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

1. Treatment Based Classification of the Spine-An Evidence Based Journey for the Physical Therapist Tara J. Manal, PT, DPT, OCS, SCS Gregory E. Hicks, PT, PhD

2. Evaluation of Fear Avoidance and Other Psychosocial Issues Related to LBP

3. Traditional Medical Model Identification and Treatment of Lesion …for LBP Health

4. Social Environment Illness Behavior Psychological Distress Attitudes & Beliefs Pain Biopsychosocial model Is There An Alternative Model?

5. Vicious Cycle of Pain Kori et al, 1990 Vlaeyen et al, 1995 Elfving et al, 2007

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

7. Pain Catastrophizing

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

9. Pain Catastrophizing Scale (PCS) • Questionnaire developed to measure exaggerated negative thoughts related to pain (Sullivan et al, 1995) • “I worry all the time about whether the pain will end.” • Scoring and Interpretation • 13 questions, 5 point likert scale • 0=totally disagree — 4=totally agree • Total scores range from 0-52 • Higher scores=higher degree of catastrophizing • Validity and reliability are established

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

11. Kinesiophobia

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

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

14. Tampa Scale of Kinesiophobia (TSK) • Scoring and Interpretation • 17 questions, 4 point likert scale • 1=strongly disagree — 4=strongly agree • Total score calculated after inversion of items 4, 8, 12 and 16 • Total scores range from 17-68 • Higher scores=higher degree of kinesiophobia • >37 is considered high (Vlaeyen, 1995) • Recommended to use total score rather than subscales

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

16. Fear-avoidance theory

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

18. Pain Perception

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

20. Fear-Avoidance Beliefs Questionnaire(Waddell et al, Pain, 1993) • Physical activity makes my pain worse • Physical activity might harm my back • I should not do physical activities which (might) make my back worse • I cannot do physical activities which (might) make my pain worse • My pain was caused by my work or by an accident at work • My work aggravated my pain • My work is too heavy for me • My work makes or would make my pain worse • My work might harm my back • I should not do my regular work with my present pain • I do not think I will back to my normal work within 3 months 0 – Completely Disagree 6 – Completely Agree

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

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

23. Cut-Off Scores Below 29 on FABQ-W is a “negative result” (conceptualize as more likely to be confronter) Above 34 on FABQ-W is a “positive result”(conceptualize as more likely to be an avoider)

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

25. Determining Prognosis Pre-test Probability Not Returning to Work (29%) Post-test Probability Not Returning to Work (58%) Perform FABQ-W (LR+ = 3.33) “Rule-in”

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

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

28. Determining Prognosis Pre-test Probability Not Returning to Work (29%) Post-test Probability Not Returning to Work (3%) Perform FABQ-W (LR- = 0.03) “Rule-out”

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

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

31. Intervention Guidelines • Encourage the use of a confrontation approach in those that normally wouldn’t • Addressing the way the patient thinks about low back pain itself and the consequences of low back pain • Addressing the way the patient participates in rehabilitation protocols Turn “avoiders” into “confronters”…

32. Education Modifications “…unambiguously educating the patient in a way such that the patient views his or her pain as a common condition, rather than as a serious disease that needs careful protection.” (Vlaeyan and Linton, Pain, 2000)

33. Education Modifications (Burton et al, Spine, 1999)

34. Study Design(George et al, Spine, 2003) • Randomized clinical trial • Patients referred to outpatient physical therapy • Study criteria • Inclusion: Ages 18 – 55; LBP for 8 weeks or less; English speaking • Exclusion: Tumor, fracture, infection, osteoporosis, nerve root compression, recent surgery, and pregnancy

35. Treatment Arms(George et al, Spine, 2003)

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

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

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

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

40. Graded Exposure • PT monitors patient’s fear of activities using Fear of Daily Activities Questionnaire • When patient reports decreased fear, activities are increased by at least 10% (duration, frequency, intensity)

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

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

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

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

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

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

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

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

50. Treatment of Fearful Patients