Treatment Based Classification of the Spine-An Evidence Based Journey for the Physical TherapistTara J. Manal, PT, DPT, OCS, SCSGregory E. Hicks, PT, PhD

Evaluation of Fear Avoidance and Other Psychosocial Issues Related to LBP

Traditional Medical ModelHealthIdentification and Treatment of Lesion for LBP

Is There An Alternative Model?

Vicious Cycle of PainKori et al, 1990Vlaeyen et al, 1995Elfving et al, 2007

Psychosocial Variables Maintenance and/or development of chronic LBP Pain CatastrophizingKinesiophobiaFear-avoidance beliefs Specific to low back pain More evidence suggesting they are involved in the acute to chronic transition Depressive symptoms

Pain Catastrophizing

Pain CatastrophizingAn exaggerated negative interpretation of pain which might occur during actual or anticipated pain experience (Sullivan et al, 2001)Associated with increased pain intensity and disabilityMore strongly associated with perceived disability than pain intensity in both acute and chronic LBP populations (Swinkels-Meewisse, 2006 and Crombez, 1999)After cognitive-behavioral treatment for LBP, changes in catastrophizing mediated the reduction in level of depression and pain behavior following treatment (Spinhoven, 2004)

Pain Catastrophizing Scale (PCS)Questionnaire developed to measure exaggerated negative thoughts related to pain (Sullivan et al, 1995)I worry all the time about whether the pain will end.Scoring and Interpretation13 questions, 5 point likert scale0=totally disagree 4=totally agreeTotal scores range from 0-52Higher scores=higher degree of catastrophizingValidity and reliability are established

Pain Catastrophizing Scale (PCS)3 subscalesRumination (0-16)Questions 8,9,10,11Magnification (0-12)Questions 6,7,13Helplessness (0-24)Questions 1,2,3,4,5,12

Kinesiophobia

Kinesiophobia An irrational and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or (re) injury.(Kori et al, 1990)

Tampa Scale of Kinesiophobia (TSK)TSK is a 17 item questionnaire developed as a measure of fear of movement/(re)injuryScale is based on the model of fear avoidance, fear of work related activities, and fear of movementAlso linked to elements of catastrophic thinkingValidity and reliability have been establishedShown to be strongly related to a lifting task and perceived disability in people with acute LBP (Swinkels-Meewisse et al, 2006)

Tampa Scale of Kinesiophobia (TSK)Scoring and Interpretation17 questions, 4 point likert scale1=strongly disagree 4=strongly agreeTotal score calculated after inversion of items 4, 8, 12 and 16Total scores range from 17-68Higher scores=higher degree of kinesiophobia>37 is considered high (Vlaeyen, 1995)Recommended to use total score rather than subscales

Tampa Scale of Kinesiophobia (TSK)2 subscalesHarm subscale (items 3,5,6,9,11,15)There is something seriously wrong with the bodyActivity Avoidance subscaleAvoiding activity might prevent increased painUsed for people with LBP, fibromyalgia, MSK injuries and whiplash associated disordersAccess-May be downloaded free at:http://www.worksafe.vic.gov.au/wps/wcm/resources/file/eb5c6742bb4ae48/tampa_scale_kinesiophobia.pdf

Fear-avoidance theory

Pain perception Sensory component of pain Physiological response Nocioceptive input Emotional reaction component of painPsychological response Pain experience, pain behavior, and physiological response

Fear-Avoidance Model of Exaggerated Pain Perception (Lethem, et al. Behav Res Ther, 1983)

Pain Perception

Fear-Avoidance Beliefs Questionnaire (Waddell et al, Pain, 1993)Fear-Avoidance Beliefs Questionnaire (FABQ)Measures amount of fear-avoidance Fear of re-injury Fear of painFear of pursuing physical activityTwo scales FABQ-PA - Physical activity, 4 questions (0-24) FABQ-W - Work, 7 questions (0-42) Higher numbers indicate higher fear-avoidance

Fear-Avoidance Beliefs Questionnaire (Waddell et al, Pain, 1993)Physical activity makes my pain worse Physical activity might harm my back I should not do physical activities which (might) make my back worse I cannot do physical activities which (might) make my pain worse

My pain was caused by my work or by an accident at work My work aggravated my pain My work is too heavy for me My work makes or would make my pain worse My work might harm my back I should not do my regular work with my present pain I do not think I will back to my normal work within 3 months 0 Completely Disagree 6 Completely Agree

Fear-Avoidance Beliefs Questionnaire (Waddell et al, Pain, 1993)To score the physical activity scale (FABQ-PA)Sum items #2 5 Report as whole number Range 0 24 To score the work scale (FABQ-W)Sum items #6-7,9-12, and 15 Report as a whole number Range 0 42

Management GuidelinesProposed by Vlaeyan and Linton (2000)Identify (screen) for elevated fear avoidance beliefsAppropriate education modificationsAppropriate exercise modifications

Cut-Off Scores 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)

CutoffScoreSubjects AboveSn (95% CI)Sp (95% CI)LR+(95% CI)LR-(95% CI)29440.95 (.87, 1.0)0.58 (.45, .71)2.28 (1.65, 3.16)0.08 (0.01, 0.54)34210.55(.34, .75)0.84(.73, .94)3.33(1.65, 6.77)0.54(.34, .87)

Determining Prognosis Patient with work-related low back pain Want to estimate the probability of NOT returning to work after four weeks of treatment Ruling in Administer FABQ-W Score on questionnaire is 36

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 This patient with work related low back pain and a positive FABQ-W test result (score > 34) has a 58% chance of not returning to work in four-weeks.

Determining Prognosis Patient with work-related LBPWant to estimate the probability of NOT returning to work after four weeks of treatment Ruling out Administer FABQ-W Score on questionnaire is 18

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 This patient with work related low back pain and a negative FABQ-W test result (score < 24) has a 3% chance of not returning to work in four-weeks.

Determining Prognosis Guidelines for general orthopedic populationsFABQ-PA score of 15 is considered to be high(Burton et al, Spine, 1999)Recent work finds describes 4-week cut-offs for successful outcome at 6-months (Fritz, George, and Childs, Spine, in review)FABQ-PA < 7 Negative LR = 0.27FABQ-W < 11Negative LR = 0.11

Intervention GuidelinesEncourage the use of a confrontation approach in those that normally wouldnt Addressing the way the patient thinks about low back pain itself and the consequences of low back painAddressing the way the patient participates in rehabilitation protocols

Turn avoiders into confronters

Education Modificationsunambiguously educating the patient in a way such that the patient views his or her pain as a common condition, rather than as a serious disease that needs careful protection.

(Vlaeyan and Linton, Pain, 2000)

Education Modifications (Burton et al, Spine, 1999)

Handy HintsThe Back BookBiomedical concepts of spine anatomy, injury, and damageNo sign of serious disease or suggestion of permanent damageThe spine is weak and avoid activity when in painThe spine is strong and pain does not mean your back has serious damageEncourages patient to be passiveEncourages positive attitudes and copingDescribes further intervention, including surgeryNumerous treatments are available, but relief depends on your effortConcentrates on pain, not activity Concentrates on activity to restore normal function

Study Design(George et al, Spine, 2003)Randomized clinical trialPatients referred to outpatient physical therapyStudy criteriaInclusion: Ages 18 55; LBP for 8 weeks or less; English speakingExclusion: Tumor, fracture, infection, osteoporosis, nerve root compression, recent surgery, and pregnancy

Treatment Arms (George et al, Spine, 2003)

George et al, Spine, 2003MeasuresDisability ODQPain IntensityFABQ

TimingPre Treatment4 weeks6 monthsResultsInteraction between FABQ and Treatment typeIf have high FABQ and got FABQ treatment saw less disabilityIf have low FABQ no benefit with FABQ treatment (graded exercise may have been too slow?)

Summary of StudyThe problem and a potential solution Fear-avoidance theoryMeasurement of fear-avoidance beliefs Management of the patient with elevated fear-avoidance beliefsIdentification Education modificationsExercise prescription modifications

FAMEPP(Fear Avoidance Model of Pain Perception)Graded ExposureExposing patient to specific situations that they are fearful of during the course of PTGraded ExerciseConsistently increasing patients exercise tolerance throughout course of PT

Graded ExposureDetermine activities that pt is fearful of using Fear of Daily Activities Questionnaire2 highest rated activities are usedPatient decides at what level (duration, frequency, intensity) activity is begun to avoid high levels of fearPT incorporates these activities into the rehab processVlaeyen, Behav Res Ther, 2001

Graded ExposurePT monitors patients fear of activities using Fear of Daily Activities Questionnaire

When patient reports decreased fear, activities are increased by at least 10% (duration, frequency, intensity)

Graded ExerciseOperant ConditioningA behavior that is immediately and systematically followed by something pleasant(positive reinforcement) will tend to be increased or strengthenedIf the consequences that follow the behavior are not pleasant or favorable, the behavior will probably weaken or ceaseFordyce

Graded Exercise ProgramsQuota Driven Exercise ProgramIntensityDuration Exercise Frequency

Exercise to Quota is GoalSub ToleranceExercise followed by something pleasant (ie rest)Not something unpleasant (ie pain)

Teaching it is safe to move and increase activity

Graded ExerciseExercises are SelectedBaseline trial and the patient exercises to toleranceQuota is below baseline (75% of baseline)Quotas are increased systematically

ProgressionsPositive ReinforcementRest Verbal EncouragementMet QuotaIncrease Quota by 10% or greaterDid not Meet QuotaNo ReinforcementEmphasis on Importance of Meeting Quota

Patient CaseFear Avoidance Treatment42 yo male with c/o left LBP that radiates into his left buttock and anterior and medial portion of legDeep ache and constant in LBStabbing and intermittent in leg

HPI: Injured 2 weeks earlier while lifting a heavy suitcase into car

Patient CaseFear Avoidance TreatmentMRI: HNP without n. root compromise at L4-L5 levelSxs worsenProlonged sittingAs day progressesSxs improveLying flat on backSpends most of time like this and has drastically limited his activities*

Patient CaseFear Avoidance TreatmentInjury was not work-related, therefore used the FABQ-Physical Activity Scale

FABQ-PA: 21/2415 or greater is considered highLikely an avoider

Patient CaseFear Avoidance TreatmentPlan of CareRepeated lumbar extension movementsGraded Exercise prescriptionFear-Avoidance based patient educationTwice/week for 4 weeks

Treatment of Fearful Patients

Discussion PointsOnly scratched the surfaceCatastrophizing, other psychosocial interventionsCan we changeAttitudes and beliefsMalingerers, head cases, high maintenance, etc.BehaviorsFollow the evidenceConsequences of not changing

Depressive Symptoms

Depressive Symptoms Depression is common in patients with low back pain (Main, 1992)Associated with:increased pain intensityincreased physical and psychosocial disabilityincreased medication useand increased likelihood of unemployment Sullivan, 1992

Depressive Symptoms It is not clear which comes first, depression or LBPBut, it is clear that the presence of depression in patients with LBP leads to worse outcomesTherefore, PTs need to know how to identify depressive symptomsNot able to diagnose depression

Depressive Symptoms Primary care physicians failed to recognize 35% to 50% of patients with depression (Pignone, 2002)Even when depression in patients with spinal pain is identified by medical practitioners, a large proportion do not receive any particular intervention or help for their depression (Cohen, 2000)

Depressive Symptoms Brief 2-item screening test for symptoms of depression taken from the Primary Care Evaluation of Mental Disorders ProcedureThe questions were: (1) "During the past month, have you often been bothered by feeling down, depressed, or hopeless?" and (2) "During the past month, have you often been bothered by little interest or pleasure in doing things?" The screening test is scored by counting the number of "yes" responses (range=02). Haggman, PTJ, 2004

Solid Line-2 questions Dashed Line-PT judgment

Outcome Measures

Outcome Measures Factors for evaluationReliabilityAre measures consistent?ValidityDoes it measure what its supposed to measure?ResponsivenessAbility to detect changeMinimum Detectable ChangeHas real change occurred? Minimum Clinically Important DifferenceSmallest change that is important to patients

Outcome Measures Oswestry Disability Questionnaire (ODQ) Region specific measure of disability Modified version contains 10 items Each item scored 0 5 Items are summed and expressed as a percentageHigher numbers indicate greater disability 10% - mild disability from low back pain 65% - extreme disability from low back pain

Oswestry QuestionnaireSelf Report of Performance LimitationPersonal HygieneLiftingWalkingSittingStanding

SleepingSocial ActivityTravelingSex LifePain IntensityScale: 0 - 5Score for 10 items = 50Multiply Score by 2/100% = Disability

Modified version: Sex life question is replaced by employment/homemaking ability

Oswestry ReliabilityEstablished as good to excellentValidityEstablishedResponsivenessGoodMinimum Detectable Change10.5 points (Davidson, 2002)Minimum Clinically Important Difference6 points (Fritz, 2001)

Outcome Measures Quebec Back Pain Disability Scale Region specific measure of disability 20 itemsrate degree of difficultyEach item scored 0 5 Items are summed and expressed as a percentageHigher numbers indicate greater disability Score range: 0-100

Quebec ReliabilityEstablished as good to excellentValidityEstablishedResponsivenessGoodMinimum Detectable Change15 points (Davidson, 2002)Minimum Clinically Important Difference15 points (Fritz, 2001)

Outcome Measures Roland-Morris Disability Questionnaire Region specific measure of disability Scale contains 24 items Because of my back pain, I lie down to rest more oftenEach item scored 0 or 1 Items are summed for final scoreHigher numbers indicate greater disability Score range: 0-24

Roland-Morris ReliabilityConflicting (ICC=.53-.86)ValidityEstablishedResponsivenessUnable to detect improvement in half the peopleMinimum Detectable Change9 points (Davidson, 2002)Minimum Clinically Important DifferenceNot available

Outcome Measures Patient Specific Functional Scale Patient specific measure of disability Patients nominate 3 important activities that they are unable to perform or have difficulty with as a result of their LBP Each activity is scored on a 0 10 scale 0=inability to perform the activity 10=ability to perform activity at pre-injury levelTotal score/number of activitiesLower scores indicate greater disability

Patient Specific Functional Scale ReliabilityEstablishedValidityEstablishedResponsivenessGood responsivenessMinimum Detectable Change2 points (Stratford, 1995)Minimum Clinically Important DifferenceNot available

Outcome Measures Medical Outcomes Short Form-36 (SF-36)a generic self-administered questionnaire used to examine health in the following eight domains: bodily pain, physical function, role limitations due to physical problems, general health, vitality, social function, role limitations due to social problems and mental health. Scores on each scale were transformed into 0-100 scales with higher scores representing better health status.

SF-36 Two subscale scores representing overall physical and mental health were also examined Physical Component Summary Scale (PCS)Mental Component Summary Scale (MCS)Norm-based scoring: each scale scored has the same average of 50 and standard deviation of 10 pointsAny score below 50 would represent health status that is below average compared to the rest of the population.

SF-36 Psychometric properties have been well established at every level. In LBP patients, Physical Functioning Subscale (10 items) has been evaluatedMDC is 16 points Validation of the 36-Item Short-Form Health Survey (Hebrew Version) in the Adult Population of IsraelLewin-Epstein et al, 1998

Outcome Measures Self-Report vs. Observed MeasuresLow to moderate agreement between measuresSalen showed a moderate correlation (r=.48) between patients self-reported difficulty in performing tasks and observer assessment After the patients actually performed the tasks, the correlation increased to r=.78Tends to be a mismatch between how patients believe they function and how they actually function

Therefore, consider supplementing self-report with observational measures

Outcome Measures Back Performance Scale (Strand, PTJ, 2002)Observed measure of mobility-related activities in people with LBP

Consists of five tests

Back Performance ScaleReliabilityEstablishedValidityDiscriminates between pts with different return to work statusHigher for LBP than other MSK painResponsivenessHigh in pts who RTW (effect size:1.33) and low in others (.31)Minimum Detectable ChangeNot availableMinimum Clinically Important DifferenceNot available

Medical History Questions

Medical History Constant Pain, Unrelated to Position or MovementSevere Night Pain Unrelated to MovementRecent Unexplained Weight Loss of >10lbsHistory of Direct Blunt TraumaAppears Acutely Ill (pale, fever, malaise)Abdominal Pain/Radiation to Groin (blood in urine)

Medical HistorySexual DysfunctionRecent Menstrual IrregularitiesBowel or Bladder DysfunctionFecal or Urinary Incontinence/RetentionRectal BleedingTemperature >100 FResting Pulse > 100 bpm

Treatment-Based ClassificationThree levels of classification need to be made by the therapist:1. First Level: Is the patient appropriate for physical therapy management? 2. Second Level: What is the level of acuity? (staging the patient)3. Third Level: What treatment should be used? (classification)

Appropriate for Physical TherapyRequires ConsultationRequires ReferralLumbosacral symptoms of primarily mechanical originMedicalPsych-ologicalMedical/ SurgicalPsych-ologicalFirst Level Classification

HistoryLevel I: Specific Questions

Screening/Outcome MeasuresMedical History FormModified Oswestry Questionnaire (OSW)Fear-avoidance Beliefs Questionnaire (FABQ)Pain Diagram

Why Self-report Forms?Saves timeStandardized questionsScreen for medical diseaseTrack change over timeClassification

Are there any red flags?Are there any yellow flags?NONOYESYESReferral/Consult with a Medical Specialist Referral/Consult with Psychological/ Vocational SpecialistPROCEED to SECOND LEVEL CLASSIFICATION

RED FLAGSSigns of fracture:Major traumaMinor trauma or strain in elderly or osteoporoticSigns of infection/osteomyelitis:Recent fever, chills, unexplained weight lossRecent bacterial infection, IV drug abuse, immune suppression

RED FLAGSSigns of cauda equina syndrome:Paresthesia of 4th sacral dermatome (saddle region)Alteration in bowel or bladder function (increased frequency, overflow incontinence, etc.)Sexual DysfunctionSevere or progressive neurological deficits

Cauda Equina Syndrome Necessitates Immediate Referral!

RED FLAGSScreening questions for risk of ankylosing spondylitis: Morning stiffness Improvement with activity Age < 40 years Local SIJ tenderness Pain not relieved when supine Paraspinal muscle spasm

RED FLAGSScreening questions for risk of cancer:Age over 50 years (or less than 20 years)Prior history of cancerUnexplained weight lossNo relief with treatment over past monthConstant pain, no relief with bed restNight pain disturbing sleepSevere pain unaffected by posture or position

Cancer as a Cause of Back Pain, Deyo, J. Internal. Med, 1988 (n=1935)

Cancer as a Cause of Back Pain, Deyo, J. Internal. Med, 1988 (n=1935)

Screening for Yellow FlagsYellow flags are factors that increase the risk of developing, or perpetuating long-term disability and work loss associated with low back pain. (Kendall et al, 1997)

First-Order ClassificationMedical pathology referring pain to lumbar spine Recognizable pathological spine lesionsTrue psychopathologyPsychological influence

First-Order ClassificationPsychological influence chronic LBP Non-organic questionnaire Pain in non-anatomical locationsAbnormal pain behaviors Pain diagram Wide spread/diffuse pain reports Drawn in non-anatomical locations

First-Order ClassificationPossibly organic pain diagram(Chan et al, Spine, 1993)

First-Order Classification Non-organic pain diagram(Chan et al, Spine, 1993)

Nonorganic SignsOverreaction

Disporportinate verbalization, facial expressions, muscle tension, collapsing, sweating, during the examination

Nonorganic SignsTenderness

Non-anatomicSuperficial

Nonorganic SignsSimulation

Axial LoadingTrunk Rotation

Nonorganic SignsDistraction

Straight Leg Raise (SLR)Supine vs. Seated

Nonorganic SignsRegional

WeaknessSensory Loss

Nonorganic Symptom DescriptorsDo you get pain in your tailbone?Do you have numbness in your entire leg (front, side, and back) at the same time?Do you have pain in your entire leg (front, side, and back) at the same time?

Does your whole leg give way?Have you had any time during this episode when you have very little back pain?Have you had to go to the ER due to back pain?Has all treatment for your back pain made you worse?

Abnormal Illness BehaviorMaladaptive overt illness related behavior which is out of proportion to the underlying physical disease and more readily attributable to associated cognitive and affective disturbances

Purpose of Nonorganic TestingWhen the test is negative, they can rule out abnormal illness behaviorNot intended to rule in only identify those at risk for unsuccessful treatment outcome

Fritz 2000 Acute LBP2 or more signs3 or more symptoms7 combined Gives greatest prediction of failure in return to work in 4wks BUT not good for use in Acute cases

First-Order ClassificationIf positive, then Associated with poor outcomes in chronic LBP(Uden, Spine, 1988)An indication of magnified illness behavior?Not synonymous with malingering Warrants additional testing in physical examination Non-organic signsMay need to consider consultation with other healthcare professional

First-Order ClassificationPsychological influence acute LBP Psychosocial factors predict chronic LBP(Gatchel et al, Spine, 1995 and Burton et al, Spine, 1995)

Pain catastrophizing, kinesiophobia, fear-avoidance and depression are specific psychosocial factors involved in the development and maintenance of chronic LBP

First-Order ClassificationPain CatastrophizingScreen with the Pain Catastrophizing ScaleNo specific cut-point available to identify this factorMean score for LBP patients: 28.2 (s.d.=12.3)What to do?Modify treatment approach Consult with other health care professional

First-Order ClassificationFearScreen with FABQ and TSKUse given cut-pointsWhat to do?Modify treatment approach Consult with other health care professional

First-Order ClassificationDepressive SymptomsScreen with 2 questions If positive (score of 1+)What to do?Consult with other health care professional

First-Order Classification Potential outcomes Suspect or known red flag (less than 1%)Refer to other health care professionalYellow flag (between 10 40%) Actively engage in demystification, education, and activation (exercise with modifications)Include other health care professional No yellow or red flags (greater than 50%)Manage with unmodified TBC physical therapy

**********************************************************************************Show screening forms from CD 1st, then show Deyo table*Show from CD and discuss their use*********45% of subjects responded with a dramatic improvement, thus a pre-test probability of 45%. Using the positive likelihood ratio, the probability of a dramatic improvement among this subgroup of patients increased from 45% to 95% when at least 4/5 of the criteria were met.*45% of subjects responded with a dramatic improvement, thus a pre-test probability of 45%. Using the positive likelihood ratio, the probability of a dramatic improvement among this subgroup of patients increased from 45% to 95% when at least 4/5 of the criteria were met.*45% of subjects responded with a dramatic improvement, thus a pre-test probability of 45%. Using the positive likelihood ratio, the probability of a dramatic improvement among this subgroup of patients increased from 45% to 95% when at least 4/5 of the criteria were met.*******************