treatment based classification of the spine- an evidence based journey for the physical therapist
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Treatment Based Classification of the Spine- An Evidence Based Journey for the Physical Therapist. Tara J. Manal, PT, DPT, OCS, SCS Gregory E. Hicks, PT, PhD. Evaluation of Fear Avoidance and Other Psychosocial Issues Related to LBP. Traditional Medical Model. - PowerPoint PPT PresentationTRANSCRIPT
Treatment Based Treatment Based Classification of the Classification of the Spine-Spine-An Evidence Based Journey An Evidence Based Journey for the Physical Therapistfor the Physical Therapist
Tara J. Manal, PT, DPT, OCS, Tara J. Manal, PT, DPT, OCS, SCSSCSGregory E. Hicks, PT, PhDGregory E. Hicks, PT, PhD
Evaluation of Fear Evaluation of Fear Avoidance and Other Avoidance and Other Psychosocial Issues Related Psychosocial Issues Related to LBPto LBP
Traditional Medical ModelTraditional Medical Model
Health
Identification and Treatment of Lesion
…for LBP
Is There An Alternative Model?
Biopsychosocial model
Vicious Cycle of PainVicious Cycle of Pain
Pain Catastrophizing
Disability, Disuse,Depressions and Sick Leave
PainExperience
Kinesiophobia
Fear AvoidanceBehaviorsKori et al, 1990
Vlaeyen et al, 1995Elfving et al, 2007
Psychosocial Variables Psychosocial Variables
Maintenance and/or development of Maintenance and/or development of chronic LBP chronic LBP – Pain CatastrophizingPain Catastrophizing– KinesiophobiaKinesiophobia– Fear-avoidance beliefs Fear-avoidance beliefs
Specific to low back pain Specific to low back pain More evidence suggesting they are involved More evidence suggesting they are involved
in the acute to chronic transition in the acute to chronic transition – Depressive symptomsDepressive symptoms
Pain Catastrophizing Pain Catastrophizing
Pain CatastrophizingPain Catastrophizing An exaggerated negative interpretation of pain An exaggerated negative interpretation of pain
which might occur during actual or anticipated which might occur during actual or anticipated pain experience (Sullivan et al, 2001)pain experience (Sullivan et al, 2001)
Associated with increased pain intensity and Associated with increased pain intensity and disabilitydisability
More strongly associated with perceived More strongly associated with perceived disability than pain intensity in both acute and disability than pain intensity in both acute and chronic LBP populations (Swinkels-Meewisse, chronic LBP populations (Swinkels-Meewisse, 2006 and Crombez, 1999)2006 and Crombez, 1999)
After cognitive-behavioral treatment for LBP, After cognitive-behavioral treatment for LBP, changes in catastrophizing mediated the changes in catastrophizing mediated the reduction in level of depression and pain reduction in level of depression and pain behavior following treatment (Spinhoven, behavior following treatment (Spinhoven, 2004) 2004)
Pain Catastrophizing Pain Catastrophizing Scale (PCS)Scale (PCS)
Questionnaire developed to measure Questionnaire developed to measure exaggerated negative thoughts related to exaggerated negative thoughts related to pain (Sullivan et al, 1995)pain (Sullivan et al, 1995)– ““I worry all the time about whether the pain will I worry all the time about whether the pain will
end.”end.” Scoring and InterpretationScoring and Interpretation
– 13 questions, 5 point likert scale13 questions, 5 point likert scale 0=totally disagree — 4=totally agree0=totally disagree — 4=totally agree Total scores range from 0-52Total scores range from 0-52
– Higher scores=higher degree of catastrophizingHigher scores=higher degree of catastrophizing Validity and reliability are establishedValidity and reliability are established
Pain Catastrophizing Pain Catastrophizing Scale (PCS)Scale (PCS)
3 subscales3 subscales– Rumination (0-16)Rumination (0-16)
Questions 8,9,10,11Questions 8,9,10,11– Magnification (0-12)Magnification (0-12)
Questions 6,7,13Questions 6,7,13– Helplessness (0-24)Helplessness (0-24)
Questions 1,2,3,4,5,12Questions 1,2,3,4,5,12
Kinesiophobia Kinesiophobia
Kinesiophobia Kinesiophobia
““An irrational and debilitating fear An irrational and debilitating fear of physical movement and activity of physical movement and activity resulting from a feeling of resulting from a feeling of vulnerability to painful injury or vulnerability to painful injury or (re) injury.”(re) injury.”
(Kori et al, 1990)(Kori et al, 1990)
Tampa Scale of Tampa Scale of Kinesiophobia (TSK)Kinesiophobia (TSK) TSK is a 17 item questionnaire developed as TSK is a 17 item questionnaire developed as
a measure of fear of movement/(re)injurya measure of fear of movement/(re)injury Scale is based on the model of fear Scale is based on the model of fear
avoidance, fear of work related activities, avoidance, fear of work related activities, and fear of movementand fear of movement
Also linked to elements of catastrophic Also linked to elements of catastrophic thinkingthinking
Validity and reliability have been establishedValidity and reliability have been established Shown to be strongly related to a lifting task Shown to be strongly related to a lifting task
and perceived disability in people with acute and perceived disability in people with acute LBP (Swinkels-Meewisse et al, 2006)LBP (Swinkels-Meewisse et al, 2006)
Tampa Scale of Tampa Scale of Kinesiophobia (TSK)Kinesiophobia (TSK)
Scoring and InterpretationScoring and Interpretation– 17 questions, 4 point likert scale17 questions, 4 point likert scale
1=strongly disagree — 4=strongly agree1=strongly disagree — 4=strongly agree Total score calculated after inversion of items Total score calculated after inversion of items
4, 8, 12 and 164, 8, 12 and 16 Total scores range from 17-68Total scores range from 17-68
– Higher scores=higher degree of Higher scores=higher degree of kinesiophobiakinesiophobia
>37 is considered high (Vlaeyen, 1995)>37 is considered high (Vlaeyen, 1995)– Recommended to use total score rather Recommended to use total score rather
than subscalesthan subscales
Tampa Scale of Tampa Scale of Kinesiophobia (TSK)Kinesiophobia (TSK)
2 subscales2 subscales– Harm subscale (items 3,5,6,9,11,15)Harm subscale (items 3,5,6,9,11,15)
There is something seriously wrong with the bodyThere is something seriously wrong with the body– Activity Avoidance subscaleActivity Avoidance subscale
Avoiding activity might prevent increased painAvoiding activity might prevent increased pain Used for people with LBP, fibromyalgia, MSK Used for people with LBP, fibromyalgia, MSK
injuries and whiplash associated disordersinjuries and whiplash associated disorders Access-May be downloaded free at:Access-May be downloaded free at:
– http://www.worksafe.vic.gov.au/wps/http://www.worksafe.vic.gov.au/wps/wcm/resources/file/eb5c6742bb4ae48/wcm/resources/file/eb5c6742bb4ae48/tampa_scale_kinesiophobia.pdftampa_scale_kinesiophobia.pdf
Fear-avoidance Fear-avoidance theory theory
Pain perception Pain perception – Sensory component of pain Sensory component of pain
Physiological response Physiological response Nocioceptive input Nocioceptive input
– Emotional reaction component of painEmotional reaction component of pain Psychological response Psychological response Pain experience, pain behavior, and Pain experience, pain behavior, and
physiological response physiological response
Fear-Avoidance Model of Fear-Avoidance Model of Exaggerated Pain Exaggerated Pain Perception Perception (Lethem, et al. (Lethem, et al. Behav Res TherBehav Res Ther, 1983), 1983)
Pain Perception Pain Perception
Fear-Avoidance Beliefs Fear-Avoidance Beliefs QuestionnaireQuestionnaire (Waddell et al, (Waddell et al, Pain, Pain, 1993)1993) Fear-Avoidance Beliefs Questionnaire (FABQ)Fear-Avoidance Beliefs Questionnaire (FABQ)
– Measures amount of “fear-avoidance” Measures amount of “fear-avoidance” Fear of re-injury Fear of re-injury Fear of painFear of pain Fear of pursuing physical activityFear of pursuing physical activity
– Two scales Two scales FABQ-PA - Physical activity, 4 questions (0-24) FABQ-PA - Physical activity, 4 questions (0-24) FABQ-W - Work, 7 questions (0-42) FABQ-W - Work, 7 questions (0-42)
– Higher numbers indicate higher “fear-avoidance” Higher numbers indicate higher “fear-avoidance”
Fear-Avoidance Beliefs Fear-Avoidance Beliefs QuestionnaireQuestionnaire (Waddell et al, (Waddell et al, Pain, Pain, 1993)1993)
2.2. Physical activity makes my pain worse Physical activity makes my pain worse 3.3. Physical activity might harm my back Physical activity might harm my back 4.4. I should not do physical activities which (might) make my back I should not do physical activities which (might) make my back
worse worse 5.5. I cannot do physical activities which (might) make my pain worse I cannot do physical activities which (might) make my pain worse
6.6. My pain was caused by my work or by an accident at work My pain was caused by my work or by an accident at work 7.7. My work aggravated my pain My work aggravated my pain 9.9. My work is too heavy for me My work is too heavy for me 10.10. My work makes or would make my pain worse My work makes or would make my pain worse 11.11. My work might harm my back My work might harm my back 12.12. I should not do my regular work with my present pain I should not do my regular work with my present pain 15.15. I do not think I will back to my normal work within 3 months I do not think I will back to my normal work within 3 months
0 – Completely Disagree 6 – Completely Agree
Fear-Avoidance Beliefs Fear-Avoidance Beliefs QuestionnaireQuestionnaire (Waddell et al, (Waddell et al, Pain, Pain, 1993)1993) To score the physical activity scale To score the physical activity scale
(FABQ-PA)(FABQ-PA)– Sum items #2 – 5 Sum items #2 – 5 – Report as whole number Report as whole number – Range 0 – 24 Range 0 – 24
To score the work scale (FABQ-W)To score the work scale (FABQ-W)– Sum items #6-7,9-12, and 15 Sum items #6-7,9-12, and 15 – Report as a whole number Report as a whole number – Range 0 – 42 Range 0 – 42
Management Management GuidelinesGuidelines Proposed by Vlaeyan and Linton Proposed by Vlaeyan and Linton
(2000)(2000)1.1. Identify (screen) for elevated fear Identify (screen) for elevated fear
avoidance beliefsavoidance beliefs2.2. Appropriate education Appropriate education
modificationsmodifications3.3. Appropriate exercise modificationsAppropriate exercise modifications
Cut-Off Scores Cut-Off Scores
CutoffCutoffScoreScore
SubjectSubjects s AboveAbove
Sn Sn (95% CI)(95% CI)
Sp Sp (95% CI)(95% CI)
LR+LR+(95% CI)(95% CI)
LR-LR-(95% CI)(95% CI)
2929 4444 0.95 0.95 (.87, 1.0)(.87, 1.0)
0.58 0.58 (.45, .71(.45, .71))
2.28 2.28 (1.65, (1.65, 3.16)3.16)
0.08 0.08 (0.01, (0.01, 0.54)0.54)
3434 2121 0.550.55(.34, .75)(.34, .75)
0.840.84(.73, .94(.73, .94))
3.333.33(1.65, (1.65, 6.77)6.77)
0.540.54(.34, .87)(.34, .87)Below 29 on FABQ-W is a “negative result”
(conceptualize as more likely to be confronter) Above 34 on FABQ-W is a “positive result” (conceptualize as more likely to be an avoider)
Determining Prognosis Determining Prognosis Patient with work-related low Patient with work-related low
back pain back pain – Want to estimate the probability of Want to estimate the probability of
NOTNOT returning to work after four returning to work after four weeks of treatment weeks of treatment ““Ruling in” Ruling in”
– Administer FABQ-W Administer FABQ-W Score on questionnaire is 36Score on questionnaire is 36
Determining Prognosis Determining Prognosis
Pre-test ProbabilityNot Returning to Work
(29%)
Post-test ProbabilityNot Returning to Work
(58%)
Perform FABQ-W (LR+ = 3.33)
“Rule-in”
Determining Prognosis Determining Prognosis
This patient with work related low This patient with work related low back pain and a “positive” FABQ-back pain and a “positive” FABQ-W test result (score > 34) has a W test result (score > 34) has a 58% chance of not returning to 58% chance of not returning to work in four-weeks.work in four-weeks.
Determining Prognosis Determining Prognosis Patient with work-related LBPPatient with work-related LBP
– Want to estimate the probability of Want to estimate the probability of NOTNOT returning to work after four returning to work after four weeks of treatment weeks of treatment ““Ruling out” Ruling out”
– Administer FABQ-W Administer FABQ-W Score on questionnaire is 18 Score on questionnaire is 18
Determining Prognosis Determining Prognosis
Pre-test ProbabilityNot Returning to Work
(29%)
Post-test ProbabilityNot Returning to Work
(3%)
Perform FABQ-W (LR- = 0.03)
“Rule-out”
Determining Prognosis Determining Prognosis
This patient with work related low This patient with work related low back pain and a “negative” FABQ-back pain and a “negative” FABQ-W test result (score < 24) has a W test result (score < 24) has a 3% chance of not returning to 3% chance of not returning to work in four-weeks.work in four-weeks.
Determining Prognosis Determining Prognosis Guidelines for general orthopedic Guidelines for general orthopedic
populationspopulations– FABQ-PA score of 15 is considered to be “high”FABQ-PA score of 15 is considered to be “high”
(Burton et al, Spine, 1999)(Burton et al, Spine, 1999)– Recent work finds describes 4-week cut-offs for Recent work finds describes 4-week cut-offs for
successful outcome at 6-months successful outcome at 6-months (Fritz, George, and Childs, Spine, in review)(Fritz, George, and Childs, Spine, in review) FABQ-PA < 7 FABQ-PA < 7
– Negative LR = 0.27Negative LR = 0.27 FABQ-W < 11FABQ-W < 11
– Negative LR = 0.11 Negative LR = 0.11
Intervention Intervention GuidelinesGuidelines Encourage the use of a confrontation Encourage the use of a confrontation
approach in those that normally wouldn’t approach in those that normally wouldn’t – Addressing the way the patient thinks about Addressing the way the patient thinks about
low back pain itself and the consequences of low back pain itself and the consequences of low back painlow back pain
– Addressing the way the patient participates in Addressing the way the patient participates in rehabilitation protocols rehabilitation protocols
Turn “avoiders” into “confronters”… Turn “avoiders” into “confronters”…
Education Education ModificationsModifications
“…“…unambiguously educating the unambiguously educating the patient in a way such that the patient in a way such that the patient views his or her pain as a patient views his or her pain as a common condition, rather than as common condition, rather than as a serious disease that needs a serious disease that needs careful protection.”careful protection.”
(Vlaeyan and Linton, (Vlaeyan and Linton, PainPain, 2000) , 2000)
Education Modifications Education Modifications (Burton et al, (Burton et al, SpineSpine, 1999), 1999)Handy HintsHandy Hints The Back BookThe Back BookBiomedical concepts of spine Biomedical concepts of spine anatomy, injury, and damageanatomy, injury, and damage
No sign of serious disease or No sign of serious disease or suggestion of permanent suggestion of permanent damagedamage
The spine is weak and avoid The spine is weak and avoid activity when in painactivity when in pain
The spine is strong and pain The spine is strong and pain does not mean your back has does not mean your back has serious damageserious damage
Encourages patient to be Encourages patient to be passivepassive
Encourages positive attitudes Encourages positive attitudes and copingand coping
Describes further Describes further intervention, including intervention, including surgerysurgery
Numerous treatments are Numerous treatments are available, but relief depends available, but relief depends on your efforton your effort
Concentrates on pain, not Concentrates on pain, not activity activity
Concentrates on activity to Concentrates on activity to restore normal functionrestore normal function
Study DesignStudy Design(George et al, (George et al, SpineSpine, 2003), 2003)
Randomized clinical trialRandomized clinical trial Patients referred to outpatient Patients referred to outpatient
physical therapyphysical therapy Study criteriaStudy criteria
– Inclusion: Ages 18 – 55; LBP for 8 Inclusion: Ages 18 – 55; LBP for 8 weeks or less; English speakingweeks or less; English speaking
– Exclusion: Tumor, fracture, infection, Exclusion: Tumor, fracture, infection, osteoporosis, nerve root compression, osteoporosis, nerve root compression, recent surgery, and pregnancyrecent surgery, and pregnancy
Treatment ArmsTreatment Arms (George et al, (George et al, SpineSpine, 2003), 2003)
B io m e d ica l E d u ca tionE x e rcis e to P a in T o le ra n ce
S ta nd a rd C a re
F e ar A vo ida n ce E du ca tionG ra de d E xe rc ise P ro g ram
F e a r-A v o id a nc e Tre a tm e nt
R a n do m iza tion
T re a tm e n t B a sed C la ss if ica t ion
George et al, George et al, SpineSpine, 2003, 2003
MeasuresMeasures– Disability ODQDisability ODQ– Pain IntensityPain Intensity– FABQFABQ
TimingTiming– Pre TreatmentPre Treatment– 4 weeks4 weeks– 6 months6 months
ResultsResults– Interaction between Interaction between
FABQ and FABQ and Treatment typeTreatment type
– If have high FABQ If have high FABQ and got FABQ and got FABQ treatment saw less treatment saw less disabilitydisability
– If have low FABQ no If have low FABQ no benefit with FABQ benefit with FABQ treatment (graded treatment (graded exercise may have exercise may have been too slow?)been too slow?)
Summary of StudySummary of Study The problem and a potential solution The problem and a potential solution Fear-avoidance theoryFear-avoidance theory Measurement of fear-avoidance beliefs Measurement of fear-avoidance beliefs Management of the patient with Management of the patient with
elevated fear-avoidance beliefselevated fear-avoidance beliefsIdentification Identification Education modificationsEducation modificationsExercise prescription modifications Exercise prescription modifications
FAMEPPFAMEPP(Fear Avoidance Model of Pain Perception)(Fear Avoidance Model of Pain Perception)
Graded ExposureGraded Exposure– Exposing patient to specific Exposing patient to specific
situations that they are fearful of situations that they are fearful of during the course of PTduring the course of PT
Graded ExerciseGraded Exercise– Consistently increasing patient’s Consistently increasing patient’s
exercise tolerance throughout exercise tolerance throughout course of PTcourse of PT
Graded ExposureGraded Exposure Determine activities that pt is fearful of Determine activities that pt is fearful of
using Fear of Daily Activities Questionnaireusing Fear of Daily Activities Questionnaire– 2 highest rated activities are used2 highest rated activities are used
Patient decides at what level (duration, Patient decides at what level (duration, frequency, intensity) activity is begun to frequency, intensity) activity is begun to avoid high levels of fearavoid high levels of fear
PT incorporates these activities into the PT incorporates these activities into the rehab processrehab processVlaeyen, Behav Res Ther, 2001Vlaeyen, Behav Res Ther, 2001
Graded ExposureGraded Exposure PT monitors patient’s fear of activities PT monitors patient’s fear of activities
using Fear of Daily Activities using Fear of Daily Activities QuestionnaireQuestionnaire
When patient reports decreased fear, When patient reports decreased fear, activities are increased by at least 10% activities are increased by at least 10% (duration, frequency, intensity)(duration, frequency, intensity)
Graded ExerciseGraded Exercise Operant ConditioningOperant Conditioning A behavior that is immediately and A behavior that is immediately and
systematically followed by something systematically followed by something pleasant(positive reinforcement) will tend pleasant(positive reinforcement) will tend to be increased or strengthenedto be increased or strengthened
If the consequences that follow the If the consequences that follow the behavior are not pleasant or favorable, the behavior are not pleasant or favorable, the behavior will probably weaken or ceasebehavior will probably weaken or cease
FordyceFordyce
Graded Exercise Graded Exercise ProgramsPrograms
Quota Driven Exercise ProgramQuota Driven Exercise Program– IntensityIntensity– Duration Duration – Exercise Frequency Exercise Frequency
Exercise to Quota is GoalExercise to Quota is Goal– Sub ToleranceSub Tolerance– Exercise followed by something pleasant (ie rest)Exercise followed by something pleasant (ie rest)– Not something unpleasant (ie pain)Not something unpleasant (ie pain)
Teaching it is safe to move and increase activityTeaching it is safe to move and increase activity
Graded ExerciseGraded Exercise Exercises are SelectedExercises are Selected Baseline trial and the patient Baseline trial and the patient
exercises to toleranceexercises to tolerance Quota is below baseline (75% of Quota is below baseline (75% of
baseline)baseline) Quotas are increased Quotas are increased
systematicallysystematically
ProgressionsProgressions Positive ReinforcementPositive Reinforcement
– Rest Rest – Verbal EncouragementVerbal Encouragement
Met QuotaMet Quota– Increase Quota by 10% or greaterIncrease Quota by 10% or greater
Did not Meet QuotaDid not Meet Quota– No ReinforcementNo Reinforcement– Emphasis on Importance of Meeting Quota Emphasis on Importance of Meeting Quota
Patient CasePatient CaseFear Avoidance Fear Avoidance TreatmentTreatment 42 yo male with c/o left LBP that 42 yo male with c/o left LBP that
radiates into his left buttock and radiates into his left buttock and anterior and medial portion of leganterior and medial portion of leg– ““Deep ache” and constant in LBDeep ache” and constant in LB– ““Stabbing” and intermittent in legStabbing” and intermittent in leg
HPI: Injured 2 weeks earlier while HPI: Injured 2 weeks earlier while lifting a heavy suitcase into carlifting a heavy suitcase into car
Patient CasePatient CaseFear Avoidance Fear Avoidance TreatmentTreatment MRI: HNP without n. root MRI: HNP without n. root
compromise at L4-L5 levelcompromise at L4-L5 level Sx’s worsenSx’s worsen
– Prolonged sittingProlonged sitting– As day progressesAs day progresses
Sx’s improveSx’s improve– Lying flat on backLying flat on back
Spends most of time like this and has Spends most of time like this and has drastically limited his activities*drastically limited his activities*
Patient CasePatient CaseFear Avoidance Fear Avoidance TreatmentTreatment Injury was not work-related, Injury was not work-related,
therefore used the FABQ-Physical therefore used the FABQ-Physical Activity ScaleActivity Scale
FABQ-PA: 21/24FABQ-PA: 21/24– 15 or greater is considered high15 or greater is considered high– Likely an “avoider”Likely an “avoider”
Patient CasePatient CaseFear Avoidance Fear Avoidance TreatmentTreatment Plan of CarePlan of Care
– Repeated lumbar extension Repeated lumbar extension movementsmovements
– Graded Exercise prescriptionGraded Exercise prescription– Fear-Avoidance based patient Fear-Avoidance based patient
educationeducation– Twice/week for 4 weeksTwice/week for 4 weeks
Treatment of Fearful Treatment of Fearful PatientsPatients
Discussion PointsDiscussion Points Only scratched the surfaceOnly scratched the surface
– Catastrophizing, other psychosocial Catastrophizing, other psychosocial interventionsinterventions
Can we changeCan we change– Attitudes and beliefsAttitudes and beliefs
Malingerers, head cases, high maintenance, etc.Malingerers, head cases, high maintenance, etc.– BehaviorsBehaviors
Follow the evidenceFollow the evidence Consequences of not changingConsequences of not changing
Depressive Depressive Symptoms Symptoms
Depressive Symptoms Depressive Symptoms Depression is common in patients with Depression is common in patients with
low back pain (Main, 1992)low back pain (Main, 1992) Associated with:Associated with:
– increased pain intensityincreased pain intensity– increased physical and psychosocial increased physical and psychosocial
disabilitydisability– increased medication useincreased medication use– and increased likelihood of unemployment and increased likelihood of unemployment
Sullivan, 1992Sullivan, 1992
Depressive Symptoms Depressive Symptoms It is not clear which comes first, It is not clear which comes first,
depression or LBPdepression or LBP But, it is clear that the presence But, it is clear that the presence
of depression in patients with LBP of depression in patients with LBP leads to worse outcomesleads to worse outcomes
Therefore, PTs need to know how Therefore, PTs need to know how to identify depressive symptomsto identify depressive symptoms– Not able to diagnose depressionNot able to diagnose depression
Depressive Symptoms Depressive Symptoms Primary care physicians failed to Primary care physicians failed to
recognize 35% to 50% of patients with recognize 35% to 50% of patients with depression (Pignone, 2002)depression (Pignone, 2002)
Even when depression in patients with Even when depression in patients with spinal pain is identified by medical spinal pain is identified by medical practitioners, a large proportion do not practitioners, a large proportion do not receive any particular intervention or receive any particular intervention or help for their depression (Cohen, help for their depression (Cohen, 2000)2000)
Depressive Symptoms Depressive Symptoms Brief 2-item screening test for symptoms Brief 2-item screening test for symptoms
of depression taken from the Primary Care of depression taken from the Primary Care Evaluation of Mental Disorders ProcedureEvaluation of Mental Disorders Procedure
The questions were: The questions were: – (1) "During the past month, have you often (1) "During the past month, have you often
been bothered by feeling down, depressed, or been bothered by feeling down, depressed, or hopeless?" and hopeless?" and
– (2) "During the past month, have you often (2) "During the past month, have you often been bothered by little interest or pleasure in been bothered by little interest or pleasure in doing things?" doing things?"
The screening test is scored by counting The screening test is scored by counting the number of "yes" responses (range=0–the number of "yes" responses (range=0–2). 2). Haggman, PTJ, 2004Haggman, PTJ, 2004
Solid Line-2 questions Dashed Line-PT Solid Line-2 questions Dashed Line-PT judgmentjudgment
Outcome Measures Outcome Measures
Outcome Measures Outcome Measures Factors for evaluationFactors for evaluation
– ReliabilityReliability Are measures consistent?Are measures consistent?
– ValidityValidity Does it measure what it’s supposed to measure?Does it measure what it’s supposed to measure?
– ResponsivenessResponsiveness Ability to detect changeAbility to detect change
– Minimum Detectable ChangeMinimum Detectable Change Has real change occurred? Has real change occurred?
– Minimum Clinically Important DifferenceMinimum Clinically Important Difference Smallest change that is important to patientsSmallest change that is important to patients
Outcome Measures Outcome Measures Oswestry Disability Questionnaire (ODQ) Oswestry Disability Questionnaire (ODQ)
– Region specific measure of disability Region specific measure of disability – Modified version contains 10 items Modified version contains 10 items – Each item scored 0 – 5 Each item scored 0 – 5 – Items are summed and expressed as a Items are summed and expressed as a
percentagepercentage– Higher numbers indicate greater disability Higher numbers indicate greater disability
10% - mild disability from low back pain 10% - mild disability from low back pain 65% - extreme disability from low back pain 65% - extreme disability from low back pain
Oswestry Oswestry QuestionnaireQuestionnaireSelf Report of Performance Self Report of Performance LimitationLimitation Personal HygienePersonal Hygiene LiftingLifting WalkingWalking SittingSitting StandingStanding
SleepingSleeping Social ActivitySocial Activity TravelingTraveling Sex LifeSex Life Pain IntensityPain Intensity
Scale: 0 - 5 Score for 10 items = 50Multiply Score by 2/100% = Disability
Modified version: Sex life question is replaced by employment/homemaking ability
Oswestry Oswestry ReliabilityReliability
Established as good to excellentEstablished as good to excellent ValidityValidity
EstablishedEstablished ResponsivenessResponsiveness
GoodGood Minimum Detectable ChangeMinimum Detectable Change
10.5 points (Davidson, 2002)10.5 points (Davidson, 2002) Minimum Clinically Important DifferenceMinimum Clinically Important Difference
6 points (Fritz, 2001)6 points (Fritz, 2001)
Outcome Measures Outcome Measures Quebec Back Pain Disability Scale Quebec Back Pain Disability Scale
– Region specific measure of disability Region specific measure of disability – 20 items—rate degree of difficulty20 items—rate degree of difficulty– Each item scored 0 – 5 Each item scored 0 – 5 – Items are summed and expressed as a Items are summed and expressed as a
percentagepercentage– Higher numbers indicate greater disability Higher numbers indicate greater disability
Score range: 0-100Score range: 0-100
Quebec Quebec ReliabilityReliability
Established as good to excellentEstablished as good to excellent ValidityValidity
EstablishedEstablished ResponsivenessResponsiveness
GoodGood Minimum Detectable ChangeMinimum Detectable Change
15 points (Davidson, 2002)15 points (Davidson, 2002) Minimum Clinically Important DifferenceMinimum Clinically Important Difference
15 points (Fritz, 2001)15 points (Fritz, 2001)
Outcome Measures Outcome Measures Roland-Morris Disability Questionnaire Roland-Morris Disability Questionnaire
– Region specific measure of disability Region specific measure of disability – Scale contains 24 items Scale contains 24 items
““Because of my back pain, I lie down to rest more Because of my back pain, I lie down to rest more often”often”
– Each item scored 0 or 1 Each item scored 0 or 1 – Items are summed for final scoreItems are summed for final score– Higher numbers indicate greater disability Higher numbers indicate greater disability
Score range: 0-24 Score range: 0-24
Roland-Morris Roland-Morris ReliabilityReliability
Conflicting (ICC=.53-.86)Conflicting (ICC=.53-.86) ValidityValidity
EstablishedEstablished ResponsivenessResponsiveness
Unable to detect improvement in half the peopleUnable to detect improvement in half the people Minimum Detectable ChangeMinimum Detectable Change
9 points (Davidson, 2002)9 points (Davidson, 2002) Minimum Clinically Important DifferenceMinimum Clinically Important Difference
Not availableNot available
Outcome Measures Outcome Measures Patient Specific Functional Scale Patient Specific Functional Scale
– Patient specific measure of disability Patient specific measure of disability – Patients nominate 3 important activities that they Patients nominate 3 important activities that they
are unable to perform or have difficulty with as a are unable to perform or have difficulty with as a result of their LBPresult of their LBP
– Each activity is scored on a 0 –10 scaleEach activity is scored on a 0 –10 scale 0=inability to perform the activity 0=inability to perform the activity 10=ability to perform activity at pre-injury level10=ability to perform activity at pre-injury level Total score/number of activitiesTotal score/number of activities
– Lower scores indicate greater disabilityLower scores indicate greater disability
Patient Specific Functional Patient Specific Functional ScaleScale ReliabilityReliability
EstablishedEstablished ValidityValidity
EstablishedEstablished ResponsivenessResponsiveness
Good responsivenessGood responsiveness Minimum Detectable ChangeMinimum Detectable Change
2 points (Stratford, 1995)2 points (Stratford, 1995) Minimum Clinically Important DifferenceMinimum Clinically Important Difference
Not availableNot available
Outcome Measures Outcome Measures Medical Outcomes Short Form-36 (SF-36)Medical Outcomes Short Form-36 (SF-36)
– a generic self-administered questionnaire used to a generic self-administered questionnaire used to examine health in the following eight domains: examine health in the following eight domains:
bodily pain, physical function, role limitations due to bodily pain, physical function, role limitations due to physical problems, general health, vitality, social physical problems, general health, vitality, social function, role limitations due to social problems and function, role limitations due to social problems and mental health. mental health.
– Scores on each scale were transformed into 0-Scores on each scale were transformed into 0-100 scales with higher scores representing better 100 scales with higher scores representing better health status.health status.
SF-36 SF-36 Two subscale scores representing overall Two subscale scores representing overall
physical and mental health were also physical and mental health were also examined examined – Physical Component Summary Scale (PCS)Physical Component Summary Scale (PCS)– Mental Component Summary Scale (MCS)Mental Component Summary Scale (MCS)
Norm-based scoring: each scale scored has Norm-based scoring: each scale scored has the same average of 50 and standard the same average of 50 and standard deviation of 10 pointsdeviation of 10 points
Any score below 50 would represent health Any score below 50 would represent health status that is below average compared to status that is below average compared to the rest of the population.the rest of the population.
SF-36 SF-36 Psychometric properties have been well Psychometric properties have been well
established at every level. established at every level. – In LBP patients, Physical Functioning Subscale In LBP patients, Physical Functioning Subscale
(10 items) has been evaluated (10 items) has been evaluated MDC is 16 points MDC is 16 points
Validation of the 36-Item Short-Form Validation of the 36-Item Short-Form Health Survey (Hebrew Version) in the Health Survey (Hebrew Version) in the Adult Population of IsraelAdult Population of Israel– Lewin-Epstein et al, 1998Lewin-Epstein et al, 1998
Outcome Measures Outcome Measures Self-Report vs. Observed MeasuresSelf-Report vs. Observed Measures
– Low to moderate agreement between measuresLow to moderate agreement between measures– Salen showed a moderate correlation (r=.48) between patient’s Salen showed a moderate correlation (r=.48) between patient’s
self-reported difficulty in performing tasks and observer self-reported difficulty in performing tasks and observer assessment assessment
– After the patients actually performed the tasks, the correlation After the patients actually performed the tasks, the correlation increased to r=.78increased to r=.78
– Tends to be a mismatch between how patients believe they Tends to be a mismatch between how patients believe they function and how they actually functionfunction and how they actually function
Therefore, consider supplementing self-report with observational Therefore, consider supplementing self-report with observational measuresmeasures
Outcome Measures Outcome Measures Back Performance Scale Back Performance Scale (Strand, PTJ, (Strand, PTJ,
2002)2002)– Observed measure of mobility-related Observed measure of mobility-related
activities in people with LBPactivities in people with LBP
– Consists of five testsConsists of five tests
Back Performance Back Performance ScaleScale
ReliabilityReliability EstablishedEstablished
ValidityValidity Discriminates between pts with different return to work statusDiscriminates between pts with different return to work status Higher for LBP than other MSK painHigher for LBP than other MSK pain
ResponsivenessResponsiveness High in pts who RTW (effect size:1.33) and low in others (.31)High in pts who RTW (effect size:1.33) and low in others (.31)
Minimum Detectable ChangeMinimum Detectable Change Not availableNot available
Minimum Clinically Important DifferenceMinimum Clinically Important Difference Not availableNot available
Medical History Medical History Questions Questions
Medical History Medical History Constant Pain, Unrelated to Position or Constant Pain, Unrelated to Position or
MovementMovement Severe Night Pain Unrelated to MovementSevere Night Pain Unrelated to Movement Recent Unexplained Weight Loss of >10lbsRecent Unexplained Weight Loss of >10lbs History of Direct Blunt TraumaHistory of Direct Blunt Trauma Appears Acutely Ill (pale, fever, malaise)Appears Acutely Ill (pale, fever, malaise) Abdominal Pain/Radiation to Groin (blood Abdominal Pain/Radiation to Groin (blood
in urine)in urine)
Medical HistoryMedical History Sexual DysfunctionSexual Dysfunction Recent Menstrual IrregularitiesRecent Menstrual Irregularities Bowel or Bladder DysfunctionBowel or Bladder Dysfunction
– Fecal or Urinary Incontinence/RetentionFecal or Urinary Incontinence/Retention– Rectal BleedingRectal Bleeding
Temperature >100 FTemperature >100 F Resting Pulse > 100 bpmResting Pulse > 100 bpm
Treatment-Based Treatment-Based ClassificationClassification
Three levels of classification need to be Three levels of classification need to be made by the therapist:made by the therapist:1.1. First Level:First Level: Is the patient appropriate Is the patient appropriate
for physical therapy for physical therapy management?management?
2. Second Level: 2. Second Level: What is the level of What is the level of acuity? (staging the patient)acuity? (staging the patient)
3. Third Level:3. Third Level: What treatment should What treatment should be used? (classification)be used? (classification)
Appropriate for Physical Therapy
Requires Consultation
Requires Referral
Lumbosacral symptoms of
primarily mechanical origin
Medical Psych-ological
Medical/ Surgical
Psych-ological
First Level ClassificationFirst Level Classification
Screening/Outcome Screening/Outcome MeasuresMeasuresMedical History FormMedical History FormModified Oswestry Questionnaire (OSW)Modified Oswestry Questionnaire (OSW)Fear-avoidance Beliefs Questionnaire Fear-avoidance Beliefs Questionnaire (FABQ)(FABQ)Pain DiagramPain Diagram
Why Self-report Why Self-report Forms?Forms? Saves timeSaves time Standardized questionsStandardized questions Screen for medical diseaseScreen for medical disease Track change over timeTrack change over time ClassificationClassification
Are there any “red flags”?
Are there any “yellow
flags”?
NO
NO
YES
YES
Referral/Consult with a Medical Specialist
Referral/Consult with Psychological/ Vocational Specialist
PROCEED to SECOND LEVEL CLASSIFICATION
RED FLAGSRED FLAGS Signs of fracture:Signs of fracture:
– Major traumaMajor trauma– Minor trauma or strain in elderly or Minor trauma or strain in elderly or
osteoporoticosteoporotic Signs of infection/osteomyelitis:Signs of infection/osteomyelitis:
– Recent fever, chills, unexplained weight lossRecent fever, chills, unexplained weight loss– Recent bacterial infection, IV drug abuse, Recent bacterial infection, IV drug abuse,
immune suppressionimmune suppression
RED FLAGSRED FLAGS Signs of cauda equina syndrome:Signs of cauda equina syndrome:
– Paresthesia of 4th sacral dermatome (saddle Paresthesia of 4th sacral dermatome (saddle region)region)
– Alteration in bowel or bladder function (increased Alteration in bowel or bladder function (increased frequency, overflow incontinence, etc.)frequency, overflow incontinence, etc.)
– Sexual DysfunctionSexual Dysfunction– Severe or progressive neurological deficitsSevere or progressive neurological deficits
Cauda Equina Syndrome Necessitates Cauda Equina Syndrome Necessitates Immediate Referral!Immediate Referral!
RED FLAGSRED FLAGS Screening questions for risk of ankylosing Screening questions for risk of ankylosing
spondylitis:spondylitis:– Morning stiffnessMorning stiffness– Improvement with activityImprovement with activity– Age < 40 yearsAge < 40 years– Local SIJ tendernessLocal SIJ tenderness– Pain not relieved when supinePain not relieved when supine– Paraspinal muscle spasmParaspinal muscle spasm
RED FLAGSRED FLAGS Screening questions for risk of cancer:Screening questions for risk of cancer:
– Age over 50 years (or less than 20 years)Age over 50 years (or less than 20 years)– Prior history of cancerPrior history of cancer– Unexplained weight lossUnexplained weight loss– No relief with treatment over past monthNo relief with treatment over past month– Constant pain, no relief with bed restConstant pain, no relief with bed rest– Night pain disturbing sleepNight pain disturbing sleep– Severe pain unaffected by posture or positionSevere pain unaffected by posture or position
Cancer as a Cause of Back Pain, Deyo, Cancer as a Cause of Back Pain, Deyo, J. Internal. MedJ. Internal. Med, 1988 , 1988 (n=1935)(n=1935)
1.01.000.98.9800Fever (temperature ≥ 100Fever (temperature ≥ 100FF1.11.100.91.9100Neurologic signsNeurologic signs1.41.4.4.4.60.60.15.15Spine tendernessSpine tenderness1.31.3.5.5.66.66.15.15Muscle spasmMuscle spasm0.90.91.61.6.85.85.23.23Appears to be in severe painAppears to be in severe pain
Physical examinationPhysical examination1.01.01.11.1.84.84.17.17Thoracic painThoracic pain1.21.200.82.8200Recent back injury (i.e. lifting, fall, blow, etc.)Recent back injury (i.e. lifting, fall, blow, etc.)0.60.62.62.6.81.81.5.5Duration of symptoms > 1 monthDuration of symptoms > 1 month0.90.91.11.1.42.42.61.61Insidious onsetInsidious onset0.00.01.81.8.46.461.01.0No relief with bedrestNo relief with bedrest0.80.833.90.90.31.31No relief with treatment over past monthNo relief with treatment over past month0.70.714.714.7.98.98.31.31Previous history of cancerPrevious history of cancer0.90.92.72.7.94.94.15.15Unexplained weight lossUnexplained weight loss0.30.32.72.7.71.71.77.77Age ≥ 50Age ≥ 50-LR-LR+LR+LRSpSpSnSnHistoryHistory
Cancer as a Cause of Back Pain, Deyo, Cancer as a Cause of Back Pain, Deyo, J. Internal. MedJ. Internal. Med, , 1988 (n=1935)1988 (n=1935)
Order ESR
Order ESR and spine radiographs(9% with cancer)
Low Back Pain n=1975
History of previous cancer
(n=45)
Only 1 clinical finding and ESR < 20 (n=369)
Stop (no cancer)
ESR ≥ 20 or more than 1 clinical finding (n=391)
Order radiographs (2.3% with cancer)
No findings(n=1170)
No further work-up needed, unless
indication arises (i.e. failure to improve with
treatment)
Age ≥ 50
Failure to improve with conservative
treatment
Unexplained weight loss
(n=760)
OR
OR
+ LR = 14.7
Previous history of cancer
Post-testprobability ofhaving cancer
= 9.4%Pre-testprobability ofhaving cancer
= .7%
+ LR = 2.4
ESR ≥ 20
Post-TestProbability ofhaving cancer
= 19.9%With previous
history of cancer, pre-test
probability ofhaving cancer
= 9.4%
+ LR = 19.2
ESR ≥ 50
Post-TestProbability ofhaving cancer
= 66.6%With previous
history of cancer, pre-test
probability ofhaving cancer
= 9.4%
Screening for Yellow Screening for Yellow FlagsFlags““Yellow flags are factors that Yellow flags are factors that increase the risk of developing, or increase the risk of developing, or perpetuating long-term disability perpetuating long-term disability and work loss associated with low and work loss associated with low back pain.” (Kendall et al, 1997)back pain.” (Kendall et al, 1997)
First-Order First-Order ClassificationClassification
Medical pathology referring pain to Medical pathology referring pain to lumbar spine lumbar spine
Recognizable pathological spine Recognizable pathological spine lesionslesions
True psychopathologyTrue psychopathology Psychological influencePsychological influence
First-Order First-Order ClassificationClassification
Psychological influence – “chronic” Psychological influence – “chronic” LBPLBP – Non-organic questionnaire Non-organic questionnaire
Pain in non-anatomical locationsPain in non-anatomical locations Abnormal pain behaviors Abnormal pain behaviors
– Pain diagram Pain diagram Wide spread/diffuse pain reports Wide spread/diffuse pain reports Drawn in non-anatomical locationsDrawn in non-anatomical locations
First-Order First-Order ClassificationClassification
Possibly organic pain diagram
(Chan et al, Spine, 1993)
First-Order First-Order Classification Classification
Non-organic pain diagram
(Chan et al, Spine, 1993)
Nonorganic SignsNonorganic Signs OverreactionOverreaction
– Disporportinate verbalization, facial Disporportinate verbalization, facial expressions, muscle tension, expressions, muscle tension, collapsing, sweating, during the collapsing, sweating, during the examinationexamination
Nonorganic SignsNonorganic Signs TendernessTenderness
– Non-anatomicNon-anatomic– SuperficialSuperficial
Nonorganic SignsNonorganic Signs SimulationSimulation
– Axial LoadingAxial Loading– Trunk RotationTrunk Rotation
Nonorganic SignsNonorganic Signs DistractionDistraction
– Straight Leg Raise (SLR)Straight Leg Raise (SLR) Supine vs. SeatedSupine vs. Seated
Nonorganic SignsNonorganic Signs RegionalRegional
– WeaknessWeakness– Sensory LossSensory Loss
Nonorganic Symptom Nonorganic Symptom DescriptorsDescriptors Do you get pain in Do you get pain in
your tailbone?your tailbone? Do you have Do you have
numbness in your numbness in your entire leg (front, side, entire leg (front, side, and back) at the and back) at the same time?same time?
Do you have pain in Do you have pain in your entire leg (front, your entire leg (front, side, and back) at the side, and back) at the same time?same time?
Does your whole leg Does your whole leg give way?give way?
Have you had any time Have you had any time during this episode during this episode when you have very when you have very little back pain?little back pain?
Have you had to go to Have you had to go to the ER due to back the ER due to back pain?pain?
Has all treatment for Has all treatment for your back pain made your back pain made you worse?you worse?
Abnormal Illness Abnormal Illness BehaviorBehavior Maladaptive overt illness related Maladaptive overt illness related
behavior which is out of behavior which is out of proportion to the underlying proportion to the underlying physical disease and more readily physical disease and more readily attributable to associated attributable to associated cognitive and affective cognitive and affective disturbancesdisturbances
Purpose of Nonorganic Purpose of Nonorganic TestingTesting
When the test is negative, they can “rule When the test is negative, they can “rule out” abnormal illness behaviorout” abnormal illness behavior
Not intended to “rule in” only identify Not intended to “rule in” only identify those at risk for unsuccessful treatment those at risk for unsuccessful treatment outcomeoutcome
Fritz 2000 Acute LBPFritz 2000 Acute LBP– 2 or more signs2 or more signs– 3 or more symptoms3 or more symptoms– 7 combined Gives greatest prediction of 7 combined Gives greatest prediction of
failure in return to work in 4wks BUT not good failure in return to work in 4wks BUT not good for use in Acute casesfor use in Acute cases
First-Order First-Order ClassificationClassification
If “positive”, then If “positive”, then – Associated with poor outcomes in chronic LBPAssociated with poor outcomes in chronic LBP
(Uden, (Uden, SpineSpine, 1988), 1988)– An indication of An indication of magnified illness behaviormagnified illness behavior??
Not synonymous with malingering Not synonymous with malingering – Warrants additional testing in physical Warrants additional testing in physical
examination examination Non-organic signsNon-organic signs
– May need to consider consultation with other May need to consider consultation with other healthcare professionalhealthcare professional
First-Order First-Order ClassificationClassification Psychological influence – “acute” LBPPsychological influence – “acute” LBP
– Psychosocial factors predict chronic LBPPsychosocial factors predict chronic LBP (Gatchel et al, (Gatchel et al, SpineSpine, 1995 and Burton et al, , 1995 and Burton et al,
SpineSpine, 1995) , 1995)
Pain catastrophizing, kinesiophobia, Pain catastrophizing, kinesiophobia, fear-avoidance and depression are fear-avoidance and depression are specific psychosocial factors involved in specific psychosocial factors involved in the development and maintenance of the development and maintenance of chronic LBP chronic LBP
First-Order First-Order ClassificationClassification Pain CatastrophizingPain Catastrophizing
– Screen with the Pain Catastrophizing Screen with the Pain Catastrophizing ScaleScale No specific cut-point available to identify No specific cut-point available to identify
this factorthis factor Mean score for LBP patients: 28.2 Mean score for LBP patients: 28.2
(s.d.=12.3)(s.d.=12.3)– What to do?What to do?
Modify treatment approach Modify treatment approach Consult with other health care professionalConsult with other health care professional
First-Order First-Order ClassificationClassification FearFear
– Screen with FABQ and TSKScreen with FABQ and TSK Use given cut-pointsUse given cut-points
– What to do?What to do? Modify treatment approach Modify treatment approach Consult with other health care professionalConsult with other health care professional
First-Order First-Order ClassificationClassification Depressive SymptomsDepressive Symptoms
– Screen with 2 questions Screen with 2 questions If positive (score of 1+)If positive (score of 1+)
– What to do?What to do? Consult with other health care professionalConsult with other health care professional
First-Order First-Order Classification Classification Potential outcomes Potential outcomes
– Suspect or known red flag (less than 1%)Suspect or known red flag (less than 1%) Refer to other health care professionalRefer to other health care professional
– Yellow flag (between 10 – 40%) Yellow flag (between 10 – 40%) Actively engage in demystification, education, Actively engage in demystification, education,
and activation (exercise with modifications)and activation (exercise with modifications) Include other health care professional Include other health care professional
– No yellow or red flags (greater than 50%)No yellow or red flags (greater than 50%) Manage with unmodified TBC physical therapy Manage with unmodified TBC physical therapy