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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 – PowerPoint PPT presentation

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Title: Treatment Based Classification of the Spine- An Evidence Based Journey for the Physical Therapist


1
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

2
Evaluation of Fear Avoidance and Other
Psychosocial Issues Related to LBP
3
Traditional Medical Model
Identification and Treatment of Lesion
for LBP
Health
4
Is There An Alternative Model?
5
Vicious Cycle of Pain
Kori et al, 1990 Vlaeyen et al, 1995 Elfving et
al, 2007
6
Psychosocial Variables
  • Maintenance and/or development of chronic LBP
  • Pain Catastrophizing
  • Kinesiophobia
  • Fear-avoidance beliefs
  • Specific to low back pain
  • More evidence suggesting they are involved in the
    acute to chronic transition
  • Depressive symptoms

7
Pain Catastrophizing
8
Pain Catastrophizing
  • An exaggerated negative interpretation of pain
    which might occur during actual or anticipated
    pain experience (Sullivan et al, 2001)
  • Associated with increased pain intensity and
    disability
  • More 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)

9
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 Interpretation
  • 13 questions, 5 point likert scale
  • 0totally disagree 4totally agree
  • Total scores range from 0-52
  • Higher scoreshigher degree of catastrophizing
  • Validity and reliability are established

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

11
Kinesiophobia
12
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)

13
Tampa Scale of Kinesiophobia (TSK)
  • TSK is a 17 item questionnaire developed as a
    measure of fear of movement/(re)injury
  • Scale is based on the model of fear avoidance,
    fear of work related activities, and fear of
    movement
  • Also linked to elements of catastrophic thinking
  • Validity and reliability have been established
  • Shown to be strongly related to a lifting task
    and perceived disability in people with acute LBP
    (Swinkels-Meewisse et al, 2006)

14
Tampa Scale of Kinesiophobia (TSK)
  • Scoring and Interpretation
  • 17 questions, 4 point likert scale
  • 1strongly disagree 4strongly agree
  • Total score calculated after inversion of items
    4, 8, 12 and 16
  • Total scores range from 17-68
  • Higher scoreshigher degree of kinesiophobia
  • gt37 is considered high (Vlaeyen, 1995)
  • Recommended to use total score rather than
    subscales

15
Tampa Scale of Kinesiophobia (TSK)
  • 2 subscales
  • Harm subscale (items 3,5,6,9,11,15)
  • There is something seriously wrong with the body
  • Activity Avoidance subscale
  • Avoiding activity might prevent increased pain
  • Used for people with LBP, fibromyalgia, MSK
    injuries and whiplash associated disorders
  • Access-May be downloaded free at
  • http//www.worksafe.vic.gov.au/wps/wcm/resources/f
    ile/eb5c6742bb4ae48/tampa_scale_kinesiophobia.pdf

16
Fear-avoidance theory
17
Fear-Avoidance Model of Exaggerated Pain
Perception (Lethem, et al. Behav Res Ther, 1983)
  • Pain perception
  • Sensory component of pain
  • Physiological response
  • Nocioceptive input
  • Emotional reaction component of pain
  • Psychological response
  • Pain experience, pain behavior, and physiological
    response

18
Pain Perception
19
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 pain
  • Fear of pursuing physical activity
  • Two scales
  • FABQ-PA - Physical activity, 4 questions (0-24)
  • FABQ-W - Work, 7 questions (0-42)
  • Higher numbers indicate higher fear-avoidance

20
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
21
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

22
Management Guidelines
  • Proposed by Vlaeyan and Linton (2000)
  • Identify (screen) for elevated fear avoidance
    beliefs
  • Appropriate education modifications
  • Appropriate exercise modifications

23
Cut-Off Scores
Cutoff Score Subjects Above Sn (95 CI) Sp (95 CI) LR (95 CI) LR- (95 CI)
29 44 0.95 (.87, 1.0) 0.58 (.45, .71) 2.28 (1.65, 3.16) 0.08 (0.01, 0.54)
34 21 0.55 (.34, .75) 0.84 (.73, .94) 3.33 (1.65, 6.77) 0.54 (.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)
24
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

25
Determining Prognosis
Pre-test Probability Not Returning to Work (29)
Post-test Probability Not Returning to Work (58)
Perform FABQ-W (LR 3.33)
Rule-in
26
Determining Prognosis
  • This patient with work related low back pain and
    a positive FABQ-W test result (score gt 34) has
    a 58 chance of not returning to work in
    four-weeks.

27
Determining Prognosis
  • Patient with work-related LBP
  • Want to estimate the probability of NOT returning
    to work after four weeks of treatment
  • Ruling out
  • Administer FABQ-W
  • Score on questionnaire is 18

28
Determining Prognosis
Pre-test Probability Not Returning to Work (29)
Post-test Probability Not Returning to Work (3)
Perform FABQ-W (LR- 0.03)
Rule-out
29
Determining Prognosis
  • This patient with work related low back pain and
    a negative FABQ-W test result (score lt 24) has
    a 3 chance of not returning to work in
    four-weeks.

30
Determining Prognosis
  • Guidelines for general orthopedic populations
  • FABQ-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 lt 7
  • Negative LR 0.27
  • FABQ-W lt 11
  • Negative LR 0.11

31
Intervention Guidelines
  • Encourage 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
    pain
  • Addressing the way the patient participates in
    rehabilitation protocols
  • Turn avoiders into confronters

32
Education Modifications
  • unambiguously 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)

33
Education Modifications (Burton et al, Spine,
1999)
Handy Hints The Back Book
Biomedical concepts of spine anatomy, injury, and damage No sign of serious disease or suggestion of permanent damage
The spine is weak and avoid activity when in pain The spine is strong and pain does not mean your back has serious damage
Encourages patient to be passive Encourages positive attitudes and coping
Describes further intervention, including surgery Numerous treatments are available, but relief depends on your effort
Concentrates on pain, not activity Concentrates on activity to restore normal function
34
Study Design(George et al, Spine, 2003)
  • Randomized clinical trial
  • Patients referred to outpatient physical therapy
  • Study criteria
  • Inclusion Ages 18 55 LBP for 8 weeks or
    less English speaking
  • Exclusion Tumor, fracture, infection,
    osteoporosis, nerve root compression, recent
    surgery, and pregnancy

35
Treatment Arms (George et al, Spine, 2003)
36
George et al, Spine, 2003
  • Measures
  • Disability ODQ
  • Pain Intensity
  • FABQ
  • Timing
  • Pre Treatment
  • 4 weeks
  • 6 months
  • Results
  • Interaction between FABQ and Treatment type
  • If have high FABQ and got FABQ treatment saw less
    disability
  • If have low FABQ no benefit with FABQ treatment
    (graded exercise may have been too slow?)

37
Summary of Study
  • The problem and a potential solution
  • Fear-avoidance theory
  • Measurement of fear-avoidance beliefs
  • Management of the patient with elevated
    fear-avoidance beliefs
  • Identification
  • Education modifications
  • Exercise prescription modifications

38
FAMEPP(Fear Avoidance Model of Pain Perception)
  • Graded Exposure
  • Exposing patient to specific situations that they
    are fearful of during the course of PT
  • Graded Exercise
  • Consistently increasing patients exercise
    tolerance throughout course of PT

39
Graded Exposure
  • Determine activities that pt is fearful of using
    Fear of Daily Activities Questionnaire
  • 2 highest rated activities are used
  • Patient decides at what level (duration,
    frequency, intensity) activity is begun to avoid
    high levels of fear
  • PT incorporates these activities into the rehab
    process
  • Vlaeyen, Behav Res Ther, 2001

40
Graded Exposure
  • PT 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)

41
Graded Exercise
  • Operant Conditioning
  • A behavior that is immediately and systematically
    followed by something pleasant(positive
    reinforcement) will tend to be increased or
    strengthened
  • If the consequences that follow the behavior are
    not pleasant or favorable, the behavior will
    probably weaken or cease
  • Fordyce

42
Graded Exercise Programs
  • Quota Driven Exercise Program
  • Intensity
  • Duration
  • Exercise Frequency
  • Exercise to Quota is Goal
  • Sub Tolerance
  • Exercise followed by something pleasant (ie rest)
  • Not something unpleasant (ie pain)
  • Teaching it is safe to move and increase activity

43
Graded Exercise
  • Exercises are Selected
  • Baseline trial and the patient exercises to
    tolerance
  • Quota is below baseline (75 of baseline)
  • Quotas are increased systematically

44
Progressions
  • Positive Reinforcement
  • Rest
  • Verbal Encouragement
  • Met Quota
  • Increase Quota by 10 or greater
  • Did not Meet Quota
  • No Reinforcement
  • Emphasis on Importance of Meeting Quota

45
Patient CaseFear Avoidance Treatment
  • 42 yo male with c/o left LBP that radiates into
    his left buttock and anterior and medial portion
    of leg
  • Deep ache and constant in LB
  • Stabbing and intermittent in leg
  • HPI Injured 2 weeks earlier while lifting a
    heavy suitcase into car

46
Patient CaseFear Avoidance Treatment
  • MRI HNP without n. root compromise at L4-L5
    level
  • Sxs worsen
  • Prolonged sitting
  • As day progresses
  • Sxs improve
  • Lying flat on back
  • Spends most of time like this and has drastically
    limited his activities

47
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48
Patient CaseFear Avoidance Treatment
  • Injury was not work-related, therefore used the
    FABQ-Physical Activity Scale
  • FABQ-PA 21/24
  • 15 or greater is considered high
  • Likely an avoider

49
Patient CaseFear Avoidance Treatment
  • Plan of Care
  • Repeated lumbar extension movements
  • Graded Exercise prescription
  • Fear-Avoidance based patient education
  • Twice/week for 4 weeks

50
Treatment of Fearful Patients
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53
Discussion Points
  • Only scratched the surface
  • Catastrophizing, other psychosocial interventions
  • Can we change
  • Attitudes and beliefs
  • Malingerers, head cases, high maintenance, etc.
  • Behaviors
  • Follow the evidence
  • Consequences of not changing

54
Depressive Symptoms
55
Depressive Symptoms
  • Depression is common in patients with low back
    pain (Main, 1992)
  • Associated with
  • increased pain intensity
  • increased physical and psychosocial disability
  • increased medication use
  • and increased likelihood of unemployment
  • Sullivan, 1992

56
Depressive Symptoms
  • It is not clear which comes first, depression or
    LBP
  • But, it is clear that the presence of depression
    in patients with LBP leads to worse outcomes
  • Therefore, PTs need to know how to identify
    depressive symptoms
  • Not able to diagnose depression

57
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)

58
Depressive Symptoms
  • Brief 2-item screening test for symptoms of
    depression taken from the Primary Care Evaluation
    of Mental Disorders Procedure
  • The 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 (range02).
  • Haggman, PTJ, 2004

59
Solid Line-2 questions Dashed Line-PT
judgment
60
Outcome Measures
61
Outcome Measures
  • Factors for evaluation
  • Reliability
  • Are measures consistent?
  • Validity
  • Does it measure what its supposed to measure?
  • Responsiveness
  • Ability to detect change
  • Minimum Detectable Change
  • Has real change occurred?
  • Minimum Clinically Important Difference
  • Smallest change that is important to patients

62
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 percentage
  • Higher numbers indicate greater disability
  • 10 - mild disability from low back pain
  • 65 - extreme disability from low back pain

63
Oswestry QuestionnaireSelf Report of Performance
Limitation
  • Personal Hygiene
  • Lifting
  • Walking
  • Sitting
  • Standing
  • Sleeping
  • Social Activity
  • Traveling
  • Sex Life
  • Pain Intensity

Scale 0 - 5 Score for 10 items 50 Multiply
Score by 2/100 Disability Modified version
Sex life question is replaced by
employment/homemaking ability
64
Oswestry
  • Reliability
  • Established as good to excellent
  • Validity
  • Established
  • Responsiveness
  • Good
  • Minimum Detectable Change
  • 10.5 points (Davidson, 2002)
  • Minimum Clinically Important Difference
  • 6 points (Fritz, 2001)

65
Outcome Measures
  • Quebec Back Pain Disability Scale
  • Region specific measure of disability
  • 20 itemsrate degree of difficulty
  • Each item scored 0 5
  • Items are summed and expressed as a percentage
  • Higher numbers indicate greater disability
  • Score range 0-100

66
Quebec
  • Reliability
  • Established as good to excellent
  • Validity
  • Established
  • Responsiveness
  • Good
  • Minimum Detectable Change
  • 15 points (Davidson, 2002)
  • Minimum Clinically Important Difference
  • 15 points (Fritz, 2001)

67
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
    often
  • Each item scored 0 or 1
  • Items are summed for final score
  • Higher numbers indicate greater disability
  • Score range 0-24

68
Roland-Morris
  • Reliability
  • Conflicting (ICC.53-.86)
  • Validity
  • Established
  • Responsiveness
  • Unable to detect improvement in half the people
  • Minimum Detectable Change
  • 9 points (Davidson, 2002)
  • Minimum Clinically Important Difference
  • Not available

69
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
  • 0inability to perform the activity
  • 10ability to perform activity at pre-injury
    level
  • Total score/number of activities
  • Lower scores indicate greater disability

70
Patient Specific Functional Scale
  • Reliability
  • Established
  • Validity
  • Established
  • Responsiveness
  • Good responsiveness
  • Minimum Detectable Change
  • 2 points (Stratford, 1995)
  • Minimum Clinically Important Difference
  • Not available

71
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.

72
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
    points
  • Any score below 50 would represent health status
    that is below average compared to the rest of the
    population.

73
SF-36
  • Psychometric properties have been well
    established at every level.
  • In LBP patients, Physical Functioning Subscale
    (10 items) has been evaluated
  • MDC is 16 points
  • Validation of the 36-Item Short-Form Health
    Survey (Hebrew Version) in the Adult Population
    of Israel
  • Lewin-Epstein et al, 1998

74
Outcome Measures
  • Self-Report vs. Observed Measures
  • Low to moderate agreement between measures
  • Salen 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.78
  • Tends to be a mismatch between how patients
    believe they function and how they actually
    function
  • Therefore, consider supplementing self-report
    with observational measures

75
Outcome Measures
  • Back Performance Scale (Strand, PTJ, 2002)
  • Observed measure of mobility-related activities
    in people with LBP
  • Consists of five tests

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Back Performance Scale
  • Reliability
  • Established
  • Validity
  • Discriminates between pts with different return
    to work status
  • Higher for LBP than other MSK pain
  • Responsiveness
  • High in pts who RTW (effect size1.33) and low in
    others (.31)
  • Minimum Detectable Change
  • Not available
  • Minimum Clinically Important Difference
  • Not available

79
Medical History Questions
80
Medical History
  • Constant Pain, Unrelated to Position or Movement
  • Severe Night Pain Unrelated to Movement
  • Recent Unexplained Weight Loss of gt10lbs
  • History of Direct Blunt Trauma
  • Appears Acutely Ill (pale, fever, malaise)
  • Abdominal Pain/Radiation to Groin (blood in urine)

81
Medical History
  • Sexual Dysfunction
  • Recent Menstrual Irregularities
  • Bowel or Bladder Dysfunction
  • Fecal or Urinary Incontinence/Retention
  • Rectal Bleeding
  • Temperature gt100 F
  • Resting Pulse gt 100 bpm

82
Treatment-Based Classification
  • Three 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)

83
First Level Classification
Appropriate for Physical Therapy
Requires Consultation
Requires Referral
Lumbosacral symptoms of primarily mechanical
origin
Medical
Psych-ological
Medical/ Surgical
Psych-ological
84
History
  • Level I Specific Questions

85
Screening/Outcome Measures
  • Medical History Form
  • Modified Oswestry Questionnaire (OSW)
  • Fear-avoidance Beliefs Questionnaire (FABQ)
  • Pain Diagram

86
Why Self-report Forms?
  • Saves time
  • Standardized questions
  • Screen for medical disease
  • Track change over time
  • Classification

87
Referral/Consult with a Medical Specialist
Are there any red flags?
YES
NO
Referral/Consult with Psychological/ Vocational
Specialist
Are there any yellow flags?
YES
NO
PROCEED to SECOND LEVEL CLASSIFICATION
88
RED FLAGS
  • Signs of fracture
  • Major trauma
  • Minor trauma or strain in elderly or osteoporotic
  • Signs of infection/osteomyelitis
  • Recent fever, chills, unexplained weight loss
  • Recent bacterial infection, IV drug abuse, immune
    suppression

89
RED FLAGS
  • Signs of cauda equina syndrome
  • Paresthesia of 4th sacral dermatome (saddle
    region)
  • Alteration in bowel or bladder function
    (increased frequency, overflow incontinence,
    etc.)
  • Sexual Dysfunction
  • Severe or progressive neurological deficits
  • Cauda Equina Syndrome Necessitates Immediate
    Referral!

90
RED FLAGS
  • Screening questions for risk of ankylosing
    spondylitis
  • Morning stiffness
  • Improvement with activity
  • Age lt 40 years
  • Local SIJ tenderness
  • Pain not relieved when supine
  • Paraspinal muscle spasm

91
RED FLAGS
  • Screening questions for risk of cancer
  • Age over 50 years (or less than 20 years)
  • Prior history of cancer
  • Unexplained weight loss
  • No relief with treatment over past month
  • Constant pain, no relief with bed rest
  • Night pain disturbing sleep
  • Severe pain unaffected by posture or position

92
Cancer as a Cause of Back Pain, Deyo, J.
Internal. Med, 1988 (n1935)
93
Cancer as a Cause of Back Pain, Deyo, J.
Internal. Med, 1988 (n1935)
94
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Screening for Yellow Flags
  • Yellow 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)

98
First-Order Classification
  • Medical pathology referring pain to lumbar spine
  • Recognizable pathological spine lesions
  • True psychopathology
  • Psychological influence

99
First-Order Classification
  • Psychological influence chronic LBP
  • Non-organic questionnaire
  • Pain in non-anatomical locations
  • Abnormal pain behaviors
  • Pain diagram
  • Wide spread/diffuse pain reports
  • Drawn in non-anatomical locations

100
First-Order Classification
Possibly organic pain diagram (Chan et al, Spine,
1993)
101
First-Order Classification
Non-organic pain diagram (Chan et al, Spine,
1993)
102
Nonorganic Signs
  • Overreaction
  • Disporportinate verbalization, facial
    expressions, muscle tension, collapsing,
    sweating, during the examination

103
Nonorganic Signs
  • Tenderness
  • Non-anatomic
  • Superficial

104
Nonorganic Signs
  • Simulation
  • Axial Loading
  • Trunk Rotation

105
Nonorganic Signs
  • Distraction
  • Straight Leg Raise (SLR)
  • Supine vs. Seated

106
Nonorganic Signs
  • Regional
  • Weakness
  • Sensory Loss

107
Nonorganic Symptom Descriptors
  • Do 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?

108
Abnormal Illness Behavior
  • Maladaptive overt illness related behavior which
    is out of proportion to the underlying physical
    disease and more readily attributable to
    associated cognitive and affective disturbances

109
Purpose of Nonorganic Testing
  • When the test is negative, they can rule out
    abnormal illness behavior
  • Not intended to rule in only identify those at
    risk for unsuccessful treatment outcome
  • Fritz 2000 Acute LBP
  • 2 or more signs
  • 3 or more symptoms
  • 7 combined Gives greatest prediction of failure
    in return to work in 4wks BUT not good for use in
    Acute cases

110
First-Order Classification
  • If 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 signs
  • May need to consider consultation with other
    healthcare professional

111
First-Order Classification
  • Psychological 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

112
First-Order Classification
  • Pain Catastrophizing
  • Screen with the Pain Catastrophizing Scale
  • No specific cut-point available to identify this
    factor
  • Mean score for LBP patients 28.2 (s.d.12.3)
  • What to do?
  • Modify treatment approach
  • Consult with other health care professional

113
First-Order Classification
  • Fear
  • Screen with FABQ and TSK
  • Use given cut-points
  • What to do?
  • Modify treatment approach
  • Consult with other health care professional

114
First-Order Classification
  • Depressive Symptoms
  • Screen with 2 questions
  • If positive (score of 1)
  • What to do?
  • Consult with other health care professional

115
First-Order Classification
  • Potential outcomes
  • Suspect or known red flag (less than 1)
  • Refer to other health care professional
  • Yellow 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
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