Course Title: Maximizing Functional Outcomes in the Evaluation and Treatment of
Chronic Low Back Pain and Knee Osteoarthritis
Time/ Location: Thursday, April 16, 2015 from 8am-noon and from 2-5pm at the
Wisconsin Physical Therapy Association Spring Conference at the Olympia Resort in
Oconomowoc, WI.
Course Description: In the current environment of health care reform, high co-pays,
increased utilization review, and required outcome reporting, the busy clinician is
required to create measureable functional change at each clinical visit. In order to be
successful in this time of change, clinicians must provide cost-effective, efficient,
patient-centered care. This course is designed for the busy outpatient orthopaedic
clinician who wants to improve their ability to create measureable, patient-centered,
functional change at each visit. Emphasis will be placed on translating research
evidence into efficient clinical treatment of patients with chronic low back pain and
patients with knee osteoarthritis. Participants will learn how to best develop a
“therapeutic alliance” with their patients in order to maximize the non-specific effects of
treatment. This course is unique in that it that focuses on both the clinician and patient
perspective with a goal of immediately improving the patient experience of care
(including quality and satisfaction).
Course Objectives: The participant will:
•
•
•
•
•
•
Recognize the role of the physical therapist as a primary care provider for patients
with chronic low back pain and knee osteoarthritis
Understand the difference between specific treatment effects and non-specific
treatment effects
Develop the ability to self-reflect and enhance one’s ability to maximize non-specific
treatment effects during each patient encounter.
Decrease unwarranted practice variations and improve functional outcomes in the
treatment of chronic low back pain and knee osteoarthritis
Translate and integrate current research evidence into the efficient treatment of
patients with chronic low back pain and knee pain
Discuss the importance of risk-adjustment and patient-reported outcome data
collection during episodes of care as it relates to improved reimbursement of care for
patients with low back and knee pain.
Speaker Bio:
J.W. Matheson PT, DPT, MS, SCS, OCS, CSCS is a 1996 graduate of the Mayo Clinic
of Health Sciences. J.W. is a 2001 graduate of the first public APTA Credentialed Sports
Physical Therapy residency at Gundersen-Lutheran Sports Medicine in Onalaska, WI.
He is both a board certified specialist in sports physical therapy and a board certified
1
specialist in orthopaedic physical therapy. J.W. completed his transitional DPT degree
from the Massachusetts General Hospital Institute of Health Professions in 2005.
Dr. Matheson is a respected author and clinical researcher. He has authored and coauthored several peer-reviewed research articles on specific exercises for the knee and
shoulder and has recently published several manuscripts on the topic of rehabilitation
outcomes. J.W. integrates clinical outcomes and functional measurements into his daily
clinical practice and is currently working with several payers on different models of
reimbursement based on rehabilitation outcomes. He has presented nationally at
conferences on the integration of patient reported and functional outcomes into clinical
practice.
Dr. Matheson is President and Clinic Director of Catalyst Sports Medicine. This is a
private outpatient physical therapy practice and sports performance center located in
Hudson, Wisconsin. J.W. is an active member of the American Physical Therapy
Association (APTA) and serves on several legislative and research committees locally
and nationally.
Matheson
WPTA Spring Conference 2015
2
Maximizing Functional
Outcomes in the
Evaluation and
Treatment of Chronic
Low Back Pain and
Knee Osteoarthritis
J.W. Matheson PT, DPT
Board Certified Sports and Orthopaedic
Physical Therapist
Contact Information
J.W. Matheson, PT, DPT, MS, OCS, SCS, CSCS
[email protected]
President / Clinic Director
Catalyst Sports Medicine
Hudson, Wisconsin 54016
785-386-1155
www.catalystsportsmedicine.com
EIP Consulting
Evidence Informed Practice = Excellence In Practice
[email protected]
952-807-6877
Presenter Disclosure Informa2on James W. Matheson, PT, DPT, MS, SCS, OCS, CSCS
Catalyst Sports Medicine
FINANCIAL DISCLOSURE:
Royalties: Stretching Charts, Inc. (VHI Kits)
Discounted EMR Software: Hands on Technology
Consultant: Hands on Technology
OTHER DISCLOSURES:
Blogger: PT Inquest, FOTO®
No Conflicts with this presentation
4 Who We Are …… Where We Work Hudson, WI Matheson
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WPTA Spring Conference 2015
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Our 2013 Pre-‐Movie Commercial Why do we do what we do? •  Keeping people in the “Game of Life!” •  “Always dream and shoot higher than you know you can do. Don't bother just to be beSer than your contemporaries or predecessors. Try to be beSer than yourself.” -‐William Faulkner •  You got to have some fun! Herb Kirk 1895 -‐ 2001 Somecmes Accng Like a Professional is Half the BaSle! 2013 MASTERS WORLD RECORDS Outdoor Mile Time Name Year Women's 75 -‐ 79 Men's 75 -‐ 79 6:58.44 Jeanne Daprano 2012 5:41.80 Ed Whitlock 2006 Women's 80 -‐ 84 9:00.52 Gerry Davidson 2001 Men's 80 -‐ 84 6:26.6 David Carr 2008 Women’s 85-‐89 11.03.11 Gerry Davidson 2006 Division Men's 95 -‐ 99 14:48.2 Herb Kirk 1990 Men’s 100 11:53.45 Fauja Singh 2011 Some Sta2s2cs •  Musculoskeletal diseases, which include back pain, arthrics, bodily injuries, and osteoporosis, are reported by persons in the U.S. more than any other health condicon. •  In 2004, the escmated total cost of treatment and lost wages associated with musculoskeletal diseases was $849 billion, equal to 7.7 percent of the gross domescc product (GDP). hSp://www.boneandjointburden.org/pdfs/
bmus_execucve_summary_low.pdf Matheson
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Some Sta2s2cs Some Sta2s2cs •  In 2004, 25.9 million persons lost an average of 7.2 days of work due to back pain, a total of 186.7 million work days lost that year. •  Research currently less than 2% of the NIH budget, while burden of musculoskeletal condicons expected to escalate in the next 10-‐20 years due to the aging populacon, and sedentary lifestyles. hSp://www.boneandjointburden.org/pdfs/
bmus_execucve_summary_low.pdf •  Musculoskeletal impairments generate 4 cmes the number of oﬃce visits related to the digescve system. •  Musculoskeletal injuries are a cri2cal na2onal health problem. Praemer et al, Musculoskeletal Condicons in the United States, 1999 A Key Ques2on for Our Profession…… •  Who should be the key ﬁrst provider for the inical evaluacon and treatment of these localized musculoskeletal condicons? – The Primary Care Physician – The Physical Therapist – The Chiropractor – The Physiatrist Status of Musculoskeletal Knowledge in Medical Educa2on •  In 1998, Freedman and Bernstein found that 82% of medical school graduates failed a 25 quescon competency examinacon in musculoskeletal medicine •  Among the 85 graduates tested, the average cme spent in rotacons or courses devoted to orthopedics in medical school was 2.1 weeks •  One third of these examinees graduates without any formal training in orthopedics Matheson
•  Musculoskeletal impairments result in the greatest number of oﬃce visits to doctors (respiratory is next). •  Musculoskeletal impairments generate nearly 2 cmes the number of oﬃce visits related to the circulatory system. Who has the adequate educa2on to evaluate and treat musculoskeletal problems? •  Matzkin E, et al. Adequacy of Educacon in Musculoskeletal Medicine. J Bone Joint Surg Am. Feb 2005;87-‐A(2):310-‐314. •  Freedman KB, Bernstein J. Educaconal deﬁciencies in musculoskeletal medicine. J Bone Joint Surg Am. Apr 2002;84-‐A(4):604-‐608. •  Freedman KB, Bernstein J. The adequacy of medical school educacon in musculoskeletal medicine. J Bone Joint Surg Am. Oct 1998; 80(10):1421-‐1427. Status of Musculoskeletal Knowledge in Medical Educa2on In 2005, Matzkin et al gave the same examinacon to 334 volunteers made up of medical students, residents, and staﬀ physicians The average examinacon score was 57% Only 21% passed the exam (passing deﬁned as a score > 73%) WPTA Spring Conference 2015
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Status of Musculoskeletal Knowledge in Medical Educa2on •  Of the sixty-‐nine with a passing score, forty (58%) were orthopaedic residents and staﬀ physicians with an overall average score of 94%. •  The average score was 69% for the 124 parccipants who stated that they had taken a required or an eleccve course in orthopedics during their training compared with an average score of 50% for the 210 who had not taken an orthopaedic eleccve Ques2on Number 23 •  What muscle(s) is/are involved in lateral epicondylics (tennis elbow)? •  Resident’s mean score: 18% Ques2on Number 6 •  A pacent comes to the oﬃce complaining of low-‐back pain that wakes him up from sleep. What two diagnoses are you concerned about? •  Resident’s mean score: 33% Primary Care MD Knowledge of Musculoskeletal Disorders •  Quesconnaire results indicated that local physicians felt relacvely uncomfortable with common musculoskeletal condicons –  4.2/10 Likert conﬁdence scale for musculoskeletal condicons –  9/10 Likert conﬁdence scale for non-‐musculoskeletal condicons •  “Findings suggest a disparity between rural primary care physicians' self-‐assessed musculoskeletal knowledge and skill and the levels they require for their praccce.” Lynch et al, Am J Orthop, 2005. Primary Care MD Knowledge of Musculoskeletal Disorders •  Recent study examined performance on the Freedman musculoskeletal competency test amongst ER physicians •  23 ER residents and twenty-‐one aSending ER MDs completed the survey •  35% of residents and 43% of aSending physicians failed the examinacon •  Pass rates were not signiﬁcantly diﬀerent amongst junior residents, senior residents or aSending physicians PTs and Musculoskeletal Diagnosis •  Childs, J. D., J. M. Whitman, et al. (2005). A descripcon of physical therapists' knowledge in managing musculoskeletal condicons. BMC Musculoskelet Disord 6(1): 32. – Random sampling of 174 PT students – 182 experienced PTs completed the 25-‐item short answer Freedman musculoskeletal competency test – Experienced PTs had higher levels of knowledge in managing musculoskeletal condicons than medical students, physician interns and residents, and all physician specialists except for orthopedists Comer et al, Journal of Orthopaedic Trauma, 2014. Matheson
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PTs and Musculoskeletal Diagnosis Physical Therapists and Imaging •  Moore, JH et al, Clinical diagnoscc accuracy and magnecc resonance imaging of pacents referred by physical therapists, orthopaedic surgeons, and non-‐orthopaedic providers. Journal of Orthopaedic and Sports Physical Therapy. 2005;35(2):67-‐71. •  US Army physical therapists can order imaging studies Childs et al., BMC Musculoskelet Disord 6(1): 32 •  This study was a retrospeccve analysis of 560 pacents referred for MRI over an 18 month period •  Comparison between clinical diagnosis and MRI ﬁndings •  Compared clinical diagnoscc accuracy between PTs, Orthopaedic surgeons, and non-‐
orthopaedic providers at Keller Army Community Hospital Have we changed since 1997? •  Turner, P. and T. W. Whiuield (1997). "Physiotherapists' use of evidence based praccce: a cross-‐naconal study." Physiother Res Int 2(1): 17-‐29. –  Quesconnaire completed by 321 physiotherapists in England and Australia –  90% of each groups choice of techniques reﬂected what was taught during their inical training –  Experience of treatment eﬀects on prior pacents, and informacon gained in praccce-‐related courses, were also primary reasons Physical Therapists and Imaging 100%
Percent Accuracy of Diagnosis and
Imaging Findings
Physical Therapists and Imaging 90%
80%
80.8%
70%
60%
50%
35.4%*
40%
30%
20%
10%
0%
Physical
Therapists
Orthopaedists
Nonorthopaedic
Providers
*Significantly different
Unwarranted Praccce Variacons •  “To generate wide‑spread change, the need to idencfy and reduce unwarranted variacon must be placed at the center of commissioning decision‑making, and also needs to be a priority for clinicians and pacents.” •  QIPP/Right Care. The NHS atlas of variacon in healthcare. 2010. www.rightcare.nhs.uk/atlas/ –  Research literature ranked least in importance as a basis for choosing techniques, and review arccles fared liSle beSer Matheson
74.5%
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Major tool to ﬁght these variacons Evidence Based Medicine (EBM) •  EBM has an extremely posicve inﬂuence on the praccce of medicine, but it has its limitacons. •  Evidence Based Medicine (EBM) •  Large clinical databases and clinical registries •  Risk adjusted outcome measurement tools •  EBM fails to properly deal with medical modalices for which the sciencﬁc plausibility ranges from very liSle to nonexistent. –  (FOTO™) –  We must stand up and be measured Science Based Medicine (SBM) Evidence Based Medicine (EBM) •  As currently praccced: •  A tool to improve the eﬀeccveness of EBM – EBM appears to worship clinical trial evidence above all else •  SBM is not a replacement for evidence-‐
based medicine (EBM), but it does importantly emphasize some neglected aspects of EBM. – EBM completely ignores basic science consideracons, relegacng them to the lowest form of evidence, lower than even small case series Why PTs Believe Silly Things Pseudoscience •  Pseudosciencﬁc intervencons are rehabilitacon beliefs or praccces that are presented as sciencﬁc, but do not adhere to a valid sciencﬁc method, lack supporcng evidence or plausibility, cannot be reliably tested, or otherwise lack sciencﬁc status. “Tooth Fairy Science” •  “PaSernicity" or apophenia – seeing paSerns when none exist •  Post hoc ergo propter hoc (correlacon ≠ causacon) •  Conﬁrmacon bias – “Backﬁre eﬀect” •  Anecdotal experience Matheson
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Pseudosciencﬁc A & E in England Have we changed since 1997? •  Carter RE, Stoecker J. Descriptors of American Physical Therapy Associacon physical therapist members' reading of professional publicacons. Physiother Theory Pract. Nov 2006;22(5):263-‐278. –  Only 10% of respondents cited a peer-‐reviewed published arccle as having been most inﬂuencal to their praccce –  Only educators or clinicians enrolled in a transiconal DPT program reported using peer reviewed arccles for “research ideas” –  Even in 2007, non peer-‐reviewed publicacons appear to be more of an inﬂuence upon praccce than peer-‐reviewed journal arccles When You Think of a PT….. Do We Have Brand Name Recogni2on ? •  Do you think of: – A professional? – A movement sciencst? – A musculoskeletal diagnosccian? – An acute care provider for low back pain? OR •  Do you think of a massage therapist, a technician, a Pilates instructor, or a personal trainer? •  WHAT DO YOUR PATIENTS THINK? hSp://www.moveforwardpt.com/ Matheson
WPTA Spring Conference 2015
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9
Professional Links for Physical Therapists
Conflict: Shameless Self Promotion
 www.apta.org
 www.orthopt.org
Google: “PT Inquest”
 www.spts.org
50 Podcasts – each reviewing
1-2 journal articles
Blogs / Discussion Forums for Physical Therapists
 http://www.bodyinmind.org/
Type “PT Inquest” in iTunes
 http://www.noijam.com
@EIPConsult
 http://www.ptnow.org/Default.aspx
A Brief Exercise Before We Begin…. #DPTstudent
#solvePT
Navigators •  DescripLon: Focused learners who chart a course for learning and follow it. •  CharacterisLcs: Focus on the learning process that is external to them by relying heavily on planning and •  monitoring the learning task, on idencfying resources, and on the criccal use of resources. •  Instructor: Schedules and deadlines are helpful. Outlining objeccves and expectacons, summarizing main points, giving prompt feedback, and preparing instrucconal situacons for subsequent lessons. Problem Solvers Engagers •  DescripLon: Learners who rely heavily on all the strategies in the area of criccal thinking. •  CharacterisLcs: Test assumpcons, generate alternacves, praccce condiconal acceptance, as well as adjust their learning process, use many external aids, and idencfy many of the resources available. •  Instructor: Provide an environment of pracccal experimentacon, give examples from personal experience, and assess learning with open-‐ended quescons and problem-‐solving accvices. Matheson
•  DescripLon: Passionate learners who love to learn, learn with feeling, and learn best when accvely engaged in a meaningful manner. •  CharacterisLcs: Must have an internal sense of the importance of learning to them personally before ge}ng involved in learning. Once conﬁdent of the value of learning, likes to maintain a focus on the material to be learned. Operates out of the aﬀeccve domain related to learning. •  Instructor: Provide an atmosphere that creates a relaconship between the learner, the task, and the teacher. Focus on learning rather than evaluacon and encourage personal exploracon for learning. Group work also creates a posicve environment. WPTA Spring Conference 2015
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Assessing The Learning Strategies of AdultS (ATLAS) 1
Matheson
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Navigators
Navigators are focused learners who chart a course for learning and follow it. These learners
initiate a learning activity by looking externally at the utilization of resources that will help them
accomplish the learning task and by immediately beginning to narrow and focus these resources.
They rely heavily on planning their learning, and their motto is ‘‘Plan the work; work the plan.’’
They are constantly striving for improvement, and consequently everything in the learning
environment relates to achieving efficiency and effectiveness.
Navigators have a demand for order and structure, are logic oriented, are objective, and are
perfectionists. In learning situations, they like structure and are highly organized, want schedules
and deadlines, desire clear learning objectives and expectations, and like summaries and recaps
at the end and advanced organizers at the beginning of the learning activity. They use many
organizational tools such as colored markers, staples, and binders. They expect and appreciate
prompt feedback and will often clarify the details of a learning task several times. Navigators are
results oriented and seek logical connections. For them, emotions are not a consideration in
learning, and liking the teacher and subject are not important. Consequently, they tend not to like
group work unless it is led by an expert because they hate slackers and feel that they can often do
the work more efficiently by themselves.
Navigators put much internal pressure on themselves by seeking perfection, are hyper-critical of
errors they make, and often need a period of time to deal effectively with criticisms of their
work.
Problem Solvers
Problem Solvers rely on critical thinking skills. Like Navigators, Problem Solvers initiate a
learning activity by looking externally at available resources; however, instead of narrowing the
options available, they immediately begin to generate alternatives based on these resources.
Problem Solvers are storytellers who elaborate extensively on stories about their experiences
because these provide concrete examples for learning. Because they are constantly seeking
alternatives, most of their learning activities relate to generating alternatives. Because they are
open minded to so many learning possibilities, they often have difficulty making decisions.
Consequently, they do not do well on multiple-choice tests because these limit divergent
thinking, and Problem Solvers procrastinate because it allows thinking to continue. Once they
are interrupted in the learning process, they have difficulty in starting it again. While Navigators
see it as a failure, Problems Solvers view trial and error as a process for generating more
alternatives. Because they are curious, inventive, and intuitive, learning is an adventure for
Problem Solvers and is one that they prefer to do in their own way without rigidity or didactic
orders. Of the three learning strategy preference groups, the Problem Solvers are the most
comfortable dealing with abstract ideas, and they often think in terms of symbols. Problem
Solvers are very confident of their own abilities and will often ask questions in class just to help
others understand better even if they do not want to know the answer. Problem Solvers are very
descriptive and detailed in their answers and insist on using many examples to explain an idea.
As a result, they are storytellers who enjoy the process of telling the story more than worrying
Matheson
WPTA Spring Conference 2015
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about its completion; although they may seem sometimes to get lost in the details, they will
eventually ‘‘boomerang’’ back to the main point of their story. The motto for Problems Solvers
is ‘‘Ask them what time it is, and they will build you a clock’’
Engagers
Engagers are passionate learners who love to learn, learn with feeling, and learn best when they
are actively engaged in a meaningful manner with the learning task; ‘‘the key to learning is
engagement – a relationship between the learner, the task or subject matter, the environment, and
the teacher’’ While the Navigators and Problems Solvers use the cognitive process of identifying
resources to start a learning task, Engagers initiate a learning activity from the affective domain;
that is, before they will begin a learning task, they involve themselves in the reflective process of
determining internally that they will enjoy the learning task enough that it is worth doing. The
motto for learning for Engagers is that , ‘‘It is FUN!!’’ For Engagers, everything in the learning
process relates to building relationships with others. Feelings are the key for the Engagers, and
this is reflected in the use of emotional words and terms with feeling such as love and fun.
Learning has an aura of excitement for Engagers, and they fully immerse themselves in the
learning once they engage in it. They seek and find joy in the learning process and delight in new
accomplishments. However, they can get bored quickly. To avoid this, the instructor needs to
have them actively engaged in the learning and must remember that Engagers are as interested in
the process of learning and the relationships that are built during this process as they are in the
academic outcomes of the learning. Unlike Problem Solvers, Engagers are not interested in
developing new or abstract ways of doing things; instead, they will often take the path of least
resistance to get to a final result or they will utilize shortcuts created by others because these
things allow more time and energy for concentrating on the dynamics of the learning process.
Engagers are excellent networkers who love group work. They tend to develop an emotional
affinity with the teacher and have a hard time separating themselves from their work; a positive
relationship with the instructor can be a catalysis for engagement for them. Because the central
feature of learning for Engagers is building relationships, they rely heavily on human resources.
1.
Conti GJ. Development of a user-friendly instrument for identifying the learning strategy
preferences of adults. Teaching and Teacher Education. 2009;25(6):887-896.
Matheson
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You Don’t Know What
You Don’t Know!
Understanding Patient Reported
Outcome Measures in Order to
Improve Care and Provide
Measureable Value
J.W. Matheson, PT, DPT, MS, OCS, SCS, CSCS
President / Clinic Director
Board Certified in Sports and Orthopaedic Physical Therapy
Catalyst Sports Medicine and Physical Therapy
Hudson, WI
[email protected]
Consultant
EIP Consulting
Evidence Informed Practice = Excellence In Practice
[email protected]
2
Health Care Costs Increasing …
•  The IHI Triple Aim is a framework developed by the Ins9tute for Healthcare Improvement that describes an approach to op9mizing health system performance. 1.  Improving the pa9ent experience of care (including quality and sa9sfac9on) 2.  Improving the health of popula9ons 3.  Reducing the per capita cost of health care. n In 1970, U.S. health care spending was
about $75 billion, or $356 per resident,
and accounted for 7.2% of GDP.
n In 2011 CMS projects that by 2020,
health care spending will be over $4.6
trillion, or over $14,000 per resident,
and account for over 20% of GDP.
4
A million seconds is 12 days
A billion seconds is 31 yrs
A trillion seconds is 31,688 yrs
Matheson
•  With a population of approximately 314
million people, you could give away $1
trillion by giving every man, woman and
child in the U.S. $ 3,185 each.
•  We could hire 1.8 million additional
teachers
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Themes in Health Care Reform Recently in the News….
Expansion of Coverage •  Preven9on and wellness, Medicaid expansion, exchanges, nondiscrimina9on n  Accountable Care Organizations (ACO)
Reﬁning / Changing Payment Methodologies •  Cuts in payment rates, reﬁnements to payment Linking Payment to Quality •  Value based purchasing, hospital readmissions policy, electronic health records, registries n  ACOs have been proposed as a means of
controlling health care costs. Physicians
and other health care professionals still
receive fees for services but get bonuses
for saving money while maintaining quality.
7
Linking Payment to Quality •  Some requirements for adequate measurement of “quality outcomes.” – Need to be able to assess individual as well as single and mul9-‐prac9ce performance – Need to be able to compare prac9ces and therapists seeing diﬀerent pa9ent/payer mixes Program Integrity Possible Value-Based Scenario
Linking Payment to Quality
Few
Visits
Average
Visits
High
Visits
Great Outcomes
Bonus
Bonus
Regular
Average Outcomes
Bonus
Regular
Less
Regular
Less
Less
Utilization = Outcome change / # of visits
Utilization = Avg amount of functional change per visit
A liXle side story……. Thoughts: Just because we get great outcomes doesn’t necessarily mean we are avoiding unwarranted prac7ce varia7ons. To discuss this, let’s use the example of shoulder manual therapy and improved pa7ent outcomes Matheson
•  Provider Enrollment •  Funding Increases for Enforcement •  Expansion of Audits (RACs) Integrated Models of Care •  Bundling – Innova9on in Programs •  Accountable Care Organiza9ons •  Medical Homes CSI: "Where every client is a partner"
Low Outcomes
– Need to be able to recognize the importance of using outcome data to drive your prac9ce systems, pa9ent assessment instruments WPTA Spring Conference 2015
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What should be measured?
n 
Impairments?
n 
Clinician measures?
n 
Patient reported measures?
13
14
¡  Unlike
clinician-based measures that
emphasize pathophysiology and
impairments, patient-based outcome
measures assess the functional status and
level of disability of the patient from the
patient’s perspective and provide
information regarding what is important
to him or her
¡  In
the past, clinicians have
emphasized the use of clinicianbased measures of outcome, such
as range-of-motion and strength,
as opposed to patient-based
outcomes
15 16 Number of Appropriate Constructs one Needs to Measure • Pain • Func9on • Generic Health Status • Work Disability • Pa9ent Sa9sfac9on (with current situa9on) ¡  It
will likely take several PRO
instruments to give one a sense of
a patients perceived HRQoL and all
it’s constructs
§  Low Back Pain
▪ SF-36, Oswestry, FABQ, Beck Depression
Inventory, PSFS, etc
Bombardier, Spine, 2000. 17 Matheson
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¡  Clinicians
need a combination of
reported measures:
§  Patient Reported Outcomes (PROs)
§  Impairment Measures (ROM, strength)
§  Physical Performance Measures
▪  (6MWT, hop tests, LEFT)
§  Think of giving each patient a report card (A+)
¡  The
LEFS, WOMAC, 6MWT, and
TUG were administered to 85
patients pre-arthroplasty and once
at 9-13 weeks postarthroplasty
21 ¡  Self-report
22 measures as dependent variables
¡  6MWT,
TUG, and occasion (pre-arthroplasty or
post-arthroplasty) were independent variables
¡  3 propositions were examined:
§  (1) the relationship between self-report and
performance measures is identical across occasions
§  (2) the relationship differs between occasions, but is
consistent
§  (3) the relationship is not consistent
23 Matheson
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¡ 
For a given 6MWT distance or TUG time, patients
reported substantially greater functional status levels
for the LEFS and WOMAC-PF post-arthroplasty
compared with pre-arthroplasty
¡ 
The magnitude of the systematic difference was
similar for both performance test reference standards
Conclusion:
Dependence on scores of self-report
measures alone, without knowledge
of the magnitude of the identified
systematic differences, will result in
over-estimating the ability of patients
to move around post-arthroplasty.
§  For the LEFS, the difference was approximately 11 points
for patients who received a TKA and 13 points for patients
who received a THA.
§  For the WOMAC-PF, the difference was approximately 12
points for patients who received a TKA and 19 points for
patients who received a THA
26 25 SHOW ME THE
PATIENT REPORTED
OUTCOMES!
Which One!? 100 • There are over spine-‐related, “life healthcare
is like a box of
chocolates, because you never know what
oriented you’re going to get.”
outcomes measures reported in the literature 27
Lower Extremity Functional Scale
“life is like a box of chocolates, because you never know
what you’re going to get.”
Lower Extremity Functional Scale
n 
n 
Based on the research by Riddle et, al,
Physical Therapy, 1999 one can recognize:
n 
n 
n 
n 
Standard Error of Measurement (SEM) is ± 3.9
Error at any single point in time is ± 5.3
Minimal Detectable Change is 9
Minimally clinically important difference is 9
35 year old recreational runner with
diagnosis of anterior knee pain
n 
n 
n 
Administered the LEFS on the first visit and scores
a 50/80
Based on the error at any time of 5 points, you
can be 90% certain that the actual score is
between 45 and 55
The short-term goal becomes:
n 
“Increase LEFS score to 60/80 in 3 weeks.”
29
Matheson
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18
¡  “The PSFS was developed by Stratford ¡  Chatman
AB, Hyams SP, Neel JM,
et al. The Patient-Specific
Functional Scale: measurement
properties in patients with knee
dysfunction. Physical Therapy,
1997;77:820-829.
and colleagues to provide a method for eliciting, measuring, and recording descriptions of patients‘ disabilities” ¡  “The PSFS is intended to complement the ﬁndings of generic or condition-‐speciﬁc measures” Chatman et al, Physical Therapy, 1997;77:820-829. 31 ¡  The minimal level of detectable change for an individual item reported for the PSFS: §  Neck pain (Informed) = 1.18 pts
§  Low back pain (Informed) = 0.96 points
§  Knee pain (uninformed) = 2.5 points
§  In general MID = 2 points of change
Westaway, Physical Therapy, 1998 SchmiX and AbboX, Phys Ther, 2014 •  Global Ra9ng of Change – GROC –  Examined close to 9000 pa9ents with a knee disorder from FOTO™ database –  Correla9ons of GROC with intake and discharge scores indicated a strong bias toward discharge status but conﬁrmed the strong bias toward discharge status. •  Conclusions -‐ These results call into ques9on the validity of GROCs for measuring change over 9me in rou9ne clinical prac9ce. Matheson
WPTA Spring Conference 2015
19
SO NOW WHAT???
n 
n 
SO NOW WHAT???
We have well established PRO
measures that we can use?
n 
So do we just need to give these to
each patient at the first and last visits
and be done ….
n 
n 
If it was only this easy…
What about the private practice in the
urban clinic in Lakewood neighborhood of
Atlanta, the private practice in rural
Georgia, versus the private practice in the
Buckhead uptown neighborhood of Atlanta?
Can you compare the Oswestry and other
patient reported data between these three
practices?
38 0 Percent (NADA) Must Risk Adjust Results
n 
n 
• How many 9mes CMS adjusts payment rate because of case mix or severity of illness • No assessment of co-‐morbidi9es You can’t compare my outcomes to Joe’s
outcomes! I treat more complicated
patients!
• This This Need an “Apples to Apples” comparison in
order to truly compare clinicians, clinics,
practices and geographic regions
39
Chertow GM. Am J Med. 2000;108:666-‐668. In Order to Risk Adjust
and Capture All The Data
Must Risk Adjust Results
n 
vs Raw, non-risk adjusted functional status
(FS) scores are affected by many factors
n 
n 
n 
Effectively collects data from the patient
n 
Age
Symptom Acuity
n 
n 
Patient selection bias
n 
n 
Requires an Electronic Database
1. 
Patient demographics
n 
n 
n 
Why did patient choose your clinic?
Did you get a complete set of data on patient?
2. 
Treatment interventions
Computer Adaptive Test (CAT) format
Uses Item Response Theory to capture data
Asks the minimal set of questions to get an
answer
Can be integrated into an Electronic
Medical Record (EMR)
41
Matheson
WPTA Spring Conference 2015
42
20
Patient Inquiry® by FOTO, Inc
Outcome Software Options in 2008
n 
Patient Inquiry® by Focus On Therapeutic
Outcomes, Inc. (FOTO™) www.fotoinc.com
n 
n 
n 
n 
Activity Measure – Post Acute Care (AM-PAC®) by
Crecare™ www.crecare.com/ampac.html
OPTIMAL® by the APTA and Cedaron™
n 
n 
www.apta.org/OPTIMAL/
43
n 
Oldest database - established in 1993
# of outcome surveys in FOTO database as of
December September 2012 was 5,146,943 and
growing
Over 3 Million CATs administered in the United
States and Israel via close to 1700 clinics
Substantial (> 85 articles) published research
History Leading to New CATs
COMPUTER ADAPTIVE
TESTING (CAT)
• Focus on Therapeutic Outcomes
(FOTO™) Patient Inquiry® Software
• Boston University Activity Measure for
Post Acute Care (AM-PAC™)
n 
1999, FOTO® began development of first CATs
n 
First CATs were general at first, but they quickly
evolved to clinically logical condition specific CATs
n 
Now have three papers published papers on
validity of body part specific CATS
n 
CMS P4P report supports validity and
responsiveness of measures, and two papers
currently under review
46
History Progression Summary
n 
Want a measure of function that is
n 
n 
n 
n 
n 
n 
Reliable and valid
As sensitive to change as possible,
Uses few questions, and
Is clinically relevant to patients and clinicians
Condition specific measures are more
sensitive to change, clinicians use them,
and CATs are efficient
47
Matheson
The Knee CAT as an Example
n 
Hart DL, Wang YC, Stratford PW,
Mioduski JE. Computerized adaptive
test for patients with knee impairments
produced valid and sensitive measures
of function. J Clin Epidemiology, 2008
Foundation was the Lower Extremity
Functional Scale by Binkley et al, 1999
WPTA Spring Conference 2015
48
21
Purposes & Patients
n 
n 
n 
To test the precision, sensitivity to change and
validity of the FS measures estimated using the
CAT (2005-2007)
To assess the number of items used during the
CAT
n 
1. 
2. 
21,896 patients (50±17 yrs, min 18, max 95, 37%
male) who were treated for their knee syndromes
in 291 outpatient clinics in 30 states
Hart et al, J Clin Epidemiology, 2008
Analyses
3. 
Intake and discharge CAT generated FS
measures were analyzed using:
Minimal detectable change (MDC)
Global rating of change data and receiver operating
characteristic (ROC) analyses to assess CAT FS measure
sensitivity to change
ANCOVAs to test CAT FS measures ability to discriminate
patients by symptom acuity, age, surgical history,
exercise history, number of functional comorbidities
Hart et al, J Clin Epidemiology, 2008
49
Results
n 
Results
Intakes used in study
n 
Completed from 2005 to 2007
n  21,896 intake CATs
n  44 ± 15 (out of 100) was mean functional
status score of all participants at intake
n 
n 
n 
n 
Effect size 1.18
Number of items in knee CAT:
Mean of 7 ± 3 items (vs. 20 of full LEFS)
Median of 6 items
n  Mean time of 2 minutes and 42 seconds to
complete
n 
n 
10,629 discharge CATs
61 ± 18 (out of 100) was mean functional
status score of all participants at discharge
Hart et al, J Clin Epidemiology, 2008
Responsiveness
n 
Discharge (Completion rate 49%)
n 
50
51
Hart et al, J Clin Epidemiology, 2007
52
Functional Status vs. Symptom Acuity: Knee
Must Risk Adjust Results
n 
One-way ANCOVA
F=77, P<.001
N=9,211
Therefore, How do you risk adjust
measures?
n 
Data collection and more data collection
n 
Statistics to first look at:
n 
n 
Subacute = -2.6 FSCH
Chronic = -6.1 FSCH
Effect of variable by itself (Univariate)
Effect of variable in overall prediction (Multivariate)
FSCH = Functional
status change points
Hart et al, J Clinical
Epidemiology, 2008
53
Matheson
WPTA Spring Conference 2015
54
22
Functional Status vs. Age: Knee
Functional Status vs. Surgery: Knee
One-way ANCOVA
F=85, P<.001
N=9,218
One-way ANCOVA
F=17, P<.001
N=10,040
1 surgery = 0 FSCH
2 surgeries = -1.5 FSCH
3 surgeries = -3.5 FSCH
>/= 4 surgeries = -5.0 FSCH
45 –64 yrs = -4.6 FSCH
> 65 yrs = -5.1 FSCH
FSCH = Functional
status change points
FSCH = Functional status
change points
Hart et al, J Clinical
Epidemiology, 2008
Hart et al, J Clinical
Epidemiology, 2008
55
Functional Status vs. Comorbidities: Knee
56
Biopsychosocial Model
Nonspecific Back Pain
One-way ANCOVA
F=101, P<.001
N=9,657
Disability
1 Cmbdty = -3.1 FSCH
2 Cmbdty = -5.5 FSCH
>/= 3 Cmbdty = -8.3 FSCH
Pain
FSCH = Functional status
change points
Green flags
Centralization
Hart et al, J Clinical
Epidemiology, 2008
57
Screening and targeting patients for specific
treatment interventions designed to reduce
these fears are recommended:
n 
n 
59
Matheson
n 
n 
International Forum Primary Care Research 2002
Clinical Guidelines e.g. Denmark, New Zealand, UK
Blue Flags
Occupational
factors
Black flags
Sociodemographic factors
Slide courtesy of Mark Werneke, PT
58
The Fear Avoidance Beliefs
Questionnaire (FABQ)
Elevated Pain -Related Fears
n 
Anatomical
Impairment
Yellow Flags
Psychosocial
factors
We have published a manuscript in the PT
journal showing fear avoidance independent of
body part
Also showed that just one triage question can
imply low or high fear avoidance beliefs
Hart DL, Werneke MW, George SZ, Matheson JW, Wang YC, Cook KF, Mioduski JE, Choi SW. Single items of fear-‐avoidance beliefs scales for work and physical activities accurately identiﬁed patients with high fear. Physical Therapy, 2010 WPTA Spring Conference 2015
60 23
Patient Inquiry® by FOTO, Inc
n 
USA Data
n  Database of over 3 million outpatient therapy
patients treated by more than 13,000
clinicians employed in more than 1800
outpatient departments and clinics across the
United States
n 
Risk Variables Influencing
Patient Outcome*
Gender
Age (years)
# Previous Surgeries
Care Type
Impairment Body Part
Acuity of this Episode
Payer Source
# of Comorbidities
Fear of Physical Activity
Patient A
Patient B
Male
31
0
Orthopaedic
Lumbar spine
Male
60
2
Orthopedic
Lumbar spine
Issues with Collecting Patient
Reported Outcomes
n 
0 to 7 days
3 to 6 months
Preferred Provider
Worker’s Compensation
None
Low
1 to 2
High
Prediction Data Following Patient Answering Questions on Computer
FOTO®** Functional Status Intake
45
45
Score (out of 100)
Oswestry Score
40%
40%
Predicted FOTO® Functional
32
11
Change Score (out of 100)
Predicted FOTO ® Outcome Score at
77
56
Discharge (out of 100)
Predicted total # of visits
8
12
Predicted duration of care
27 days
Approximately 15 percent of the patients in
the recent FOTO database are Medicare Part B
beneficiaries
Cherry Picking
n 
n 
Entering only the best patients
To avoid cherry picking
Need approx. > 80% or more of all
new patients entered into database
n  Must account for non-participation
of any patient not entered
n 
64
39 days
Issues with Collecting Patient
Reported Outcomes
n 
n 
THANK YOU FOR
YOUR TIME TODAY!
Floor or ceiling effects
A better model – What other risk
adjusted measures are needed?
65
Matheson
WPTA Spring Conference 2015
66
24
CLINICIAN TO READ AND FILL IN BELOW: Complete at the end of the history and
prior to physical examination.
Initial Assessment:
I am going to ask you to identify up to three important activities that you are unable to do or
are having difficulty with as a result of your __________ problem. Today, are there any
activities that you are unable to do or are having difficulty with because of your __________
problem? (Clinician: show scale to patient and have the patient rate each activity.)
Follow-up Assessment:
When I assessed you on (state previous assessment date), you told me that you had difficulty
with (read all activities from list at this time). Today, do you still have difficulty with: (read
and have patient score each item in the list)?
PATIENT-SPECIFIC ACTIVITY SCORING SCHEME (Point to one number):
0
1
2
3
4
5
6
Unable to
perform
activity
(Date and Score)
Activity
1.
8
9
10
Able to
perform
activity at
same level
as before
injury or
problem
Initial
2.
3.
4.
5.
Additional
Additional
Matheson
7
WPTA Spring Conference 2015
Matheson
WPTA Spring Conference 2015
SCORE: _____/ 80
Extreme Difficulty
or Unable to
Perform Activity
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Quite a Bit of
Difficulty
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Moderate
Difficulty
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Source: Binkley et al (1999): The Lower Extremity Functional Scale (LEFS): Scale development, measurement properties, and
clinical application. Physical Therapy. 79:371-383.
Minimum Level of Detectable Change (90% Confidence): 9 points
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Activities
Any of your usual work, housework, or school activities.
Your usual hobbies, re creational or sporting activities.
Getting into or out of the bath.
Walking between rooms.
Putting on your shoes or socks.
Squatting.
Lifting an object, like a bag of groceries from the floor.
Performing light activities around your home.
Performing heavy activities around your home.
Getting into or out of a car.
Walking 2 blocks.
Walking a mile.
Going up or down 10 stairs (about 1 flight of stairs).
Standing for 1 hour.
Sitting for 1 hour.
Running on even ground.
Running on uneven ground.
Making sharp turns while running fast.
Hopping.
Rolling over in bed.
Column Totals:
Today, do you or would you have any difficulty at all with:
A Little Bit of
Difficulty
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
No Difficulty
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are
currently seeking attention. Please provide an answer for each activity.
The Lower Extremity Functional Scale
25
26
Corrections
Appendix 1.
Modified Low Back Pain Disability Questionnairea
This questionnaire has been designed to give your therapist information as to how your back pain has affected your ability to
manage in everyday life. Please answer every question by placing a mark in the one box that best describes your condition
today. We realize you may feel that 2 of the statements may describe your condition, but please mark only the box that
most closely describes your current condition.
Pain Intensity
❑ I can tolerate the pain I have without having to use pain
medication.
❑ The pain is bad, but I can manage without having to take
pain medication.
❑ Pain medication provides me with complete relief from pain.
❑ Pain medication provides me with moderate relief from pain.
❑ Pain medication provides me with little relief from pain.
❑ Pain medication provides has no effect on my pain.
Personal Care (eg, Washing, Dressing)
❑ I can take care of myself normally without causing increased
pain.
❑ I can take care of myself normally, but it increases my pain.
❑ It is painful to take care of myself, and I am slow and
Standing
❑ I can stand as long as I want without increased pain.
❑ I can stand as long as I want, but it increases my pain.
❑ Pain prevents me from standing more than 1 hour.
❑ Pain prevents me from standing more than ½ hour.
❑ Pain prevents me from standing more than 10 minutes.
❑ Pain prevents me from standing at all.
Sleeping
❑ Pain does not prevent me from sleeping well.
❑ I can sleep well only by using pain medication.
❑ Even when I take pain medication, I sleep less than 6 hours.
❑ Even when I take pain medication, I sleep less than 4 hours.
❑ Even when I take pain medication, I sleep less than 2 hours.
❑ Pain prevents me from sleeping at all.
careful.
❑ I need help, but I am able to manage most of my personal
care.
❑ I need help every day in most aspects of my care.
❑ I do not get dressed, wash with difficulty, and stay in bed.
Lifting
❑ I can lift heavy weights without increased pain.
❑ I can lift heavy weights, but it causes increased pain.
❑ Pain prevents me from lifting heavy weights off the floor, but
I can manage if the weights are conveniently positioned
(eg, on a table).
❑ Pain prevents me from lifting heavy weights, but I can
manage light to medium weights if they are conveniently
positioned.
❑ I can lift only very light weights.
❑ I cannot lift or carry anything at all.
Walking
❑ Pain does not prevent me from walking any distance.
❑ Pain prevents me from walking more than 1 mile.b
❑ Pain prevents me from walking more than ½ mile.
❑ Pain prevents me from walking more than ¼ mile.
❑ I can only walk with crutches or a cane.
❑ I am in bed most of the time and have to crawl to the toilet.
Sitting
❑ I can sit in any chair as long as I like.
❑ I can only sit in my favorite chair as long as I like.
❑ Pain prevents me from sitting for more than 1 hour.
❑ Pain prevents me from sitting for more than ½ hour.
❑ Pain prevents me from sitting for more than 10 minutes.
❑ Pain prevents me from sitting at all.
a
b
Social Life
❑ My social life is normal and does not increase my pain.
❑ My social life is normal, but it increases my level of pain.
❑ Pain prevents me from participating in more energetic
activities (eg, sports, dancing).
❑ Pain prevents me from going out very often.
❑ Pain has restricted my social life to my home.
❑ I have hardly any social life because of my pain.
Traveling
❑ I can travel anywhere without increased pain.
❑ I can travel anywhere, but it increases my pain.
❑ My pain restricts my travel over 2 hours.
❑ My pain restricts my travel over 1 hour.
❑ My pain restricts my travel to short necessary journeys under
½ hour.
❑ My pain prevents all travel except for visits to the
physician/therapist or hospital.
Employment/Homemaking
❑ My normal homemaking/job activities do not cause pain.
❑ My normal homemaking/job activities increase my pain, but I
can still perform all that is required of me.
❑ I can perform most of my homemaking/job duties, but pain
prevents me from performing more physically stressful
activities (eg, lifting, vacuuming).
❑ Pain prevents me from doing anything but light duties.
❑ Pain prevents me from doing even light duties.
❑ Pain prevents me from performing any job or homemaking
chores.
© 2001 and 2007 American Physical Therapy Association.
1 mile=1.6 km.
January 2008
Matheson
Volume 88 Number 1 Physical Therapy ■ 139
WPTA Spring Conference 2015
Catalyst Sports Medicine - Catalyst Sports Medicine Physical Therapy
Functional Intake Summary
Patient Id #:
Patient:
Date of Birth:
Previous Episodes:
Primary Body Part:
Initial Date of Service:
Referrals:
Surgery Type:
Risk Adjustment Criteria
Gender: Male
Age: 43
Surgery: None
Care Type: Orthopedic
Impairment: Muscle, Tendon + Soft Tissue D...
Acuity: 15 - 21 days
Payer Source: Workers' Comp
Co morbidities: Two or Three
Fear: Low
Severity: Very Severe
TESTTEST6543218
PITT, BRAD
10/10/1969
No
Knee
9/22/2013
None
Not Applicable
Functional Status Measures:
Physical FS Primary Measure
PSFS Activ. #1
PSFS Activ. #2
Patient's Specific Functional Limitation:
27
Patient's
39
2/10
3/10
FOTO*
44
1. Taking care of kids
2. Playing golf with George
Rehabilitation Resource Predictor
FOTO Patients with similar risk adjusted parameters (Care type, Body Part/Impairment, Severity, Age, Acuity, Gender, Surgery, Fear, Payer
Source, and Co-morbidities) have utilized rehabilitation resource and experienced the following results:
FOTO Mean data
Change Score:
Physical FS Primary Measure
Physical FS Change
21
Statistics:
Visits per episode
12
Duration of episode
44
Satisfaction:
97.9 %
Patient reported:
Patient reports other health problems as: Allergies, Headaches.
BMI: 24 (Height: 70 inches, Weight: 170 lbs)
20 minutes of exercise prior to onset of condition are completed at least three (3) times a
week
Is not taking prescription medicine for this condition
Surgeries for this primary condition: None
Fear avoidance belief about physical activity = 26(8)
Patient responses to functional health questions that indicate dysfunction were as follows:
Activity (Question)
Walking two blocks?
Putting on your shoes or socks?
Getting into or out of a car?
Amount of Limitation (Response) at Intake
Quite a bit of difficulty
A little bit of difficulty
Moderate difficulty
Lifting an object, like a bag of groceries from the
floor?
Getting into or out of the bath?
Moderate difficulty
A little bit of difficulty
Produced and © 2001-2013 by
Matheson
Focus OnSpring
Therapeutic
Outcomes,
Inc.
WPTA
Conference
2015
Page 1
Functional Limitation
Mobility - G8978
Self Care - G8987
Changing & Maintaining Body
Position - G8981
Carrying, Moving & Handling
Objects - G8984
Changing & Maintaining Body
Position - G8981
Catalyst Sports Medicine - Catalyst Sports Medicine Physical Therapy
Functional Intake Summary
Patient Id #:
Patient:
Date of Birth:
Previous Episodes:
Primary Body Part:
Initial Date of Service:
Referrals:
Surgery Type:
Risk Adjustment Criteria
Gender: Male
Age: 43
Surgery: None
Care Type: Orthopedic
Impairment: Muscle, Tendon + Soft Tissue D...
Acuity: 15 - 21 days
Payer Source: Workers' Comp
Co morbidities: Two or Three
Fear: Low
Severity: Very Severe
TESTTEST6543218
PITT, BRAD
10/10/1969
No
Knee
9/22/2013
None
Not Applicable
FOTO Knee Survey
CMS G-Code Options**
Functional Limitations Assessed in FOTO Knee Survey
Current Goal
D/C
Status
Status
Status
Asked Descriptor
G8978
G8979
G8980
1
Mobility: walking & moving around functional limitation
G8981
G8982
G8983
2
Changing & maintaining body position functional limitation
G8984
G8985
G8986
1
Carrying, moving & handling objects functional limitation
G8987
G8988
G8989
1
Self care functional limitation
G8990
G8991
G8992
0
Other physical or occupational primary functional limitation
++
++
Only report if this is a one time visit
CMS Impairment/Limitation/Restriction for FOTO Knee Survey
Status Limitation
G-Code
CMS Severity Modifier
Intake
39%
61%
Current Status CL - At least 60 percent but less than 80 percent
Predicted
60%
40%
Goal Status
CK - At least 40 percent but less than 60 percent
D/C Status
CL **only report if this is a one time visit
+
+
Based on FOTO predicted change score
Clinician/Date/Time: MATHESON, JAMES
* Mean, Risk Adjusted, Intake Composite FHS measures from FOTO aggregate database.
** As indicated by the ICF assignments to the survey items in the FOTO survey used.
Produced and © 2001-2013 by
Matheson
28
Focus OnSpring
Therapeutic
Outcomes,
Inc.
WPTA
Conference
2015
Page 2
29
Who We Are ... Knee
Osteoarthritis:
The role of the
physical therapist
An Evidence Based PT
Course
J.W. Matheson DPT
Board Certified Sports and Orthopaedic
Physical Therapist
1
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
1 Clinic Director / Physical Therapist (Co-‐owner) 1 CEO (Co-‐Owner) 4 Physical Therapists (4/5 of our PTs are board cerDﬁed) 2 Physical Therapist Assistants 1 Licensed AthleDc Trainer 1 Strength and CondiDoning Coach 2 Physical Therapist Aide / Massage Therapist 2 Student Aides / RecepDonists (evening hours) 1 Billing Manager 1 Front Oﬃce Manager 5 Contract employees (ATCs / Strength Coaches) Knee Osteoar thritis
 Osteoarthritis is the most prevalent form
of arthritis, with an associated risk of
mobility disability (defined as needing
help walking or climbing stairs) for those
with affected knees being greater than
that due to any other medical condition
in people aged ≥ 65.
¡  Insertion
of coronary artery stents:
§  620,000 (2005); 528,000 (2009); 454,000 (2010)
¡  Coronary
artery bypass graft:
§  466,000 (2005); 415,000 (2009); 395,000 (2010)
¡  Total
knee replacement:
§  534,000 (2005); 676,000 (2009); 719,000 (2010)
¡  Total
hip replacement:
§  235,000 (2005); 327,000 (2009); 332,000 (2010)
Source: CDC NCHS Fast Statistics, 2009 Data
http://www.cdc.gov/nchs/fastats/insurg.htm
DramaDc Increase in Total Knee Arthroplasty Cannot be Explained by Aging PopulaDon •  “PopulaDon growth and obesity cannot fully explain the rapid expansion of total knee replacements in the last decade, suggesDng that other factors must also be involved.” ¡  Relieve
¡  Restore
function
•  “The disproporDonate increase in total knee replacements among younger paDents may be a result of a growing number of knee injuries and expanding indicaDons for the procedure.” ¡  Restore
mobility
Losina E, Thornhill TS, Rome BN, Wright J, Katz JN. The dramatic increase in total knee
replacement utilization rates in the United States cannot be fully explained by growth in
population size and the obesity epidemic. J Bone Joint Surg Am. Feb 1 2012;94(3):201-207.
Matheson
WPTA Spring Conference 2015
pain!!!
6 30
Knee Osteoar thritis
Osteoarthritis of the Medial Side of the Knee
  Osteoarthritis is a disease of the whole joint, not just
cartilage
  The diagnosis of osteoarthritis is based on clinical
presentation and supported by radiography
  There are effective non-pharmacological and
pharmacological treatments available for the management
of osteoarthritis; nonpharmacological treatments should
be tried first
  Surgical intervention should be considered when medical
treatment has failed
Radiograph Showing Osteoarthritis of the Medial Side of the Knee
Felson D. N Engl J Med 2006;354:841-848
Knee Osteoar thritis
  The reported prevalence of osteoarthritis varies
according to the method used to evaluate it
  About 6% of adults age ≥ 30 have frequent knee pain and
radiographic osteoarthritis
  Osteoarthritis is caused by aberrant local mechanical
factors acting within the context of systemic
susceptibility
  Systemic factors that increase the vulnerability of the
joint to osteoarthritis include increasing age, female sex,
and possibly nutritional deficiencies
Felson D. N Engl J Med 2006;354:841-848
Knee Osteoar thritis
  Epidemiological studies have shown a major genetic
component to risk that is probably polygenic, the genes
responsible have not yet been identified
  In people at risk, local mechanical factors such as
misalignment, muscle weakness, or alterations in the
structural integrity of the joint environment (such as
meniscal damage) facilitate the progression of the disease
  Loading can also be affected by obesity and joint injury,
both of which can increase the likelihood of developing
osteoarthritis or experiencing its progression.
Matheson
WPTA Spring Conference 2015
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Ann Fam Med. 2005 May-Jun;3(3):209-14.
Ann Fam Med. 2005 May-Jun;3(3):209-14.
"On
the basis of recommendations from national
clinical care guidelines for preventive services and
chronic disease management, and including the
time needed for acute concerns, sufficiently
addressing the needs of a standard patient panel of
2,500 would require 21.7 hours per day.”
“The problem of insufficient time indicates that primary
care requires broad, fundamental changes. The creation of
primary care teams that include members such as
physician assistants, nurse practitioners, dietitians, health
educators, and lay coaches is important to meeting
patients’ primary care needs."
Cottrell et al. BMC Family Practice, 2010
  Systematic review on the attitudes, beliefs and
behaviors of GPs regarding exercise for chronic
knee pain
  Although 99% of GPs agreed that exercise should
be used for CKP/KOA up to 29% believed that rest
was the optimum management approach.
  Reviews of actual practice revealed:
  Exercise advice 5% - 52%
  Physiotherapy referral 13% - 63%
“Despite the presence of numerous
consistent OA management
guidelines and some dissemination
attempts, clinical practice does not
reflect these recommendations.”
January 2011
Do We Have Brand Name Recognition ?
PT
Matheson
WPTA Spring Conference 2015
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LifeDme Risk and Age of Diagnosis of SymptomaDc Knee OsteoarthriDs in the USA Diagnosis of
Knee
Osteoarthritis
•  “EsDmated that the mean age of diagnosis of symptomaDc knee osteoarthriDs was 53.5 years (median age of 55 years)” •  “With half of the cases of symptomaDc knee OA diagnosed by the age of 55 years, the burden of future health care uDlizaDon for knee OA may be too high” 19
Osteoarthritis: Knee Criteria*
Clinical and Lab
Clinical and Imaging
Clinical
Knee Pain and
Knee Pain and
Knee Pain and
5 or more of these:
One or more of these:
3 or more of these:
Age > 50
Age > 50
Age > 50
Stiffness < 30 min
Stiffness < 30 min
Stiffness < 30 min
Crepitus
Crepitus
Crepitus
Bony tenderness
Plus osteophytes on
imaging
Bony tenderness
Bony enlargement
No palpable warmth
Losina E, Weinstein AM, Reichmann WM, et al. LifeDme risk and age of diagnosis of symptomaDc knee osteoarthriDs in the US. Arthri&s care & research. Nov 30 2012. Osteoarthritis: Knee Criteria
•  Knee ACR criteria
– Clinical and Lab
• Sensitivity 92%
• Specificity 75%
Bony enlargement
•  Knee ACR criteria
– Clinical and Imaging
• Sensitivity 91%
• Specificity 86%
•  Knee ACR criteria
– Clinical
• Sensitivity 95%
• Specificity 69%
No palpable warmth
ESR < 40 mm/hour
RF < 1:40
Synovial signs OA
*Altman et al. The ACR criteria for the classification and reporting of
osteoarthritis of the knee. Arthritis and Rheumatism, 1986;29:1039-49.
¡  Please
see handout in manual at end of unit
¡  Like
Altman criteria – Clinical diagnosis of knee
OA can be made
¡  In
Matheson
patient’s meeting criteria (Sn=99.6, Sp=93)
WPTA Spring Conference 2015
33
Clinical PracDce Guidelines (CPGs) Recommended Treatment Algorithm
•  Six current CPGs available at NaDonal Guideline Clearinghouse Database (www.guideline.gov) –  2013 AAOS revision CPG for knee OA •  h_p://www.aaos.org/Research/guidelines/guide.asp –  2013 American College of Rheumatology Guidelines •  h_ps://www.rheumatology.org/PracDce/Clinical/Guidelines/
Clinical_PracDce_Guidelines/ •  MulDple InternaDonal Guidelines –  OsteoarthriDs Research Society IniDaDve (OARSI) •  h_p://www.oarsi.org/educaDon/oarsi-‐guidelines Hunter DJ, Felson DT. BMJ 2006;332:639–42
2014
Matheson
WPTA Spring Conference 2015
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American Academy of Orthopaedic Surgeons (AAOS) 2013 Knee OA Guidelines American Academy of Orthopaedic Surgeons (AAOS) 2013 Knee OA Guidelines •  Exercise – strong evidence for eﬀec2veness •  Weight loss – moderate evidence for weight loss with a BMI > 25 •  Acupuncture – strong evidence against •  Physical agents (TENS, ultrasound, etc.) – inconclusive •  Manual therapy (chiroprac2c, massage) – inconclusive •  Valgus-‐direc2ng force brace – inconclusive •  Lateral wedge insoles – moderate evidence against •  Glucosamine and chondroi2n – strong evidence against •  NSAIDs – strong evidence for •  Acetaminophen, opioids, pain patches – inconclusive h_p://www.aaos.org/Research/guidelines/GuidelineOAKnee.asp h_p://www.aaos.org/Research/guidelines/GuidelineOAKnee.asp American Academy of Orthopaedic Surgeons (AAOS) 2013 Knee OA Guidelines American Academy of Orthopaedic Surgeons (AAOS) 2013 Knee OA Guidelines •  Intraar2cular cor2costeroid injec2ons – inconclusive •  Hyaluronic acid injec2ons – strong evidence against (and if injec2ons are ineﬀec2ve, those oral diet supplements certainly don’t have a chance) •  Growth factor injec2ons and/or platelet-‐rich plasma – inconclusive •  Needle lavage – moderate evidence against •  Arthroscopy with lavage and debridement – strong evidence against •  Par2al meniscectomy in osteoarthri2s pa2ents with torn meniscus – inconclusive •  Valgus-‐producing proximal 2bial osteotomy – limited evidence •  Free-‐ﬂoa2ng interposi2onal device – no evidence; consensus against h_p://www.aaos.org/Research/guidelines/GuidelineOAKnee.asp h_p://www.aaos.org/Research/guidelines/GuidelineOAKnee.asp Matheson
WPTA Spring Conference 2015
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Complementary and AlternaDve Medicine (CAM) •  Cross secDonal studies have found out that arthriDs is the most common reason for older adults to use CAM •  Nearly 1/3 of older adults reported using > 1 CAM modality for treaDng OA •  Persons with more severe pain or sDﬀness reported more CAM use •  Older adults with more co-‐morbidiDes were less likely to report use of dietary supplements What about
Supplements?
37
Yang S, Dube CE, Eaton CB, McAlindon TE, Lapane KL. Longitudinal use of complementary and alternaDve medicine among older adults with radiographic knee osteoarthriDs. Clinical therapeu&cs. Nov 2013;35(11):1690-‐1702. Glucosamine
•  Large molecule found in joint cartilage
Knee Osteoarthritis:
Glucosamine and Chondroitin
•  Plays role in production of collagen
•  Plays role in production of synovial fluid
lubricants
•  Supplements either harvested from shellfish
or produced synthetically
J.W. Matheson PT, MS, SCS, OCS, CSCS
39
Chondroitin
40
2003-2006 GAIT NIH Study
•  Naturally occurring chondroitin inhibits
the enzymes which normally break
down cartilage
•  May be used separately or in
conjunction with glucosamine as a
nutritional supplement
•  Glucosamine / Chondroitin Arthritis MultiCenter Intervention Trial
•  Compared 5 groups ( approx. N=300 each)
–  Placebo
–  Celebrex® (celecoxib)
–  1500 mg of glucosamine hydrochloride
daily
–  1200 mg of chondroitin sulfate daily
–  The above two in combination
41
Matheson
WPTA Spring Conference 2015
42
36
The GAIT NIH Study
•  Glucosamine and chondroitin sulfate were not
significantly better than placebo in reducing
knee pain by 20 percent
–  Response to placebo (60%)
–  Rate of response to glucosamine was 3.9% higher than
placebo
–  Rate of response to chondroitin sulfate was 5.3% higher
–  Rate of response to combined treatment was 6.5% higher
–  Rate of response to Celebrex was 10% higher
43
Recent News
Clegg et al, NEJM, 2006
The GAIT NIH Study
•  9/29/08 NICAM Headline
•  “On the basis of the results from GAIT,
it seems prudent to tell our patients with
symptomatic osteoarthritis of the knee
that neither glucosamine hydrochloride
nor chondroitin sulfate alone has been
shown to be more efficacious than
placebo for the treatment of knee pain.”
–  Dietary Supplements Glucosamine
and/or Chondroitin Fare No Better
than Placebo in Slowing Structural
Damage of Knee Osteoarthritis
–  Extension of Original GAIT study
45
46
The GAIT NIH Study
•  “Three months of treatment is a
sufficient period for the
evaluation of efficacy; if there is
no clinically significant
decrease in symptoms by this
time, the supplements should be
discontinued”
What’s in your
supplement?
47
Matheson
WPTA Spring Conference 2015
www.consumerlab.com
www.quackwatch.com
37
Complementary and AlternaDve Medicine (CAM) •  Cross secDonal studies have found out that Speaking of Placebo Response… arthriDs is the most common reason for older adults to use CAM •  Nearly 1/3 of older adults reported using > 1 CAM modality for treaDng OA •  Persons with more severe pain or sDﬀness reported more CAM use •  Older adults with more co-‐morbidiDes were less likely to report use of dietary supplements Yang S, Dube CE, Eaton CB, McAlindon TE, Lapane KL. Longitudinal use of complementary and alternaDve medicine among older adults with radiographic knee osteoarthriDs. Clinical therapeu&cs. Nov 2013;35(11):1690-‐1702. Moseley et al, NEJM, 2002 •  180 paDents with knee osteoarthriDs randomly assigned to receive either: – Arthroscopic debridement – Arthroscopic lavage – Placebo surgery •  Did he just say “placebo surgery?” Moseley et al, NEJM, 2002 •  Outcomes were assessed at mulDple points over a 24-‐month period – Three scales for pain – Two scales for funcDon – One test of stair walking and stair climbing •  A total of 165 paDents completed trial Matheson
Moseley et al, NEJM, 2002 •  PaDents in the placebo group received “skin incisions and underwent a simulated debridement without inser&on of the arthroscope” •  PaDents and assessors of outcome were blinded to the treatment group assignment Moseley et al, NEJM, 2002 •  At no point did either of the intervenDon groups report less pain or be_er funcDon than the placebo •  “The 95 % conﬁdence intervals for the diﬀerences between the placebo group and the intervenDon groups excluded any clinically meaningful diﬀerence” WPTA Spring Conference 2015
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A second NEJM study…….. Kirkley et al, NEJM, 2008 Kirkley et al, NEJM, 2008 •  A single-‐center, randomized, controlled trial of arthroscopic surgery in paDents with moderate-‐
to-‐severe osteoarthriDs of the knee •  PaDents were randomly assigned to: –  Surgical lavage and arthroscopic débridement together with opDmized physical and medical therapy –  Treatment with physical and medical therapy alone •  PaDent reported outcome measures (WOMAC, SF-‐36) at 2 years NO DIFFERENCE!!! Katz et al, NEJM, 2013 •  A mulDcenter, randomized, controlled trial involving symptomaDc paDents 45 years of age or older with a meniscal tear and evidence of mild-‐to-‐moderate knee osteoarthriDs on imaging •  Researchers randomly assigned 351 paDents to surgery and postoperaDve physical therapy or to a standardized physical-‐therapy regimen (with the opDon to cross over to surgery at the discreDon of the paDent and surgeon) •  PaDents were evaluated at 6 and 12 months. The primary outcome was the diﬀerence between the groups with respect to the change in the Western Ontario and McMaster UniversiDes OsteoarthriDs Index (WOMAC) physical-‐funcDon score Matheson
WPTA Spring Conference 2015
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Katz et al, NEJM, 2013 Katz et al, NEJM, 2013 •  In the intenDon-‐to-‐treat analysis, the researchers did not ﬁnd signiﬁcant diﬀerences between the study groups in funcDonal improvement 6 months aper randomizaDon •  30% of the paDents who were assigned to physical therapy alone underwent surgery within 6 months. Katz et al, NEJM, 2013 Sihvonen et al, NEJM, 2014 •  Researchers conducted a mulDcenter, randomized, double-‐blind, sham-‐controlled trial in 146 paDents 35 to 65 years of age who had knee symptoms consistent with a degeneraDve medial meniscus tear and no knee osteoarthriDs. •  PaDents were randomly assigned to arthroscopic parDal meniscectomy or sham surgery Matheson
Sihvonen et al, NEJM, 2014 •  For the sham surgery, a standard arthroscopic parDal meniscectomy was simulated •  To mimic the sensaDons and sounds of a true arthroscopic parDal meniscectomy, the surgeon asked for all instruments, manipulated the knee as if an arthroscopic parDal meniscectomy was being performed, pushed a mechanized shaver (without the blade) ﬁrmly against the patella (outside the knee), and used sucDon. •  The paDent was also kept in the operaDng room for the amount of Dme required to perform an actual arthroscopic parDal meniscectomy. WPTA Spring Conference 2015
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Sihvonen et al, NEJM, 2014 Sihvonen et al, NEJM, 2014 •  In this trial involving paDents without knee osteoarthriDs but with symptoms of a degeneraDve medial meniscus tear, the outcomes aper arthroscopic parDal meniscectomy were no be_er than those aper a sham surgical procedure. Khan et al., Meta-‐Analysis “There is moderate evidence to suggest that there is no beneﬁt to arthroscopic meniscal debridement for degeneraDve meniscal tears in comparison with non-‐operaDve or sham treatments in middle-‐aged paDents with mild or no concomitant osteoarthriDs.” Khan M, Evaniew N, Bedi A, Ayeni OR. Arthroscopic surgery for degeneraDve tears of the meniscus: a systemaDc review and meta-‐analysis. CMAJ. Aug 25 2014. Knee Osteoarthritis and Weight Loss
•  Seven Randomized Controlled Trials made ﬁnal selecDon of arDcles for systemaDc review and meta-‐analysis •  805 paDents were pooled for the meta-‐analysis •  “The pooled treatment eﬀect of arthroscopic surgery did not show a signiﬁcant or minimally important diﬀerence between treatment arms for long-‐term funcDonal outcomes” Khan M, Evaniew N, Bedi A, Ayeni OR. Arthroscopic surgery for degeneraDve tears of the meniscus: a systemaDc review and meta-‐analysis. CMAJ. Aug 25 2014. • Meta-regression analysis of several RCTs indicated
that physical disability of patients with knee OA and
overweight diminished after a moderate weight
reduction regime
• Supported that a weight loss of 5% should be
achieved within a 20-week period
• Supported rate of 0.25% loss per week
Christensen et al. Ann Rheum Dis, 2007
Matheson
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Knee Osteoarthritis and Obesity
– Relative risk of knee OA
increased from 0.1 for a BMI <
20 kg/m to 13.6 for a BMI >
36 kg/m
– If overweight patients reduced
weight by 5 kg, approx 24% of
TKA might be avoided
Coggon, D., I. Reading, et al. (2001). "Knee osteoarthritis and
obesity." Int J Obes Relat Metab Disord 25(5): 622-7
Weight Loss and Knee OA
•  A body weight loss of 11 lb lowers the risk of
developing OA by over 50%
•  Only one out of five people who embark on
a weight loss program ultimately lose 10%
or more of their initial body weight and
maintain that loss for at least 1 year
Felson DT, Zhang Y, et al (1992) Weight loss reduces the risk for symptomatic
knee osteoarthritis in women. The Framingham Study. Ann Intern Med 116:535.
Wing RR (2005) Long-term weight loss maintenance. Am J Clin Nutr 82:222.
Body Weight Change and RelaDonship to Decreased Pain and Improved FuncDon “Our data suggest a dose-response relationship exists
between changes in body weight and corresponding
changes in pain and function. The threshold for this
response gradient appears to be body weight shifts of
>10%. Weight changes of >10% have the potential to lead
to important changes in pain and function for patient
groups as well as individual patients”
Body Weight Change and RelaDonship to Decreased Pain and Improved FuncDon •  A dose response relaDonship was found between body weight changes and self reported pain and funcDon over a three-‐year period. •  WOMAC used as self reported outcome measure •  Threshold seems to be a ≥ 10% weight gain or weight reducDon •  ObjecDve – Determine if dose-‐response relaDonship exists between weight loss in paDents with knee OA and self reported pain and funcDon •  Analyzed data from two public data sets –  OsteoarthriDs IniDaDve (OAI) –  MulDcenter OsteoarthriDs Trial (MOST) Riddle DL, Strarord PW. Body weight changes and corresponding changes in pain and funcDon in persons with symptomaDc knee osteoarthriDs. A cohort study. Arthri&s care & research. Apr 13 2012. Recent Video Editorial in JAMA Sherry Pogota, PhD •  Associate professor of medicine and a licensed clinical psychologist at the UMass Memorial Weight Center •  h_p://www.youtube.com/watch?v=YbISv8f4FIw •  h_p://www.youtube.com/watch?v=7-‐cP6qyogN8 Riddle DL, Strarord PW. Body weight changes and corresponding changes in pain and funcDon in persons with symptomaDc knee osteoarthriDs. A cohort study. Arthri&s care & research. Apr 13 2012. Matheson
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Very Recently in the News! Knee Osteoarthritis and Exercise
See patient handout
Be careful with your exercise advice..
Fransen M, McConnell S. Exercise for osteoarthritis of the knee.
Cochrane Database Syst Rev. 2008 Oct 8;(4):CD004376. Review.
Fransen M, McConnell S. Exercise for osteoarthritis of
the knee. Cochrane Database Syst Rev. 2008
  Authors’ conclusions
  “There is platinum level evidence that land-based
therapeutic exercise has at least short term
benefit in terms of reduced knee pain and
improved physical function for people with knee
OA.”
  “The magnitude of the treatment effect would be
considered small, but comparable to estimates
reported for non-steroidal anti-inflammatory
drugs.”
Matheson
What about Aquatic Therapy??
  Appears to have comparable benefits for
participants to that of land based exercise in the
short term
  Not enough high quality studies in this area to
provide further recommendations on dosage,
intensity, or duration.
Lu M, Su Y, Zhang Y, et al. Effectiveness of aquatic exercise
for treatment of knee osteoarthritis : Systematic review and
meta-analysis. Zeitschrift fur Rheumatologie. 2015.
WPTA Spring Conference 2015
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Aerobic Exercise and Knee OA
 Mangani et al. Exercise and
comorbidity. Results from the Fitness
and Arthritis in Seniors Trial (FAST).
Aging Clin Exp Res. 2006;18(5):374.
Aerobic Exercise and Knee OA
  18 month Aerobic Exercise Program in Study  60 min walking sessions, 3 x per week 1.  Three month facility based walking program 2.  15 month home based walking program 3.  InvesDgators followed up by phone every three weeks during home program -‐Mangani et al. Aging Clin Exp Res. 2006
Strength Training and Knee OA
  18 month Weight Training Program in Study
 9 exercises , 3 x per week, 2 sets of 12 reps
1. 
2. 
3. 
4. 
5. 
Leg extension
Leg curl
Step up
Heel Raise
Chest fly
6. 
7. 
8. 
9. 
Upright row
Military press
Pelvic tilt
Biceps curl
Weight training increased in a stepwise fashion per tolerance
-‐Mangani et al. Aging Clin Exp Res. 2006
Aerobic Exercise and Knee OA
  Aerobic exercise improved physical function
in individuals with comorbidity
  Weight training improved physical function in
individuals with comorbidity
  Aerobic exercise alone improved knee pain
independently of the presence of comorbidity
-‐Mangani et al. Aging Clin Exp Res. 2006
Strength Training and Knee OA
Strength Training and Knee OA
  Hurley MV. The influence of arthrogenous
muscle inhibition on quadriceps rehabilitation of
patients with early, unilateral osteoarthritic
knees. Br J Rheumatol 1993;32:127
  “Reflex arthrogenous muscle inhibition (AMI)
may cause muscle atrophy or impede effective
rehabilitation of affected muscle groups”
Matheson
 Mikesky et al. Effects of strength
training on the incidence and
progression of knee osteoarthritis
Arthritis Rheum. 2006 55:690.
WPTA Spring Conference 2015
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Strength Training and Knee OA
  Supervised clinic program with gradual
progression to a home exercise program over
12 months time
  3 sets of 8-12 repetitions used (8-10 RM)
  Control group only performed ROM exercises
Mikesky et al. Effects of strength training on the incidence and
progression of knee osteoarthritis Arthritis Rheum. 2006 55:690.
Strength Training and Knee OA
Strength Training and Knee OA
 Clinic: leg presses, leg curls, seated chest presses, and seated back rows  Home: wall squats, standing leg curls, wall pushups, and seated rows Mikesky et al. Eﬀects of strength training on the incidence and progression of knee osteoarthriDs Arthri&s Rheum. 2006 55:690. Strength Training and Knee OA
 The strength training group retained more
strength and exhibited less frequent
progressive joint space narrowing over 30
months than the ROM control group
 The increase in incident joint space
narrowing >0.50 mm in the strength
training group is unexplained and
requires confirmation
Mikesky et al. Effects of strength training on the incidence and
progression of knee osteoarthritis Arthritis Rheum. 2006 55:690.
Strength Training and Knee OA
 Resistance training improved muscle
strength and self-reported measures of
pain and physical function in over 50–
75% of this cohort
 50–100% of the studies reported a
significant improvement in all but 1
performance-based physical function
measure (walk time).
Lange, A. K., B. Vanwanseele, et al. (2008). "Strength training for treatment of
osteoarthritis of the knee: a systematic review." Arthritis Rheum 59(10): 1488-1494.
Matheson
Lange, A. K., B. Vanwanseele, et al. (2008). "Strength
training for treatment of osteoarthritis of the knee: a
systematic review." Arthritis Rheum 59(10): 1488-1494.
Eﬃcacy of Strengthening – Recent Meta-‐Analysis •  SystemaDc Review and Meta-‐Analysis up to March 2013 completed •  Trials categorized into three subgroups: – Non-‐weight bearing strengthening exercises – Weight bearing strengthening exercises – Aerobic exercise •  Data from 8 studies integrated in ﬁnal paper Tanaka R, Ozawa J, et al. Eﬃcacy of strengthening or aerobic exercise on pain relief in people with knee osteoarthriDs: a systemaDc review and meta-‐analysis of randomized controlled trials. Clinical rehabilita&on. Dec 2013;27(12):1059-‐1071 WPTA Spring Conference 2015
45
Eﬃcacy of Strengthening – Recent Meta-‐Analysis •  Overall eﬀect of exercise was signiﬁcant with a large eﬀect size •  Subgroup analysis showed a larger mean diﬀerence for non-‐weight bearing strengthening exercise compared to weight bearing or aerobic exercise Tanaka R, Ozawa J, et al. Eﬃcacy of strengthening or aerobic exercise on pain relief in people with knee osteoarthriDs: a systemaDc review and meta-‐analysis of randomized controlled trials. Clinical rehabilita&on. Dec 2013;27(12):1059-‐1071 Exercise Therapy May Reduce Pain SensiDvity in PaDents with Knee OA Exercise Therapy May Reduce Pain SensiDvity in PaDents with Knee OA •  RCT with parDcipants with knee OA assigned to either 12 weeks of supervised exercise (36 sessions!) or a no a_enDon control group •  Outcomes: – Pressure pain thresholds (PPT) – VAS scores during pressure at 125% of PPT – KOOS self report quesDonnaire Henriksen M, Klokker L, Graven-‐Nielsen T, et al. Exercise therapy reduces pain sensiDvity in paDents with knee osteoarthriDs: A randomized controlled trial. Arthri&s care & research. Jun 6 2014. Exercise Adherence / PaDent AcDvaDon •  At follow-‐up, the exercise group demonstrated: – Pressure pain sensiDvity reduced > control – Temporal summaDon reduced > control – Self reported pain reduced > control (increased) •  Preliminary study – more work needed Henriksen M, Klokker L, Graven-‐Nielsen T, et al. Exercise therapy reduces pain sensiDvity in paDents with knee osteoarthriDs: A randomized controlled trial. Arthri&s care & research. Jun 6 2014. Bennell KL, Dobson F, Hinman RS. Exercise in osteoarthriDs: moving from prescripDon to adherence. Best Pract Res Clin Rheumatol. Feb 2014;28(1):93-‐117. Exercise Adherence / PaDent AcDvaDon •  Exercise Rx should be individualized based on evaluaDon and examinaDon ﬁndings •  Exercise Rx should be paDent – centered involving shared decision making between the paDent and clinician •  Barriers to exercise adherence should be discussed with paDent Bennell KL, Dobson F, Hinman RS. Exercise in osteoarthriDs: moving from prescripDon to adherence. Best Pract Res Clin Rheumatol. Feb 2014;28(1):93-‐117. Matheson
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MANUAL THERAPY AND KNEE
OSTEOARTHRITIS
Chesbro S, Conti G, B. W. Using the Assessing The Learning Strategies of Adults Tool
With Older Adults Comparisons Based on Age and Functional Ability. Topics in
Geriatric Rehabilitation. 2005;21(4):323–331.
104
Knee OA and Manual Therapy
Is manual therapy supported by
the evidence as an appropriate
intervention for individuals with
knee osteoarthritis?
Deyle, Annals of Internal Medicine, 2000
 Subjects had sub-therapeutic
ultrasound to the knee at an intensity
of 0.1 W/cm2 with a 10% pulsed mode
 Both groups were seen two times per
Matheson
Deyle, Annals of Internal Medicine, 2000
 TREATMENT
 PLACEBO
week for 4 weeks (8 visits)
http://www.annals.org/cgi/content/abstract/132/3/173
 Subjects received manual therapy,
applied to the knee as well as to the
lumbar spine, hip, and ankle as
required, and performed a
standardized knee exercise program
in the clinic and at home
WPTA Spring Conference 2015
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Deyle, Annals of Internal Medicine, 2000
  Manual therapy: Deyle, Annals of Internal Medicine, 2000
• Exercise therapy: Standard quad sets and
 Passive physiologic and accessory joint movements  Muscle stretching  Sop-‐Dssue mobilizaDon closed kinetic chain progression program
•  For complete description of exercise therapy a
full text version of the article may be found at:
• 
  Manual therapy primary applied to knee but the same treatments were also applied to the lumbar spine, hip, or ankle based on iniDal examinaDon Can mobilizing the hip improve knee
function in knee osteoarthritis?
Currier et al. Development of a clinical prediction
rule to identify patients with knee pain and
clinical evidence of knee osteoarthritis who
demonstrate a favorable short-term response to
hip mobilization. Phys Ther. 2007;87(9):1106.
Currier et al, Phys Ther, 2007
http://www.annals.org/cgi/content/abstract/132/3/173
•  This is an excellent article to share with your
primary care referral sources
“The primary purpose of this
study was to develop a clinical
prediction rule (CPR) for
identifying patients with knee
pain and clinical evidence of
knee osteoarthritis with
favorable short-term response
to hip mobilizations.”
Currier et al, Phys Ther, 2007
• The CPR developed in this study
comprised 5 variables:
1.  Hip or groin pain or paresthesia
2.  Anterior thigh pain
3.  Passive knee flexion <122°
4.  Passive hip medial rotation < 17 °
5.  Pain with hip distraction
Matheson
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Outcome Measures at 48 hours
• WOMAC: Western Ontario McMaster
Universities Osteoarthritis Index
• PSFS: Patient Specific Functional Scale
Criteria for Success
1.  Decrease of at least 30% on the
composite NPRS score obtained
during the 2 functional activities
– Squat test
– Sit to stand test
• NPRS: Numeric Pain Rating Scale
2.  A GRCS score of at least 3
• GROC: Global Rating of Change
Currier et al, Phys Ther, 2007
• If one variable had a positive likelihood
ratio of 5.1 and increased the probability
of a successful response to 92% at 48hour follow-up
• If 2 variables were present, the positive
likelihood ratio was 12.9 and the
probability of success increased to 97%
Hip Mobilization – Caudal Glide
Matheson
Currier et al, Phys Ther, 2007
A detailed description of the
hip mobilizations utilized in
this study is included in
your laboratory handout
Hip Mobilization – Posterior Anterior Glide
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Hip Mobilization – Posterior Anterior Glide
in FABER position
Mobilization Protocol for Hip/Knee OA
•  Physiological Warm-Up (Stationary Bike)
•  * sign (e.g. NPRS 0 -10 for FABER, squat, stairs)
•  8-10 min of mobilizations
–  Static or Oscillations at rate of 2 per second
–  Grade IV-V to increase ROM, Grade II-III for pain
control
•  * sign (repeat and reassess NPRS 0-10)
•  Give HEP to maintain positive results
–  Exercises in new ROM / Self mobilizations
Bennell et al, PT Hip OA Study, JAMA, 2014 •  Randomized, placebo controlled, parDcipant and assessor-‐
blinded trial involving 102 community volunteers with hip pain levels > 40/100 on VAS and radiographic dx hip OA •  ParDcipants a_ended 10 Rx sessions over 12 weeks •  AcDve treatment included educaDon and advice, manual therapy, home exercise, and gait aid •  Sham treatment included inacDve ultrasound and inert gel •  For 24 weeks aper treatment, the acDve group conDnued unsupervised home exercise while the sham group self-‐
applied US gel 3 Dmes weekly. Bennell KL, Egerton T, MarDn J, et al. Eﬀect of physical therapy on pain and in paDents with hip osteoarthriDs: a randomized clinical trial. Jama. May funcDon 21 2014;311(19):1987-‐1997. Bennell et al, PT Hip OA Study, JAMA, 2014 •  “We found that a 12-‐week mulDmodal physical therapy treatment typical of current pracDce for people with symptomaDc hip osteoarthriDs did not confer addiDonal beneﬁts over a realisDc sham treatment that controlled for the therapeuDc environment, therapist contact Dme, and home tasks.” •  “Both groups showed signiﬁcant improvements in pain and funcDon following treatment. The acDve group reported a signiﬁcantly greater number of adverse events although these were relaDvely mild in nature.” Bennell KL, et al. Eﬀect of physical therapy on pain and funcDon in paDents with hip osteoarthriDs: a randomized clinical trial. JAMA. May 21 2014;311(19):1987-‐1997. Matheson
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Peat, G., E. Thomas, et al. (2007). "Estimating
the probability of radiographic osteoarthritis in
the older patient with knee pain." Arthritis
Rheum 57(5): 794-802.
Objective. To determine whether clinical
information can practically rule in or rule out the
presence of radiographic osteoarthritis in older
adults with knee pain.
Methods. The authors conducted a crosssectional diagnostic study involving 695 adults
ages >50 years reporting knee pain within the
last year identified by postal survey and
attending a research clinic. Participants
underwent plain radiography. Radiographic
osteoarthritis was defined as the presence of
definite osteophytes in at least 1 joint
compartment of the index knee.
Results. Independent predictors of radiographic
osteoarthritis were age, sex, body mass index,
absence of whole leg pain, traumatic onset,
difficulty descending stairs, palpable effusion,
fixed-flexion deformity, restricted-flexion range
of motion, and crepitus.
Using this model, 245 participants had a
predicted probability >80% (practical rule in), of
whom 231 (94%) actually had radiographic
osteoarthritis (specificity 93%). Twenty-one
participants had a predicted probability <20%
(practical rule out), of whom only 2 (10%) had
radiographic osteoarthritis (sensitivity 99.6%).
The predicted probability of radiographic
osteoarthritis for the remaining 429 participants
fell into an intermediate category (20–79%).
Conclusions. Simple clinical information can be
used to estimate the probability of radiographic
osteoarthritis in individual patients. However,
for the majority of community-dwelling older
adults with knee pain this method enables the
presence of radiographic osteoarthritis to be
neither confidently ruled in nor ruled out.
Prospective validation and updating of these
findings in an independent sample is required.
Matheson
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Maximizing The Eﬀects of Manual Therapy Where Are We In 2015? J.W. Matheson, DPT Board Cer5ﬁed in Orthopedic and Sports Physical Therapy President / Clinic Director Catalyst Sports Medicine, Hudson, WI QuesFons of PresentaFon •  What are the eﬀects of manual therapy? •  How can clinicians maximize these eﬀects of manual therapy? Physical Therapy Journal, December 1992 “Looking at the ubiquitous use of manual therapy and my own personal preferences for many manual techniques, it is with sorrow that I observe how the great ediﬁce of manual therapy has been built upon the shakiest of founda>ons…” SystemaFc Reviews conclude: •  SystemaFc reviews yield some evidence that manual therapy appears to increase either acFve or passive mobility •  Trends found favoring manual therapy for decreasing pain, but the eﬀect on funcFon and quality of life remains inconclusive •  Manual therapy oNen examined as an add-‐on to exercise, never alone •  Problems with examining mulFple manual therapy studies in reviews secondary to clinical heterogeneity Clinical heterogeneity a problem … •  DeﬁniFon of manual therapy is expansive: –  Joint based •  ManipulaFon / MobilizaFon –  SoN Fssue based •  Swedish, deep Fssue, trigger point, Shiatsu massage –  Nerve biased •  Neurodynamic / neural Fssue provocaFon –  Other techniques clinicians consider “manual therapy” Matheson
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So…. Issues With Manual Therapy Research •  Post hoc ergo propter hoc –  Correla3on ≠ Causa3on •  Natural history –  Regression to the mean •  Tooth Fairy Science –  Could do a sound study on price per tooth, Fssue v. bag, income of parents, etc. –  Ignores prior probability •  Why do a myriad of diﬀerent manual techniques, diﬀerent dosages, diﬀerent intensi3es (thrust v. mobiliza3on) oFen result in small measureable short ac3ng changes in pain relief and func3onal improvement? Proposed MechanisFc Model of Manual Therapy Speciﬁc Eﬀects of Shoulder Manual Therapy •  Mechanical sFmulus iniFates a number of possible neurophysiological eﬀects –  Peripheral mechanisms •  May alter biochemical markers including pro-‐inﬂammatory and immunoregulatory cytokines –  Spinal mechanisms •  Several animal and human studies indirectly associaFng manual therapy with hypoalgesia, aﬀerent discharge, and changes in m. acFvity. Figure 1 from -‐ Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. Oct 2009;14(5):531-‐538. Proposed MechanisFc Model of Manual Therapy Speciﬁc Eﬀects of Shoulder Manual Therapy •  Mechanical sFmulus iniFates a number of possible neurophysiological eﬀects –  Supraspinal mechanisms •  Decreased acFvaFon of central pain processing centers in the brain •  Autonomic responses –  Skin temperature –  Heart rate •  Endocrine response –  Opioid responses –  Β-‐endorphins Figure 1 from -‐ Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. Oct 2009;14(5):531-‐538. Matheson
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Treatment Eﬀects •  Improvement aNer treatment can happen in one of three ways: 1.  Speciﬁc eﬀects of treatment 2.  Non-‐speciﬁc (general) eﬀects of treatment 3.  Unexplained variability Non – Speciﬁc / General Treatment Eﬀects •  A treatment outcome is not due solely to nonspeciﬁc eﬀects or to speciﬁc eﬀects. •  A treatment outcome is always due to some interacFve combinaFon of speciﬁc nonspeciﬁc treatment eﬀects plus some unexplained variability. Non – Speciﬁc Treatment Eﬀects •  “There is a greater chance for successful outcome when the psychological components of pain are treated with cogniFve-‐behavioral therapy, fear-‐avoidance training, and interdisciplinary rehabilitaFon for persons with chronic pain compared with convenFonal medical intervenFons alone.” (Jamison, IASP, 2011) I should have been an infec3ous disease physician! •  “Kill bug, don’t kill bug” •  More black and white than when dealing with pain •  Inﬂuence of non-‐speciﬁc eﬀects limited on desired outcome Speciﬁc Unexplained Non – Speciﬁc Treatment Eﬀects •  Psychological factors play a signiﬁcant role in pain management and have a direct eﬀect on outcome of treatment. (CelesFn et al, Pain Med, 2008) •  A review of outcomes from lumbar surgery among back pain paFents showed that 92% of published studies demonstrated a signiﬁcant negaFve eﬀect on outcome when psychological and psychiatric factors were idenFﬁed in paFents. (van Wijk et al, Pain Med, 2008) What really happens in an episode of PT? •  CombinaFon of intervenFons having a percentage of speciﬁc, non-‐speciﬁc, and unexplained treatment eﬀects (Chou et al, Ann Int Med, 2007; Bunzli et al, Phys Res Int, 2010; Brox et al, Spine J, 2008) Speciﬁc (20%) Non-‐Speciﬁc (65%) Unexplained (15%) Matheson
Non-‐Speciﬁc WPTA Spring Conference 2015
Speciﬁc (8%) Non-‐Speciﬁc (70%) Unexplained (22%) Speciﬁc (40%) Non-‐Speciﬁc (55%) Unexplained (5%) 54
Miciak et al., Scand J Caring Sci, 2011 Common Factors Model in Physical Therapy •  Evidence from systemaFc reviews of hands-‐
on physical therapy technique indicate that factors common (e.g. non-‐speciﬁc) across intervenFons contribute more to treatment outcomes than eﬀects associated with the speciﬁc technical intervenFon. Non – Speciﬁc Treatment Eﬀects •  Develop a “TherapeuFc Alliance” with the PaFent –  (Ferreira et al, Phy Ther, 2013) TherapeuFc or Working Alliance •  Refers to the sense of collaboraFon, warmth, and support between the paFent and PT •  Components of the therapeuFc / working alliance: 1.  Therapist and PaFent agreement on goals 2.  Therapist-‐paFent agreement on intervenFons 3.  AﬀecFve bond between paFent and therapist Bodin, Psychotherapy: Theory, Research, and Prac3ce, 1979 Ferreira et al, Phy Ther, March 2013 •  Does the therapeuFc alliance between PTs and paFents with chronic low back pain predict outcomes? •  Primary outcomes of funcFon, global perceived eﬀect of treatment, pain, and disability were assessed before and aNer 8 weeks of treatment. •  Regression models were used to invesFgate whether the alliance was a predictor of outcome or moderated the eﬀect of treatment. Matheson
Ferreira et al, Phy Ther, March 2013 •  TherapeuFc alliance was consistently a predictor of outcome for all the measures of treatment outcome. •  The therapeuFc alliance moderated the eﬀect of treatment on global perceived eﬀect for 2 of 3 treatment contrasts –  (general exercise vs. motor control exercise, spinal manipulaFve therapy vs. motor control exercise). •  There was no treatment eﬀect modiﬁcaFon when outcome was measured with funcFon, pain, and disability measures. WPTA Spring Conference 2015
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TherapeuFc / Working Alliance Fuentes et al., Phys Ther , April 2014 •  When clients come to physical therapy, they expect to ﬁnd clinicians with whom they can develop a close relaFonship •  They expect that their therapists will want the same outcomes for them that they want for themselves “The context in which physical therapy intervenFons are oﬀered has the potenFal to dramaFcally improve therapeuFc eﬀects. “ •  They expect that therapists will suggests ways to aqain these goals that they ﬁnd acceptable Published online 1/24/2014 •  ObjecFve: To determine the relaFve eﬀecFveness of spinal manipulaFon, medical management, physical therapies, and exercise for acute and chronic low back pain • 
Fuentes et al. Physical Therapy, April 2014 (published online) Published online 1/24/2014 Results: –  Of 84% acute pain variance, 81% non-‐speciﬁc eﬀects, 3% speciﬁc eﬀects –  Most acute results were within 95% conﬁdence bands of that predicted by natural history Maximize the non-‐speciﬁc treatment eﬀects Engage the pa5ent Understand the paFent’s expectaFons and concerns Greet in a warm, present, and friendly manner and maintain good eye contact Empathize with the pa5ent Be aware of feelings, values, and thoughts Employ humor where appropriate •  Manual… “treatments serve to moFvate, reassure, and calibrate paFent expectaFons -‐ features that might reduce medicalizaFon and augment self-‐care. Exercise with authoritaFve support is an eﬀecFve strategy for acute and chronic low back pain” Matheson
Educate the pa5ent Assess what the paFent understands Address key concerns Enlist the pa5ent Seek paFent’s input on treatment plan (Use FOTO data J) NegoFate prioriFes End the visit AnFcipate and forecast the end of the visit Restate the plan and express personal conﬁdence , caring and hope. WPTA Spring Conference 2015
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Purng It All Together in 2014 •  Try to maximize both your speciﬁc and non-‐
speciﬁc eﬀects –  Accomplish the 5 E’s –  Be knowledgeable and have empathy –  Develop a strong therapeuFc alliance –  Apply your manual therapy in a consistent and reproducible manner –  Encourage self eﬃcacy and paFent acFvaFon Outcomes of Pa5ent Engagement and Ac5va5on Jim Kinsey, Senior ConsultaFon Services pecialist-‐ConFnuing Care Pa5ent Ac5va5on aSnd Engagement: Empowering the Pa5ent Health Activation
• The term “patient (or health) activation” refers to having the
knowledge, skills, beliefs, and confidence to manage one’s
health
•  By understanding participants’ “activation levels,” health
Pa5ent starts to take a role Pa5ent builds conﬁdence and knowledge Pa5ent takes ac5on Pa5ent maintains behaviors professionals can better tailor participant coaching to an
individual’s level of activation, helping him or her identify
and overcome barriers to behavior change
•  Higher levels of activation are correlated with improved selfcare behaviors
•  Increasing health activation results in improved adherence
to plan of care
The Pa3ent Ac3va3on Measure® (PAM®) 34
Patient Activation
Activation is Developmental
Judy Hibbard, PhD
Give a man a fish and
you feed him for a day.
Teach a man to fish
and you feed him for a
lifetime.
- Chinese Proverb
Knowledge/Skills
ACTIVATION
Empowerment
Matheson
Confidence
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Health Style Varies Dramatically When Seen
Through Lens of Self-Management
“I was really confident before I
got sick. I smoked, drank. I felt
fine. Then, I had to have open
heart surgery. I don’t know if
I’ll ever feel confident about
my health again”
Patient Activation Measure™ (PAM)
•  The Patient Activation Measure™
“I don’t really understand what
they do (medications), but I try
to understand their side effects”
“My doctor takes care of me”
“I don’t know (treatment
options) … I just try to do what
the doctor tells me”
“I joined a support group. I
determined that I’m not going
to let this take over my life”
“My doctor can only do
so much. I have to
manage my health”
“I write down my concerns. I
also have goals for myself –
like losing weight. I write down
how I’m doing with my goals.
I’ve lost 20 pounds!”
“I try to keep a positive
attitude. I exercise frequently,
limit intake of cholesterol, and
try to learn about my disease
and survivability”
(PAM) was designed to assess an
individual’s knowledge, skills
and confidence in playing a role
in one’s own health and
healthcare.
•  PAM consists of a 10 to 13-
question survey that asks people
about their beliefs, knowledge
and confidence for engaging in a
wide range of health behaviors.
Based on responses to the survey,
each person is assigned an
“activation score” and “level”
37
37
Why is activating the patient so important?
§ Healthcare resources are scarce; it is
increasingly important for people to
take an active role in managing their
care
§ Lifestyle management is the key to
prevention and treatment of chronic
conditions
§ Activation can be influenced in a brief
intervention and, in turn, influences
the person across all risk factors
38
Motivational Interviewing:
Key Component of Engagement and Activation
• “Directive, client-centered counseling style for
eliciting behavior change by helping clients to explore
and resolve ambivalence.”
• “Overall goal is to increase client’s intrinsic
motivation so that change arises from within, rather
than being imposed from without.”
• “Motivational interviewing is particularly useful for
clients who are reluctant to change or who are
ambivalent about changing behavior.”
Rubak, S., “Motivational Interviewing: a Systematic Review and Metaanalysis”, British Journal of General Practice, April 2005
40
PAM™ in the Low Back Pain Research Literature
Skolasky, Quality of Life Research, 2009
•  Purpose: To determine the psychometric
properties and construct validity of the
recently developed Patient Activation
Measure (PAM) (previously unused in spine
research) in persons undergoing elective
lumbar spine surgery.
•  Used the PAM to assess activation in 283
patients undergoing elective surgery
41
Matheson
42
WPTA Spring Conference 2015
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Skolasky, Quality of Life Research, 2009
•  Conclusions:
• The PAM is a reliable, valid measure of
patient activation for individuals
undergoing elective lumbar spine surgery
LAB ACTIVITIES
• Review Working Alliance Measure
• The PAM may have clinical utility in
identifying those at risk for poor
engagement in postsurgical rehabilitation
43
Matheson
44
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Goal of each patient visit is to maximize non-specific effects by meeting the following “5 E’s”
Important Components to Every Patient Encounter to Maximize the Nonspecific Effects of Treatment
1. Engage
Work to build a professional partnership.
Greet in a warm, pleasant, and friendly manner.
Maintain good eye contact.
Reduce any barriers.
Maintain a posture that shows interest.
Show curiosity and concern as to how the patient is doing.
Understand the patient’s expectations and concerns.
2. Empathize
Listen, and feed back what you have heard.
Be aware of feelings, values, and thoughts.
Note body language and demeanor.
Reflect understanding.
Acknowledge and legitimize feelings.
Employ humor when appropriate.
3. Educate
Assess what the patient understands.
Address key concerns.
Let the patient know that you have reviewed his or her medical record.
Answer with compassion.
Inform the patient about what will happen, who will be there, and what
the risks and realistic expectations will be.
4. Enlist
Seek the patient’s input on the treatment plan.
Ask for patient’s agreement and active participation.
Provide options.
Negotiate priorities.
Explain what will happen if a problem arises
5. End Visit
Anticipate and forecast at the close of the visit.
Summarize the encounter.
Review the plan and next steps.
Express personal confidence, caring, and hope.
Follow through.
References:
Jamison RN. Nonspecific Treatment Effects in Pain Medicine. International
Association for the Study of Pain 2011; 29(2).
http://www.iasp-pain.org/PublicationsNews/NewsletterIssue.aspx?ItemNumber=2079
Matheson
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Recommended items, instructions and scale to assess the Therapeutic Alliance in Physical
Rehabilitation Settings1
Please rate your treatment session with your therapist according to the following descriptions. For each
item, circle the number that best describes your reaction session using the rating system below:
Please rate your treatment session with your therapist according to the following descriptions. For each
item, circle the number that best describes your reaction session using the rating system below:
Strongly
Disagree
1
2
3
4
5
6
Strongly
Agree
My therapist and I agree about the things I will need
to do in therapy to help improve my situation.
Strongly
Disagree
1
2
3
4
5
6
Strongly
Agree
What I am doing in therapy gives me new ways of
looking at my problem.
Strongly
Disagree
1
2
3
4
5
6
Strongly
Agree
I am confident in my therapist’s ability to help me.
Strongly
Disagree
1
2
3
4
5
6
Strongly
Agree
I feel that my therapist appreciates me.
Strongly
Disagree
1
2
3
4
5
6
Strongly
Agree
We agree on what is important for me to work on.
Strongly
Disagree
1
2
3
4
5
6
Strongly
Agree
We have established a good understanding of the
kind of changes that would be good for me.
Strongly
Disagree
1
2
3
4
5
6
Strongly
Agree
I believe the way we are working with my problem
is correct.
Strongly
Disagree
1
2
3
4
5
6
Strongly
Agree
I feel that the things I do in therapy will help me to
accomplish the changes I want.
Strongly
Disagree
1
2
3
4
5
6
Strongly
Agree
We agree on what is important for me to work on.
Strongly
Disagree
1
2
3
4
5
6
Strongly
Agree
1
Reduced item version based on RASCH Analysis of the Working Alliance/Theory of Change
Inventory (WATOCI)
References
Hall, A. M., Ferreira, M. L., Clemson, L., Ferreira, P., Latimer, J., & Maher, C. G. (2012). Assessment of the therapeutic alliance in physical rehabilitation: a RASCH analysis. Disability and rehabilitation, 34(3), 257-‐-‐-‐266. doi: 10.3109/09638288.2011.606344 Hall, A. M., Ferreira, P. H., Maher, C. G., Latimer, J., & Ferreira, M. L. (2010). The influence of the therapist-‐-‐-‐patient relationship on treatment outcome in physical rehabilitation: a systematic review. Physical therapy, 90(8), 1099-‐-‐-‐1110. doi: 10.2522/ptj.20090245 Matheson
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The 13-Item Patient Activation Measure (PAM)
Below are some statements that people sometimes make when they talk about their health. Please indicate
how much you agree or disagree with each statement as it applies to you personally by circling your
answer. Your answers should be what is true for you and not just what you think the doctor wants you to
say. If the statement does not apply to you, circle N/A.
1. When all is said and done, I am the person
who is responsible for taking care of my
health.
2. Taking an active role in my own health care
is the most important thing that affects my
health.
3. I am confident I can help prevent or reduce
problems associated with my health.
4. I know what each of my prescribed
medications do.
5. I am confident that I can tell whether I need
to go to the doctor or whether I can take
care of a health problem myself.
6. I am confident that I can tell a doctor
concerns I have even when he or she does
not ask.
7. I am confident that I can follow through on
medical treatments I may need to do at
home.
8. I understand my health problems and what
causes them.
9. I know what treatments are available for my
health problems.
10. I have been able to maintain (keep up with)
lifestyle changes, like eating right or
exercising.
11. I know how to prevent problems with my
health.
12. I am confident I can figure out solutions
when new problems arise with my health.
13. I am confident that I can maintain lifestyle
changes, like eating right and exercising,
even during times of stress.
Disagree
Strongly
Disagree
Agree
Agree
Strongly
Not
Applicable
Disagree
Strongly
Disagree
Agree
Agree
Strongly
Not
Applicable
Disagree
Strongly
Disagree
Agree
Agree
Strongly
Not
Applicable
Disagree
Strongly
Disagree
Agree
Agree
Strongly
Not
Applicable
Disagree
Strongly
Disagree
Agree
Agree
Strongly
Not
Applicable
Disagree
Strongly
Disagree
Agree
Agree
Strongly
Not
Applicable
Disagree
Strongly
Disagree
Agree
Agree
Strongly
Not
Applicable
Disagree
Strongly
Disagree
Agree
Agree
Strongly
Not
Applicable
Disagree
Strongly
Disagree
Agree
Agree
Strongly
Not
Applicable
Disagree
Strongly
Disagree
Agree
Agree
Strongly
Not
Applicable
Disagree
Strongly
Disagree
Agree
Agree
Strongly
Not
Applicable
Disagree
Strongly
Disagree
Agree
Agree
Strongly
Not
Applicable
Disagree
Strongly
Disagree
Agree
Agree
Strongly
Not
Applicable
1Insignia Health holds the worldwide exclusive rights to PAM per a technology transfer from University of Oregon. Insignia licenses PAM and other related products to organizations in the U.S. and abroad. PAM is being used in 16 countries today.
References:
Hibbard, J. H., Mahoney, E. R., Stock, R., & Tusler, M. (2007). Do increases in patient activation result
in improved self-management behaviors? Health services research, 42(4), 1443-1463.
Hibbard, J. H., Mahoney, E. R., Stockard, J., & Tusler, M. (2005). Development and testing of a short
form of the patient activation measure. Health services research, 40(6 Pt 1), 1918-1930.
Hibbard, J. H., Stockard, J., Mahoney, E. R., & Tusler, M. (2004). Development of the Patient Activation
Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health
services research, 39(4 Pt 1), 1005-1026.
Matheson
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Low Back Pain
  Second greatest cause of disability in the USA.
  Despite an enormous increase in healthcare
resources spent on LBP disorders, LBP related
disability continues to increase.
  Exponential increase in use of physical
therapies, opioid medications, spinal injections,
and spine surgery.
Please Take Survey
Please complete Pain
Attitudes and Beliefs Scale
for Physiotherapists.
Deyo RA, Mirza SK, Turner JA, et al. Over treating chronic back
pain: time to back off? J Am Board Fam Med 2009 ; 22 : 62 – 8 .
Bagnall DL. Physiatry: what’s the end game? PM&R 2010 ; 2:3-5 .
Low Back Pain (LBP)
  Contrary to the evidence, there remains the underlying
belief that LBP is a patho-anatomical disorder and should
be treated with a biomedical model v. a bio-psycho-social
model.
Chronic Low Back Pain
  In 2011report, the IOM estimated that chronic
pain affects 100 million adults in USA
  Only 8-15% of patients with LBP have an identified
  Annual cost of $635 billion
  Direct medical expenditures
  Loss of work productivity
  Of this population of non-specific LBP, a small group
  Worldwide lifetime prevalence of 39%
patho-anatomical diagnosis, with the remaining being
labeled as non-specific LBP.
labeled non-specific c chronic low back pain (NSCLBP),
consuming a disproportionate amount of healthcare cost.
  Majority of people who experience low back pain
have reoccurrences
Croft PR, Macfarlane GJ, Papageorgiou AC, et al. Outcome of low back
pain in general practice: a prospective study. BMJ 1998 ; 316 : 1356-9.
Chronic Low Back Pain
  Growing evidence that chronic low back pain:
  May progress to a complex condition that
involves persistent changes to the central
nervous system
  May or may not have findings of structural
pathoanatomy
  Often not a clear association between pain
and identifiable pathology of the spine or
the surrounding soft tissue
Matheson
Hoy et al, Arthritis Rheum, 2012
Chronic Low Back Pain (LBP)
  Common interventions for Chronic LBP
  Spine Surgery
  Injections
  Medications
  Psychological Interventions
  Manual Therapy
  Exercise
  Nutritional Supplements
  Life style change
  Self Management Approaches
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Chronic Low Back Pain
  Despite being increasingly recognized as a complex
condition demanding a bio-psycho-social framework
  Alarming trends are evident in the medical literature
  Care discordant with clinical guidelines
  Prescribing more MRIs and radiographs
  Strong pain-medication
  Injection therapy
  Surgery
O’Sullivan, P.: It’s time for change with the management of
non-specific chronic low back pain. Br J Sports Med, 2012.
46(4): p. 224-7.
Chronic Low Back Pain
  Defining the chronicity of Chronic LBP:
1.  How long has this back pain been a problem for you?
2.  How often has low back pain been an ongoing problem
for you over the past 6 months?
A response of greater than 3 months to question 1 and
a response of ‘‘at least half the days in the past 6
months’’ to question 2 would define chronic LBP.
Deyo, R. A., et al. (2014). "Focus article: report of the NIH
Task Force on Research Standards for Chronic Low Back
Pain." European Spine Journal. 23(10): 2028-2045.
Chronic Low Back Pain
  Stratification by Impact as defined by:
  Pain intensity
  Pain interference with normal ADLs
  Functional status
Deyo, R. A., et al. (2014). "Focus article: report of the NIH
Task Force on Research Standards for Chronic Low Back
Pain." European Spine Journal. 23(10): 2028-2045.
Matheson
Chronic Low Back Pain
“Many of these (interventions) have
shown some clinical benefit, but few
appear to consistently provide
substantial, long-term reductions in pain
with increased function”
Deyo, R. A., et al. (2014). "Focus article: report of the NIH
Task Force on Research Standards for Chronic Low Back
Pain." European Spine Journal. 23(10): 2028-2045.
Chronic Low Back Pain
  Task Force Recommendations:
1.  Defining the chronicity of LBP
2.  Stratify LBP by Impact
3.  Report a Minimum dataset
4.  Outcome Measures
5.  Research on Proposed Standards
6.  Dissemination of Proposed Standards
Deyo, R. A., et al. (2014). "Focus article: report of the NIH
Task Force on Research Standards for Chronic Low Back
Pain." European Spine Journal. 23(10): 2028-2045.
Chronic Low Back Pain
Clinical Practice Guidelines
Rossignol M, Poitras S, Dionne C, et al. An
interdisciplinary guideline development
process: the Clinic on Low-back pain in
Interdisciplinary Practice (CLIP) low-back
pain guidelines. Implementation science : IS.
2007;2:36.
PDF of 43 page CLIP low back pain guidelines at
http://publications.santemontreal.qc.ca/uploads/
tx_asssmpublications/978-2-89494-556-8.pdf
WPTA Spring Conference 2015
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The 6 “Rs” of Chronic LBP Rehabilitation
  Red flags
  Reassure
  Reconceptualize
  Recalibrate
  Robust (What I call Resiliency)
The 6 “Rs” of Chronic LBP Rehabilitation
  Red flags – Rule out
  Nice summary of current red flag
research may be found in 2012
APTA Orthopaedic Section Clinical
Practice Guideline. Pages A-18 to
A-19
  Reasoning
Ben Cormack - http://www.cor-kinetic.com/the-5-rs-of-rehab/
Red Flags – Imaging
  Many LBP guidelines allow for older
adults with back pain to undergo
imaging without waiting 4-6 weeks
Red Flags – Imaging
  5239 patients examined over 12 months
  Compared early imaging (1523 patients)
with controls
  Propensity score matched
  Compared disability at 1 year
  Is this necessary?
  No difference
Jarvik et al. Association of Early Imaging for Back Pain with Clinical
Outcomes in Older Adults. JAMA 313:11, 2015, 1143-53.
Jarvik et al. Association of Early Imaging for Back Pain with Clinical
Outcomes in Older Adults. JAMA 313:11, 2015, 1143-53.
The 6 “Rs” of Chronic LBP Rehabilitation
The 6 “Rs” of Chronic LBP Rehabilitation
  Reassure – In a way they understand
  Reassure – In a way they understand
“Few of the existing medical terms were understood
and accepted by lay participants in the way discussed
and expected by health professionals.”
“Misunderstandings, unintended meanings and
negative emotional responses to terms were common”
Barker et al. Divided by a lack of common language? A qualitative
study exploring the use of language by health professionals treating
back pain. BMC Musculoskeletal Disorders. 2009;10:123.
Matheson
Barker et al. Divided by a lack of common language? A qualitative
study exploring the use of language by health professionals treating
back pain. BMC musculoskeletal disorders. 2009;10:123.
WPTA Spring Conference 2015
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The 6 “Rs” of Chronic LBP Rehabilitation
  Reassure – In a way they understand
The 6 “Rs” of Chronic LBP Rehabilitation
Bargh et al.
Understand the process of “priming” your
patients – You don’t want to be priming
them for pain.
•  This study demonstrated that environmental
Bargh et al. Automaticity of social behavior: direct effects of
trait construct and stereotype-activation on action. Journal of
personality and social psychology. 1996;71(2):230-244.
Bargh et al. Automaticity of social behavior: direct effects of
trait construct and stereotype-activation on action. Journal of
personality and social psychology. 1996;71(2):230-244.
The 6 “Rs” of Chronic LBP Rehabilitation
  Reassure – How will you answer these ?s:
  Will the pain go away?
stimulus, in the shape of language, has the
capacity to prime social behavior. Word choice
changed the way the students behaved. With the
students being unaware of what was going on.
The 6 “Rs” of Chronic LBP Rehabilitation
  Reassure – Avoid structuralism!
  Why do I have this pain?
  Why can no one help me?
  My MRI states I have degenerative disc disease!
  My SI joint is out?
https://www.painscience.com/articles/structuralism.php
Reassure – Avoid Structuralism
Haig et al. Spinal stenosis, back pain, or no symptoms at all? A masked
study comparing radiologic and electrodiagnostic diagnoses to the
clinical impression. Arch Phys Med Rehabil 2006;87:897-903.
Reassure – Avoid Structuralism
  Objective: Assess relation between clinically recognized
•  Imaging findings of spine degeneration are
present in high proportions of asymptomatic
individuals
  Subjects: 150 subjects 55-80 yrs. of age with or without LBP
•  Many imaging-based degenerative features are
likely part of normal aging and unassociated
with pain.
lumbar spinal stenosis and conclusions of masked
radiologists and electrodiagnosticians
  Conclusions: “The impression obtained from an MRI scan
does not determine whether lumbar stenosis is a cause of
pain.”
  “Electrodiagnostic consultation may be useful, especially
if age-related norms obtained in this study are applied.”
Haig et al. Spinal stenosis, back pain, or no symptoms at all? A masked
study comparing radiologic and electrodiagnostic diagnoses to the
clinical impression. Arch Phys Med Rehabil 2006;87:897-903.
Matheson
•  Imaging findings must be interpreted in the
context of the patient’s clinical condition
Brinjikji et al. Systematic Literature Review of Imaging Features of
Spinal Degeneration in Asymptomatic Populations. AJNR. American
Journal of Neuroradiology. 2014.
WPTA Spring Conference 2015
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Reassure – Avoid Structuralism
•  No studies that demonstrate a clear
relationship between spinal or pelvic
mobility, degenerative processes, pain and
disability
•  Common findings such as DDD, annular
tears, annular fissures, disc bulges, facet
joint arthrosis have ben found not to be
predictive of future low back pain.
Jarvik JG, Hollingworth W, Heagerty PJ, et al. Three-year incidence
of low back pain in an initially asymptomatic cohort: clinical and
imaging risk factors. Spine 2005 ; 30 : 1541 – 8 .
The 6 “R’s” of Chronic LBP Rehabilitation
  Reconceptualize our understanding what is
currently known about the biology of pain
1.  Pain does not provide a measure of the state of
the tissues
2.  Pain is modulated by many factors from across
somatic, psychological and social domains
Moseley GL. Reconceptualising pain according to modern pain
science. Physical Therapy Reviews. 2007;12(3):169-178.
The 6 “Rs” of Chronic LBP Rehabilitation
  Reconceptualize our understanding what is
currently known about the biology of pain
3. 
4. 
Relationship between pain and the state of
the tissues becomes less predictable as pain
persists
Pain can be conceptualized as a conscious
correlate of the implicit perception that tissue
is in danger.
Moseley GL. Reconceptualising pain according to modern pain
science. Physical Therapy Reviews. 2007;12(3):169-178.
Fear Avoidance Model
Acute Onset
Pain experience
Disuse
Depression
Disability
Recovery
Avoidance
Confrontation
Fear of reinjury
Catastrophizing
Matheson
No Fear
WPTA Spring Conference 2015
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Results:
Clinician’s Fear Avoidance Beliefs
Scores ≥ 4 (high fear)
Scores ≤ 3 (low fear)
  Traditional or biomedical
  Biopsychosocial
  Reduction in pain
  Practice guidelines
concept of pain
prerequisite for activity
  Rest and sick leave
  Identifying high risk
patients for developing
chronicity
perspective
  Patient education
  Self care
  Return to activity
Elevated Pain -Related Fears
Screening and targeting patients for
specific treatment interventions designed
to reduce these fears are recommended:
•  International Forum Primary Care
Research 2002
•  Clinical Guidelines e.g. Denmark, New
Zealand, UK, APTA Orthopaedic Section
  Hurt vs. Harm
Fear Avoidance Model
  Provides compelling scientific evidence
supporting the assessment and treatment of
patients with elevated fears
  For patients experiencing elevated pain related
fears: augment conventional Rx strategies with
cognitive behavioral techniques
  “Operant graded exercise” via Fordyce et al
  “Exposure in vivo” via Vlaeyen et al
Review Surveys
•  Pain Beliefs Questionnaire
•  Back Beliefs Questionnaire
•  Fear Avoidance Beliefs Questionnaire
•  Tampa Scale of Kinesiophobia (TSK)
•  Patient Version of the
Neurophysiology of Pain Test
Reconceptualize
  Blinded Randomized Controlled Trial
  256 PT students performed a lifting capacity
test (placed with one of two examiner types)
  24 PT students served as examiners
  12 had low scores on TSK
  Influence of examiners kinesiophobia
beliefs significantly reduced lifting capacity
by 14.4 kg (32 lbs.) in subjects with
kinesiophobia beliefs
  Influence of examiners beliefs significantly
reduced lifting capacity by 8 kg (18 lbs.) in
subjects without kinesiophobia beliefs
  12 had high scores on TSK
Lakke SE, Soer R, Krijnen CP. Influence of Physical Therapists’
Kinesiophobic Beliefs on Lifting Capacity in Healthy Adults. Phys Ther.
2015;In Press.
Matheson
Reconceptualize
Lakke SE, Soer R, Krijnen CP. Influence of Physical Therapists’
Kinesiophobic Beliefs on Lifting Capacity in Healthy Adults. Phys Ther.
2015;In Press.
WPTA Spring Conference 2015
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Reconceptualize
Reconceptualize
suggests that fear avoidance
beliefs are prognostic for poor outcome
in sub-acute LBP, and thus early
treatment, including interventions to
reduce fear avoidance beliefs, may avoid
delayed recovery and chronicity.”
  Authors compared a range of 20 factors in predicting
Wertli et al. The role of fear avoidance beliefs as a prognostic factor for
outcome in patients with nonspecific low back pain: a systematic
review. Spine Journal, 2014; 14(5): 816-836
Foster NE, Thomas E, Bishop A et al. Distinctiveness of psychological
obstacles to recovery in low back pain patients in primary care. Pain,
2010; 148(3):398-406
  “Evidence
Reconceptualize
  Four scales remained significantly associated with
outcome in the multivariate model explaining
56.6% of the variance:
  Perceptions of personal control
  Acute/chronic timeline
  Illness identify
  Pain self-efficacy
Foster NE, Thomas E, Bishop A et al. Distinctiveness of psychological
obstacles to recovery in low back pain patients in primary care. Pain,
2010; 148(3):398-406
Reconceptualize
outcome in primary care.
  Clinical outcome was defined using the Roland and
Morris Disability Questionnaire (RMDQ)
  The relative strength of the baseline psychological
measures to predict outcome was investigated using
adjusted multiple linear regression techniques
Reconceptualize
  When all independent factors were
included, depression, catastrophizing and
fear avoidance were no longer significant.
  A small number of psychological factors are
strongly predictive of outcome in primary
care low back pain patients
Foster NE, Thomas E, Bishop A et al. Distinctiveness of psychological
obstacles to recovery in low back pain patients in primary care. Pain,
2010; 148(3):398-406
Reconceptualize
  Most participants held biomedical beliefs
about the cause of CLBP, attributing pain to
structural/ anatomical vulnerability of their
spine.
  This belief was attributed to the advice
from healthcare practitioners and the results
of spinal radiological imaging.
Lin IB, O'Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM.
Disabling chronic low back pain as an iatrogenic disorder: a qualitative
study in Aboriginal Australians. BMJ open. 2013;3(4).
Matheson
Lin IB, O'Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM.
Disabling chronic low back pain as an iatrogenic disorder: a qualitative
study in Aboriginal Australians. BMJ open. 2013;3(4).
WPTA Spring Conference 2015
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Reconceptualize
Reconceptualization
  Negative causal beliefs and a pessimistic
future outlook were more common among
those who were more disabled.
  Those who were less disabled held more
positive beliefs that did not originate from
interactions with healthcare practitioners
Lin IB, O'Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM.
Disabling chronic low back pain as an iatrogenic disorder: a qualitative
study in Aboriginal Australians. BMJ open. 2013;3(4).
Reconceptualization
Moseley G. Painful yarns. Metaphors & Stories to Help Understand
the Biology of Pain. Canberra: Dancing Giraffe Press; 2007:131
Reconceptualization
  79 people with chronic pain randomized to
receive either:
  A booklet of metaphors and stories conveying key
pain biology concepts
  A booklet containing advice on how to manage
chronic pain according to established cognitivebehavioral principles
Gallagher L, McAuley J and Moseley GL. A randomized-controlled
trial of using a book of metaphors to reconceptualize pain and
decrease catastrophizing in people with chronic pain. Clinical Journal of
Pain, 2013; 29(1): 20-25
Reconceptualization
Gallagher L, McAuley J and Moseley GL. A randomized-controlled
trial of using a book of metaphors to reconceptualize pain and
decrease catastrophizing in people with chronic pain. Clinical Journal of
Pain, 2013; 29(1): 20-25
Reconceptualization
  Written material that used metaphor to explain
key biological concepts increased knowledge of
pain biology and decreased catastrophic thought
processes about pain
  Results showed that people are very likely to read
much of the material, which is an important
although often overlooked consideration.
Gallagher L, McAuley J and Moseley GL. A randomized-controlled
trial of using a book of metaphors to reconceptualize pain and
decrease catastrophizing in people with chronic pain. Clinical Journal of
Pain, 2013; 29(1): 20-25
Matheson
Gallagher L, McAuley J and Moseley GL. A randomized-controlled
trial of using a book of metaphors to reconceptualize pain and
decrease catastrophizing in people with chronic pain. Clinical Journal of
Pain, 2013; 29(1): 20-25
WPTA Spring Conference 2015
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The 6 “R’s” of Chronic LBP Rehabilitation
 Recalibrate –
Recalibrate – Reset the System
  Research has shown that back pain
  Reducing anticipatory responses to
activities perceived as painful
  Graded exposure to activities that
previously caused heightened pain
responses
suffers benefit from movement
through graded exposure and exercise
Macedo LG, Smeets RJ, Maher CG et al. Graded activity and
graded exposure for persistent nonspecific low back pain: a
systematic review. Physical Therapy, 2010; 90(6): 860-879
Smith BE, Littlewood C and May S. An update of stabilization
exercises for low back pain: a systematic review with meta-analysis.
BMC Musculoskeletal Disorders, 2014; 15(416)
Recalibrate – Graded Activity
•  Systematic review suggests that graded activity in
the short term and intermediate term is slightly
more effective than a minimal intervention but
not more effective than other forms of exercise for
persistent low back pain.
•  The limited evidence suggests that graded
exposure is as effective as minimal treatment or
graded activity for persistent low back pain.
Recalibrate –
Motor Control / Stabilization Exercises
•  “There is strong evidence stabilization (core) exercises
are not more effective than any other form of active
exercise in the long term.
•  The low levels of heterogeneity and large number of
high methodological quality of available studies, at
long term follow-up, strengthen our current findings,
and further research is unlikely to considerably alter
this conclusion.
Macedo LG, Smeets RJ, Maher CG et al. Graded activity and graded
exposure for persistent nonspecific low back pain: a systematic review.
Physical Therapy, 2010; 90(6): 860-879
Smith BE, Littlewood C and May S. An update of stabilization
exercises for low back pain: a systematic review with meta-analysis.
BMC Musculoskeletal Disorders, 2014; 15(416)
Recalibrate –
Core Stability v. General Exercise for CLBP
Recalibrate –
Core Stability v. General Exercise for CLBP
  Systematic Review and Meta-Analysis of
Randomized Controlled Trials (RCTs) from
1970 to 2011 where reviewed.
  Found 629 abstracts that authors refined down
to 28 full text articles
  Found 5 articles that met inclusion criteria
  Pooled data on 414 subjects
Wang XQ, Zheng JJ, Yu ZW, et al. A meta-analysis of core stability
exercise versus general exercise for chronic low back pain. PLOS
One. 2012;7(12):e52082.
Matheson
•  Compared to general exercise, core stability
exercise is more effective in decreasing pain
and may improve physical function in patients
with chronic LBP in the short term.
•  No significant long-term differences in pain
severity were observed between patients in
either the core stability or general exercise
groups
Wang XQ, Zheng JJ, Yu ZW, et al. A meta-analysis of core stability
exercise versus general exercise for chronic low back pain. PLOS
One. 2012;7(12):e52082.
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Recalibrate – Patient’s Perspective
Recalibrate —
Stabilization vs. Graded Activity?
  “Exercise is an effective treatment for
  Recent research may help predict which
persistent low back pain but the type of
exercise does not seem particularly
important”
patients may respond to one treatment over
the other
  A simple 15-item self report questionnaire on
clinical instability may identify patients with
CLBP who respond best to either type of
exercise
Macedo LG, Smeets RJ, Maher CG et al. Graded activity and graded
exposure for persistent nonspecific low back pain: a systematic review.
Physical Therapy, 2010; 90(6): 860-879
Macedo LG, Smeets RJ, Maher CG et al. Graded activity and graded
exposure for persistent nonspecific low back pain: a systematic review.
Physical Therapy, 2010; 90(6): 860-879
Recalibrate —
Stabilization vs. Graded Activity?
Lumbar Spine Instability Questionnaire
  Lumbar Spine Instability Questionnaire (LSIQ)
  Subjects with score > 9 did better at 1 year
follow-up when they had received graded
activity
  Subjects with a score < 9 at evaluation did
better at 1 year follow-up when they had
received motor control / stabilization exercises
Macedo LG, Smeets RJ, Maher CG et al. Graded activity and graded
exposure for persistent nonspecific low back pain: a systematic review.
Physical Therapy, 2010; 90(6): 860-879
Recalibrate – Movement is Medicine
  New articles explaining how clinicians may
integrate pain neuroscience education with
exercise intervention and how they can
apply graded exposure principles.
Nijs J, Meeus M, Cagnie B, et al. A Modern Neuroscience Approach to
Chronic Spinal Pain: Combining Pain Neuroscience Education With
Cognition-Targeted Motor Control Training. Phys Ther. 2014.
Nijs J, Lluch Girbes E, Lundberg M, Malfliet A, Sterling M. Exercise
therapy for chronic musculoskeletal pain: Innovation by altering pain
memories. Man Ther. 2015
Matheson
Recalibrate – Movement is Medicine
  Meta-Analysis examining the effects of
acute exercise in pain perception in healthy
adults and adults with chronic pain.
  Examined effects of:
  Isometric exercise
  Aerobic
  Dynamic resistance
Naugle KM, Fillingim RB, Riley JL, 3rd. A meta-analytic review of the
hypoalgesic effects of exercise. J Pain. 2012;13(12):1139-1150.
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Recalibrate – Movement is Medicine
Recalibrate – Movement is Medicine
  In healthy individuals:
  Moderate effect size for aerobic exercise
  Large effect size for isometric exercise
  Large effect size for dynamic resistance
  Reminder – short term effect
  Typically measured within minutes of exercise
completion
Naugle KM, Fillingim RB, Riley JL, 3rd. A meta-analytic review of the
hypoalgesic effects of exercise. J Pain. 2012;13(12):1139-1150.
Naugle KM, Fillingim RB, Riley JL, 3rd. A meta-analytic review of the
hypoalgesic effects of exercise. J Pain. 2012;13(12):1139-1150.
Recalibrate – Movement is Medicine
  In individuals with chronic pain:
  Small to large effects of exercise induced
hypoalgesia (EIH) in adults with regional chronic
pain at the painful muscle when a distal muscle
was being exercised
  EIH was not present in individuals with chronic
widespread pain when exercising at moderate to
high intensity
Interventions for
Chronic Low Back Pain
The Catalyst Sports Medicine
Low Back Pain Program
Naugle KM, Fillingim RB, Riley JL, 3rd. A meta-analytic review of the
hypoalgesic effects of exercise. J Pain. 2012;13(12):1139-1150.
Stratified Primary Care Tool –
The STarT Back Tool
Matheson
Catalyst Sports Medicine Chronic Back Pain Program
WPTA Spring Conference 2015
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Recalibrate –
Catalyst Sports Medicine Program
  Initial Visit
  Interview / History
  STarT Score
  FABQ
  FOTO™ PI-Web® Functional Status Score
  Patient Specific Functional Scale (PSFS)
  Physical Examination
  MedX testing:
Recalibrate – Reset the System
•  Isolated Lumbar Extension (ILEX)
resistance training as effective for significant
and meaningful improvements in perceived
pain, disability, and global perceived
outcomes for CLBP participants.
Steele J, Bruce-Low S, Smith D. A Review of the Clinical Value of
Isolated Lumbar Extension Resistance Training for Chronic Low Back
Pain. PMR. 2015;7(2):169-187.
Steele J, Bruce-Low S, Smith D, Jessop D, Osborne N. A Randomized
Controlled Trial of Limited Range of Motion Lumbar Extension
Exercise in Chronic Low Back Pain. Spine. 2013.
  (Isometric lumbar extension strength)
ILEX and ICEX MedX® Training
Initial MedX Test Results
Resiliency
The 6 “R’s” of Chronic LBP Rehabilitation
 Robust or Resiliency
  Encourage Patient Activation
  Encourage Self Efficacy
  Encourage a “Resiliency” Model
https://www.youtube.com/watch?v=BOjTegn9RuY
Matheson
WPTA Spring Conference 2015
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The 6 “Rs” of Chronic LBP Rehabilitation
  Red flags
  Reassure
The 6 “R’s” of Chronic LBP Rehabilitation
 Reasoning
  Each individual patient situation
may require different application of
the 6 “R’s”
  Reconceptualize
  Recalibrate
  Robust (What I call Resiliency)
  Reasoning
Ben Cormack - http://www.cor-kinetic.com/the-5-rs-of-rehab/
The 6 “R’s” of Chronic LBP Rehabilitation
 Reasoning
  Each individual patient situation
may require different application of
the 6 “R’s”
Red Flags
Reassure
Reconceptualize
Recalibrate
Resiliency
Matheson
WPTA Spring Conference 2015
Red Flags
Reassure
Reconceptualize
Recalibrate
Resiliency
75
Report of the Task Force on Research Standards for Chronic Low-Back Pain
Minimal Dataset
(PROMIS items marked with 1; STarT Back or nearly identical items
marked with 2; RTF Impact Classification items marked with *)
1. How long has low-back pain been an ongoing problem for you?
 Less than 1 month
 1–3 months
 3–6 months
 6 months–1 year
 1–5 years
 More than 5 years
2. How often has low-back pain been an ongoing problem for you over the past 6 months?
 Every day or nearly every day in the past 6 months
 At least half the days in the past 6 months
 Less than half the days in the past 6 months
3. In the past 7 days, how would you rate your low-back pain on average?*1,2

1

2

3

4

5

6

7

8

9

10
No pain
Worst
Imaginable
pain
4. Has back pain spread down your leg(s) during the past 2 weeks?2
 Yes
 No
 Not sure
5. During the past 4 weeks, how much
have you been bothered by …
 Stomach pain
 Pain in your arms, legs, or
joints other than your spine
or back
 Headaches
 Widespread pain or pain in
most of your body
Not bothered
at all

Bothered a little
Bothered a lot











6. Have you ever had a low-back operation?
 Yes, one operation
 Yes, more than one operation
 No
Matheson
WPTA Spring Conference 2015
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Report of the Task Force on Research Standards for Chronic Low-Back Pain
7. If yes, when was your last back operation?
 Less than 6 months ago
 More than 6 months but less than 1 year ago
 Between 1 and 2 years ago
 More than 2 years ago
8. Did any of your back operations involve a spinal fusion? (also called an arthrodesis)
 Yes
 No
 Not sure
In the past 7 days…
Not at all
A little
bit
Somewhat
Quite a
bit
Very
much
9. How much did pain interfere with
your day-to-day activities?*1





10. How much did pain interfere with
work around the home?*1





11. How much did pain interfere with
your ability to participate in social
activities?*1





12. How much did pain interfere with
your household chores?*1





13. Have you used any of the following treatments for your back pain? (Check all that apply)



Opioid painkillers (prescription medications such as Vicodin, Lortab,
Norco, hydrocodone, codeine, Tylenol #3 or #4, Fentanyl, Duragesic, MS
Contin, Percocet, Tylox, OxyContin, oxycodone, methadone, tramadol,
Ultram, Dilaudid)
If you checked yes, are you currently using this medication?………….
Injections (such as epidural steroid injections, facet injections) ……………..
Exercise therapy…………………………………………………………………………………..

Psychological counseling, such as cognitive-behavioral therapy……………
The next two questions are for people who normally work outside the home.
14. I have been off work or unemployed for 1 month or more due to low-back pain.
 Agree
 Disagree
 Does not apply
Matheson
WPTA Spring Conference 2015
Yes
No
Not
sure














77
Report of the Task Force on Research Standards for Chronic Low-Back Pain
15. I receive or have applied for disability or workers’ compensation benefits because I am unable to
work due to low-back pain.
 Agree
 Disagree
 Does not apply
Physical Function
Without
any
difficulty
With a
little difficulty
With
some
difficulty
With
much difficulty
Unable
to do




















In the past 7 days...
20. I felt worthless1
21. I felt helpless1
22. I felt depressed1
23. I felt hopeless1
Never




Rarely




Sometimes




Often




Always




In the past 7 days…
24. My sleep quality
was1
Very poor
Poor
Fair
Good
Very good





In the past 7 days…
25. My sleep was
refreshing1
26. I had a problem
with my sleep1
27. I had difficulty
falling asleep1
Not at all
A little bit
Somewhat
Quite a bit
Very much















16. Are you able to
do chores such
as vacuuming or
yard work?*1
17. Are you able to
go up and down
stairs at a normal
pace?*1
18. Are you able to
go for a walk of
at least 15
minutes?*1,2
19. Are you able to
run errands and
shop?*1
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Report of the Task Force on Research Standards for Chronic Low-Back Pain
28. It’s not really safe for a person with my back problem to be physically active. 2
 Agree
 Disagree
29. I feel that my back pain is terrible and it’s never going to get any better.2
 Agree
 Disagree
30. Are you involved in a lawsuit or legal claim related to your back problem?
 Yes
 No
 Not sure
In the past year:
Never
31. Have you drunk or used drugs more than you
meant to?

32. Have you felt you wanted or needed to cut
down on your drinking or drug use?

Rarely
33. Age: _____ years (0–120)
34. Gender:
 Female
 Male
 Unknown
 Unspecified
35. Ethnicity: (“X” ONLY one with which you MOST CLOSELY identify)
 Hispanic or Latino
 Not Hispanic or Latino
 Unknown
 Not Reported
36. Race: (“X” those with which you identify)
 American Indian or Alaska Native
 Asian
 Black or African-American
 Native Hawaiian or Other Pacific Islander
 White
 Unknown
 Not Reported
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WPTA Spring Conference 2015
Sometimes
Often






79
Report of the Task Force on Research Standards for Chronic Low-Back Pain
37. Employment Status:
 Working now
 Looking for work, unemployed
 Sick leave or maternity leave
 Disabled due to back pain, permanently or temporarily
 Disabled for reasons other than back pain
 Student
 Temporarily laid off
 Retired
 Keeping house
 Other, Specify:_________________
 Unknown
38. Education Level: (select the highest level attained)
 No high school diploma
 High school graduate or GED
 Some college, no degree
 Occupational/technical/vocational program
 Associate degree: academic program
 Bachelor’s degree
 Master’s degree (e.g., M.A., M.S., M.Eng., M.Ed., M.B.A.)
 Professional school degree (e.g., M.D., D.D.S., D.V.M., J.D.)
 Doctoral degree (e.g., Ph.D., Ed.D.)
 Unknown
39. How would you describe your cigarette smoking?
 Never smoked
 Current smoker
 Used to smoke, but have now quit
40. Height: _____
Weight: ____
 inches
 pounds
 centimeters
 kilograms
 measured
 measured
 self-reported
 self-reported
Deyo, R. A., et al. (2014). "Focus article: report of the NIH Task Force on Research
Standards for Chronic Low Back Pain." European Spine Journal. 23(10):
2028-2045.
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Low Back Pain: Clinical Practice Guidelines
be made with the Primary Care Evaluation of Mental Disorders tool that has been described for depressive symptom
screening in physical therapy settings.136 A patient with a
positive screening result for major or severe depressive
symptoms should receive a focused clinical interview and
should complete a full-length depressive symptom questionnaire (eg, Patient Health Questionnaire or Beck Depression
Inventory). A referral to a mental healthcare provider is indicated to confirm a depression diagnosis if the results of
the interview and questionnaire provide further indication
that major or severe depressive symptoms are present and
the patient is unaware of this. An immediate assessment by
a medical and/or mental health professional is indicated for
safety reasons if the patient had a plan to harm himself/
herself or others. A similar process could be used for clinicians who screen for other psychopathology (eg, anxiety).
The authors of these clinical guidelines acknowledge that
this is a general description for a rather important process.
However, there are no absolute guidelines for the levels of
psychological symptoms that indicate referral. Therefore,
clinicians will have to work within their own clinical environments, using available resources, to ensure this screening
is handled appropriately.
care treatment for low back pain, the rate of serious pathology was quite low (0.9%), with most of the identified red
flag cases, 8 of 11, being spinal fractures.150 Because most patients had at least 1 red flag, Henschke et al150 have cautioned
against use of isolated red flags because of poor diagnostic
accuracy. To improve diagnostic accuracy, a diagnostic prediction rule for identifying spinal fracture, which included
being female, older than 70 years, significant trauma, and
prolonged use of corticosteroids, was developed.149
In addition to medical conditions, clinicians should
be aware of psychological and social factors that
may be contributing to a patient’s persistent pain
and disability, or that may contribute to the transition from
an acute condition to a chronic, disabling condition. Researchers have shown that psychosocial factors are an important prognostic indicator of prolonged disability. 315
I
The term “yellow flags” is commonly used in the
literature to differentiate psychosocial risk factors
for persistent pain from medical red flags. Identification of psychological factors is assisted with the use of
standard questionnaires described in the Measures section
of these clinical guidelines. When relevant psychological
factors are identified, the rehabilitation approach should be
modified to emphasize active rehabilitation, graded exercise
programs, positive reinforcement of functional accomplishments, and/or graduated exposure to specific activities that
a patient fears as potentially painful or difficult to perform.
These approaches will be described in the Interventions section of these clinical guidelines. In addition, there should
be standard processes so that clinicians screening for severe
psychiatric disturbances (eg, clinical depression) have a clear
indication of when referral for appropriate care is expected
in a given clinical setting. An example of such a process can
V
Clinicians should consider diagnostic classifications associated with serious medical conditions or
psychosocial factors and initiate referral to the appropriate medical practitioner when (1) the patient’s clinical
findings are suggestive of serious medical or psychological
pathology, (2) the reported activity limitations or impairments of body function and structure are not consistent
with those presented in the diagnosis/classification section of
these guidelines, or (3) the patient’s symptoms are not resolving with interventions aimed at normalization of the patient’s
impairments of body function.
A
RED FLAGS FOR THE LOW BACK REGION
Condition
Back-related
tumor82,84,148
Sensitivity
Specificity
+LR (95% CI)
–LR (95% CI)
Odds Ratio
(95% CI)
...
...
...
...
...
Age over 50
0.84
0.69
2.2 (1.8, 2.7)
0.34 (0.17, 0.68)
...
History of cancer
0.55
0.98
23.7 (11.3, 49.4)
0.25 (0.01, 9.19)
...
Failure of conservative intervention (failure to
0.29
0.90
3.0 (1.4, 6.3)
0.79 (–0.58, 1.07)
...
...
History and Physical Examination Data
Constant pain not affected by position or
activity; worse with weight bearing, worse
at night
improve within 30 days)
Unexplained weight loss
0.15
0.94
3.0 (1.0, 9.3)
0.87 (0.68, 1.12)
No relief with bed-rest
1.00
0.46
1.7 (1.2, 2.2)
0.22 (0.02, 3.02)
...
(continued)
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81
Low Back Pain: Clinical Practice Guidelines
Condition
Cauda equina
syndrome 74,84
History and Physical Examination Data
Urine retention
Sensitivity
Specificity
+LR (95% CI)
–LR (95% CI)
Odds Ratio
(95% CI)
0.90
0.95
18.0
0.11
...
Fecal incontinence
...
...
...
...
...
Saddle anesthesia
0.75
...
...
...
...
Sensory or motor deficits in the feet (L4, L5,
0.80
...
...
...
...
0.40
...
...
...
...
Concurrent immunosuppressive disorder
...
...
...
...
...
Deep constant pain, increases with weight
...
...
...
...
...
Fever, malaise, and swelling
...
...
...
...
...
Spine rigidity; accessory mobility may be
...
...
...
...
...
S1 areas)
Back-related infection84
Recent infection (eg, urinary tract or skin),
intravenous drug user/abuser
307
bearing
limited
Spinal compression
fracture149
Fever: tuberculosis osteomyelitis
0.27
0.98
13.5
0.75
...
Fever: pyogenic osteomyelitis
0.50
0.98
25.0
0.51
...
Fever: spinal epidural abscess
0.83
0.98
41.5
0.17
...
History of major trauma, such as vehicular
0.30
0.85
12.8 (8.3, 18.7)
0.37 (0.20, 0.57)
...
Age over 50
0.79
0.64
2.2 (1.4, 2.8)
0.34 (0.12, 0.75)
...
Age over 75
0.59
0.84
3.7 (2.9, 4.5)
0.49 (0.37, 0.62)
...
Prolonged use of corticosteroids
...
...
...
...
...
Point tenderness over site of fracture
...
...
...
...
...
Increased pain with weight bearing
...
...
...
...
...
Back, abdominal, or groin pain
...
...
...
...
...
Presence of peripheral vascular disease or
...
...
...
...
...
Smoking history
...
...
...
...
5.07 (4.13, 6.21)
Family history
...
...
...
...
1.94 (1.63, 2.32)
Age over 70
...
...
...
...
1.71 (1.61, 1.82)
Non-Caucasian
...
...
...
...
1.02 (0.77, 1.35)
Female
...
...
...
...
0.18 (0.07, 0.48)
Symptoms not related to movement stresses
...
...
...
...
...
0.91
0.64
2.5
0.14
...
...
...
...
...
...
Palpation of abnormal aortic pulse
0.88
0.56
2.0
0.22
...
Aortic pulse 4 cm or greater
0.72
...
...
...
...
Aortic pulse 5 cm or greater
0.82
...
...
...
...
accident, fall from a height, or direct blow
to the spine
Abdominal aneurysm
(4 cm)97
coronary artery disease and associated risk
factors (age over 50, smoker, hypertension,
diabetes mellitus)
associated with somatic low back pain
Abdominal girth <100 cm
Presence of a bruit in the central epigastric
area upon auscultation
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82
Pain Beliefs Questionnaire
Linton et al. 2002 J Occ Rehabil
Please answer the following questions. The questions are related to “the most common
forms of back pain. We do not mean back pain related to fractures, infections, cauda
equine syndrome, tumors, or nerve root injury”
1. Pain intensity is directly related to the degree of the injury.
1----------2----------3----------4----------5----------6
Do not at all agree
Unsure
Completely agree
2. Pain reduction is a prerequisite for returning to normal work.
1----------2----------3----------4----------5----------6
Do not at all agree
Unsure
Completely agree
3. If a patient complains of pain during an exercise, I worry that it might cause an injury.
1----------2----------3----------4----------5----------6
Do not at all agree
Unsure
Completely agree
4. I advise my patient with back pain to continue with their daily activities even if it
hurts.
1----------2----------3----------4----------5----------6
Do not at all agree
Unsure
Completely agree
5. Patients with monotonous or heavy jobs should not work when they have pain.
1----------2----------3----------4----------5----------6
Do not at all agree
Unsure
Completely agree
6. If a movement increases the pain, I advise my patients to avoid it.
1----------2----------3----------4----------5----------6
Do not at all agree
Unsure
Completely agree
7. Back pain suggests that something is seriously wrong with the back.
1----------2----------3----------4----------5----------6
Do not at all agree
Unsure
Completely agree
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83
Pain Beliefs Questionnaire (continued)
8. Mental stress can cause back pain even if there is no organic damage.
1----------2----------3----------4----------5----------6
Do not at all agree
Unsure
Completely agree
9. Psychosocial factors can cause back pain.
1----------2----------3----------4----------5----------6
Do not at all agree
Unsure
Completely agree
10. Treatment can be successful even if the pain persists.
1----------2----------3----------4----------5----------6
Do not at all agree
Unsure
Completely agree
11. I always provide advice and instructions about pain management.
1----------2----------3----------4----------5----------6
Do not at all agree
Unsure
Completely agree
12. I always provide my patients with clear instructions about activities, e.g. what they
should and should not do.
1----------2----------3----------4----------5----------6
Do not at all agree
Unsure
Completely agree
13. Sick leave is a good treatment for back pain.
1----------2----------3----------4----------5----------6
Do not at all agree
Unsure
Completely agree
14. I can predict the patients who will develop chronic pain problems.
1----------2----------3----------4----------5----------6
Do not at all agree
Unsure
Completely agree
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84
Back Beliefs Questionnaire
The primary measure of beliefs about back pain was the back beliefs questionnaire, which is designed to
measure beliefs about the inevitable consequences of future life with low back problems.
Respondents indicate their degree of agreement with each of 14 statements on a 5-point scale (1 = agree
to 5 = disagree). A higher score indicates a more positive belief about low back trouble, suggesting a
better ability to cope with low back pain.
We are trying to find out what people think about low back trouble. Please indicate your general views
towards back trouble, even if you have never had any.
Please answer ALL statements and indicate whether you agree or disagree with each statement by
circling the appropriate response on the scale. 1= you completely disagree and 5 = you completely agree
Completely Disagree
1
2
3
1. There is no real treatment for back trouble.
4
2. Back trouble will eventually stop you from working.
Completely Agree
5
Agree Disagree 1 2 3 4 5 1 2 3 4 5 3. Back trouble means periods of pain for the rest of one's life. 1 2 3 4 5 4. Doctors can not do anything for back trouble 5. A bad back should be exercised.
1 2 3 4 5 1 1 2 2 3 3 4 4 5 5 1 2 3 4 5 1 1 2 2 3 3 4 4 5 5 10. Back trouble means long periods of time off work.
11. Medication is the only way of relieving back trouble.
1 2 3 4 5 1 2 3 4 5 12. Once you have had back trouble there is always a weakness.
1 1 2 2 3 3 4 4 5 5 1 2 3 4 5 6. Back trouble makes everything in life worse 7. Surgery is the most effective way to treat back trouble 8. Back trouble may mean you end up in a wheelchair.
9. Alternative treatments are the answer to back trouble.
13. Back trouble must be rested.
14. Later in life back trouble gets progressively worse.
The inevitability measure comprises 1 scale using a sub-set of 9 items. Items: 1, 2, 3, 6, 8, 10, 12, 13,
and 14. The scale is calculated by reversing and summing the 9 scores. References:1,2 1. Symonds TL, Burton AK, Tillotson K, Main C. Do attitudes and beliefs influence work loss due to low back trouble? Occup Med. 1996;46:25-‐32. 2. Bostick GP, Schopflocher D, Gross DP. Validity evidence for the back beliefs questionnaire in the general population. Eur J Pain. Aug 2013;17(7):1074-‐1081. Matheson
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Functional Activity
Back Questionnaire (FABQ)
Name:
FABQ-PA Physical Activity:
Here are some of the things that other patients have
told us about their pain. For each statement, please
circle any number from 0-6 to say how much physical
activities, such as bending lifting, walking, or driving
affect, or would affect your back pain.
1.
My pain was caused by physical activity.
2.
Physical activity makes my pain worse.
3.
Physical activity might harm my back
4.
5.
Date:
Completely
Disagree
Completely
Agree
Unsure
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
I should not do physical activities which (might)
make my pain worse
0
1
2
3
4
5
6
I cannot do physical activities which (might) make
my pain worse
0
1
2
3
4
5
6
FABQ-Work:
The following statements are about how your normal
work affects or would affect your back.
6.
My pain was caused by my work or an accident at
work.
7.
My work aggravated my pain.
8.
I have a claim for compensation for my pain
9.
My work is too heavy for me.
Completely
Disagree
Completely
Agree
Unsure
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
14. I cannot do my normal work until my pain is
treated.
0
1
2
3
4
5
6
15. I do not think I will be back to my normal work
within 3 months
0
1
2
3
4
5
6
16. I do not think that I will ever be able to do my
normal work.
0
1
2
3
4
5
6
10. My work makes or would make my pain worse.
11. My work might harm my back
12. I should not do my regular work with my present
pain.
13. I cannot do my normal work with my present pain.
SCORE: FABQ-PA _______ FABQ-Work_______
Source: Waddell G, Newton M. A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefes in chronic low
back pain and disablity. Pain 1993;52:157-168.
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Tampa Scale-11 (TSK-11)
Name:
Date:
86
This is a list of phrases which other patients have used to express how the view their condition. Please circle the number that best
describes how you feel about each statement.
Strongly
Disagree
Somewhat
Disagree
Somewhat
Agree
Strongly
Agree
1. I’m afraid I might injure myself if I exercise.
1
2
3
4
2. If I were to try to overcome it, my pain would increase.
1
2
3
4
3. My body is telling me I have something dangerously wrong.
1
2
3
4
4. People aren’t taking my medical condition serious enough.
1
2
3
4
5. My accident/problem has put my body at risk for the rest of
my life.
1
2
3
4
6. Pain always means I have injured my body.
1
2
3
4
7. Simply being careful that I do not make any unnecessary
movements is the safest thing I can do to prevent my pain
from worsening.
1
2
3
4
8. I wouldn’t have this much pain if there wasn’t something
potentially dangerous going on in my body.
1
2
3
4
9. Pain lets me know when to stop exercising so that I don’t
injure myself.
1
2
3
4
10. I can’t do all the things normal people do because it’s too
easy for me to get injured.
1
2
3
4
11. No one should have to exercise when he/she is in pain.
1
2
3
4
Source: Woby et al. (2005), Psychometric properties of the TSK-11: A shortened version of the Tampa Scale for Kinesiophobia. Pain,
117, 137-144.
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Patient Version of the Neurophysiology of Pain Test Adapted From Moseley et al.1,2
QUESTION
T
F
U
1. Receptors on nerves work by opening ion channels in the wall of the nerve.*
2. When part of your body is injured, special pain receptors convey the pain message to your
brain.
3. Pain only occurs when you are injured or at risk of being injured.
4. Special nerves in your spinal cord convey ‘‘danger’’ messages to your brain.
5. Pain is not possible when there are no nerve messages coming from the painful body part.*
6. Pain occurs whenever you are injured.
7. The brain sends messages down your spinal cord that can change the message going up your
spinal cord.
8. The brain decides when you will experience pain
9. Nerves adapt by increasing their resting level of excitement.
10. Chronic pain means that an injury hasn’t healed properly.
11. The body tells the brain when it is in pain.*
12. Nerves can adapt by producing more receptors.*
13. Worse injuries always result in worse pain.
14. Nerves adapt by making ion channels stay open longer.*
15. Descending neurons are always inhibitory.
16. When you injure yourself, the environment that you are in will not affect the amount of pain
you experience, as long as the injury is exactly the same.
17. It is possible to have pain and not know about it.
18. When you are injured, special receptors convey the danger message to your spinal cord.
19. All other things being equal, an identical finger injury will probably hurt the left little finger
more than the right little finger in a violinist but not a piano player.*
Abbreviations: T = true; F = False; U = Undecided.
Key:
1. True
5. False
9. True
13. False
17. False
2. False
6. False
10. False
14. True
18. True
3. False
7. True
11. False
15. False
19. True
4. True
8. True
12. True
16. False
* These items functioned erratically for persons of differing abilities or were psychometrically redundant.2
1
Moseley L. Unraveling the barriers to reconceptualization of the problem in chronic pain: the actual and perceived ability
of patients and health professionals to understand the neurophysiology. J Pain. 2003;4(4):184-189.
2
Catley MJ, O'Connell NE, Moseley GL. How good is the neurophysiology of pain questionnaire? A Rasch analysis of
psychometric properties. J Pain. 2013;14(8):818-827.
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The Keele STarT
Back Screening Tool
Name:
Date:
Thinking about the last 2 weeks tick your response to the following questions:
Disagree
Agree
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
0
1 My back pain has spread down my leg(s) at some time in the last 2 weeks
2 I have had pain in the shoulder or neck at some time in the last 2 weeks
3 I have only walked short distances because of my back pain
4 In the last 2 weeks, I have dressed more slowly than usual because of back pain
5 It’s not really safe for a person with a condition like mine to be physically active
6 Worrying thoughts have been going through my mind a lot of the time
7 I feel that my back pain is terrible and it’s never going to get any better
8 In general I have not enjoyed all the things I used to enjoy
1
9. Overall, how bothersome has your back pain been in the last 2 weeks?
Not at all
Slightly
Moderately
Very much
Extremely
0
0
0
1
1
□
□
□
Total score (all 9): __________________
□
□
Sub Score (Q5-9):______________
© Keele University 01/08/07 Funded by Arthritis Research UK
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Functional Activity
Back Questionnaire (FABQ)
Name:
FABQ-PA Physical Activity:
Here are some of the things that other patients have
told us about their pain. For each statement, please
circle any number from 0-6 to say how much physical
activities, such as bending lifting, walking, or driving
affect, or would affect your back pain.
1.
My pain was caused by physical activity.
2.
Physical activity makes my pain worse.
3.
Physical activity might harm my back
4.
5.
Date:
Completely
Disagree
Completely
Agree
Unsure
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
I should not do physical activities which (might)
make my pain worse
0
1
2
3
4
5
6
I cannot do physical activities which (might) make
my pain worse
0
1
2
3
4
5
6
FABQ-Work:
The following statements are about how your normal
work affects or would affect your back.
6.
My pain was caused by my work or an accident at
work.
7.
My work aggravated my pain.
8.
I have a claim for compensation for my pain
9.
My work is too heavy for me.
Completely
Disagree
Completely
Agree
Unsure
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
14. I cannot do my normal work until my pain is
treated.
0
1
2
3
4
5
6
15. I do not think I will be back to my normal work
within 3 months
0
1
2
3
4
5
6
16. I do not think that I will ever be able to do my
normal work.
0
1
2
3
4
5
6
10. My work makes or would make my pain worse.
11. My work might harm my back
12. I should not do my regular work with my present
pain.
13. I cannot do my normal work with my present pain.
SCORE: FABQ-PA _______ FABQ-Work_______
Source: Waddell G, Newton M. A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefes in chronic low
back pain and disablity. Pain 1993;52:157-168.
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Name:
Date:
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This is a list of phrases which other patients have used to express how the view their condition. Please circle the number that best
describes how you feel about each statement.
Strongly
Disagree
Somewhat
Disagree
Somewhat
Agree
Strongly
Agree
1. I’m afraid I might injure myself if I exercise.
1
2
3
4
2. If I were to try to overcome it, my pain would increase.
1
2
3
4
3. My body is telling me I have something dangerously wrong.
1
2
3
4
4. People aren’t taking my medical condition serious enough.
1
2
3
4
5. My accident/problem has put my body at risk for the rest of
my life.
1
2
3
4
6. Pain always means I have injured my body.
1
2
3
4
7. Simply being careful that I do not make any unnecessary
movements is the safest thing I can do to prevent my pain
from worsening.
1
2
3
4
8. I wouldn’t have this much pain if there wasn’t something
potentially dangerous going on in my body.
1
2
3
4
9. Pain lets me know when to stop exercising so that I don’t
injure myself.
1
2
3
4
10. I can’t do all the things normal people do because it’s too
easy for me to get injured.
1
2
3
4
11. No one should have to exercise when he/she is in pain.
1
2
3
4
Source: Woby et al. (2005), Psychometric properties of the TSK-11: A shortened version of the Tampa Scale for Kinesiophobia. Pain,
117, 137-144.
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Hill, J. C., et al. (2011). "Comparison of stratified primary care management for
low back pain with current best practice (STarT Back): a randomised controlled
trial." Lancet 378(9802): 1560-1571.
BACKGROUND: Back pain remains a challenge for primary care internationally. One
model that has not been tested is stratification of the management according to the
patient's prognosis (low, medium, or high risk). We compared the clinical
effectiveness and cost-effectiveness of stratified primary care (intervention) with
non-stratified current best practice (control).
METHODS: 1573 adults (aged >/=18 years) with back pain (with or without
radiculopathy) consultations at ten general practices in England responded to
invitations to attend an assessment clinic. Eligible participants were randomly
assigned by use of computer-generated stratified blocks with a 2:1 ratio to
intervention or control group. Primary outcome was the effect of treatment on the
Roland Morris Disability Questionnaire (RMDQ) score at 12 months. In the
economic evaluation, we focused on estimating incremental quality-adjusted life
years (QALYs) and health-care costs related to back pain. Analysis was by
intention to treat. This study is registered, number ISRCTN37113406.
FINDINGS: 851 patients were assigned to the intervention (n=568) and control groups
(n=283). Overall, adjusted mean changes in RMDQ scores were significantly
higher in the intervention group than in the control group at 4 months (4.7 [SD
5.9] vs. 3.0 [5.9], between-group difference 1.81 [95% CI 1.06-2.57]) and at 12
months (4.3 [6.4] vs. 3.3 [6.2], 1.06 [0.25-1.86]), equating to effect sizes of 0.32
(0.19-0.45) and 0.19 (0.04-0.33), respectively. At 12 months, stratified care was
associated with a mean increase in generic health benefit (0.039 additional
QALYs) and cost savings (₤240.01 vs. ₤274.40) compared with the control group.
INTERPRETATION: The results show that a stratified approach, by use of prognostic
screening with matched pathways, will have important implications for the future
management of back pain in primary care.
FUNDING: Arthritis Research UK.
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Stratified Interventions from Hill et al, STarT Tool Study, Lancet, 20111 Prior to meeting the patient, physiotherapists were provided with administrative clinical
information about the patient including their STarT Back Screening Tool score.
Structure of the standardized 30-‐minute assessment and examination: - A screen for potential serious pathology (red flags) and neurological examination (lower limb changes to reflexes, sensation and muscle power). - Patients were asked about their symptom history, concerns and treatment expectations. - A brief examination was also made of back pain movements (including optional testing for a directional preference) and to identify any hip pathology. - Patients received reassurance to address concerns related to their back pain and any resulting loss of function. Messages of advice focused on: o Appropriate levels of activity including return to work (if appropriate) and avoiding bed rest. o Supplemental information of local exercise venues and self-‐help groups together with a 15-‐minute educational video to reinforce messages o Addressing patient fears supported by the “Back Book”. o Addressing an individual’s uncertainty about issues such as use of pain relief (medication), the role of further investigations, work issues, and the patient's likely future prognosis including methods to deal with future episodes of back pain. The Three Stratified Intervention Pathways for Ongoing Physical Therapy 1. Low risk-‐group: a. Patients allocated to the “low risk-‐group” received the one-‐off clinic appointment described above, were reassured that further treatment was unlikely to be beneficial or necessary and were encouraged not to seek further treatment. They were, however, advised that if their symptoms deteriorated they should re-‐visit their family physician. They were therefore discharged from further physiotherapy care at the end of the clinic consultation. b. Physiotherapists were responsible for providing good clinical governance to their patients and were allowed to over-‐rule the stratified tool if they believed the pathway being recommended for a patient was inappropriate. 2. Medium risk-‐group: a. In addition to the first clinic session described above, all medium-‐risk patients were recommended for referral to ongoing physiotherapy treatment. The training was designed to standardize the pathway for medium-‐risk patients as follows: Matheson
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i.
Individualized 30-‐minute physiotherapy sessions focused on restoring function and targeting physical characteristics (disabling back pain, referred leg pain and co-‐morbid pain). ii. Up to 6 sessions over a 3-‐month period. § The first session re-‐assessed/examined the patient and included making a differential diagnosis particularly for patients with referred leg pain/radiculopathy. § The main focus of treatment was to reduce back-‐
related disability. § A tailored management plan was negotiated using evidence-‐based treatments, including advice and explanation, reassurance, education, exercise, manual therapy and acupuncture. § Consistent with evidence-‐based guidelines, bed rest, traction, massage and electrotherapy were not included in the treatment protocol. § Moderate levels of psychological prognostic indicators were addressed, but specific training on techniques to target psychological factors was not provided for physiotherapists treating the medium risk-‐group of patients. iii. Therapists were advised to refer non-‐responders on for further investigations or secondary care interventions, with supervision provided if required from a spinal specialist physiotherapist. 3. High risk-‐group a. In addition to the first clinic session described above, all high-‐risk patients were recommended for referral to ongoing physiotherapy treatment with one of four physiotherapists who attended a total of nine days training. The training was designed to standardize the pathway for high-‐risk patients as follows: i. Individualized 45-‐minute physiotherapy sessions focused on restoring function using combined physical and psychological approaches and targeting physical and psychological obstacles to recovery. ii. Treatments were held in NHS community outpatient premises with guidance that patients should receive up to 6 sessions over a 3-‐month period. § The first session re-‐assessed/examined the patient and included a differential diagnosis particularly for patients with referred leg pain/radiculopathy, and bio-‐psychosocial assessment to explore patient concerns, adopting cognitive behavioral principles to address unhelpful beliefs and behaviors. Matheson
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Therapists were trained to use “stem & leaf” questions to identify unhelpful beliefs and behaviors. § Physical treatment modalities (exercise and manual therapy) were integrated with psychologically informed techniques to provide a credible explanation for symptoms, reassurance, education, collaborative goal setting, problem solving, pacing, graded activity, and relaxation. There was a specific focus on the prognostic psychological indicators identified by the STarT Back Tool such as low mood, anxiety, pain-‐related fear and catastrophising. § Reasons for psychological distress were addressed using enhanced communication skills with a focus on promoting appropriate levels of activity, return to normal activities and the management of future back pain recurrences. § Patient expectations about prognosis and implications for function were addressed and the role of active self-‐ management emphasized. Advice about sleep and work was provided and if necessary a return to work plan implemented. § Patients were encouraged to put management plans into practice between treatment sessions and help was given to problem solve any difficulties that arose. § Monthly group mentoring sessions were held for physiotherapists to discuss individual cases and consolidate the training throughout the trial, with supervision provided from a Consultant Physiotherapist (pain management expertise) and a Professor of Clinical Psychology. Therapists were advised to refer non-‐responders on for further investigations or secondary care interventions. §
iii.
iv.
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Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. Oct 29 2011;378(9802):1560-‐1571. WPTA Spring Conference 2015
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Bulging Discs and MRI In the 1980's, a new technology emerged, which was designed to help physicians examine tissue injuries, such as disc lesions, called Magnetic Resonance Imaging or MRI. MRI's detect water content in tissues. In certain pathologies, increased or decreased water content correlates with injury or disease. Unfortunately, this has lead to an increased awareness of (and blaming of) disc lesions. Many patients often view these images as the "gold standard" for proving there is something wrong with their disc, while this may not be the case: ●
●
●
●
●
Studies now confirm that approximately 40% of people have a bulging (swollen) disc in their back WITHOUT any low back pain.(Videman, Battie et al. 2003; Alyas, Turner et al. 2007) MRI studies now show that when a patient has a bulging disc on MRI and a second (repeat) MRI is taken 2 months later, the bulge is 50% smaller and approximately 1 year later completely gone, as the body reabsorbs the fluid while the disc heals. (Komori, Shinomiya et al. 1996; Yukawa, Kato et al. 1996; Autio, Karppinen et al. 2006) An MRI is static. It is a picture in time. Just because someone has a "bulging disc" on an image, nothing is known about the properties of the disc during normal, functional movement. It could very likely be that the "normal" disc above or below may be the source of pain. MRI's are conducted with the patient lying down. When a disc is swollen it will push down, further enhancing the idea of a "bulging disc." Disc's are swollen on average 20% more in the morning compared to evening. The time of day that an MRI is done may affect the results of the MRI. (Malko, Hutton et al. 1999) The reality is that many people could have what appears to be a "bulging disc" on tests (such as MRI), which may or may not be the source of their symptoms. The good news is that many physicians are now downplaying MRI findings, unless the MRI findings match a patient's symptoms, history of injury or disease, other tests and physical examination. References: •
•
•
•
•
•
Alyas, F., M. Turner, et al. (2007). "MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players." Br J Sports Med 41(11): 836-‐41; discussion 841. Autio, R. A., J. Karppinen, et al. (2006). "Determinants of spontaneous resorption of intervertebral disc herniations." Spine 31(11): 1247-‐52. Komori, H., K. Shinomiya, et al. (1996). "The natural history of herniated nucleus pulposus with radiculopathy." Spine 21(2): 225-‐9. Malko, J. A., W. C. Hutton, et al. (1999). "An in vivo magnetic resonance imaging study of changes in the volume (and fluid content) of the lumbar intervertebral discs during a simulated diurnal load cycle." Spine 24(10): 1015-‐22. Videman, T., M. C. Battie, et al. (2003). "Associations between back pain history and lumbar MRI findings." Spine 28(6): 582-‐8. Yukawa, Y., F. Kato, et al. (1996). "Serial magnetic resonance imaging follow-‐up study of lumbar disc herniation conservatively treated for average 30 months: relation between reduction of herniation and degeneration of disc." J Spinal Disord 9(3): 251-‐6. Courtesy Adriaan Louw at the ISPI (http://www.ispinstitute.com) Matheson
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Catalyst Sports
Medicine:
Back Book
+
DO YOU SUFFER FROM BACK PAIN?
Back pain could be described as an epidemic, or even
worse, a 20th century medical disaster. With all the
advances in modern medicine, you would naturally think
clinicians could accurately diagnose the cause of back pain
and prescribe solutions to fix the problems. Unfortunately,
research shows consistently increased costs, increasing
divergence from practice guidelines and outcomes that are
getting worse, not better, with back pain.
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Back pain treatment costs our healthcare system
$90 billion annually…
…Almost as much as the care and treatments for all
cancers combined!
Catalyst Sports Medicine has
a systematic program to
address back pain and deal
with it head on. While back
pain is very common and at
times debilitating, there is
good news; commonly there
will be no serious or
permanent damage. More
often than not people are
willing to try anything to
alleviate the pain, which can
lead to irrational choices for
remedies. Here at Catalyst
Sports Medicine our Physical
Therapists, Athletic Trainers
and Strength Coaches work
with you to assess your
2
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condition and devise a
specific plan of care from
proven methods to get you
better, faster. More than 90%
of back pain patients can be
helped with physical therapy.
Our goal as a team is to
encourage and help you
restore and improve motion
to achieve long-term quality
of life.
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The Three Categories of Back Pain Duration at the Initial Consultation or Evaluation
Type of Back Pain
Length of Disability
Probability of Return
Acute Back Pain
0-4 Weeks
80-100%
Sub-acute Back Pain
4-12 Weeks
60-80%
Persistent Back Pain
More than 12 Weeks
Less than 60%
When individuals experience back pain, it’s
normal to be concerned. People often think
something drastic happened and that pain
will cause additional injury. The truth is that
serious or permanent long-term harm is rare.
At Catalyst Sports Medicine, we take great
pride in practicing evidence-based physical
therapy. Our credentialed therapists and
clinicians will use best practice techniques to
get you better faster. Our opinion, backed
by scientific research, shows that treatments
such as ultrasound, electrical stimulation,
acupuncture, or other passive interventions
are unwarranted and may add unneeded
expense to your plan of recovery.
You need to be realistic. No pain control
method is a quick or lasting fix. The most
important thing is that any active treatment
you select will assist you to become active
again to aid in your recovery.
Matheson
What can Catalyst Sports Medicine do for
you?
With a comprehensive and thorough physical
exam and a series of disability scales and
questionnaires, we will be able to work with
you on a plan of care that will:
-‐ Improve your motion and
mobility
-‐
-‐
Provide a possible alternative to
painful and expensive surgery
and
In many cases, help manage or
eliminate your pain without long-term
use of prescription medications and
exposure to their side effects
At Catalyst Sports Medicine we’re
knowledgeable and professional as
musculoskeletal experts, but most
importantly we listen to you and we care.
Our goal is to help you understand where
you are, consider all the options and develop
a plan of care and deliver that program
efficiently, yet with compassion.
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Facts vs. Fiction…
Facts:
•
•
•
•
•
•
•
Most back problems are often muscle strains or overuse conditions and are not caused by
an injury or a disease.
“Time heals all things.” In part that’s true with back pain. The long-term outlook for
recovery is excellent with time and acute pain usually improves within days or a few
weeks. The exercise, motion and activity will be beneficial in your recovery.
Studies do show that 50% of those who experience back pain will get it again, maybe years
later, however it is rarely serious and most return to normal activity with minor, if any, pain.
Inactivity for more than a day or two may actually prolong the pain.
With a bulging disc, the body – being the amazing machine it is – will often heal itself
within three to four months.
When doctors refer to degeneration in older patients, you need not be alarmed; that is
typical and normal with changes in life just like getting gray hair.
When a doctor cannot pinpoint the exact source of your pain, while frustrating, that’s
actually good news that you do not have any obvious signs of spinal damage.
Fiction:
•
•
•
•
4
Prolonged bed rest is the best thing…in time it will just go away.
Aches and pain mean injury or damage.
A slipped disc is causing my pain. Few people actually have a slipped disc that puts
pressure on the spinal cord or nerves.
I need X-Rays or an MRI to tell me what’s wrong. These types of scans usually DO NOT
help back problems and rarely detect serious spinal injuries. In fact, it’s been proven that
they may actually harm a patient’s recovery plan.
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The back…one of the strongest parts of your
body
It is surprisingly difficult to injure your back or
spine because of how it is designed. Your
back is one of the strongest parts of your body
and is made for movement and motion. The
vertebrae are strong bones separated, yet
joined, by discs to provide both flexibility and
strength. That structure is reinforced with
incredibly strong ligaments, and surrounded
by large muscles that are both powerful and
protective. When people experience a strain,
it’s usually not a ligament or muscle tear, and
rarely dangerous, or anything that will result
in a serious injury.
So, what causes the back pain and why
can’t anyone clearly identify my problem?
Despite the brightest minds in modern
medicine…as complex as the human body is,
we often don’t know for sure. For a very small
subset, 10 to 15% of patients, there is a
specific answer for what causes their back
pain. For the majority of people, we don’t
actually know and they usually end up with the
diagnosis of “nonspecific” back
pain…meaning they simply don’t know what’s
causing the pain.
Matheson
The fact that we don’t know what causes 85
to 90% of back pain cases almost seems
inconceivable given the technological
advances in medicine.
Again, the practical problem is the
complexity of the back. Doctors and clinicians
are far more confident with something like a
disease, where you either have it or you
don’t…and if you do have it, there is a clearly
identifiable or defined care plan to cure the
patient or make things better. Back
problems, on the other hand, are more
difficult to diagnose exactly.
What we do know about back pain is that it’s
not good for you to stay off work for weeks
doing nothing. What’s even worse is waiting
for months thinking it will go away, and then
visiting a surgeon who may tell you that you
don’t need an operation. Those things simply
delay your recovery. Your recovery depends
on what you do yourself. Communicate to
your doctor or therapist that you realize and
understand all this and that you’re determined
to take your care into your own hands and get
on with your life.
If you are off work more than a month because
of back problems, there is a risk of long-term
problems!
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Statistics show that after an extended period off work, there is a 10% risk you
will still be off work in a year’s time.
Once you start down the path of inactivity, things tend to spiral downward and get worse.
Having said that, don’t assume that some discomfort or pain means harm or permanent damage.
The answer to getting better is to implement your own plan of care by becoming active as
quickly as possible!
What we do know is that activity is proven to be far better for back pain than rest or inactivity. If
you feel better when you exercise, then understand that your back will feel better with
movement and motion too. To get back to normal and feeling better, get up and get moving!
The old-fashioned treatment for back pain was rest, waiting for the pain to go away. As we learn
more from science, studies and experience, we now know rest prolongs the pain.
Bed rest is NOT a treatment method; it’s NOT good for your back and it’s NOT the answer. If the
pain is intense, it may force you to rest, sit, or take a break…but bed rest for prolonged periods
of time, waiting for the pain to go away, isn’t the answer. Bed rest is only a temporary respite
and should be for short periods only. The most important thing you can do with back pain is
early intervention with movement and motion and staying active.
Here’s what
you get with
bed rest:
•
•
•
•
Stiffness
Muscles weaken
Bones weaken
Depression
•
•
•
•
Loss of fitness level
You want more pain medication
Harder and more difficult to get up
Pain feels worse
Activity is the answer!
An active body is a healthier body! When it comes to physical fitness, if you don’t use it, you lose it.
So, with regular physical activity, you get:
•
•
•
•
•
•
stronger muscles
stronger bones
increased flexibility
makes you feel better
activity releases natural chemicals in your body that reduce the pain
helps you look and feel better and healthier
Catalyst Sports Medicine recommends the following activities on your own:
•
•
•
•
•
•
6
Walking
Swimming
Bicycling or an exercise bike
Elliptical or step machines
Dance
Yoga
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Serious warning signs…not to ignore
If your pain is getting worse instead of better
over several weeks, to ensure you don’t have
a medical emergency, you should see your
doctor. Also see your doctor or medical
professional if you exhibit any of the
following symptoms, which are all very rare,
that develop along with your back pain:
•
•
•
•
Incontinence; difficulty passing or
controlling urine
Numbness, pins and needles, or severe
weakness that stays in both legs, groin
or buttocks
Severe unsteadiness on your feet
Any accident with forces that may have
been sufficient to fracture your spine
Aches and some pain are normal when you
push yourself by working out. Athletes
understand that they must push through the
pain to get to the level they need for
competition. Aches and pain do not mean
you are causing serious damage. Don’t be
alarmed by some pain or discomfort at first
when you exercise. Your fitness level will
reduce the amount of pain you feel as you get
more physically fit.
How should I deal with a back pain
episode or flare up?
Drugs can mask the pain, but do not take
care of the cause. Again, it won’t get better
on its own. The best choice will always be to
get active and resume your normal activities,
even a fitness routine, to recover. If you rest,
you will more than likely prolong the pain or
get worse.
Matheson
After a flare up, you need to assess how your
back feels. Use something to control the pain
if needed. *Acetaminophen is suggested as
the simplest and safest pain reliever. You
can also use or add anti-inflammatory
medications like ibuprofen or aspirin. They
will help you mask the pain to get back into
your activities. Used properly, simple overthe-counter medications are often most
effective for your back pain.
*NOTE: Please consult with your physician or
pharmacist on proper medications for your
particular situation. Do not take ibuprofen or
aspirin together or if you are pregnant, have
asthma, indigestion, or an ulcer. See your
physician if any problems arise.
In the first 48 hours of back pain you can try a
cold pack or compress on the affected area
for 5-10 minutes at a time. Commonly, a bag
of frozen vegetables wrapped in a damp
towel work well. Others prefer heat – a hot
water bottle, a heating pad, or even a hot
bath or shower. Heat or cold can be used if
they make you relax and help to relieve the
pain.
Another popular treatment method is
massage. Many people find that a gentle
massage relieves the pain and greatly
relaxes the muscles to help make them feel
better. Consider calling Catalyst Sports
Medicine to schedule a sports massage.
Manipulation done by a qualified
professional such as a physical therapist is
also safe and often effective. You should
notice and feel the benefit within a few
sessions.
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How does stress or anxiety
affect my back pain?
Will this pain last forever?
Actually, most of the warning
Stress and anxiety exacerbate the signs with back pain are not
pain you feel as tension can cause medical findings, but are more
muscles to tighten and become
about how people think and
painful. When back pain strikes
feel, as well as how active they
it can cause anxiety, especially
remain.
when you don’t get better as
Signs and symptoms of people
quickly as you would like. It’s
at risk for long-term pain:
hard to decide what the best
treatment or plan can be when
• High fear level that your
you get advice from family and
pain is or will lead to a
friends who all tell you to try
serious injury or damage.
different things.
• The inability to accept
reassurance that you are
Stress is part of our daily lives
going to be OK.
and you can’t always avoid it. Try
•
Equating hurt or pain with
to control your breathing, work
injury and damage to the
on relaxing your muscles or try to
point of feeling you may
calm your mind. One of the best
become disabled.
ways to reduce stress and tension
• Fear of movement or
is to exercise.
activity.
Here is a simple relaxation
• Applying rest and inactivity
exercise:
as the remedy, instead of
renewing your activity.
• Relax naturally, don’t try too
• Thinking someone can fix or
hard to relax.
solve your problem instead
• Find a comfortable position,
of staying active to help
sitting, lying down or just
yourself recover.
somewhere quiet.
• Limiting activity, becoming
• Take deep breaths that are
withdrawn and depressed.
slow and steady, gradually try
Your recovery is in your hands.
to make your exhale last up to
If you have some of the signs
twice as long as your inhale.
above, it’s time to take charge
• Focus your mind on something
of your own care and recovery
calm and repetitive.
plan by becoming more active
• “Let Go” when exhaling.
sooner than later.
Imagine and concentrate on
breathing, not relaxing.
Catalyst Sports Medicine can
help you with our training
The “relaxation response” can
programs. Our certified
sometimes be achieved quite
strength and conditioning
quickly. Deep relaxation may
coaches can work with you, one
take 10-15 minutes or longer.
on one or in a small group
Don’t be scared by your back
setting to develop a program
pain; it’s rarely serious. Fear and for you to get consistent training
worrying will only make things
to strengthen your muscles and
worse for you.
get you back to where you want
to be!
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Should I get X-Rays or an MRI?
Magnetic Resonance Imaging
(MRI) technology emerged in the
1980 s to help physicians
examine tissue injuries, such as
disc lesions. MRIs detect water
content in tissues. In certain
pathologies, increased or
decreased water content
correlates with injury or disease.
While many patients view MRIs
as the “Gold Standard” for
proving there is something
wrong with their disc, it is often
not the case.
•
•
•
•
Studies now confirm that
approximately 40% of
people have a bulging or
swollen disc in their back
WITHOUT any low back
pain.
Patients with a bulging disc
and getting a second MRI 2
months later show the bulge
as 50% smaller and
approximately 1 year later
the bulge is completely gone
as the body reabsorbs the
extra fluid.
MRIs are often conducted
with the patient lying down.
When a disc is swollen it will
push down, further
enhancing the idea of a
“bulging disc.”
The time of day may affect
the MRI…discs are swollen
on average 20% more in the
morning compared to
evening.
So while many people could
have what appears to be a
“bulging disc” on tests such as
an MRI, it may not be the source
of their symptoms or back pain.
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How can I be active with the pain?
With severe pain, you may need to rest, or even take some time off of work. If pain is keeping
you from doing your day-to-day tasks, instead of focusing on what you can’t do, focus on what
you can do and start there. You may need to modify your routine and make some adjustments.
When you think about what you need to get done, there are often modifications that can be
incorporated to accomplish the task. Just a few minutes of thinking about things in different
ways usually solves your problems.
The secret is finding that compromise between being as active as possible and not irritating
your back to make things worse. These reminders will help:
•
•
•
•
•
Keep moving
Don’t stay in one position for too long
Move around before you stiffen up
Go a little farther, go a little faster, each day
Do the things you need to do by modifying how you do them
When sitting…Try different chairs and positions and choose one that is comfortable for you. Put
some support behind the small of your back to help. Get up and move regularly as needed.
When working at your desk…Adjust your chair height, keyboard and monitor to be comfortable
at your desk. Again, get up and move as necessary to stay comfortable.
While driving…Adjust the seat height and the length from your pedals to get into a comfortable
position. Try some lumbar support for your lower back. Make regular stops or take breaks as
necessary and get out of the car and walk for a few minutes.
If you are lifting…Be sure you think before you lift! Lift what you need to, not more. Use your
legs and keep the weight close to your body. DO NOT twist while you are lifting. If you need to
turn, use your feet to change directions. Use wheels or carts whenever possible.
Playing sports…While you can adjust your intensity or duration, don’t quit playing! It may take a
bit longer, but the exercise and movement will be good for you.
When sleeping…Acetaminophen or ibuprofen taken an hour before you go to bed might help
you. The firmness of the mattress will also affect your comfort. Experiment and try firmer
mattresses or settings on your bed.
What about sex? It’s fine…but you may need to try different positions to be comfortable.
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+ Can my Doctor help?
105
While the solution often starts with you becoming more active, you may experience pain or
discomfort and feel the need to be checked by your doctor…that’s normal and very reasonable.
Do what you think is right, but remember, there is no quick fix for most back pain, so be realistic
about what to expect from doctors.
Here’s what doctors CAN DO:
•
•
•
•
With an exam they can ensure that you don’t have a serious disease
They can reassure you that you will not cause additional harm by doing your daily tasks
Suggest medication or treatments to help control your pain
Advise you on how you can best deal with the pain and get on with your life
It’s hard, but you need to accept their reassurance. At the very least you have to share, if not take
control of your own process and recovery with back pain. If clinicians recommend that you rest
for extended periods of time, press them to explain why, and be sure it makes sense to you. Your
intentions of wanting to remain active should be what they are interested in too.
The reality, and getting on with your life
The cold, hard, truth is that you will experience good days and bad days with back pain, from
mild to more intense pain, which is normal during the healing process while your body helps heal
itself.
Continuing to work, and play and do what you’re accustomed to doing is the key to recovery.
Doing the things you do, at the very least, will distract you from the pain rather than have you
focus on the pain. Your normal routine will not cause additional harm compared to changing to
more menial tasks, so try to do what you need to and modify the routine when you must to help
accomplish your goals and tasks. At work, don’t be afraid to ask co-workers for help with “heavy
jobs.” Help along with simple changes should make your job easier.
If you do see a doctor or clinician, be sure to tell them about your work; they may have advice on
how you can make changes to help alleviate some pain or discomfort. Talk to your supervisor or
boss too, so they understand where you are coming from. If you have solutions and ideas to
accomplish the tasks, they should be very receptive as well. Let everyone know you prefer to
stay working! In the event you do need to leave work or be off for a period of time, again, it’s
important to return to work as quickly as possible. Returning within days, even with some pain,
will be better for you in the long run than more extended time off. Inactivity and extended time off
will increase the time it takes to become comfortable again. It also risks your health by increasing
the chances of long-term pain and disability.
Most companies are interested in the ergonomics, safety and welfare for all their employees and
may be very willing to make temporary or permanent changes for you to get you back doing your
job sooner than later.
10
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Get your life back!
Back pain will only cripple you if you let it.
It’s proven that back pain is rarely due to
anything serious or damaged. You now have
the most up-to-date facts and advice on how
to deal with your back pain and
problems…now it’s up to you to take the
responsibility for your plan of care. How
your back feels and responds will depend on
how you react to pain and what you do about
it yourself.
The two things you always have under your
control are your attitude and your effort.
With pain, there are two types of
sufferers…you could be the one who
complains and avoids activity waiting for
someone or something to solve the problem
for them, OR, you can be the positive person
who copes with pain.
The avoider often gets frightened by the pain
and laments their future with pain. The
avoider believes that hurting means further
damage. The avoider believes that resting
will help the pain go away.
The person willing to take charge of his or
her care and cope with the pain knows that
things will get better with continued activity.
This person maintains a normal routine as
much as possible. The “coper” deals with
the pain by being positive, staying active and
getting on with life.
Matheson
The prescription for getting “back” your
life!
•
•
•
•
•
•
•
Avoid prolonged bed rest that may
make things worse in the long run.
Stay active and fit with exercise to start
feeling better. Do what you can, then a
little more for a little longer each day,
knowing it won’t cause more harm!
Get back to work as soon as possible.
Avoid heavy lifting and modify your
work tasks to do what you can for a few
days or weeks.
Don’t rely entirely on painkillers.
Understand that it’s normal to have
some aches, twinges or even some
pain, but you can manage and cope
with it!
Don’t listen to other people’s horror
stories! There’s no need to be
frightened or scared that major damage
will come from the pain.
Pain or some levels of hurt DOES NOT
mean injury or permanent harm.
Know there will be some ups and
downs. Stay positive, take back your
life and believe it can and will get
better!
You really can help yourself!
WPTA Spring Conference 2015
11
107
Catalyst Sports
Medicine
+
Help yourself today. Call Catalyst Sports Medicine to talk to one of our clinicians
about your back pain. Our team can provide you with any of the following:
•
•
•
•
Free Evaluation
Improved Strength
Massage Therapy
Increased Flexibility
•
•
•
Insurance Questions
Rehabilitation
Training Plan
Catalyst Sports Medicine
2305 Willis Miller Drive
Hudson, WI 54016
Phone: 715-386-1155
www.catalystsportsmedicine.com
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Lumbar Spine Instability Questionnaire1
Please identify if the following activities, positions, or descriptions are appropriate in describing
your current low back condition. You may check as many of the indicators that you feel are
appropriate.
Please mark “YES” if the following descriptions are appropriate in describing your current
condition and “NO” if the description does not describe your current condition.
Questions
Yes No
I feel like my back is going to “give way” or “give out” on me
I feel the need to frequently pop my back to reduce the pain
I have frequent times when my pain occurs throughout the day
I have a past history where my back catches or locks when I twist or bend my spine
I have pain when I sit to stand or stand to sit
I have a lot of pain when I sit up from lying down if I don’t rise up the right way
My pain is sometimes increased with quick, unexpected, or mild movements
I have difficulty sitting without a back support such as a chair and feel better with a
supportive backrest
I cannot tolerate prolonged positions when I can’t move
It seems like my condition is getting worse over time
I have had this problem a long time
I sometimes get temporary relief with back brace or corset
I have many occasions when I get muscle spasms
I sometimes am fearful to move because of my pain
I have had a back injury from trauma in the past
1 Macedo
LG, Maher CG, Hancock MJ, et al. Predicting Response to Motor Control Exercises and Graded Activity
for Low Back Pain Patients: Preplanned Secondary Analysis of a Randomized Controlled Trial. Phys Ther. 2014.
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Clinical Guidelines
ANTHONY DELITTO, PT, PhD • STEVEN Z. GEORGE, PT, PhD • LINDA VAN DILLEN, PT, PhD • JULIE M. WHITMAN, PT, DSc
GWENDOLYN SOWA, MD, PhD • PAUL SHEKELLE, MD, PhD • THOMAS R. DENNINGER, DPT • JOSEPH J. GODGES, DPT, MA
Please note, to save paper, this is just a selected portion of the CPG, you will
need to go to http://www.jospt.org to download the complete guideline.
Low Back Pain
Clinical Practice Guidelines Linked to the
International Classification of Functioning,
Disability, and Health from the Orthopaedic Section
of the American Physical Therapy Association
J Orthop Sports Phys Ther. 2012;42(4):A1-A57. doi:10.2519/jospt.2012.0301
RECOMMENDATIONS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A2
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3
METHODS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A4
CLINICAL GUIDELINES:
Impairment/Function-Based Diagnosis.. . . . . . . . . . . . . . . . . A11
CLINICAL GUIDELINES:
Examinations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A21
CLINICAL GUIDELINES:
Intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A31
SUMMARY OF RECOMMENDATIONS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . A44
AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS.. . . . . . A47
REFERENCES.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A48
CONTRIBUTORS: Jason M. Beneciuk, DPT • Mark D. Bishop, PT, PhD
Christopher D. Kramer, DPT • William Koch, DPT • Mark Shepherd, DPT
REVIEWERS: J. Haxby Abbott, MScPT, PhD • Roy D. Altman, MD • Matthew Briggs, DPT • David Butler, BPhty, GDAMT, MAppSc, EdD
Joseph P Farrell, DPT, MAppSci • Amanda Ferland, DPT • Helene Fearon, PT • Julie M. Fritz, PT, PhD • Joy MacDermid, PT, PhD
James W. Matheson, DPT • Philip McClure, PT, PhD • Stuart M. McGill, PhD • Leslie Torburn, DPT • Mark Werneke, PT, MS
For author, coordinator, contributor, and reviewer affiliations, see end of text. ©2012 Orthopaedic Section, American Physical Therapy Association (APTA), Inc, and the
Journal of Orthopaedic & Sports Physical Therapy. The Orthopaedic Section, APTA, Inc, and the Journal of Orthopaedic & Sports Physical Therapy consent to reproducing
and distributing this guideline for educational purposes. Address correspondence to: Joseph Godges, DPT, ICF Practice Guidelines Coordinator, Orthopaedic Section,
APTA, Inc, 2920 East Avenue South, Suite 200, La Crosse, WI 54601. E-mail: [email protected]
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Low Back Pain: Clinical Practice Guidelines
even when still experiencing pain, and (6) the importance of
improvement in activity levels, not just pain relief.
PROGRESSIVE ENDURANCE EXERCISE AND FITNESS
ACTIVITIES
Presently, most national guidelines for patients
with chronic low back pain endorse progressive
aerobic exercise with moderate to high levels of
evidence.5,20,46,56,265 High-intensity exercise has also been demonstrated to have a positive effect on patients with chronic
low back pain.47,68,225,246-248,275,277 The samples of these studies
included patients with long-term duration of symptoms that
were primarily confined to the lumbopelvic region without
generalized pain complaints.
I
Patients with low back pain and related generalized pain are
believed to have increased neural sensitivity to afferent stimuli, including proprioception and movement. This sensitizing
process has been termed central sensitization.44,229,320 Along
with underlying psychosocial factors, deficits in aerobic fitness,91,162,274,299,322 and tissue deconditioning, this sensitizing
process is believed to impact a person’s functional status and
pain perception. Aerobic fitness has been hypothesized to be
an important component of reducing pain and improving/
maintaining function of these patients.
I
Findings in patients with generalized pain complaints have demonstrated altered central pain
processing, supporting that these patients should
be managed at lower-intensity levels of training.228,229 Endurance exercise has been demonstrated to have a positive effect
on global well-being (standardized mean difference [SMD],
0.44; 95% CI: 0.13, 0.75), physical functioning (SMD, 0.68;
95% CI: 0.41, 0.95), and pain (SMD, 0.94; 95% CI: –0.15,
2.03) associated with fibromyalgia syndrome.40 Excessively
elevated levels of exercise intensity may be responsible for
increased symptom complaints due to increases in immune
activation with release of proinflammatory cytokines,208
blunted increases in muscular vascularity leading to widespread muscular ischemia,93 and inefficiencies in the endogenous opioid and adrenergic pain-inhibitory mechanism.281
Clinicians should consider (1) moderate- to highintensity exercise for patients with chronic low
back pain without generalized pain, and (2) incorporating progressive, low-intensity, submaximal fitness and
endurance activities into the pain management and health
promotion strategies for patients with chronic low back pain
with generalized pain.
A
RECOMMENDED LOW BACK PAIN IMPAIRMENT/
FUNCTION-BASED CLASSIFICATION CRITERIA WITH
RECOMMENDED INTERVENTIONS*
Patients with low back pain often fit more than 1 impairment/function-based category, and the most relevant impairments of body function, primary intervention strategy, and
the associated impairment/function-based category(ies) are
expected to change during the patient’s episode of care.
ICF-Based Category
(With ICD-10 Associations)
Symptoms
Impairments of Body Function
Primary Intervention Strategies
Acute Low Back Pain with
• Acute low back, buttock, or thigh
• Lumbar range of motion limitations
• Manual therapy procedures (thrust
Mobility Deficits
Lumbosacral segmental/somatic dysfunction
pain (duration 1 month or less)
• Unilateral pain
• Restricted lower thoracic and lumbar segmental mobility
• Onset of symptoms is often linked
• Low back and low back–related lower extrem-
to a recent unguarded/awkward
ity symptoms are reproduced with provoca-
movement or position
tion of the involved lower thoracic, lumbar, or
sacroiliac segments
manipulation and other nonthrust
mobilization techniques) to diminish
pain and improve segmental spinal or
lumbopelvic motion
• Therapeutic exercises to improve or
maintain spinal mobility
• Patient education that encourages the
patient to return to or pursue an active
lifestyle
Subacute Low Back Pain with
• Subacute, unilateral, low back,
Mobility Deficits
Lumbosacral segmental/
buttock, or thigh pain
• May report sensation of back
somatic dysfunction
stiffness
• Symptoms reproduced with end-range spinal
motions
• Symptoms reproduced with provocation
of the involved lower thoracic, lumbar, or
sacroiliac segments
• Manual therapy procedures to improve
segmental spinal, lumbopelvic, and hip
mobility
• Therapeutic exercises to improve or
maintain spinal and hip mobility
(continued)
a40
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Low Back Pain: Clinical Practice Guidelines
ICF-Based Category
(With ICD-10 Associations)
Symptoms
Subacute Low Back Pain with
Mobility Deficits
Impairments of Body Function
Primary Intervention Strategies
• Presence of 1 or more of the following:
• Focus on preventing recurring low back
- Restricted thoracic range of motion and
Lumbosacral segmental/
associated segmental mobility
somatic dysfunction
- Restricted lumbar range of motion and
(continued)
associated segmental mobility
- Restricted lumbopelvic or hip range of
motion and associated accessory mobility
pain episodes through the use of (1)
therapeutic exercises that address
coexisting coordination impairments,
strength deficits, and endurance deficits, and (2) education that encourages
the patient to pursue or maintain an
active lifestyle
Acute Low Back Pain with
• Acute exacerbation of recurring
• Low back and/or low back–related lower
• Neuromuscular re-education to
Movement Coordination
low back pain that is commonly
extremity pain at rest or produced with initial
promote dynamic (muscular) stability
Impairments
associated with referred lower
to mid-range spinal movements
to maintain the involved lumbosacral
Spinal instabilities
extremity pain
• Low back and/or low back–related lower
• Symptoms often include numerous episodes of low back and/or
low back–related lower extremity
pain in recent years
extremity pain reproduced with provocation
of the involved lumbar segment(s)
• Movement coordination impairments of the
structures in less symptomatic, midrange positions
• Consider the use of temporary external
devices to provide passive restraint
lumbopelvic region with low back flexion and
to maintain the involved lumbosacral
extension movements
structures in less symptomatic, midrange positions
• Self-care/home management training
pertaining to (1) postures and motions
that maintain the involved spinal structures in neutral, symptom-alleviating
positions, and (2) recommendations to
pursue or maintain an active lifestyle
Subacute Low Back Pain with
• Subacute, recurring low back
• Lumbosacral pain with mid-range motions
• Neuromuscular re-education to provide
Movement Coordination
pain that is commonly associated
that worsen with end-range movements or
dynamic (muscular) stability to main-
Impairments
with referred lower extremity pain
positions
tain the involved lumbosacral structures
Spinal instabilities
• Symptoms often include numer-
• Low back and low back–related lower extrem-
ous episodes of low back and/or
ity pain reproduced with provocation of the
low back–related lower extremity
involved lumbar segment(s)
pain in recent years
• Lumbar hypermobility with segmental mobility assessment may be present
• Mobility deficits of the thorax and/or lumbopelvic/hip regions
• Diminished trunk or pelvic-region muscle
strength and endurance
• Movement coordination impairments while
performing self-care/home management
activities
in less symptomatic, mid-range positions during self–care-related functional
activities
• Manual therapy procedures and therapeutic exercises to address identified
thoracic spine, ribs, lumbopelvic, or hip
mobility deficits
• Therapeutic exercises to address trunk
and pelvic-region muscle strength and
endurance deficits
• Self-care/home management training
in maintaining the involved structures
in mid-range, less symptom-producing
positions
• Initiate community/work reintegration
training in pain management strategies
while returning to community/work
activities
(continued)
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Low Back Pain: Clinical Practice Guidelines
ICF-Based Category
(With ICD-10 Associations)
Symptoms
Chronic Low Back Pain with
• Chronic, recurring low back pain
Movement Coordination
and associated (referred) lower
Impairments
extremity pain
Spinal instabilities
Impairments of Body Function
Primary Intervention Strategies
Presence of 1 or more of the following:
• Neuromuscular re-education to provide
• Low back and/or low back–related lower
dynamic (muscular) stability to main-
extremity pain that worsens with sustained
tain the involved lumbosacral structures
end-range movements or positions
in less symptomatic, mid-range posi-
• Lumbar hypermobility with segmental motion
assessment
• Mobility deficits of the thorax and lumbopelvic/hip regions
• Diminished trunk or pelvic-region muscle
strength and endurance
tions during household, occupational,
or recreational activities
• Manual therapy procedures and therapeutic exercises to address identified
thoracic spine, ribs, lumbopelvic, or hip
mobility deficits
• Movement coordination impairments while
• Therapeutic (strengthening) exercises to
performing community/work-related recre-
address trunk and pelvic-region muscle
ational or occupational activities
strength and endurance deficits
• Community/work reintegration training
in pain management strategies while
returning to community/work activities
Acute Low Back Pain with
• Acute low back pain that is com-
• Low back and lower extremity pain that can
• Therapeutic exercises, manual therapy,
Related (Referred) Lower
monly associated with referred
be centralized and diminished with specific
or traction procedures that promote
Extremity Pain
buttock, thigh, or leg pain
postures and/or repeated movements
centralization and improve lumbar
Flatback syndrome
Lumbago due to displacement
• Symptoms are often worsened
with flexion activities and sitting
• Reduced lumbar lordosis
• Limited lumbar extension mobility
• Lateral trunk shift may be present
of intervertebral disc
• Clinical findings consistent with subacute or
extension mobility
• Patient education in positions that
promote centralization
• Progress to interventions consistent
chronic low back pain with movement coor-
with the Subacute or Chronic Low Back
dination impairments classification criteria
Pain with Movement Coordination
Impairments intervention strategies
Acute Low Back Pain with
• Acute low back pain with associ-
• Lower extremity radicular symptoms that
Radiating Pain
ated radiating (narrow band of
are present at rest or produced with initial to
Lumbago with sciatica
lancinating) pain in the involved
mid-range spinal mobility, lower-limb tension
lower extremity
tests/straight leg raising, and/or slump tests
• Lower extremity paresthesias,
numbness, and weakness may
• Signs of nerve root involvement may be
present
be reported
• Patient education in positions that
reduce strain or compression to the
involved nerve root(s) or nerves
• Manual or mechanical traction
• Manual therapy to mobilize the articulations and soft tissues adjacent to the
involved nerve root(s) or nerves that
It is common for the symptoms and impairments of body function in patients who have
exhibit mobility deficits
• Nerve mobility exercises in the pain-
acute low back pain with radiating pain to also
free, non–symptom-producing ranges to
be present in patients who have acute low back
improve the mobility of central (dural)
pain with related (referred) lower extremity
and peripheral neural elements
pain
Subacute Low Back Pain with
• Mid-back, low back, and back-related radiat-
• Manual therapy to mobilize the articula-
Radiating Pain
• Subacute, recurring, mid-back
and/or low back pain with associ-
ing pain or paresthesia that are reproduced
tions and soft tissues adjacent to the
Lumbago with sciatica
ated radiating pain in the involved
with mid-range and worsen with end range:
involved nerve root(s) or nerves that
lower extremity
1. Lower limb tension testing/straight leg
• Lower extremity paresthesias,
numbness, and weakness may
be reported
raising tests, and/or...
2. Slump tests
• May have lower extremity sensory, strength,
exhibit mobility deficits
• Manual or mechanical traction
• Nerve mobility and slump exercises in
the mid- to end ranges to improve the
or reflex deficits associated with the involved
mobility of central (dural) and periph-
nerve(s)
eral neural elements
(continued)
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Low Back Pain: Clinical Practice Guidelines
ICF-Based Category
(With ICD-10 Associations)
Symptoms
Impairments of Body Function
Primary Intervention Strategies
Chronic Low Back Pain with
• Manual therapy and therapeutic
• Chronic, recurring, mid- and/or
• Mid-back, low back, or lower extremity pain
Radiating Pain
low back pain with associated
or paresthesias that are reproduced with
Lumbago with sciatica
radiating pain in the involved
sustained end-range lower-limb tension tests
lower extremity
and/or slump tests
• Lower extremity paresthesias,
numbness, and weakness may
• Signs of nerve root involvement may be
exercises to address thoracolumbar and
lower-quarter nerve mobility deficits
• Patient education pain management
strategies
present
be reported
Acute or Subacute Low Back
• Acute or subacute low back and/
Pain with Related Cognitive
or low back–related lower extrem-
or Affective Tendencies
ity pain
One or more of the following:
• Two positive responses to Primary Care
• Patient education and counseling to
address specific classification exhibited
Evaluation of Mental Disorders screen and
by the patient (ie, depression, fear-
Low back pain
affect consistent with an individual who is
avoidance, pain catastrophizing)
Disorder of central nervous
depressed
• High scores on the Fear-Avoidance Beliefs
system, specified as central
nervous system sensitivity
Questionnaire and behavioral processes con-
to pain
sistent with an individual who has excessive
anxiety or fear
• High scores on the Pain Catastrophizing
Scale and cognitive process consistent with
rumination, pessimism, or helplessness
Chronic Low Back Pain with
Related Generalized Pain
• Low back and/or low back–
related lower extremity pain with
One or more of the following:
• Two positive responses to Primary Care
Low back pain
symptom duration for longer than
Evaluation of Mental Disorders screen and
Disorder of central nervous
3 months
affect consistent with an individual who is
system
Persistent somatoform pain
disorder
• Generalized pain not consistent
with other impairment-based
depressed
• High scores on the Fear-Avoidance Beliefs
classification criteria presented in
Questionnaire and behavioral processes con-
these clinical guidelines
sistent with an individual who has excessive
• Patient education and counseling to
address specific classification exhibited
by the patient (ie, depression, fearavoidance, pain catastrophizing)
• Low-intensity, prolonged (aerobic)
exercise activities
anxiety and fear
• High scores on the Pain Catastrophizing
Scale and cognitive process consistent with
rumination, pessimism, or helplessness
*Recommendation for classification criteria based on moderate evidence.
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Low Back Pain: Clinical Practice Guidelines
CLINICAL GUIDELINES
Summary of Recommendations
B
RISK FACTORS
Current literature does not support a definitive cause for initial episodes of low back pain. Risk factors are multifactorial, population
specific, and only weakly associated with the development of low
back pain.
E
CLINICAL COURSE
The clinical course of low back pain can be described as acute, subacute, recurrent, or chronic. Given the high prevalence of recurrent
and chronic low back pain and the associated costs, clinicians should
place high priority on interventions that prevent (1) recurrences and
(2) the transition to chronic low back pain.
B
DIAGNOSIS/CLASSIFICATION
Low back pain, without symptoms or signs of serious medical or
psychological conditions, associated with clinical findings of (1)
mobility impairment in the thoracic, lumbar, or sacroiliac regions,
(2) referred or radiating pain into a lower extremity, and (3) generalized pain, is useful for classifying a patient with low back pain into
the following International Statistical Classification of Diseases and
Related Health Problems (ICD) categories: low back pain, lumbago,
lumbosacral segmental/somatic dysfunction, low back strain, spinal instabilities, flatback syndrome, lumbago due to displacement
of intervertebral disc, lumbago with sciatica, and the associated
International Classification of Functioning, Disability, and Health
(ICF) impairment-based category of low back pain (b28013 Pain in
back, b28018 Pain in body part, specified as pain in buttock, groin,
and thigh) and the following, corresponding impairments of body
function:
• A
cute or subacute low back pain with mobility deficits (b7101 Mobility of several joints)
• Acute, subacute, or chronic low back pain with movement coordination impairments (b7601 Control of complex voluntary
movements)
• Acute low back pain with related (referred) lower extremity pain
(b28015 Pain in lower limb)
• Acute, subacute, or chronic low back pain with radiating pain
(b2804 Radiating pain in a segment or region)
• Acute or subacute low back pain with related cognitive or affective
tendencies (b2703 Sensitivity to a noxious stimulus, b1522 Range
of emotion, b1608 Thought functions, specified as the tendency
to elaborate physical symptoms for cognitive/ideational reasons,
b1528 Emotional functions, specified as the tendency to elaborate
physical symptoms for emotional/affective reasons)
• Chronic low back pain with related generalized pain (b2800 Generalized pain, b1520 Appropriateness of emotion, b1602 Content
of thought)
The ICD diagnosis of lumbosacral segmental/somatic dysfunction
and the associated ICF diagnosis of acute low back pain with mobil-
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ity deficits are made with a reasonable level of certainty when the
patient presents with the following clinical findings:
• A
cute low back, buttock, or thigh pain (duration of 1 month or less)
• Restricted lumbar range of motion and segmental mobility
• Low back and low back–related lower extremity symptoms reproduced with provocation of the involved lower thoracic, lumbar, or
sacroiliac segments
The ICD diagnosis of lumbosacral segmental/somatic dysfunction
and the associated ICF diagnosis of subacute low back pain with
mobility deficits are made with a reasonable level of certainty when
the patient presents with the following clinical findings:
• S
ubacute, unilateral low back, buttock, or thigh pain
• Symptoms reproduced with end-range spinal motions and
provocation of the involved lower thoracic, lumbar, or sacroiliac
segments
• Presence of thoracic, lumbar, pelvic girdle, or hip active, segmental, or accessory mobility deficits
The ICD diagnosis of spinal instabilities and the associated ICF diagnosis of acute low back pain with movement coordination impairments are made with a reasonable level of certainty when the patient
presents with the following clinical findings:
• A
cute exacerbation of recurring low back pain and associated (referred) lower extremity pain
• Symptoms produced with initial to mid-range spinal movements
and provocation of the involved lumbar segment(s)
• Movement coordination impairments of the lumbopelvic region
with low back flexion and extension movements
The ICD diagnosis of spinal instabilities and the associated ICF
diagnosis of subacute low back pain with movement coordination
impairments are made with a reasonable level of certainty when the
patient presents with the following clinical findings:
• S
ubacute exacerbation of recurring low back pain and associated
(referred) lower extremity pain
• Symptoms produced with mid-range motions that worsen with
end-range movements or positions and provocation of the involved
lumbar segment(s)
• Lumbar segmental hypermobility may be present
• Mobility deficits of the thorax and pelvic/hip regions may be
present
• Diminished trunk or pelvic-region muscle strength and endurance
• Movement coordination impairments while performing self-care/
home management activities
The ICD diagnosis of spinal instabilities and the associated ICF diag-
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Low Back Pain: Clinical Practice Guidelines
nosis of chronic low back pain with movement coordination impairments are made with a reasonable level of certainty when the patient
presents with the following clinical findings:
• C
hronic, recurring low back pain and associated (referred) lower
extremity pain
• Presence of 1 or more of the following:
- Low back and/or low back–related lower extremity pain that
worsens with sustained end-range movements or positions
- Lumbar hypermobility with segmental motion assessment
- Mobility deficits of the thorax and lumbopelvic/hip regions
- Diminished trunk or pelvic-region muscle strength and
endurance
- Movement coordination impairments while performing community/work-related recreational or occupational activities
The ICD diagnosis of flatback syndrome, or lumbago due to displacement of intervertebral disc, and the associated ICF diagnosis of acute
low back pain with related (referred) lower extremity pain are made
with a reasonable level of certainty when the patient presents with
the following clinical findings:
• L ow back pain, commonly associated with referred buttock, thigh,
or leg pain, that worsens with flexion activities and sitting
• Low back and lower extremity pain that can be centralized and
diminished with positioning, manual procedures, and/or repeated
movements
• Lateral trunk shift, reduced lumbar lordosis, limited lumbar extension mobility, and clinical findings associated with the subacute or
chronic low back pain with movement coordination impairments
category are commonly present
The ICD diagnosis of lumbago with sciatica and the associated ICF
diagnosis of acute low back pain with radiating pain are made with
a reasonable level of certainty when the patient presents with the following clinical findings:
• A
cute low back pain with associated radiating pain in the involved
lower extremity
• Lower extremity paresthesias, numbness, and weakness may be
reported
• Symptoms are reproduced or aggravated with initial to mid-range
spinal mobility, lower-limb tension/straight leg raising, and/or
slump tests
• Signs of nerve root involvement (sensory, strength, or reflex deficits) may be present
It is common for the symptoms and impairments of body function
in patients who have acute low back pain with radiating pain to also
be present in patients who have acute low back pain with related
(referred) lower extremity pain.
The ICD diagnosis of lumbago with sciatica and the associated ICF
diagnosis of subacute low back pain with radiating pain are made
with a reasonable level of certainty when the patient presents with
the following clinical findings:
• Subacute, recurring mid-back and/or low back pain with associat-
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ed radiating pain and potential sensory, strength, or reflex deficits
in the involved lower extremity
• Symptoms are reproduced or aggravated with mid-range and
worsen with end-range lower-limb tension/straight leg raising and/
or slump tests
The ICD diagnosis of lumbago with sciatica and the associated ICF
diagnosis of chronic low back pain with radiating pain are made
with a reasonable level of certainty when the patient presents with
the following clinical findings:
• C
hronic, recurring mid-back and/or low back pain with associated
radiating pain and potential sensory, strength, or reflex deficits in
the involved lower extremity
• Symptoms are reproduced or aggravated with sustained end-range
lower-limb tension/straight leg raising and/or slump tests
The ICD diagnosis of low back pain/low back strain/lumbago and the
associated ICF diagnosis of acute or subacute low back pain with
related cognitive or affective tendencies are made with a reasonable level of certainty when the patient presents with the following
clinical findings:
• A
cute or subacute low back and/or low back–related lower extremity pain
• Presence of 1 or more of the following:
- Two positive responses to Primary Care Evaluation of Mental
Disorders for depressive symptoms
- High scores on the Fear-Avoidance Beliefs Questionnaire and
behavior consistent with an individual who has excessive anxiety
or fear
- High scores on the Pain Catastrophizing Scale and cognitive
processes consistent with individuals with high helplessness,
rumination, or pessimism about low back pain
The ICD diagnosis of low back pain/low back strain/lumbago and the
associated ICF diagnosis of chronic low back pain with related generalized pain are made with a reasonable level of certainty when the
patient presents with the following clinical findings:
• L ow back and/or low back–related lower extremity pain with
symptom duration for longer than 3 months
• Generalized pain not consistent with other impairment-based
classification criteria presented in these clinical guidelines
• Presence of depression, fear-avoidance beliefs, and/or pain
catastrophizing
A
DIFFERENTIAL DIAGNOSIS
Clinicians should consider diagnostic classifications associated
with serious medical conditions or psychosocial factors and initiate referral to the appropriate medical practitioner when (1) the
patient’s clinical findings are suggestive of serious medical or
psychological pathology, (2) the reported activity limitations or
impairments of body function and structure are not consistent with
those presented in the diagnosis/classification section of these
guidelines, or (3) the patient’s symptoms are not resolving with
interventions aimed at normalization of the patient’s impairments
of body function.
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A
EXAMINATION – OUTCOME MEASURES
Clinicians should use validated self-report questionnaires, such as
the Oswestry Disability Index and the Roland-Morris Disability Questionnaire. These tools are useful for identifying a patient’s baseline
status relative to pain, function, and disability and for monitoring a
change in a patient’s status throughout the course of treatment.
F
EXAMINATION – ACTIVITY LIMITATION AND PARTICIPATION RESTRICTION MEASURES
Clinicians should routinely assess activity limitation and participation
restriction through validated performance-based measures. Changes
in the patient’s level of activity limitation and participation restriction
should be monitored with these same measures over the course of
treatment.
A
INTERVENTIONS – MANUAL THERAPY
Clinicians should consider utilizing thrust manipulative procedures to
reduce pain and disability in patients with mobility deficits and acute
low back and back-related buttock or thigh pain. Thrust manipulative
and nonthrust mobilization procedures can also be used to improve
spine and hip mobility and reduce pain and disability in patients with
subacute and chronic low back and back-related lower extremity
pain.
A
INTERVENTIONS – TRUNK COORDINATION,
STRENGTHENING, AND ENDURANCE EXERCISES
Clinicians should consider utilizing trunk coordination, strengthening,
and endurance exercises to reduce low back pain and disability in patients with subacute and chronic low back pain with movement coordination impairments and in patients post–lumbar microdiscectomy.
A
INTERVENTIONS – CENTRALIZATION AND DIRECTIONAL
PREFERENCE EXERCISES AND PROCEDURES
Clinicians should consider utilizing repeated movements, exercises,
or procedures to promote centralization to reduce symptoms in patients with acute low back pain with related (referred) lower extremity
pain. Clinicians should consider using repeated exercises in a specific direction determined by treatment response to improve mobility
and reduce symptoms in patients with acute, subacute, or chronic
low back pain with mobility deficits.
C
INTERVENTIONS – FLEXION EXERCISES
Clinicians can consider flexion exercises, combined with other interventions such as manual therapy, strengthening exercises, nerve
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mobilization procedures, and progressive walking, for reducing pain
and disability in older patients with chronic low back pain with radiating pain.
C
INTERVENTIONS – LOWER-QUARTER NERVE
MOBILIZATION PROCEDURES
Clinicians should consider utilizing lower-quarter nerve mobilization
procedures to reduce pain and disability in patients with subacute
and chronic low back pain and radiating pain.
D
INTERVENTIONS – TRACTION
There is conflicting evidence for the efficacy of intermittent lumbar
traction for patients with low back pain. There is preliminary evidence that a subgroup of patients with signs of nerve root compression along with peripheralization of symptoms or a positive crossed
straight leg raise will benefit from intermittent lumbar traction in the
prone position. There is moderate evidence that clinicians should not
utilize intermittent or static lumbar traction for reducing symptoms
in patients with acute or subacute, nonradicular low back pain or in
patients with chronic low back pain.
B
INTERVENTIONS – PATIENT EDUCATION AND
COUNSELING
Clinicians should not utilize patient education and counseling strategies that either directly or indirectly increase the perceived threat
or fear associated with low back pain, such as education and counseling strategies that (1) promote extended bed-rest or (2) provide
in-depth, pathoanatomical explanations for the specific cause of the
patient’s low back pain. Patient education and counseling strategies
for patients with low back pain should emphasize (1) the promotion
of the understanding of the anatomical/structural strength inherent
in the human spine, (2) the neuroscience that explains pain perception, (3) the overall favorable prognosis of low back pain, (4) the use
of active pain coping strategies that decrease fear and catastrophizing, (5) the early resumption of normal or vocational activities, even
when still experiencing pain, and (6) the importance of improvement
in activity levels, not just pain relief.
A
INTERVENTIONS – PROGRESSIVE ENDURANCE EXERCISE
AND FITNESS ACTIVITIES
Clinicians should consider (1) moderate- to high-intensity exercise
for patients with chronic low back pain without generalized pain, and
(2) incorporating progressive, low-intensity, submaximal fitness and
endurance activities into the pain management and health promotion
strategies for patients with chronic low back pain with generalized pain.
WPTA Spring Conference 2015
| number 4 | journal of orthopaedic & sports physical therapy
3/21/2012 5:07:37 PM