Musculoskeletal– Part 1

Musculoskeletal– Part 1
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Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name Relationships with commercial interests: Grants/Research Support: PharmaCorp ABC Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd Consulting Fees: MedX Group Inc. Other: Employee of XYZ Hospital Group Please fill out all applicable areas (highlighted in red). One slide per speaker.

Disclosure of Commercial Support
This program has received financial support from [organization name] in the form of [describe support here – e.g. educational grant]. This program has received in-kind support from [organization name] in the form of [describe the support here – e.g. logistical support]. Potential for conflict(s) of interest: [Speaker/Faculty name] has received [payment/funding, etc.] from [organization supporting this program AND/OR organization whose product(s) are being discussed in this program]. [Supporting organization name] [developed/licenses/distributes/benefits from the sale of, etc.] a product that will be discussed in this program: [enter generic and brand name here]. Please fill out all applicable areas (highlighted in red).

Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been mitigated]. Refer to the College of Family Physicians of Canada’s “Quick Tips” document. Please fill out all applicable areas (highlighted in red). Please visit the following link for the CFPC’s “Quick Tips” document:

Some info A few housekeeping items: cells, washrooms. We know emergencies sometimes come up, please feel free to leave the room if you need to take a call The agenda is on the table in front of you. Of importance you will note we are having a break for coffee around: (time) Housekeeping washrooms and nearest fire exist Ground rules Respect all ideas and opinions Share experiences with your peers On time back from break Cell phones on mute or vibrate?

LS1 AP1 LS2 AP2 LS3 Structure of Module Ongoing Support
Learning Sessions peer-led learning, team based approach to care Action Periods periods between Learning Sessions; working with PSP Coordinator to implement changes into practice Created through a tripartite agreement with the Ministry of Health, the BCMA, and the Health Authorities Based on feedback from the GPs: Trained, Supported. Paid Supports GPs and their practices to integrate new ways of doing things into their practices Goals: -Improve access for patients to guideline-based care -Improve physician satisfaction -Make family practice a more attractive option to graduating physicians Ongoing Support LS1 AP1 LS2 AP2 LS3

MSK Facilitators Peer Mentors: Specialist: PSP Support: Peer Mentors:
Coordinators supporting this module:

Needs Assessment Results
Current challenges for GPs: Learning Objectives:

Aim We aim to improve the quality of care and support in GP offices for patients living with RA, OA and Low Back Pain. We will know we have improved when we can demonstrate: A reduction in pain An increase, or reduced decline, in functioning Informed and activated patients managing their condition to the best of their abilities Specialist support and consult available in a timely manner when needed

Learning Objectives Describe the rationale for using a syndrome-approach to mechanical low back pain. Select the appropriate pattern when assessing patients with low back pain. Report increased confidence in supporting patients with low back pain.

A Syndrome Approach to Low Back Pain
Hamilton Hall MD FRCSC Professor, Department of Surgery, University of Toronto Executive Director, Canadian Spine Society

Low Back Pain https://www.youtube.com/watch?v=BOjTegn9RuY
11:06 minute white board video by Dr. Mike Evans may be used as introduction to concepts

How is our Current Approach Working?
Guideline: discordant indicators 23,918 primary care visits for back pain Jan 1999 – Dec 2010 MRI increase use 7.2% to 11.3% NSAID/acetaminophen decrease use 36.9% to 24.5% Narcotic increase use 19.3% to 29.1% Specialist referrals increase 6.8% to 14.0%

Specialist referrals increase 6.8% to 14.0% Less than 30% of referrals to a spine surgeon are appropriate for spine surgery. Wai E et al. Can J Surg 2009

Back pain remains an enormous social burden. More than 13 types of health care provider with over 30 treatment approaches. Still the commonest cause of recurrent lost time from work.

There is no correlation between degenerative changes on plain x-ray and back pain. CT has a 30% false positive rate. MRI has a 60-90% false positive rate. Early MRI without indication has a strong iatrogenic effect in acute LBP… it provides no benefits, and worse outcomes are likely. Webster BS et al. Spine 2013

With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients. Everything else is labeled “non-specific” back pain. It is treated “non-specifically”, which doesn’t work.

In most cases it doesn’t give the patient what the patient needs: immediate pain relief reassurance a clear prognosis a method of control

Most back pain is not the result of: Tumor Infection Major trauma Or any medical problem Most back pain begins spontaneously: In a study of over 11,000 patients, 2/3rds of the subjects could not recall any cause for the pain.

We memorize the Red Flags
Sphincter disturbance: bowel or bladder History of cancer Unexplained weight loss Immunosuppression Intravenous drug use Recent onset of structural deformity Recent or on-going infection Fever Night sweats Non-mechanical pattern of pain Constant pain Wide spread neurological signs or symptoms Disproportionate night pain Lack of treatment response Thoracic dominant pain Under 20 and over 55 Noseworthy J.N.Neurological Therapeutics

So why don’t we look there first?
There is another way Over 90% of back pain is caused by minor altered mechanics. Most back pain is mechanical. So why don’t we look there first?

There is another way Over 90% of back pain is caused by minor altered mechanics. Mechanical back pain is pain Related to movement Related to position Related to a physical structure It means there is a sore “something” in the back. This means that something is sore in the back, and that something doesn’t need to be defined or labelled.

There is another way We can all recognize there is a sore thing - we just can’t agree on which sore thing. And for all the non-invasive treatments locating the sore thing isn’t even necessary.

Syndromes of back pain “Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.” What is a syndrome?

Syndromes of back pain A syndrome is a constellation of signs and symptoms that appear together in a consistent manner and respond to treatment in a predictable manner. What is the difference between a disease and a syndrome?

The only difference is that we know the etiology of a disease
A disease has an etiology. Does a syndrome have an etiology? Do you think that constellation of signs and symptoms just appears in exactly the same way every time merely by chance? Of course, a syndrome has an etiology. We just don’t know what it is yet.

Syndrome recognition The key to syndrome recognition is the history and that begins with three questions: Where is your pain the worst? Is your pain constant or intermittent? Does bending forward make your typical pain worse?

Where is your pain the worst?
Is it back or leg dominant? Back dominant pain is referred pain from a physical structure. Back dominant: back buttocks coccyx greater trochanters groin

Is it back or leg dominant? Back dominant pain is referred pain from a physical structure. Sites of referred pain can become locally tender. Trochanteric bursitis Piriformis syndrome

Is it back or leg dominant? Leg dominant pain is radicular pain from nerve root involvement. Leg dominant: Around or below the gluteal fold, to the: thigh calf ankle foot

Is it back or leg dominant? The patient will often report both. But it must be one or the other. “ If I could stop only one pain, which one do I stop? “I have a back pill and a leg pill, which one do you want?”

Is your pain consistent or intermittent?
Is there ever a time when you are in your best position, in your best time of your day and everything is going well when your pain stops even for a moment? I know it comes right back but is there ever a time, even a short time when the pain is gone?

Is your pain consistent or intermittent?
When your pain stops does it stop completely? Is it all gone? Are you completely without your pain?

When the pain is constant consider:
Malignancy Systemic conditions Pain disorder Constant mechanical pain

Questions to ask: Where is your pain the worst?
Is your pain constant or intermittent? Does bending forward make your typical pain worse? What are the aggravating movements/positions? Has there been a change in your bowel or bladder function? What can’t you do now that you could do before you were in pain and why? What are the relieving movements/ positions? Have you had this same pain before? What treatment have you had? Did it work?

History takes precedence over physical examination.
But the physical examination must support the history.

Three questions – two tests to rule out the Red Flags
Where is your pain the worst? Is your pain constant or intermittent? Has there been a change in your bowel or bladder function? Test upper motor function. Test lower sacral sensation. PRINT FOR HANDOUT

2:34 video 2:43 minute Dr. Hamilton Hall video on Pattern Overview
– link embedded in picture in slide.

There are four mechanical patterns
Pattern 1 PEN Pattern 4 FA Pattern 4 FR Pattern 1 PEP Note change in nomenclature of Pattern 4 from the video, PEP and PEN become Flexion Aggravated (FA) and Flexion Relieved (FR)

Pattern 1 Probably Discogenic

History Pattern 1 Back dominant pain Worse with flexion
Constant or Intermittent

Physical Examination Pattern 1 Back dominant pain Worse with flexion
Neurological examination is normal or unrelated to the pattern

Neurological examination is normal Better with 5 prone passive extensions Pattern 1 Prone Extension Positive PEP The patient has a directional preference.

Neurological examination is normal No change/worse with 5 prone passive extensions Pattern 1 Prone Extension Negative PEN The patient has no directional preference.

Exercises for Pattern 1: (Demonstrate on patient actor on table at front or use video – link embedded in picture: 13:46 min) Prone Lie (PEN) Prone Lie on elbows (PEN) “Z” lie (PEN) Lumbar Roll Sitting (PEP/PEN) Night Roll Lying Down (PEP/PEN) Sloppy Push-up (PEP)

Pattern 1 Pattern 1 PEN Pattern 1 PEP PRINT FOR HANDOUT

Pattern 1: Pattern 1 Tx Pattern 1 PEN Pattern 1 PEP Back Dominant
Worse with Flexion Intermittent or Constant PEP or PEN Tx PEP- sloppy pushups extension PEN- Z-rest, prone lying, work towards extension Pattern 1 PEN Pattern 1 PEP

Pattern 2 Unknown cause!

History Pattern 2 Back dominant pain Worse with extension
Never worse with flexion or equivocal Always intermittent

History Pattern 2 Back dominant pain Worse with extension
Never worse with flexion or equivocal Always intermittent If the pain is constant or if there is any pain on flexion the patient is Pattern 1

Physical Examination Pattern 2 Back dominant pain Worse with extension
Neurological examination is normal or unrelated to the pattern No effect or better with flexion

Exercises: (Use patient to demonstrate at front on table or use video: – 1:46 min)

Pattern 1 Pattern 2 Pattern 1 PEN Pattern 1 PEP PRINT FOR HANDOUT

Pattern 2 Pattern 1 Pattern 2 Tx Pattern 1 PEN Pattern 1 PEP
Back Dominant Never worse with flexion or equivocal, extension worse Always intermittent Tx Flexion- Knee/Chest Child’s Pose Sitting Flexion Work toward Extension Pattern 2 Pattern 1 PEN Pattern 1 PEP

Pattern 3 Certainly nerve root irritation “Sciatica”

History Pattern 3 Leg dominant pain Always consistent
Affected by back movement/position

and/or conduction loss
Physical Examination Pattern 3 Leg dominant pain Leg pain affected by back movement Positive irritative test and/or conduction loss

Exercises: (Demonstrate on patient at front of audience on table or use video: 1:17 min)

Pattern 1 Pattern 2 Pattern 3 Pattern 1 PEN Pattern 1 PEP

Pattern 1 Pattern 2 Pattern 3 Pattern 3 Tx Pattern 1 PEP Pattern 1 PEN
Leg Dominant Always constant Affected by movement Positive Irritative Test- Sciatica Tx Rest- Z-rest, Prone Lie, Passive extension, Hands/Knees, Side Lie Pattern 1 PEP Pattern 1 PEN

Pattern 4 FA – Flexion Aggravated

History Leg dominant pain Always intermittent Worse with flexion
Pattern 4 FA Leg dominant pain Always intermittent Worse with flexion

Physical Examination Pattern 4 FA Rarely a positive irritative test and/or conduction loss Always better with unloaded back extension movement or position Leg dominant pain that responds to mechanical treatment.

Pattern 4 FA – Flexion Aggravated Exercises
Sloppy push-up Lumbar roll: sitting “Z” lie Night Roll: Lying Down Prone Lie on Elbows Prone Lie

Pattern 4 FR – Flexion Relieved
Neurogenic claudication

History Leg dominant pain Always intermittent
Pattern 4 FR Leg dominant pain Always intermittent Worse with activity in extension Better with rest in flexion May have transient weakness

History Pattern 4 FR Leg dominant pain Always intermittent
Worse with activity in extension Better with rest in flexion May have transient weakness

Physical Examination Pattern 4 FR Negative irrtative tests
Possible permanent conduction loss

Exercises for Pattern 4 (FR):
Single leg abdominal press Sitting Flexion Cat/Camel Partial Sit-up or Crunch Pelvic Tilt

Constant /Intermittent
Back dominant Leg dominant Constant /Intermittent Intermittent Constant Intermittent Pattern 1 Pattern 4 Pattern 2 Pattern 3 Pattern 1 PEN Pattern 4 FR Pattern 4 FA Pattern 1 PEP PRINT FOR HANDOUT

Constant /Intermittent
Back dominant Leg dominant Constant /Intermittent Intermittent Constant Intermittent Pattern 1 Pattern 4 Pattern 2 Pattern 3 Pattern 4 FR Leg Dominant Worse with Flexion Better with Ext. Tx Sloppy Pushup Z-rest, prone lie Pattern 4 FA: Neurogenic Claud. Worse with activity extension (walking) Better rest in Flexion Tx- core strengthening Pattern 1 PEN Pattern 4 FR Pattern 4 FA Pattern 1 PEP

Physical Examination Observation General activity and behaviour
Back specific: contour colour scars palpation (if you must)

Physical Examination Observation Movement flexion extension

Physical Examination Observation Movement Nerve root irritation tests
straight leg raising

A positive straight leg raise:
Passive test - the examiner lifts the leg Reproduction/exacerbation of typical leg dominant pain Back pain is not relevant Produced at any degree of leg elevation To reduce confusion with hamstring tightness, flex the opposite hip and knee.

straight leg raising femoral stretch test-when history indicates

Nerve root conduction tests L4 knee reflex L5 great toe extension hip abduction ankle dorsiflexion (+ L4) S1 great toe flexion hip extension-gluteus maximus power ankle reflex ankle plantar flexion

Nerve root conduction tests Upper motor test plantar response clonus

Nerve root conduction tests Upper motor test Saddle sensation lower sacral nerve roots (2,3,4) test

High-Low tests Physical Examination Observation Movement
Nerve root irritation tests Nerve root conduction tests Upper motor test Saddle sensation High-Low tests

Nerve root conduction tests Upper motor test Saddle sensation Sensory testing (if indicated)

Nerve root conduction tests Upper motor test Saddle sensation Sensory testing (if indicated) Ancillary testing (if indicated) Hip, abdomen, peripheral pulses

There are only four Mechanical Syndromes
That’s all there is There are only four Mechanical Syndromes

That’s all there is Mechanical Syndromes Concordant
physical examination Unequivocal history Anticipated treatment response

Start with the patterns
There will be a pattern in ninety percent of your patients. If it responds as expected, you have your solution. If there is no syndrome or it doesn’t respond as anticipated, that is the group that needs to be investigated. That is the time to consider the Red Flags.

LBP CORE Tool

Practice: 26 y/o man lifting dead weight at gym with sudden pain to his lower back, no leg pain better with sitting, intermittent slight decrease in pain with bending forward worse with extension ? Pattern ? Management

53 y/o woman, recurrent back pain, no specific trigger
mild pain to buttocks worse with flexion intermittent but initially continuous ? Pattern What would you like to know next? ? Management

45 y/o woman riding in a speedboat, over a wave and jarred down onto seat with sudden pain in her mid back no leg pain constant worse with flexion and extension radiates around her sides tender point lower T spine ? Pattern

64 y/o man with back to left leg pain, history of same, no specific trigger
constant worse with bending forward positive straight leg raising ? Pattern ? Management

64 y/o man with back to left leg pain improving
intermittent worse with bending forward better with extension negative straight leg test ? Pattern ? Management

75 y/o woman with bilateral leg pain onset with walking
better with rest in sitting negative straight leg testing decreased sensation lateral right leg to foot ? Pattern ? Management

Start with the Pattern. If it responds as anticipated you have your solution. Further investigation is unnecessary.

GP’s and MOA to break out into separate rooms
96

MOA breakout report back

10 minutes

Demonstrate the algorithm
Demonstrate the algorithm. Use this slide to link to the algorithm pdf file and show how the algorithm works.

Brief Action Planning 30 minutes

What can we do to help people with MSK conditions?

What is Brief Action Planning?
A self-management support tool based on the principles and practice of motivational interviewing It is: Structured Patient-centered Evidence-informed The Centre for Comprehensive Motivational Interventions

Spirit of Motivational Interviewing
Compassion Acceptance Partnership Evocation The Spirit of Motivational Interviewing is described by Miller and Rollnick, the founders and researchers who established this approach. There are four things that make up the spirit of MIPartnership Partnership: working in collaboration. Avoid the expert role. Acceptance: Respect the person’s autonomy, the right to change or not to change Evocation: The ideas come from the person, our job is to help draw them out. Compassion: The interaction is based on the best interests of the other person It has been shown in studies that when clinicians demonstrate the Spirit of MI in their interactions, the people they are working with are more likely to change. (Miller and Rose, 2009; Miller et al 1993, Patterson et al, 1985) Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change, 3ed, 2013

“Is there anything you would like to do for your health in the next week or two?”
Behavioral Menu SMART Behavioral Plan Elicit a Commitment Statement “How confident (on a scale from 0 to 10) do you feel about carrying out your plan?” If Confidence <7, Problem Solve Barriers Step through the slide. Blue = three questions 5 skills are yellow and green. Yellow are skills used every time, green are skills used as needed. “Would you like to check in with me to review how you are doing with your plan?” Follow-up

Offer a behavioral menu when needed or requested.
Skill #1 Behavioral Menu Offer a behavioral menu when needed or requested. Slide builds automatically with 2 clicks When people aren’t sure what they want to do, a behavioral menu is offered. It’s offered in a particular way to demonstrate the Spirit of MI.

If yes, share two or three ideas briefly
Behavioral Menu “Is it okay if I share some ideas from other people who are working to improve their health? “ If yes, share two or three ideas briefly “Maybe one of these would be of interest to you or maybe you have thought of something else while we have been talking?” Exercise EDITED A behavioral menu looks like this if you put it on paper. Key points 1) Ask permission before providing suggestions 2) Always end with some other idea of their own that you did not think of. A behavioral menu can be done on paper to set a visit agenda, or mid-way through a visit to determine which of the many things discussed may be of most importance to the patient. Weight management Resuming Daily Activities Taking meds Adapted from Stott et al, Family Practice 1995; Rollnick et al, 1999, 2010

Skill #2 SMART Behavioral Plan Action Planning is “SMART”: Specific, Measurable, Achievable, Relevant and Timed. Slide builds automatically with 2 clicks Specific: described in detail, exactly what are they going to do Measurable: like minutes, distance, times completed, days of the week Achievable: realistic for that person Relevant: related to their overall goal Timed: Describes how long, when they will start Evidence: A Theory of Goal Setting and Task Performance by Locke and Latham, supports specific and achievable. Bodenheimer reviewed studies and found that proximal seemed more useful than distal. Bandura studied this in 1981. . Based on the work of Locke (1968) and Locke & Latham (1990, 2002); Bodenheimer, 2009

Elicit a Commitment Statement
Skill #3 Elicit a Commitment Statement After the plan has been formulated, the clinician/coach elicits a final “commitment statement.” Strength of the commitment statement predicts success on action plan. Slide builds automatically with 2 clicks Evidence: the studies were in drug use and gambling. We can all hear the strength of the commitment-- the difference between saying “I’ll try” and “I will.” Aharonovich, 2008; Amrhein, 2003

Problem-solving is used for confidence levels less than 7.
Skill #4 Problem Solving Problem-solving is used for confidence levels less than 7. Slide builds automatically with 2 clicks Confidence is a key predictor of success, and higher confidence is associated with healthier behaviors and better outcomes. Started with Bandura’s theory (1983) in studying education and student motivation. Has since been applied to health, including healthy behaviors and risk reducing behaviors.(Lorig et al, Medical Care 2001, Bodenheimer, CHCF 2005, Bodenheimer, 2009) Self-efficacy is the purpose of goal setting. This is important--if the clinician believes the new behavior won’t change the outcome (which often a small lifestyle change won’t) and they minimize the importance of the behavior, they have missed the point. The point is to increase self-efficacy, which is associated with better health in the long term. Success on an action plan increases confidence. When we make action plans, we ask the person to rate their confidence. If there confidence is less than 7, we use problem solving. Bandura, 1983; Lorig et al, Med Care 2001; Bodenheimer review, CHCF 2005; Bodenheimer, Pt Ed Couns 2009.

Problem Solving “A ___ (the number they chose) is higher than a zero.
That’s good.” “Is there something you could do to raise your confidence?” Yes No How to respond to a low confidence level. Behavioral Menu Restate plan and repeat confidence measure

Skill #5 Follow-up builds confidence. Follow-up
Slide builds automatically with 2 clicks Evidence: If you consider nearly every drug trial or trial to improve clinical control in chronic illness they all have specific follow-up schedules that are adhered to. No one is “lost to follow-up.” How does a patient interpret “Lost to follow’up?” (It wasn’t really that important, they didn’t care about me…” Follow-up often with early action plans and decrease frequency as behavior is more secure. Regular contact over time is better than 1x intervention. Follow-up builds a trusting relationship Resnicow, 2002; Artinian et al, Circulation,2010

Follow-up “How did it go with your plan?”
Success Partial success Did not try or no success Reassure that this is common occurrence Recognize success Recognize partial success A stepped response to three possible results of an action plan: success, partial success, or did not try/no success. For those who experienced success, affirm success: “You really made that happen.” “You followed through on your plan.” (for example) and see if they want to continue their plan, add to it or make a new plan. Partial success: if they felt successful, it’s the same thing as completing the whole plan, so continue as with success. If they didn’t feel successful, affirm what they did accomplish: “Trying it once shows willingness. What did you learn?” The goal is to help people turn any “failures” into lessons learned so that they can make a SMARTer plan and achieve success to build confidence. “What would you like to do next?”

“Is there anything you would like to do for your health in the next week or two?”
Have an idea? Not sure? Behavioral Menu Not at this time Permission to check next time SMART Behavioral Plan Specific Measureable Achievable Relevant Timely 1) Ask permission to share ideas. 2) Share 2-3 ideas. 3) Ask if any of these ideas or something else might work. Elicit a Commitment Statement “How confident (on a scale from 0 to 10) do you feel about carrying out your plan?” Confidence <7, Problem Solving Confidence ≥7 “Would you like to set a specific time to check back in with me so we can review how things have been going with the plan?” Follow-up “Would you like to set a specific time to check back in with me so we can review how things have been going with the plan?” “Would you like to set a specific time to check back in with me so we can review how things have been going with the plan?” “Would you like to set a specific time to check back in with me so we can review how things have been going with the plan?” “Would you like to set a specific time to check back in with me so we can review how things have been going with the plan?”

Tips for Giving Information and Advice
When? They ask for information You ask permission to give it You have a professional obligation to inform your client of something they don’t know Here’s how to give info and advice using the Spirit of MI remember, patients rarely haven’t been told something important!

Tips for Giving Information and Advice
How? ASK-TELL-ASK ASK Ask what they already know TELL Fill in any gaps or gently correct misunderstandings Concentrate on key messages Use Teach-Back Ask what they think about your information or advice Using the Spirit of MI, we want to evoke (ask what they know) With permission, fill in any gaps Teach back “I just gave you a bit of information, can you say back to me the key things so I know if I was clear.” Ask what they think, “So what do you think about that?”

Time to Practice Work in pairs
One is the helper, helping a partner make a Brief Action Plan. Refer to your guide and flow chart. The second is the partner, making the Brief Action Plan Make a plan for something you want to do in the next week or two Make some kind of a follow-up plan (with each other, with yourself or someone else) Switch roles Since skills mastery is important, we’re going to practice BAP Model with a partner if possible Remind the group that “health” is broad. things to relieve stress, connect with family and friends, volunteer, work on something important like a craft of hobby are all good for your health.

Questions? 5 minutes

Action period work

Try the CORE back tool with at least 4 patients
Number of patients in your registry with LBP: Initials of 4 patients with LBP: Patient 1 Patient 2 Patient 3 Patient 4 CORE Back Tool (at least 4 patients) Pattern 1 (at least 2 patients) Pattern 2 (at least 1 patient) Pattern 3 Pattern 4 PEP/PEN As coordinators had come in to your practice to ensure you are set up for this module, please select 4 of the patients you will follow throughout this module Try the CORE back tool with at least 4 patients Pattern 1 with at least 2 patients Pattern 2 with at least 1 patient Pattern 3 with at least 1 patient; And pattern 4 PEP/PEN with at least 2 patients Please indicate challenges you anticipate after this learning session, as the coordinators will be following up on that to help you overcome these challenges Coordinators will be connecting with you to book a time in the next 2 weeks before Christmas break

Who will be supporting you?
Module Leads:

Before You Leave… Action Period 1 Learning session evaluation Surveys
Learning session invoices Action period forms, evaluation and Hollander surveys will be exchanged for an invoice at the registration table Payments for MOAs are attached to the physician invoices Please fax invoices to the number on the bottom of your registration form A coordinator will connect with you to meet for AP follow up work If you are a salaried physician, you will not be compensated for the action period work, but if you do the work, you will still be able to receive the full mainpro C. If you need more information about the credits, please do not hesitate to contact Central, the contact information is on the back of the agenda.

Next Learning Session Date
Please make a note of the date of the next learning session – evening session, same format to be expected. Thanks to the physician facilitators for their leadership in this module. Again, we at PSP are here to support you and coach you each step of the way.

Practice Support Program
For more information Practice Support Program West Broadway Vancouver, BC V6J 5A4 Tel:

Musculoskeletal– Part 1

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