Renowned spine surgeon is transforming the way Ontario deals with back pain

It was discouraging news for patients who had waited up to 18 months for their appointments. And that was typically after they had already waited up to six months for MRIs. Many were unable to work, many were on painkillers, some were even addicted.

Because the patients were not candidates for surgery, the best Rampersaud could offer was referrals to other physicians — for example, pain specialists and physiatrists — who also had long waiting lists.

Had these patients received appropriate treatment earlier, their problems may not have become chronic.

“You can see how the system is failing the individual at every level, every step of the way. That was the impetus for us to say this is not good for me, it’s not good for the patient and it’s not good for the family doctor … I get frustrated talking about it because it is such a horrible experience,” says Rampersaud, who works out of the Toronto Western Hospital campus of the University Health Network.

The Guyanese-born doctor knew there had to be a better way, so he set about creating one himself. He has since succeeded in overhauling the way Ontario’s health system deals with lower back pain.

A six-year pilot project he led wrapped up in March. Ontario’s health ministry, through Health Quality Ontario, is now in the process of opening “rapid assessment clinics” across the province, based on Rampersaud’s vision for providing better and faster care for patients with back pain.

The clinics are staffed by specially trained physiotherapists and chiropractors who teach patients how to manage their pain.

The results have been good and other provinces have taken notice. Small pilots are now underway in British Columbia and New Brunswick. (These pilots are also built upon research from Saskatchewan, another province that has made great strides in improving care for patients with back pain.)

Ontario is lucky to have physicians of his calibre, says Dr. Bob Bell, former deputy health minister for the province and former president of the University Health Network.

“Ontarians are fortunate that he has devoted so much energy and time to improving care for a common problem, back pain, in the province,” Bell says.

A former orthopedic surgeon, Bell trained Rampersaud when the younger doctor was a resident from Western University. Bell says he knew from the start Rampersaud was someone to watch: “You could tell as a student that he was highly skilled and was going to be a leader.”

Over the last 10 years, during typical 80-hour work weeks, Rampersaud devised a new clinical pathway for patients, one that allows them to get more appropriate care earlier on, when the chances of success are best.

It meant getting different kinds of health-care providers involved, including physiotherapists and chiropractors with advanced training.

With funding and support from the Ontario health ministry, Rampersaud and his team launched ISAEC, the Inter-professional Spine Assessment and Education Clinics, in 2012. The pilot was set up in three centres: Toronto, Thunder Bay and Hamilton.

Some 478 family doctors and nurse practitioners were recruited. Traditionally, these practitioners have had few tools to help patients with persistent back pain. If anti-inflammatories and some standard exercises didn’t work, they would send patients for MRIs and then refer them to surgeons such as Rampersaud.

But with ISAEC, they have another tool in their toolkit. They can quickly refer patients to community clinics where they are assessed by physiotherapists or chiropractors. These health professionals are trained to help weed out the very small percentage of patients who might benefit from anti-inflammatory steroid injections or surgery.

The remaining patients receive education about the nature of back pain and are given self-management and exercise programs, personalized to address their specific conditions.

More than 7,000 patients have so far been treated. The average wait to get into a clinic has been 12 days.

Surveys of patients have shown that 99 per cent are satisfied with their ISAEC consultations, 97 per cent are satisfied with their wait times and 94 per cent have a better understanding of their conditions. Ultimately, they have reported a reduced prevalence of unmanageable chronic lower back pain.

The ISAEC pilot also saw:

• A 30 per cent plunge in MRI use.

• Fewer unnecessary and costly referrals to spine surgeons and other specialists.

• And a decrease in waits to see such specialists from as long as 18 months to as little as two weeks.

Bell says ISAEC’s success has solidified Rampersaud’s reputation as a top-notch surgeon.

“Raj is one of the premier back surgeons in the world based on both his innovation in non-surgical care for patients with back pain and the terrific results achieved with developing minimally invasive microsurgery to deal with nerve compression. He is certainly recognized worldwide as a surgical innovator and leader.”

Asked where his drive comes from, Rampersaud credits his parents and tells a familiar story of immigrants sacrificing much for the next generation.

The youngest of 11 children, Rampersaud was born in a small village in the former British Guiana around the time the colony gained independence from the United Kingdom. Because of political unrest, the family moved abroad with not much more than the clothes on their backs.

Most of the family immigrated to Canada. The young Rampersaud was 7 when they settled in a working class neighbourhood of Hamilton.

Racism was rife and Rampersaud recalls being regularly called a “paki” and even getting into fisticuffs because of the colour of his skin.

His father, a dentist back in Guyana, found employment as a janitor. Rampersaud’s mother, who did not work outside the home back in Guyana, found a job as a seamstress.

Rampersaud excelled in school and the idea of becoming a doctor was first planted by his parents who wanted a better life for their bright son.

Today, he lives a comfortable life in the west end of Toronto with his wife and four children, three girls and a boy, ages 5 to 12.

His success with ISAEC is especially significant because back pain is one of the most common reasons patients see doctors and is responsible for more than half of all opioid prescriptions.

Up to 80 per cent of adults experience lower back pain at some point in their lives, Rampersaud notes.

Back pain is also one of the most common reasons people miss work, he says, adding worldwide it is responsible for the most days spent with a disability. Persistent back pain can prevent people from working and even socializing. It can also result in mood dysfunction.

“Prevention of chronic back pain is one of the principal goals of ISAEC,” Rampersaud says.

Toronto patient Adam Jagelewski was referred to ISAEC last year, after suffering with severe back pain for more three years. Sharp pain radiated down the back of his left leg, making it uncomfortable to sit for more than 15 minutes.

The 34-year-old director at the MaRS Centre for Impact Investing had sought help from chiropractors, physiotherapists, massage therapists, osteopaths, and a number of different doctors at a sports medicine clinic — all to no avail.

Through ISAEC, he received a personalized exercise program, but that proved not to be enough to ameliorate his pain. He was then referred to Marcia Correale, an advanced practice physiotherapist and practice lead with ISAEC. Correale, who works out of Toronto Western Hospital with Rampersaud, advised that Jagelewski get a steroid injection.

During a recent interview, he said he was feeling much improvement and could sit for four hours.

“I saw doctor after doctor after doctor and it felt like there was really no end game in all of this … It was only until (coming to) this clinic ... that I got help,” he said. “I wouldn’t say that I have no pain. But it’s mitigated, it’s manageable pain right now.”

Correale says back pain tends to recur. It can be managed but not cured.

“Sometimes when people go to different practitioners, they are looking for someone who will fix them. Sometimes no one is really going to fix them, but people can give you tools to help you manage your symptoms,” she says.

Rampersaud calls this “ping-pong” health care and says patients deserve better.

“What I mean is patients are being bounced back and forth from provider to provider, often getting contradictory opinions and treatments. With lack of co-ordinated care for conditions that require multiple providers to manage, our provider-centric system produces what it is designed to give — fragmented, episodic care that is of poor quality and value to patients, providers and the payers.”

Rampersaud explains that Ontario’s health system, like many around the world, is siloed and is “provider centred” rather than “patient centred.”

Different types of health-care providers have not worked well together. Turf wars, payment schemes and a lack of political will are among the reasons the system has not evolved in a way that is best for patients and taxpayers.

‘The first thing we did was break down the silos and plop the patient in the middle,” Rampersaud remarks.

Primary-care practitioners are a key part of this new “shared-care model” as are patients who are expected to play a central role in the “self management” of their pain, he notes.

Dr. Sarah Newbery, former president of the Ontario College of Family Physicians, participated in the pilot project. She says ISAEC has been a boon to primary-care providers such as herself.

“ISAEC has been designed by clinicians for clinicians,” says Newbery, who works in a rural practice in Marathon, Ont., along the northern shore of Lake Superior. “It has made management of lower back pain easier for my patients and it has made this challenging area of medicine easier for me.”

Rampersaud says his career is much more satisfying today than it was a decade ago. His waiting list is shorter and most of the patients he sees for surgical consultations are actually candidates for surgery.

Other patients who might have been referred to him in the past are getting faster and more appropriate care from physiotherapists and chiropractors at rapid assessment clinics.

“I can’t see myself ever wanting to practise the way we used to practise,” he says.

The Star is profiling 12 Canadians who are making our lives better. Next week we talk to overdose prevention advocate Sarah Blyth.