A Treatment-Based Classification Approach to Low Back Pain

1. Monte Wong PT, DPT, ATC, CSCS Senior Physical Therapist TRIA Orthopaedic Center Minneapolis, MN A Treatment-Based Classification Approach to Low Back Pain

2. A Treatment-Based Classification Approach to Low Back Syndrome: Identifying Patients for Conservative Treatment Delitto et. al, 1995 Evidence Based Practice 2

3. Management of low back disorders are difficult Inability to identify a causative agent Difficulty getting a specific diagnosis “illness in search of a disease” Limitation to pathology based model becomes apparent if you do not have a specific diagnosis Low Back Pain 3

4. Agency for Health Care Policy and Research (1994) Developed clinical practice guidelines Recommendations Aspirin/NSAIDS, trial of manipulation Assure and educate about back problems Encourage low stress aerobic exercise Avoid irritating activities Low Back Pain 4

5. AHCPR (1994) Options for patients Physical agents or modalities (home use) Shoe insoles Muscle conditioning exercises after a few weeks Epidural steroid injections in the presence of radiculopathy Low Back Pain 5

6. AHCPR (1994) Recommendations against Physical agents provided a healthcare provider TENS Lumbar corsets and support belts Traction Bed rest (> 4 days) Low Back Pain 6

7. United Kingdom (2000) “on the evidence available at present, it is doubtful that specific back exercises produce significant improvement in acute low back pain, or that it is possible to select which patient’s will respond to which exercises” Low Back Pain 7

8. Delitto et al, 1995 There is a need for classification Current systems of grouping patients are inadequate (mostly based on pathology) The use of clearly described classification systems may enhance the effectiveness of treatment Without classification, the choice of treatments takes on an appearance of a lottery Low Back Pain 8

9. Purpose Classification approach specifically directs conservative management of low back pain Will result in a management strategy that is detailed with regards to the precise type of treatment Precise type of treatment is prescribed and not relegated to nonspecific terminology where any number of conservative strategies can be used for one classification Low Back Pain 9

10. 3 levels of classification First Level- appropriate of conservative treatment by the clinician Second Level- Staging of the Patient Third Level- assigning patient to specific treatment classification Low Back Pain 10

11. First level of decision is determining the patient’s care: Can be managed by a clinician solely Can be managed by a clinician in consultation with another specialist Cannot be managed by a clinician and requires referral to another specialist First Level Classification 11

12. 2 things to ponder: Is there a serious pathology that might be referring pain to the low back? (Red Flags) Is there a psychosocial influence on the symptom behavior (Yellow Flags) First Level Classification 12

13. Red Flags Fracture Trauma (major/minor) Severe muscle spasm on physical examination Radiological examination Infection/Osteomyelitis Fever Chills Unexplained weight loss First Level Classification 13

14. Red flags Continued Cauda Equina Syndrome Saddle anesthesia Recent onset of bladder dysfunction Severe or progressive neurological deficit in the lower extremity First Level Classification 14

15. Red flags Continued Ankylosing Spondylitis Morning stiffness Improvement with activity Onset before 40 Pain not relieved in supine Local SI joint tenderness Paraspinal muscle spasm First Level Classification 15

16. Red Flags Continued Cancer Age > 50 years or < 20 Previous history of cancer Unexplained weight loss No relief with complete bed rest Pain that worsens when supine Severe night time pain First Level Classification 16

17. Yellow Flags Factors that increase the risk of developing, or perpetuating long-term disability and work loss associated with low back pain (Kendall et al, 1997) Factors known to consistently predict poor outcomes: Fear-Avoidance Beliefs and Behaviors Expectation that passive treatments will help more than active treatments Tendency to low mood and withdrawal from social interaction First Level Classification 17

18. Measurement Tools for Yellow Flags Fear Avoidance Belief Questionnaire Modified Oswestry Questionnaire Numeric Pain Rating Scale Pain Body Diagram Waddell’s Nonorganic Signs and Symptoms First Level Classification 18

19. The following statements are about how your physical activity affects 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. I should not do physical activities which (might) make my pain worse 5. I cannot do physical activities which (might) make my pain worse FABQ 19

20. The following statements are about how your normal work affects or would affect your back pain 6. My pain was caused by my work or by 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 10. My work makes or would make my pain worse 11. My work might harm my back 12. I should not do my normal work with my present pain 13. I cannot do my normal work with my present pain 14. I cannot do my normal work until my pain is treated 15. I do not think that I will be back to my normal work within 3 months 16. I do not think that I will ever be able to go back to work FABQ 20

21. FABQ 16 item questionnaire developed by Waddell et al in 1993 2 subscales Work (items 6-7, 9-12, 15)- 42 points possible Physical activity (items 2-5)- 24 points possible >30 for the FABQ-W; >15 for the FABQ-PA First Level Classification 21

22. 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 has no effect on my pain. Oswestry Pain Questionnaire 22

23. Personal Care (e.g., 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 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, I wash with difficulty, and I stay in bed. Oswestry Continued 23

24. 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 (e.g., 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. Oswestry Continued 24

25. Walking Pain does not prevent me from walking any distance. Pain prevents me from walking more than 1 mile. (1 mile = 1.6 km). Pain prevents me from walking more than 1/2 mile. Pain prevents me from walking more than 1/4 mile. I can walk only with crutches or a cane. I am in bed most of the time and have to crawl to the toilet. Oswestry Continued 25

26. 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 1/2 hour. Pain prevents me from sitting for more than 10 minutes. Pain prevents me from sitting at all. Oswestry Continued 26

27. 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 for more than 1 hour. Pain prevents me from standing for more than 1/2 hour. Pain prevents me from standing for more than 10 minutes. Pain prevents me from standing at all. Oswestry Continued 27

28. Sleeping Pain does not prevent me from sleeping well. I can sleep well only by using pain medication. Even when I take medication, I sleep less than 6 hours. Even when I take medication, I sleep less than 4 hours. Even when I take medication, I sleep less than 2 hours. Pain prevents me from sleeping at all. Oswestry Continued 28

29. 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 (e.g., sports, dancing). Pain prevents me form going out very often. Pain has restricted my social life to my home. I have hardly any social life because of my pain. Oswestry Continued 29

30. 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 1/2 hour. My pain prevents all travel except for visits to the physician / therapist or hospital. Oswestry Continued 30

31. 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 (e.g., 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. Oswestry Continued 31

32. Scoring Scale: 0 1 2 3 4 5 Add Scores / 50 x 100% Total x 2 (if all 10 questions are answered) Oswestry Pain Questionnaire 32

33. Numeric Pain Rating Scale 33

34. Pain Body Diagram 34

35. Pain Body Diagram 35

36. Waddell’s Nonorganic Signs and Symptoms Proposed characteristics Able to separate physical and nonorganic elements of examination Able to identify abnormal illness behavior Predictive of treatment outcome First Level Classification 36

37. Waddell’s Nonorganic Signs (5 possible) Regional disturbance of sensory changes or weakness that is divergent from accepted neuroanatomy Superficial/Nonanatomic Tenderness Simulation Axial loading Rotation Distraction Straight leg raise Overreaction First Level Classification 37

38. Rotation 38

39. Axial Loading (done in standing) 39

40. Distraction- SLR 40

41. Distraction-SLR 41

42. Waddell’s Nonorganic Symptoms (7 possible) Do you get pain in your tailbone? Do you have numbness in your entire leg? Do you have pain in your entire leg? Does your whole leg ever give way? Have you had any time during this episode when you have had very little back pain? Have you had to go to the emergency room because of your back pain? Has all treatment for your back made you worse? First Level Classification 42

43. Now that you have some info….what do you do??? Red Flags: Refer to Physician Yellow Flags: Consult and treat No red flags/yellow flags: proceed to stage 2 First Level Classification 43

44. Clinician only Stage 1 inflammatory Stage 1 mechanical Stage 2 Stage 3 Consultation Inflammatory process (medical) Psychological Referral Medical Psychological Surgical First Level Classification 44

45. Easy to classify movement disorders into stages based on acuteness of the injury Studies have shown the usefulness of assigning patients related to acute, sub-acute and chronic Most classifications of acuteness of injury are based on the number of days since the injury Cutoffs for categorizations in this manner are arbitrarily set and now always useful in directing conservative care Second Level Classification 45

46. Rather than days since injury, define acuteness as more related to the severity of symptoms Data from testing in first level classification will be related to staging criteria (ie) Oswestry questionnaire Second Level Classification 46

47. Stage 1 Characterized as the inability to perform the basic mechanical functions of standing, walking or sitting If people can’t perform these functions, we cannot expect them to perform a more complex and stressful activity Unable to stand > 15 minutes Unable to sit > 30 minutes Unable to walk > ¼ mile Oswestry within 40%-60% Second Level Classification 47

48. Stage 1 Proposal of therapeutic intervention Pain modulation Specific exercises, lateral shift regimens, manipulation, traction, occasional immobilization regimens Adjunctive pharmacological treatments Second Level Classification 48

49. Stage 2 Exceeds the requirements for stage 1 (sitting, standing, walking) but unable to perform basic functional ADL’s Oswestry score between 20-40% Able to sit, stand and walk with little difficulty Improve on weakness, flexibility that falls outside the ideal range, poor aerobic capacity, faulty body mechanics and posture Second Level Classification 49

50. Stage 3 About to return to activity Tolerates ADL’s and even activities involving high physical demand Oswestry score < 20% Usually asymptomatic but deconditioned from inactivity Need to tolerate high demands of activity for prolonged periods of time without exacerbation of symptoms Second Level Classification 50