine care that's being used, uh, in this study and in our World Spine Care clinics, uh, throughout the world. So, the steps of the, um, the steps begin with the, an awareness of the problem.

The patient goes to the initial triage. Through an initial triage using seven screening questions or an algorithm, the questions ask about location, intensity of pain, numbness, muscle weakness, loss of balance, new onset of bowel or bladder problems, length of time since the symptoms have been present, interference with ADLs, associated physical trauma, and any history or risk of systemic disease, cancer, or infection. These direct the patient into one or more of six classes. Um, then if further assessment is required, a primary spine care provider performs an assessment. This allows for a subclassification.

Once subclassified, the clinician can then refer to flashcards that are part of the model to determine evidence based interventions that are recommended. The patient is then reassessed after a treatment period to determine whether they have achieved the desired outcome or whether alternative interventions are needed.

So here's an example of a recently designed triage algorithm, um, that was, um, Requested by, um, the triage nurses at, uh, in this study in, uh, Manitoba, uh, in Cross Lake. Um, and this addresses the same items as the seven questions, uh, mentioned previously to determine a class. And so the triage nurses are starting to use this, which is great.

Um, here they're starting to... They start to rule out the most serious things first, and if the answers are no to each section, as you see there, then they may refer the patients to the chiropractic clinic, or the community movement program, and can provide advice on self care, depending on the class. If the answers are yes, Um, referrals are made immediately, uh, to emergency or on a non emergent basis, um, and the referral, uh, situations are represented here by the yellow boxes.

So, um, as I mentioned earlier, once the triage has occurred, a classification, and a classification has been made, then a provider sees the patient if need, if required. The provider does a more focused and detailed history, um, including a systems review, past medical history, medication list, known core morbidities, and red flags, psychosocial history, um, and it, it may be necessary to further investigate with imaging or blood work, and then also outcome measures, uh, would be appropriate to use here, Thank you.

that would, um, uh, give us information or give them information about the patient's quality of life or disability level, so that that can be tracked over the course of the treatment plan. And outcome measures, as you know, are numeric pain scale, patient specific functional scales, uh, Uroqual, HODAS, there's, there's a few that can be used in our, um, uh, project here.

Those are some of the ones that we are using. Um, and then of course a thorough exam is then done, and this leads to a sub classification, as I had said previously. Let me just briefly tell you about the subclasses. Um, so of each class, which is determined by the provider assessment, as I had said, so Class zero involves no or minimal spine related symptoms.

It has the potential for prevention. Um, uh, in this class, there's no interference with activities, no neurologic deficits, no severe pathology. The two subclasses that you see there are divided by web. The patient has a risk factor for spine related disorders or pain or not. Classes one and two include conditions of the spine amenable to manual therapy.

Um, class one has mild pain and no disability. Class two represents moderate and severe pain and disability, and the subclasses are differentiated into acute. and chronic. Classes 5 relate to spinal conditions which may require a referral out on an emergency basis or a non emergent basis. Some can be treated at the primary level like class 3a and c and 4a.

Class 3 deals with spine related symptoms with neurologic symptoms or deficits. Interference with activities of daily living, focal pathology, compromising neural structures, but with no red flags for serious systemic disease. So subclass A includes minor or non progressive conditions like radiculopathy.

Um, B, acute, major, and progressive conditions like caudaequina. C, chronic and stable conditions like post operative radiculopathies or degenerative spinal stenosis. Um, class four includes severe structural bony and spinal deformity, fracture or instability, with or without interference with function or activities with or without neurologic deficits. So subclass A, stable with no related symptoms like a mild scoliosis, for example, and B, which represents conditions with symptoms related to spine related structural issues like a fracture or an unstable spondylolisthesis. And finally, Class 5, spine related symptoms caused by serious systemic disease determined by red flags or clinical history and exam.

Um, subclass A, acute and severe symptoms or pathology like vascular dissections, neoplastic disease. Uh, B, slowly progressive symptoms and pathology like inflammatory arthropathies. And C, referred pain from non spinal pathology like kidney stones. All of class 5 will require some form of referral. Thank you.

André Bussières: Thank you, Patricia. We will now hear from Melissa, who is, uh, currently in Crosslink. Melissa?

Melissa Atkinson-Graham: Thank you, Andre. Hi, everyone. I am Melissa, just to introduce myself, um, I am a settler, I'm an anthropologist, and I'm a chiropractor, and as Andre mentioned, um, I'm here in Pimicikamak this evening on Treaty 5. So it's really my pleasure to speak with you all about the spinal care service that we're now offering in Cross Lake.

Um, as Andre also mentioned, myself and Dr. Ward are the two chiropractors who are working here on site to provide care. Um, and as also mentioned, We began practicing on October 5th of this year. We're currently holding clinic four days a week and there are no costs associated with our services as part of the research that we are conducting.

For reference, the closest musculoskeletal services are about three to four hours away, and that's both physiotherapy services and other chiropractic services, so there is some real immediate benefit to having chiropractic services here in Cross Lake. Um, and in terms of the, the service we're providing, um, Patricia just gestured to this where, um, in our initial assessments, we're conducting full assessments, we're classifying our spinal, uh, complaints using the triage system, and we are developing, uh, plans of management based on that classification and best evidence, and of course, discussion, uh, with our patients, um, um, engaging in shared decision making and making sure our care aligns to their goals and, uh, expectations.

And so far, we've seen 60 patients and we're growing. We have very little loss to follow up to, which has been really great to see. Um, the referrals, as we're using the triage system, um, are coming directly from medical staff, so they're coming from physicians and nurses within the nursing station. And as you can imagine, in a small community, word travels quite quickly, so we're getting a number of self referrals already, although we haven't, um, began advertising our services and this study in community as of yet.

In our assessments we are of course learning how to best adapt, how we're using our measurement tools and how we're proceeding to collect information in a way that is respectful and appropriate for this context. And we're asking questions that pertain to the larger research goals and research questions associated with this project, so that has to do with Information on medication use, uh, previous care, and things like specialist referrals, um, and right now the kind of services that we're offering, again, aligned with, um, best evidence and with the classification system are things like manual therapy, so spinal manipulative therapy, mobilization, soft tissue work, uh, we also have the opportunity to offer a little light laser therapy, and shockwave modalities, and as a Dr. Ward already mentioned, exercise based rehabilitation, which you can imagine is sometimes challenging in the tiny room that we're currently working out of, which you'll see visualized, um, on the slide here in the emergency department in the Cross Lake Nursing Station.

Um, and I will say, I think we're really fortunate to be working out of the nursing station and working in the emergency department, um, really significant from a chiropractic perspective. So it's been really beneficial in terms of socializing, uh, the work we're doing, um, socializing and teaching and educating about the triage and the model of care. And we're already seeing really effective forms of interprofessional collaboration, um, emerging, whereby we're getting called into musculoskeletal complaints that are presenting to the emergency room. We're getting called into consults and equally, we're really able to work with, um, our medical colleagues, our physicians, nurses, and administrative, um, folks to, um, to get additional testing or additional imaging, you know, where required and to, to get folks, to ensure we're getting folks, um, to the right people in the right time, which is one of the goals of the project.

Um, yeah, so I'll leave it there and perhaps pass on to Deb.

Deborah Kopansky-Giles: Thank you very much. It's such a privilege, um, to present at the rounds in Saskatchewan. Thanks, Mark and others for facilitating this. And it's also an honour to work with this incredible group of researchers and to be part of advancing the model of care that GSCI worked on for many years and published in the European Spine Journal, as Scott said.

But it's also an incredible privilege to be working in this community of wonderfully welcoming people. Um, Anybody involved in doing research understands how challenging implementation research can be. It's really looking at bringing a whole new concept forward into an environment that's relatively naive to that and and seeing how feasible it is.

And so this is a big initiative and over the past two years we've been having the privilege of working closely with the community and especially core members of our team who've been to the community and are Um, and the clinicians that work actively in the community on an ongoing basis have developed these amazing relationships, uh, that are, are, have created trust back and forth between, uh, the research project members and the community members, um, and other, and the clinicians that are providing services in the community.

Some of the, uh, I just want to take a couple minutes and talk about some of the challenges and opportunities that we've noticed in the last two plus years of work that this project's been ongoing. And some of that is really something I think that would, um, probably come to the forefront in most people's views, is really understanding and respecting different worldviews.

And with GSCI and developing the model of care and thinking about testing it in. uh, communities like in Botswana and India and Indigenous communities like in Northern Canada. We recognize that there are different cultural contexts and we can't make assumption as researchers that we understand those contexts.

And so it is really important, especially in this study, that we really respect and make efforts to try to learn as much as possible about Indigenous ways of knowing compared to our Western perspectives that many of us would look at how we can merge those. Um, those concepts together in a way that is, uh, collaborative and appreciative, respecting each other's differences.

We also have to know that when we're, especially with respect to implementation research, is being aware of our own personal limitations, including our lack of knowledge about the context in which we're coming into, and, and unconscious biases that we might not be very aware of. And a lot of times qualitative research brings us out really nicely um, amongst participants.

The other thing about qualitative research is that it also brings the researcher into the equation. So we actually have an opportunity to learn about ourselves. Also, in the context of the project, some of the other challenges we we've seen, and we heard a little bit about already.

Um, are competing priorities for the community. So, for example, things happen, like Jackie referred to, the fires that really stopped everything for a long period of time. People had to be evacuated. Other events happening within the community that have to take priority. And so things get slowed down or stopped in the process of those.

So in any sort of feasibility or implementation research, these need to be thought about and planned for as much as possible. That everything's not going to run clickety boo from day one moving forward. We also, you know, because of these competing priorities and challenges, we also find sometimes frustrating as a researcher, but also just respecting that responses from the community can be delayed, not within our time frame, and it's really working with how do we make sure that we can work within the time frames that work within the community.

We also saw a lot of competing demands for time and resources, human resources and financial resources, and that was really why it was so important for us to have an element of this feasibility study or implementation project, as how do we help with capacity building, so we actually help improve the ability of community members to support ongoing human resources provision.

Also, you know, in the initial parts of our study, we're not co located there, so it's a lot harder to develop trusting relationships and create those relationships and have that opportunity to interact quickly when issues emerge. So the research takes a little bit longer because that trust has to be there, has to be created, has to be nurtured, and has to be maintained.

And when you're not co located, as we were in the first part of the study, that's a bit challenging. That has really come around because now we have, um, Jennifer and Melissa that are in the community, Jackie going up to the community frequently, and others also visiting, and that's made a huge difference on how quickly the pace of the research can move along, and also how quickly the program development can occur.

It's also important that you have to take time to look at existing infrastructure and look at how you can adapt or add to existing infrastructure to support the program development, and that also is a step by step process that takes time. thoughtful planning and input from the community and the community leaders and other clinicians.

We also have challenges with looking at funding mechanisms. There are different funding mechanisms that come from the province. They have different priorities, they have different structures, different responsibilities and reporting accountability versus federal grants. And so we can see how sometimes these can be a little bit conflicting as well when you're looking at different funding mechanisms.

also the challenges of reporting. So we're very used to, as a research team, looking at how to report a research project, but we also understand the importance of getting the message across to politicians or policymakers that can help drive policy forward. Obviously, the outcome of a research we want to see is, can we create a program and a model of care that can be implemented and sustained financially and through human resources within the community?

So you need to know that you're going to. Your reporting needs to be considered about how you balance the scientific reporting versus the importance of, um, advocating for the community and amongst policymakers. And so we also know the implementation research is, is just challenging on its own. It's a very interesting type of research, very complicated if you saw, even from what Andre described in the methodology.

And at the same time, you need to keep it pragmatic and as easy to understand for study participants without making it overly complex. And some of the other challenges is how do we sustain momentum that we've created, and how do we support ongoing efforts in the community as the study comes to its closure over a certain period of time.

But out of all of this, there's been amazing opportunities that have emerged. We were very fortunate to receive It's funded, seed funding from the CCRF and the Canadian Chiropractic Association, and that enabled the health funding from Health Canada's Substance Abuse and Addiction Program, and it's also led to the Health Canada Excellent Funding that, um, was recent, that we've just been notified we've recently received to take on another component of this project.

We've also had the opportunity to build excellent community engagement and support, and you can see how many people. Even just participated in the community engagement survey, 130 households. That's really amazing for a small community. So building on that collaboration, building on the momentum with the new nursing station and the inclusion of our services and being very welcome within the other healthcare providers turf to provide care.

And so again, we spoke about capacity building and those are opportunities now to sort of strengthen the provision of Uh, manual and non pharmacological care for spine conditions in the community. We're also going to be learning from our study outcomes, already learning and adapting as we move, and that's the beauty of implementation research, that you can adapt as you see the different challenges and opportunities that come ahead.

It's looking at how we also disseminate. How do we disseminate within the community, sharing what we've learned, also public through publications and presentations, so those are opportunities to, um, share what we've learned and also build those, uh, allies and partners for future program sustainability.

And, you know, the other opportunities are coming up from up people learning about our project, just like we're doing, sharing with you today and looking at expanding the project in local or broader context. So we all already have seen just from our sharing projects with colleagues and other collaborators from other provinces that we're starting to even hear people expressing interest to collaborate with other Indigenous communities, both within Manitoba and across Canada.

So the need to do that to support that is the need to go to political levels. Once we have our results, there's also massive funding that's coming out of the federal government through Team Primary Care Initiative that are looking at opportunities for collaborative funding, where we may be able to qualify for that if the new funding call comes out, which looks at more capacity, sustainability and scaling up these models that we've tested.

So we're really hoping that there may be an opportunity to get longer term funding to continue our work through that mechanism. But we don't know yet. We're keeping our fingers crossed. And other potential collaborative opportunities. We've had conversations with folks in Saskatchewan and British Columbia, also Australia, Botswana, the United Kingdom, South Africa, Nepal, Puerto Rico, India.

So all of these are opportunities for expanding the impact of our work, but also learning and Potentially thinking about how do we look at the GSEI model of care, but also we have the feasibility and learning from our experience here to look at other cultural contexts and how we can enhance the quality of care people are receiving in those, in those environments.

Thanks, Andre. You're next.

André Bussières: Thank you, Deborah. So hopefully this will provide you with the understanding of the work that is being done with amazing people. I've been fortunate to work with over the last couple of years, and this project will keep going on for another two years of funding. What we're hoping is that the adults with spine symptoms and concerns and community residents using the new spine care service, as well as the community movement program, will become aware of the services and opportunities to be managed within the programs that we're offering.

They will receive knowledge, tools. on the potential negative impact of opioids for spine care and better understand the potential negative effect, um, that are associated with some, uh, investigation or treatment. Our goal is really for, um, the community to be able to sustain the program over, over time.

And as, uh, Debra mentioned, it is important at this stage that we start connecting with politics at the provincial and federal level to be able to, uh, receive funding. and that these services will be ongoing. We really want to acknowledge Mark Tracy for allowing this presentation, our stakeholders, cross state First Nation leadership and community residents, funders that have been generous in supporting this research, including Skoll Foundation, Health Canada, Substance Use and Addiction Program, the Canadian Catholic Research Foundation, Canadian Catholic Association, and recently Health Care Excellence Canada.

Thank you all. And we're now, uh, welcoming any questions from the group. Mark will help us, uh, manage the different questions, uh, open to all.

Mark Labrecque: Great. Thanks, Andre. Um, I'll just leave it up to, um, any questions, uh, Dr. Miller.

David Millar: Um, hi, uh, Jean, you'd mentioned, uh, early in the, your talk about, uh, donations, and I just wondered how people, um, are able to donate to this project.

Jean Moss: The best way to do it, David, is to go to our website, www.worldspinecare.org, um, and, um, There you can, uh, donate there through the website to each one of the individual World Spine Cares and it can be designated for certain, um, projects and, and that sort of thing. That's the best way to do it. So www.worldspinecare.org.

David Millar: Thank you.

Mark Labrecque: That was an excellent question, Dr. Miller, and I was going to bring that up at the end there, too, though, that everybody tonight is volunteering their time, and, uh, worldspinecare. org also is a link there to volunteer, but also, uh, to World, uh, Global Spine Care Initiative, and the articles, uh, for there, too, though, um, Brian, in the chat, you gave a little message there.

Would you like to unmike and, uh, and, uh, ask that question, please?

Brian McWhirter: Yeah, sure. Thanks for, uh, letting me join in. That was a great presentation, by the way. And, uh, yeah, I was just wondering, has the, uh, the, uh, it was specifically for Deb Kopansky Giles. But I was just wondering if she, if there's been any move to sort of

alert the, the media to this because it's such a great initiative and I think that this is a feel good story, um, especially, um, given the location and, and, uh, the community that serving.

So I just think that it's worthy of getting the word out to, uh, Um, to tell people about this, you know, in terms of the public.

Deborah Kopansky-Giles: Thank you so much, Brian. You're absolutely right. It is imperative to, uh, do our best, um, to work with the community, to reach out to the public and also to policymakers, as I mentioned.

We're very fortunate when we received the, uh, Health Canada funding through Substance Abuse and Addictions Program, that actually Carolyn Bennett, who is the Minister for Public Health, At that point in time when we received the grant, she actually did a press release and included two of the studies that were funded.

One was ours, when they did a press release across the Canadian media to announce these studies had been funded and we had the opportunity to describe and talk about these studies. So we had a little bit of press at the beginning. Um, And the local community has done their own, quite a lot of their own internal press, also promoting the program.

And that's how we've been able to have increased community participation. I would say though that a lot of times, and I'll just say this from my own experience, I think Andre and Steven and Jean will probably best answer this as well, is that with government grants, there are a lot of restrictions about what you can and can't.

Um, so there's a lot of things that you can say, um, while you're in the contract of the grant. Um, for example, another project that's funded by the federal government allows us, we have to have anything that we put out in the media approved by them before we can release it. So there are limitations about that.

And of course, we, Once we finish the project, we start having these hard outcomes that we can start reporting, there will be publications, but there will be approaches to media and the government to advocate for this work further and within First Nations, Inuit and Métis populations, as well, utilizing the momentum of their own advocacy voices.

Jean, do you want to add to that?

Jean Moss: Uh, yeah. Thanks, Deb. Uh, whenever we make a public announcement about the, um, about the project, we do have to work with Health Canada over it. Um, it depends a little bit on what's going on in Health Canada at the time, but they've been very supportive to this point. I think right now what we're waiting for is to begin to get some of the results, um, that can be shared.

Um, it's also been commented by a liaison person that, you know, potentially this has the possibility of affecting government policy outside of Cross Lake. And it was quite interesting to be in that meeting and hear her actually say that. So, that's what we hope for in the long run. Uh, it's quite clear that the government could Potentially save a considerable amount of money by having these services available in the community, um, so that people don't have to travel out of the community or not travel and then have, uh, chronic conditions, um, develop.

So, uh, as things move along, we certainly hope to be doing that.

Brian McWhirter: Great. Thank you.

Mark Labrecque: Any other questions?

Jacqueline?

Deborah Kopansky-Giles: Sorry, it's Deborah. Steve, I noticed that you had responded to quite a few of the questions. Did you want to, um, expound on any of those responses? Because you were responding and thank you for doing that in the chat as people were arising, making comments.

Steven Passmore: Yeah, I, I, uh, was happy to see that people were utilizing the chat function.

That's one of the nice things about the online forum is that, uh, there, there can be sort of a sidebar discussion happening at the same time. And so it was nice to see people, uh, participating in that sense. And so, um, I, I did my best to try to field some of those in, in real time for people as we move through them.

So, uh, one of the interesting questions was, uh, can people get a copy of the triage algorithm? And, uh, sure, that's not, um, private information at all. So. We're happy to share those kinds of things with practitioners that are interested in seeing what those look like and perhaps incorporating them into their own clinical practice environment.

So feel free to send me an email. Um, my email's in the chat, uh, for anybody that wants to, uh, to follow up with that.

Mark Labrecque: Well, what I was going to mention too is, uh, Jacqueline there too, I like the, uh, term of Movement, program, so I wish you all the luck with that too, though.

Jacqueline Ladwig: Oh, thank you so much.

Deborah Kopansky-Giles: I think there's another question in the chat, what other physical therapies are involved? So, Jennifer or... Melissa?

Melissa Atkinson-Graham: Yeah, absolutely. Um, so we're primarily using exercise based, uh, physical therapy following existing guidelines, uh, from the Canadian Chiropractic Initiative and other evidence based guidelines to advise folks on, um, exercise, uh, stretching, strengthening exercises for, uh, spinal complaints.

I hope, I hope that's what you're asking. There are more, um, robust physical therapy, uh, practices that are located in Thompson, and that's, um, a city that's about three hours north of, uh, Cross Lake.

Jennifer Ward: And just to add to that, we've had some, like Melissa said in her presentation, we have some, um, laser therapy and some shockwave therapy.

We also do acupuncture as one of our modalities, uh, soft tissue therapy. Um, we have a thumper that we use and we do lots of like exercises, home stretches. Try to keep the exercise program like pretty simple for patients to kind of incorporate into their day to day functioning. So simple stretches that they can do without having to go to the gym or go to, uh, change their clothes, those types of things, so that they're more, um, apt to do those, um, and then some strengthening programs.

So, Like Melissa said, it's hard to show some of those and we don't have a plate plant or anything like that to, uh, uh, get the patients going on those devices. But, um, yeah, trying to keep it simple, um, keep it down to like three or four exercises, things that they can do, and they would kind of track that we use, um, physio tech as one of our, um, Apps that we can kind of print off exercise therapies and give them to patients, or we can kind of send them a link if they're on their phone and they have good, good service, um, so that they can kind of track when they're doing the exercise and how much they're doing.

So those are really integral parts of the, uh, the therapy as well.

Mark Labrecque: And Jennifer, there's just one more, um, in the chat there too, uh, from, uh, Dr. Morrison. Do you see patients? Who are coming with non spinal MSK complaints? For example, extremities, knees, shoulders, etc. Or do you only take on patients with spine pain?

Jennifer Ward: No, we, uh, part of the agreement with the community and providing chiropractic services and being there in the community was that we wouldn't turn patients away.

So some of the patients who are maybe outside the study parameters, for example, adults, um, If they're not adults coming in, so we have some students or some basketball players. We have some younger students. They're not technically part of the setting. We're not gathering the data and collecting the consent form to participate.

But we are still providing services for those patients. Um, so that's one example. And then for sure, non spinal MSK, uh, we're chiropractors, right? So we treat everything, every, every joint and bone in the body. And so, um, we definitely, um, will treat patients, uh, with knee problems or shoulder injuries, um, and some of the, um, other, um, areas that as long as it's under our scope of practice for chiropractic, then we can manage those.

So definitely we can work outside of just the spine, but, um, but for purposes of this study, then the data, actually there is, um, a section in the collection of the data that includes extremities as well. So then that is included under the study.

Mark Labrecque: Thank you. Um, Andre, any closing comments?

André Bussières: Well, again, thank you everyone for attending. Uh, we're very excited to be able to present this, um, data today and look forward to hopefully being invited again when we're done, um, with the post implementation, um, data. We'll start... Collecting soon. We have, um, we'll be repeating the quality of assessment, interviews of community leaders and clinicians, as well as people in the community.

We will also be reviewing the charts in the nursing station, as Jennifer said, post implementation. And also have an adoption questionnaire that will be administered to clinicians and leaders. And so, looking forward to the next steps. Thanks again.

Mark Labrecque: And we're all looking forward to the next steps also to this wonderful research and thank you to everybody that's making this possible.

It's not going to help Manitoba, it helps Canada, it helps the world, so much, much appreciated for all your hard work.

With that, I guess we'll close rounds, this very special round. I thank everybody for taking their time out of this crazy, busy, You know, Tuesday evening and, uh, spending time together. It's much appreciated also.

And, uh, in the, um, uh, chat, I did leave my email address. If there's any other, uh, questions, uh, please, uh, send them along, uh, through there too, though, but otherwise. Very good. And, uh, this session was recorded and, uh, this will be sent to World Spine Care and will be put onto their website, I believe. And that way it makes it much easier to go to the first page of the worldspinecare.

org. And there's a little button on the right hand side that says donate. And, uh, to show your appreciation, we can all make a donation. And again, much appreciated.

André Bussières: Thanks everybody. Good night.

Jennifer Ward: Take care. Thanks, everybody. Merry Christmas. Happy New Year.

Deborah Kopansky-Giles: Take care, everybody. Thank you.

Jean Moss: Thank you, Mark. We appreciate you setting all this up.

Thank you very much. Good night, everybody.

Scott Haldeman: Thanks for attending.

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