Rehabilitation of the Spine: A Practitioner's Manual

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I

DVD Index

Note: Throughout the DVD when a common dys­ function is contrasted with normal func­ tion-either during a test or exercise-the Pain icon will be shown as a visual cue sig­ nifying that the dysfunction represents a "weak link" which can cause biomechanical overload and eventual pain.

•

Dead Bug Floor o Half Foam o Full Foam McGill's Abdominal Curl Up Superman Wall Ball Hamstring Curls Balance Training o Rocker Board Push-Up with Plus Deep Neck Flexors Scapulo-Thoracic Facilitation

• • • • •

• • •

•

Introduction I. Physical Perfonnance Evaluation • Vele Forward Lean • 1 Leg Standing Balance • Squat • One Leg Squat • Vleeming Hip Flexion • Janda Hip Extension • Janda Hip Abduction • Side Bridge Endurance • Wall Angel • Respiration • Push-Up • Arm Abduction • Neck Flexion

n. Sparing Strategies Micro Breaks o McGill Overhead Arm Reach o Brugger's Postural Relief Position Hip Hinge Advice o Sit to Stand o Standing o Putting on Socks o Putting on Shoes Psoas Stretch Mid-Thoracic Extension Mobilization o Foam Roll: Supine o Foam Roll: Upper Back Cat o Foam Roll: Horizontal Back Stretch Health Club Tips o Hamstring Curl o Hip Extension Multi-Hip Machine o Hip Abduction Multi-Hip Machine o Rowing o Hanging Leg Raise o Incline Sit Ups o Seated Abdominal Crunch o Lat Pull Down & Lateral Raises o Sit Up o pec Dec & Sit Up III. Stabilizing Strategies • Functional Bracing • Quadruped o Cat Camel o Bracing o Quadruped Leg Raise o Quadruped Arm Leg Raise (Bird Dog) • Side Bridge o On Knees o On Ankles o Roll Over

IV. Functional Integrated Training (FIT) Squats o With Ball o Facing Wall o Back to Wall o Wall Slide (Angel) o 1 Leg Squat Facing Wall Lunges o Vele/Janda Forward Lunge Step o Forward Lunge o Angle Lunges with Reach (Push) o Angle Lunges with Pull

•

Functional Reaches o Star Reaches o Running Man Pulley-Pushes o Punch with Step o Punch with Trunk Twist & Shoulder Internal Rotation o Weight Shift o Forehand o Throw o Volleyball Spike o Overhead Pull Down • Standing • 1 Arm (2 Leg or 1 Leg) Kneeling Pulleys-Pulls o Backhand Dynamic o Golf Swing Static o Weight Shift o Pull with Trunk Twist and Shoulder External Rotation o PNF Sword o PNF Seatbelt o Lawn Mower Core Resistance o Dead-Bug Resistance with Stick •

•

•

o o

o

Squat with Stick Bosu • with Manual Resistance • with Stick Core Twist

V. Czech School of Manual Medicine • Jiri Cumpelik-Spinal Exercises o Ready-Supine Position o Supine Position with Legs Semi-Flexed o Supine Twist-Supine Position with Legs Flexed and Lifted Side Lying The Sphinx o The Cobra Pavel Kolar-Developmental Kinesiology o Postural Ontogenesis o o

•

First Homolateral Pattern, e.g. the Development of Grasping Supine o Reflex Locomotion • Reflex Turning o The Deep Stabilizing System of the Spine • Palpation of Lateral Group of the Deep Abdominal Muscles • The Deep Stabilizing System of the Spine-Treatment o Examination and Mobilization of the Lumbar Spine Karel Lewit-Mobilization, Soft Tissue and Relaxation Techniques o Mobilization of the Fascia on the Back in a Cranial Direction o Mobilization of the Fascia on the Back in a Caudal Direction o Palpation of the Pelvic Floor o PIR: Pelvic Floor Plus M. Transversus Abdominis Examination and Mobilization of the Thoracic Spine into Extension o Mid Thoracic Spine Self Mobilization Dagmar Pavlu-Brugger Concept o The Agistic-Eccentric Contraction to Influence the Fingers Flexors o Agistic-Eccentric Contraction Influence the Wrist Flexors o Thera-Band Exercises to Improve Function of the Thigh Adductors and Plantar Flexors and Supinators of the Foot o "Great" Combined Exercise with a Thera-Band o Activities of Daily Living Misa Veverkova-Sensory Motor Stimulation/Movement Pattern Assessment o Sensory Motor Stimulation Sta­ bility Test Standing on One Leg • Standing on One Leg with Eyes Closed • Standing on One Leg on a Firm Mattress Standing on One Leg on a Firm Mattress with the Eyes Closed o The "Small Foot" Passive Modeling of the "Small Foot" • Modeling the Small Foot with Patient's Cooperation Active Small Foot Exercise o Balance Sandals • Sensory Motor Stimulation Walking with Balance Sandals • Walking Under Supervision • Walking by Oneself o Hip Extension Movement Pattern • Movement Pattern Assessment-Motor Stereotype of Hip Extension • Motor Stereotype of Hip Extension Walking o Arm Abduction Movement Pattern •

o

•

•

Second Edition

Rehabilitation of the Spine A Practitioner's Manual

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Second Edition

Rehabilitation of the Spine A Practitioner's Manual Craig Liebenson, Editor

-

t=l- Lippincott Williams & Wilkins a

Wolters Kluwer business

Pnilfil�phiOi • hilimoft • New Yorl· Loodon Buenos Airts· �g Kong· 5ydrwy· Tokyo

Acquisitions Editor: Pete Darcy Managing Editor: Laura Horowitz Marketing Manager: Christen Murphy Production Editor: Christina Remsberg Designer: Risa Clow Compositor: Circle Graphics Printer: Quebecor-Taunton Copyright © 2007 Lippincott Williams & Wilkins 351 West Camden Street Baltimore, MD 21201 530 Walnut Street Philadelphia, P A 19106 All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system with­ out wrillen permission [Tom the copyright owner. The publisher is not responsible (as a matter of product liability, negligence, or otherwise) for any injury resulting [Tom any material contained herein. This publication contains information relating to general prin­ ciples of medical care that should not be construed as specific instructions for individual patients. Manufac­ turers' product information and package inserts should be reviewed for current information, including contraindications, dosages, and precautions.

Printed in the United States ofA merica First Edition, 1996

Library of Congress Cataloging-in-Publication Data CIP data has been requested and is available from the Library of Congress.

The publishers have made every effort tently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 824-7390. International customers should call (301) 714-2324. Visit Lippincott Williams & Wilkins on the Internet: http://www.LWW.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6:00 pm, E ST. 06 1

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Dedication

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To my wife, Deannie, who has sacrificed much so that this book could see the light of day.

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I

I

Foreword

It is a pleasure and a privilege to welcome the sec­

mean we should all become rehabilitation special­

ond edition of

ists: rather, it goes to the heart of what health care

Rehabilitation of the Spine.

It is diffi­

cult to believe that nearly 10 years have passed since the first edition. So much that seemed revolu­ tionary then is now accepted as the standard for good back care, and Liebenson's textbook has become a classic.

is all about. The basic approach of this book remains the same. It updates the evidence base for an active approach, integrates it with clinical experience, and shows how it can be applied to routine practice. Every

The goal remains to improve clinical management

chapter is completely re-written and there are many

of spinal pain; more specifically, to integrate relief

distinguished new authors. The new format incor­

of symptoms with restoration of function. There is

porates modern teaching aids and a DVD. Ten years

now broad agreement on the importance of rehabil­

on, the philosophy is more developed and more

itatiop. and the need to improve functional and occupational outcomes. There is al so growing

mature, but it remains true to the original. We are now more confident that we really can improve clin­

recognition that rehabilitation is not a separate,

ical management of spinal pain: the challenge

second-stage intervention after "proper" treatment

remains to deliver that to every patient with spinal

has no more to offer yet recovery remains incom­

pain. I am confident this new edition will continue

plete. Rather, rehabilitation should be an integral

to deliver that message and help to make it a reality.

part of good clinical management. Every health professional who cares for these patients should

Gordon Waddell, MD, F R C

accept at least some responsibility for their func­

Western Infirmary

tional and occupational outcomes. That does not

Glasgow, Scotland

vii

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I

Preface

I

In the 10 years that h ave passed since this book's first

Part I: Overview introduces readers to the new

edition w as published, rehabilitation for p atients with

p ar adigm.

activity-limiting p ain of spinal origin h as become the st andard of c are. The l atest scientific evidence h as identified patient reassur ance and reactivation as the first steps in the self-man agement journey. A team approach involving p atients, he alth c are providers, employers, and p ayors all working together is needed to alter the course of distressing or dis­ abling b ack and neck pain. Rehabilitation of the Spine,

Second Edition, sheds light on v arious i atrogenic risk f actors of current pr actice approaches, in particular, the routine recommendation of bed rest, excessive diagnostic testing, overpresCliption of n arcotic anal­ gesics, and in appropri ate selection criteria for spinal surgery. With new preemptive societal measures, via the Internet and m ass media, providing the momen­ tum, this book hopes to offer a practical manual for heal th c are providers to shift towards a confident, empathetic, self-m an agement approach to spinal disorders.

A New Paradigm A new strategy utilizing the mass media to educate

Part II: Basic Science covers the mechanisms of injury, restabilization, and p ain. Part III: Assessment covers di agnostic triage, functional assessment, psychosocial screening, and outcomes m an agement. Part IV: Acute Care Management outlines the modem approach for m an aging the acute phase of spine disorders. Part V: Recovery Care Management focuses on the tools and techniques needed for recovery, including such topics as sensory-motor tr aining, yoga, func­ tional st ability tr aining, cognitive-beh avioral train­ ing, and nutrition. Part VI: Practical Application by Region contains a Visual Atlas of key assessment and tr aining tech­ niques designed to give the re ader the full l and­ scape and context of key reh ab "tools of the tr ade." Part VII: Implementing the Functional Paradigm sums up the book by covering implementation of the new p ar adigm in pr actice.

consumers directly about the positive benefits of physical activity and the d angers of deconditioning h as been undert aken in both Austr alia and Scotland. This book supports this approach by giving he alth c are providers a guide to the modern principles of evidence-b ased, outcome-b ased, p atient-centered, functional, and active self-care for p atients suffering dis abling musculoskelet al spinal p ain. M any of the architects of this new p ar adigm­ Steven Linton, Stuart McGill, and Nikol ai Bogduk­ h ave been added as contributors to this second edition to distill the new literature into a practical fr amework. Accordingly, each and every chapter h as been entirely re-written. However, the book's b asic premise of focusing on active c are, outcomes, and psychosocial f actors rem ains unchanged.

Organization The book's organization is similar to the first edi­ tion, with the most signific ant addition being a new regional application section (Part V I).

Pedagogical Features Icons: An icon system h as been designed for this second edition to guide re aders to essenti al topics. You will find these icons highlighted on the chapter openers, and they will let you know what topics will be covered.

" 4'

•

Di agnosis

Function al evalu ation

Cl assific ation ix

x

--

Preface

• .ll �.�

•

·(It,, ..

fa 'l�

Design: The second edition has been completely redesigned. The hierarchy of the content is more clearly delineated, and the special features are Psychosocial factors

easier to find and access.

Accompanying DVD Reassurance

To support the hundreds of illustrations of assess­ ment and self-care techniques, a DVD is included to better demonstrate the correct application of the

Pain

most important methods. A DVD icon

(----""

.

"

()

in the

book indicates methods that are shown on the DVD. Some of the methods included are: •

Reactivation

Reconditioning

Vleeming's active straight leg raise test

•

McGill's side bridge endurance test

•

Hip hinge advice

•

Brugger's micro-break

•

A bdominal bracing

•

Lewit's examination and mo bilization of the thoracic spine

Learning objectives: Each chapter starts with a list

Vojta's basic reflex locomotion positions

of Learning O bjectives to emphasize the most

•

relevant information in the chapter.

•

Balance sandal training

Audit Process: Each chapter ends with an Audit

•

Star lunges

Process box-a self-check of the learning o bjectives.

•

Functional training with pulleys

Clinical Pearls: This special feature is found throughout the book and contains "pearls" of wisdom from experienced practitioners. Practice-Based Problems: Found in many chap­ ters, these boxes present common clinical dilemma encountered in practice, wherein clinical decision making is highlighted. Illustrations: The second edition utilizes a highly illustrative presentation style, and many new line drawings and photographs have been added.

Rehabilitation of the Spine is a practical guide book for identification of reha bilitation candidates and solutions. Hopefully, restoring function in the loco­ motor system will become the. standard of care for managing patients with complex neuromusculo­ skeletal disorders.

Craig Liebenson Los Angeles, Califomia

I

Acknowledgments

I have had the good fortune to have had my chiro­ practic education complemented by an introduc­ tion to a broader paradigm of care, Many conversations with one of the grandfathers of spinal surgery and pioneers of taking a functional view of spinal problems William Kirkaldy-Willis helped sharpen this author's view of the locomotor system.

In the mid 1980s I was fortunate to begin my studies with the great Czech neurologists and manual medicine practitioners, Karel Lewit and Vladimir Janda. This laid the groundwork for inte­ gratin6 rehabilitation with manipulative therapy. In particular, they have contributed to our approach, a comprehensive analysis of the locomotor system, which enables clinicians to see how various func­ tional pathologies such as stiff joints, thigh mus­ cles, and weak muscles are all part of a chain of events amendable to a specific prescription of manipulation and rehabilitation. In the late 1980s another great pioneer, from San Francisco, Dennis Morgan showed me how spine stabilization training had sprung forth from P.N.F .. Stabilization training has spread around the world, and I have been fortunate to have had the chance to spend a great deal of time over the last decade with Pro Stuart McGill one the preeminant researchers of the spine stability system. In the past few years, I have begun visiting him at the University of Water-

I 100 where many of the ideas of Pro Janda and Den­ nis Morgan are being researched with "state of the art" biomechanical and neuropsychological tech­ niques. Institutions such as the Los Angeles College of Chi­ ropractic, Anglo-European College of Chiropractic, and Charles University, and organizations such as Chiropractic Education of Australia have all con­ tributed greatly to this work through their support of educational programs designed to expand the musculoskeletal paradigm to include a more func­ tional, biopsychosocial approach to rehabilitation of the locomotor system. Certainly, I could not have accomplished this task without the tremendous support of Dr.'s Sylvia Deily and Tanya Broaded in proo[Teading and com­ menting on hundreds upon hundreds of manuscript pages. My first and second edition editors, Linda Napora, Laura Horowitz, and Christina Remsberg under the stewardship of Pete Darcy have bee a reg­ ular source of support and encouragement driving me on to the finish line. My photographer Howard Linton and artists Jiri Hlavaeek and Joseph DePinho have done exceptional work, along with my amaz­ ingly patient and persistant videographer and DVD editor Robert Fisher. Craig Liebenson Los Angeles, California

Xl

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Contributors

Charles Aprill, MD

Scott Fonda, DC

New Orleans, LA

Rehabilitation Institute of Chicago

Cindy Bailey, DPT, ATC

Chicago, Illinois

Associate Professor of Clinical Physical Therapy

Clare Frank, DPT

University of Southern California

Back in Balance Physical Therapy

Los Angeles, CA

Kaiser Permanente Orthopedic Physical Therapy

Nikolai Bogduk, PhD Professor of Pain Medicine, University of Newcastle Head, Department of Clinical Research, Royal Newcastle Hospital, Newcastle,

Residency and Movement Science Fellowship Los Angeles, CA

Michael C. Geraci, Jr., MD, PT Buffalo Spine and Sports Institute

New South Wales, Australia

Buffalo, New York

Jennifer Bolton, PhD

Natalie Gluck-Bergman, DC

Anglo-European College of Chiropractic

Los Angeles, CA

Bournemouth, England

Steve Heffner, DC

Mark R. Bookhout, PT

Williamsport, PA

Physical Therapy Orthopaedic Specialists

Alena Herbenova, PhD

Minneapolis, MN

Institute for Postgraduate Medical Education

Alan Breen, DC, PhD Institute ror Musculoskeletal Research and Clinical Implementation

Charles University Prague, Czech Republic

Helena Hermach, PT

Anglo-European College or Chiropractic

Cmund, Austria

Bournemouth, UK

Paul W. Hodges, BPhty(Hons) PhD, MedDr

Wendy Burke, DPT

Professor and NH MRC Senior Research Fellow

Assistant Professor of Clinical Research

Division of Physiotherapy

University of Southern California

The University of Queensland

Department of Biokinesiology and Physical Therapy

Brisbane, Australia

Department of Orthopaedic Surgery

Gary Jacob, DC, LAc, MPH

Los Angeles, CA

Los Angeles, CA

Micheal A. Clark, DPT

Vladimir Janda, MD

National Academy or Sports Medicine

Former Chief, Department of Rehabilitation

Calabasas, CA

Medicine in Prague

Jonathan Cook, DC Anglo-European College of Chiropractic Bournemouth, UK

Neil Craton, MD Assistant Professor, Ul1iversity of Manitoba, Faculty of Medicine Director, Legacy Sport Medicine Winnipeg, Manitoba Canada

Jin

Cumpelik, PT

Faculty of Physical Education and Sport Faculty o{Dance, Academy of Pelforming Arts Charles University Prague, Czech Republic

George DeFranca, DC W. Boylston, MA

Postgraduate Institute of Medicine University Hospital Prague, Czech Republic

Gwendolen A. Jull, PT, PhD Head of Division of Physiotherapy School of Health and Rehabilitation Sciences The University of Queensland Brisbane, Australia

William H. Kirkaldy-Willis, MD, BChir, FRCS (E and C), FACS, LLD (Hon), FICC (Han) Emeritus Professor of Orthopaedic SurgelY Royal University Hospital University of Saskatchewan Saskatoon, Saskatoon Canada

Alena Kobesova, MD 2nd Medical Faculty

Sylvia Deily, DC

University Hospital Motol

Los Angeles, CA

Charles University, Prague, Czech Republic

XIII

xiv

--

Contributors

Pavel Kolar, PaedDr

Maria Perri, DC

2nd Medical Faculty

Highland Mills, NY

University Hospital Motol

Sibyle Petak-Krueger, PT

Charles University, Prague, Czech Republic

Martin Lambert, PT Buffalo, NY

Switzerland

Charles Poliquin Poliquin Performance Center

Ellen Lee, PhD

Tempe, AZ

School of Physical Therapy

Joel Press, MD

Texas Woman's University Houston, Texas

Medical Director, Spine and Sports Rehabilitation Center Rehabilitation Institute of Chicago

Karel Lewit, MD, DSc

Chicago, IL

2nd Medical FaculLy

David R. Seaman, DC

University Hospital Motol Charles University, Prague, Czech Republic

Craig Liebenson, DC Los Angeles Sports and Spine Los Angeles, CA

Steven J. Linton, PhD brebro University Department of Behavioral, Social and Legal Sciences­ Psychology brebro, Sweden

Leonard Matheson, PhD Washington University School of Medicine St. Louis, MO

Stuart M. McGill, PhD Professor of Spine Biomechanics Faculty of Applied Health Sciences Department of Ki nesiology

Palmer College of Chiropractic Florida Port Orange, FL

Maureen J. Simmonds, PhD, PT School of Physical and Occupational Thel-apy McGill University Montreal, Quebec, Canada

Clayton Skaggs, DC Central Institute for Human Performance St. Louis, MO

John J. Triano, DC, PhD, FCCS(c) Texas Back Institute Plano, TX

Pamela Tunnell, DC Ri dgefield, CT

Marie Vavrova, PT Prague, Czech Republi c

University of Waterloo, Canada

Frantisek Vele, MD, PhD

Robin McKenzie, PT

Faculty of Physical Education and Sport

President McKenzie Institute International

Charles University, Prague, Czech Republic

Raumati Beach, New Zealand

Howard Vernon, DC, PhD

Vert Mooney, MD

Director, Center (or the Study of the Cervical Spine

Clinical Professor Orthopaedics

Canadian Memorial Chiropractic College

University of California, San Di ego

Toronto, Ontario, Canada

Medical Director of Spine & Sport Centers

Michaela Veverkova, PT

San Diego, CA

Institute for Postgraduate Medical Education

Donald R. Murphy, DC

Prague, Czech Republic

Rhode Island Spine Center

Robert Watkins, MD

Providence, RI

Los Angeles Spine Surgery Institute

Chris Norris, PT

Professor of Clinical Orthopaedic Surgery

Manchester, UK

Neil Osborne, DC, FRSH, FCC(Orth) Anglo-European College of Chiropractic Bournemouth, UK

Dagmar Pavlu, PaedDr, PhD Faculty of Physical Education and Sport Charles University Prague, Czech Republic

University of Southern California Los Angeles, CA

Steven Yeomans, DC Yeomans-Edinger Chiropractic Center Ripon, WI

Contents

PART IV ACUTE CARE MANAGEMENT

PART I OVERVIEW

1. Active Care: Its Place in the Management of Spinal Disorders- Crai g Liebenson

3

2. The Role of Muscles, Joints, and the Nervous System in Painful Conditions of the Spine­

Craig Liebenson

30

Problem and Modern Attempts to Manage It­

51

Steve Heffner

Craig Liebenson

-

16. Brugger Methods for Postural Correction­

Vladimir Janda

72

Maria Perri

5. Lumbar Spine Stability: Mechanism of Injury and Restabilization-Stuart M. McGill

93

6. The Sources of Back Pain-Nikolai Bogduk

1 12

125

S. Outcome Assessment-Steven Yeomans, Craig Liebenson, Jennifer Bolton, and Howard Vernon

9. Assessment of Psychosocial Risk Factors of C raig Liebenson Chronicity-"Yellow Flags "-

183

Appendix 9A Yellow Flag Form

Ability-Craig Liebenson and

and Charles Poliquin

460

Model of Assessment and Outcome­

Maureen J. Simmonds and Ellen Lee

260

13. Employment Screening and Functional Capacity Evaluation to Determine Safe Return to Work-Leonard Matheson and

Tension-Michael C. Geraci, Jr.,

Martin Lambert, and Mark R. Bookhout

464

21. Manipulation Techniques for Key Joints­ 487

511

22. Sensory Motor Stimulation-V ladimir Janda, Marie Vavrova, Alena Herbenova, and Michaela Veverkova

226

12. Physical Performance Tests: An Expanded

276

Appendix 19A The Role of Active Release Technique in Rehabilita t ion- Clayton Skaggs

(AFTER 4 WEEKS)

203

11. Quantification of Physical Performance

Vert Mooney

407

PART V RECOVERY CARE MANAGEMENT

Vladimir Janda, Clare Frank, and

Steven Yeomans

403

and Natalie Gluck- Bergman

George DeFranca

201

10. Evaluation of Muscular Imbalance­ Craig Liebenson

Helena Hermach

and Treatment of Adverse Neurodynamic

169

and Steven Yeomans

388

20. Neuromobilization Techniques-Evaluation

146

Appendix SA Forms

Alena Kobesova

Appendix ISA Exteroceptive Therapy­

Liebenson, Pamela Tunnell, Donald R. Murphy,

7. Diagnostic Triage in Patients with Spinal Pa in-Neil Craton

369

IS. Soft Tissue Manipulation-Karel Lewit and

19. Manual Resistance Techniques-Craig

123

PART III ASSESSMENT

352

17. Rehabilitation of Breathing Pattern Disorders­

91

PART II BASIC SCIENCE

and Charles Aprill

330

Dagmar Pavlu, Sibyle Petak-Krueger, and

4. Putting the Biopsychosocial Model Into Practice

15. McKenzie Spinal Rehabilitation Methods­ G ary Jacob, Robin McKenzie, and

3. Quality Assurance: The Scope of the Spine Craig Liebenson

293

(FIRST 4 WEEKS)

14. Active Self-Care: Functional Reactivation for Spine Pain Pati ents- Crai g Liebenson 295

5 13

23. Facilitation of Agonist-Antagonist Co-activation by Reflex Stimulation Methods-Pavel Kolar

53 1

24. Yoga-Based Training for Spinal Stability­ Jiri Cumpelik and Frantisek Vele 566 25. Spinal Segmental Stabilization Training­ Paul W. Hodges and Gwendolen A. Jull

585

xv

xvi

--

Contents

26. Functional Stability Training­

34. Integrated Approach to the Lumbar Spine­

612

Craig Liebenson

Craig Liebenson, Scott Fonda,

Appendix 26A Proprioceptive Taping-An Adjunct to Treating Muscle Imbalances­

35. Integrated Approach to the Cervical Spine­

Clare Frank, Wendy Burke, and Cindy Bailey

798

and Sylvia Deily

Craig Liebenson, Clayton Skaggs, Scott Fonda,

663

852

and Sylvia Deily

27. Global Muscle Stabilization Training­ Isotonic Protocols-Neil Osborne and Jonathan Cook

PART VII IMPLEMENTING THE FUNCTIONAL

667

PARADIGM

28. Weight Training for Back Stability­ Chris Norris

688

William H. Kirkaldy-Willis

29. Advanced Stabilization Training for

Elderly-Craig Liebenson

712

30. Nutritional Considerations for Inflammation and Pain-David R. Seaman

728

31. A Cognitive Behavioral Therapy Program for Spinal Pain-Steven J. Linton PART VI PRACTICAL ApPLICATION

741 BY

REGION

Appendix 37A Physical Activity Readiness Questionnaire

751

753 776

91 4

38. Role of Non-Operative Spinal Specialist in Managing the Spine Patient-Joel Press, John and Robert Watkins

915

39. From Guidelines to Practice: What is the Practitioner's Role?-Alan Breen

33. Managing Common Syndromes and Finding the Key Link-Karel Lewit

898

J. Triano, Craig Liebenson,

32. An Integrated Approach to Regional Disorders-Craig Liebenson

889

37. The Role and Safety of Activity in the

Performance Enhancement­ Micheal Clark

887

36. The Patient and the Doctor­

INDEX

947

933

PART

Overview CHAPTER 1

Active Care: Its Place in the Management of Spinal Disorders

Craig Liebenson CHAPTER 2

The Role of Muscles, Joints, and the Nervous System in Painful Conditions of the Spine

Craig Liebenson CHAPTER 3

Quality Assurance: The Scope of the Spine Problem and Modern Attempts to Manage It

Craig Liebenson CHAPTER 4

Putting the Biopsychosocial Model Into Practice

Craig Liebenson

Editor's Note

A new patient-centered model is being applied to spine disorders. Rather than focusing m erely on pathology and symptoms, t h e emp h asis is on recov­ ery, reactivation, and self-management. Passive care approaches u tilizing medication, modali ties, and man ipulation are being replaced with an active self­ care paradigm. This first section of the book lays out the added value to patients of a reactivation approach . The overwhelming evidence i n support of this new direction i s reviewed along with the rea­ sons why a traditional biomedical way of th inking is far from ideal for a multi factorial problem such as spine pain . This section concludes with a discussion of why, when , and how to integrate the basic steps of this broad n ew biopsychosocial model in to every­ day clinical practice.

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Active Care: Its Place in the Management of Spinal Disorders

Craig Liebenson

Introduction

Learning Objectives

The Functional Paradigm in Diagnosis and Therapy

After reading this chapter you should be able to

The Diagnostic Dilemma in Back Pain The Rationale for Active Care The Deconditioning Syndrome­ Functional and Cognitive­ Behavioral Aspects

understand: •

•

The Clinical Examination of Function and Perfor­ mance

•

Correlation Between Specific Performance Deficits and Low Back Pain Cognitive-Behavioral Components The Negative Effects of Immobilization and Bed Rest

•

A Patient-Centered Approach Evidence of Active Care's Effectiveness: Does It Exist? Prevention Acute Phase (First 4-6 Weeks) Subacute Phase Reactivation and Exercise (From 4-12 Weeks) Chronic Phase Reactivation and Exercise (After

12 Weeks) Active Care and the Neck

•

The c urrent state of k nowledge for t h e diagnosis and classification o f pati en ts with low back dis­ orders The relationship between functional distur­ bances and spi nal disorders The relationship between psychosoci al factors, s uc h as fear-avoidance behavior, and decondi­ tioning syndrome The distinction between specific dysfunctions s uc h as losses of strength or mobi l i t y and general dysfunctions such as walking or sitting i ntoler­ a nces The evidence for t h e effectiveness of active care in t h e treatmen t of spinal disorders "One of the most tragic events of our time is that

we know more than ever before about the pains and sufferings less able to respond to them. "

Henri Nouwen

3

4

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Part One: Overview

Introduction

Activity has been shown to be effective for preventing or treating many of t h e most common c hronic ail­ m ents i n our soc i ety today (77). In particular, active care or pati ent reactivation plays a decisive role in the modern management of disorders of t h e cardiovascu­ lar and locomotor systems (75,94,95,161,183,189,195, 200,201). From simple, uncomplicated reactivation advice to com prehensive, m ultidiscipl i nary rehabili­ tation, t h e goal is to restore function. The functional goal i s a n essen t i al h i nge for guiding c l i n ic i an s i n t h e dec ision-making process. Biomec hanical, neuro­ physiological, psychosocial, and biochem i cal ratio­ nales exi s t for t h e benefi ts of active care. However, t h e m ost i m portant justification for making reacti­ vat ion a pri mary focus of care is that patients i n pain tend to accept the adage " l et pain be your guide," with the result bei ng they decondition as a result of t heir pain. Persistent pain rei n forces negative attitudes about the relationship of activity and pain as the patient takes on the "sick" role (147). Diagnostic tests that focus on pathoanatomy are frequently ordered to find the "cause" of the pain. Unfortunately, t h ese tests have h igh false-posi tive rates for coincidental structural findings, such as degenerative joint disease or herni­ ated discs, and thus reinforce the pati ents self-image as having a "bad" back or needing to "learn to live with it" (14,15,23,96,99,111,239,255,271). The result is fur­ ther activity avoidance and deconditioni ng. Unfortu­ nately, excessive i m mo bilization interferes with t h e h ealing, copi ng, a n d recovery process. Thus, h ealth care professionals are being urged by each successive international guideline on spinal disorders to first per­ form a diagnostic triage to rule out "red flags" of rare but serious disease, and t h en to reassure pati ents of the benign nature of thei r back pain and the safety and value of gradually resum ing activities (2,25,38,94, 148,217). The evidence i n favor of reactivation for spin e patients i s strong. Reactivation advice t o resum e near­ normal activi ties is both safe and effective for acute low back pain (LBP) patients (148) . Similarly, early activation has been found to be effective for neck pain after a whiplash i njury (18,166,213). Deconditioning normally accompanies acute LBP and i ts preven tion has been s hown to reduce recurrence rates (82,83, 234). Active therapies involving such diverse exercise methods as cognitive-behavioral, stabi li zation, and strengthening have demonstrated t heir effect iveness for subacute and chronic LBP (11,58-60,83,94,95,113, 128,150,190). Therefore, at each phase of the acute to chronic pain continuu m , patien t reactivation has been shown to play a fundam en tal role.

The Functional Paradigm in Diagnosis and Therapy

L B P is a subjective symptom t hat correlates poorly with objective findi ngs. Less than 1 5% of LBP patients can be given a precise pathoanatomical diagnosis. These patients are labeled with general terms such as sprain/strai n , "non-specific," or idiopat hic LBP. Fortu­ nately, most low back conditions have a favorable nat­ ural history. However, pat ients who don't recover rapidly with "tincture of t i me" can become frustrated. The physician shares in this fTustration with the result being t hat tests are ordered that have low predictive value and thus are u n l i kely to make a di fference in patient care. I n fact, the reservoir of coi nciden tal struc­ tural pathology ( false-positive results) in pat ients is so h igh that performi ng advanced i m aging i njud iciously has the unwanted side effect of i ncreasing anxiety and propagating an u ndesirable, interventionist cascade in pursuit of the cause of the pain ( 1 77 ,269,27 5 ) . The problem of back pain then i s not what t o d o for the majority o f patients who have a satisfactory outcome,

l

but rather what to do for the disproportionately costly m inority who do not. Because the goal of care is to restore function, are we able to identi fy the impairments and cognitive-behavio �a 1 factors that linlit performance . . so that treatment deCISIons can be gUIded by a valid, logical reason ing process?

The Diagnostic Dilemma in Back Pain The Problem

Optimal cli nical m a n agem ent depends on accurate d i agnosis. Unfortunately, only a m i nori ty of back pain pati ents can be given a clear diagnosis of their pain generator or relevan t pathoanatomy (2). The conundrum o f t h e LBP problem is that whereas most patients do well despite this diagnostic failure, the vast majority of the costs arise [yom the mi nority of t hose who become chronically disabled (80). Current "state-of-the-art" guidelines suggest per­ forming a diagnostic triage to classify patients with low back problems i n to t h ree distinct groups. First, caused by "red flags" of serious disease, e.g., tumor, infection, fracture, or serious m edical disease «2%); second, caused by nerve root compression (<10%); or t h ird, caused by "non-specific" m echan ical factors (850/0-90%) (2,38,217) (see C hapter 7). This "state of the art" will hopefully evolve because the most crucial of all "stake holders" -the pati ents-are dissatisfied with t h e diagnosis "non-specific" back pain (20,25).

Chapter One: Active Care: Its Place in the Management of Spinal Disorders

Cause

4

--

5

system for "non-specific" L BP was thei r top resea rch priority (19).

Subclassification of "Non-Specific" Cause

Cause

1 --+--+�

Low Back Pain

2 --\----+�

Cause 3

Figure 1 . 1 Non-specific L B P may consisL of subtypes

of LBP wiLh di fferent causes. From Laboeuf-Yde C, LauriLsen JM, Lauritzen T. Why has Lhe search for causes of low back pain largely been nonconclusive? Spine 1997;22:878.

A lthough a prec i se pathoanatom ic d iagnosi s of the pain generator remai n s elusive, emerging evi ­ dence shows a strong association between psychoso­ cial factors and c h ronic LBP. T h ese psyc hosocial illness trai ts (i . e. , fear-avoidance behavior, anxi ety) have been term ed "yel low flags" to d i st inguish their relative i m portance from "red f lags" of poten tia lly serious di sease processes (see C hapter 9). Individu­ als w i t h a preponderance of "yel low flags" are a t h eigh t ened risk for c hronic symptoms a n d d i sabi l i ty (26,53,110, 165,202) and t h us require a carefully mapped out management strategy. T h e strength o f the association between "yellow flags" a n d spinal pain syndromes i s reinforced by the prospect ive studies i nvolving asymptomatic individuals who have shown predicted fut ure acute episodes (133) and who will have c hronic problems (240). Important ly, t h ere is prelim i nary evidence that psychosocial i llness behav­ ior can be i mproved merely by active reh a b i li tation alone without a struct ured cogni t ive-behavioral component ( 152). A burning question i n the low back field cont i n ues to be how to identi f y t h e patients who will respond best to individual interven t io n s. Whereas general guidelines adh ering to a biopsychosocial m odel have em erged t hat poi n t out past elTors and suggest a n ew path , t h ere are still many unanswered questions (21). For i n stance, which patients respond best to manip­ ulation, react ivation advice, exerci se, m edication, cogni tive-behavioral approaches, or to various com­ binations of t hese? A report from the 2nd Interna­ tional Forum of Pri mary Care Research ers on LBP concluded that achieving a val idated classification

Cont emporary research on the effectiveness of di ffer­ ent treatments has assumed t hat "non-speci fic" back pain is a homogenous group (256). LaBouef has urged researchers to appreciate t hat patients lacking ei ther "red flags" or n erve root signs or symptoms are most l ikely a h et erogenous group (117,118) (Figs. 1.1 and 1. 2). S h e points o ut t hat research t hat assum es t h i s l arge p a t i en t pop ulati o n i s h o m ogenous a n d would fail to show stati stical clinical effectiveness for speci fic interventions beneficial for a certain smal ler subgroup. The result is t hat a promisi ng treatmen t would be erro­ n eously assumed to be i neffective. The Cochrane Back Review Group refers to identification of subgroups as "th e Holy Grail" (22) (see Chapter 34). Work at t h e University of Pittsb urgh has convinc­ ingly shown that subclassification of the "non-specific" group is possi b l e w i t h a n evaluation c o n si st i n g of a thoro ug h h i story, d isabi l ity q uest ionnai res, and examination using a battery of low-tech yet reliable t ests (i. e. , sacroiliac, McKenzie) (Table 1.1) (46,55,56). T h ey h ave shown t h a t trea t m en t t h a t i s m a tc h ed to t h e appropriate subclassification i s superior to unmatched treatments (46). Furth ermore, a recen t randomized , c l i n i cal trial (ReT) shows that treat­ m en t driven by subclassification is superior to t h e "gen eric" trea tment recommended b y the Agency for Health Care Policy and Research (AHCPR) for the

Figure 1 .2 A posi tive associaLion beLween a suspected

risk factor and non-specific L B P w i l l become apparenL only if the study sample con tains a sufficient number o f people with the "right" subtype o f L B P L h a L maLches Lhe risk factor u ndergoing sLudy. From Laboeuf-Yde C, Lauritsen JM, Lauritzen T. Why has the search fOl- causes of low back pain largely been nonconclusive? Spine 1 997;22:878.

6

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Part One: Overvie\N

Table 1 . 1 (34, 41) • •

Treat m en t - Based Classification System

Immobilization Mobilizatio n Sacro i liac mobilization Lu mbar mobilization Specific Exercise Extension syndrome Flexion syndro m e Lateral s h i ft Traction o o

•

o o

• •

broad "non-specific" category (57). Outcomes i nc luded reduced disabi l i ty a n d accel erated ret u rn t o work. Trea t m en t classifi c a t i o n s i nclud ed m a n i p u l a t i o n/ mobil ization of lumbar or sacro-iliac joints, central­ i zation (McKenzie) w i t h flexion/extension, stabiliza­ tion, and traction for n erve root syndromes not exhibiting a cen trali zation phenomena. The McKenzie method by i tsel f has been shown to be a promising classification system (56,112, 206,270) (see Chapter 15). Kilop i koski and colleagues demon­ strated that classi fication o f 39 c hron i c LBP patients, by two h ighly trained i ndividuals, i n to the spec i fic M c Kenzie syndromes (posture, dysfunction, and derangem en t ) was possible w i t h 95% agreem ent (K=0.6; P=O. OOO) (112). The classic M c Kenzie approach o f u s i ng repeat ed movements and end­ range loadi ng strategies to i dent ify: (a) if t h e central­ ization p h enom en o n was present and (b) t h e patien t 's movem ent b i a s (i . e. , di rec tional prefer­ ence) had agreem ent of 9 5% (K=0. 7; P=0.002) and 9 0% (K=0.9 ; P
iden t i fyi n g the posture or movement that is consis­ tently associated with i ncreasi ng the pati ent's LBP (149,251-254). Similarly, i n Toronto, a group associ­ ated wit h t h e Canadian Back Inst i tu t e showed the reliab il ity of a pain pattern system using key elements from t h e h istory and exami nation (273). They demon­ strated 78. 9% agreem ent among exa m i n ers using t h ei r approac h . Furth ermore, u n l i ke t h e successful M c Kenz i e study m en t i o n ed , only m i n imal tra i n i ng was required. Table 1. 2 h ighlights the steps required to evaluate diagnostic/classification procedures. The emerging evidence shows great promise for the ability to deter­ m i n e mutually exclusive categories of mechanical LBP that can guide the treatment decision -making process.

The Rationale for Active Care

Because t h e realization has dawned that there are no "quick fixes" for back pain , there has been an increas­ ing realization t hat t each i ng pati ents what to do for t hemselves-self-management-is a growing priority. Is this m erely an acceptance of our failure to cure LBP, or is it an acknowledgment of the physician's ancient role as teacher and h elper? Active care adheres to psychosocial pri nciples by provid i n g u na m b iguous cogni t ive and behavi oral advice to enhance coping ability and motivate patients to gradually resum e normal activi t i es. Patients who worry about t h ei r functional status or fear t h ei r pain are more likely to have chronic problems (201, 207, 240). They are particularly vulnerable to being "labeled" with an injured back (i .e. , ruptured disc) or degenerative condition (16,40). Patients who expect an activity to be pain ful or disabl ing are less likely to perform at a normal level (5,119,120). Thus, one's per-

Table

1 .2 Evaluation of Diagnostic Procedures

1. Establish i n t erobserver reliabili ty of individual t ests 2. Establis h reproducibility of combinations o f rel i­ abl e t ests to i dent i fy homogenous LBP subgroups associated wit h specific syndromes 3. Determi n e sensitivity and specificity-predictive validity-of identification of LBP subgroups 4. Perform RCT of i ndividualized care matched to t h e subgroup vs unmatched or generic treatment using clearly defi n ed patient populations, well­ accepted outcomes, and follow-up data Modified fyom The International Federation for Manual! M usculoskeletal Medicine Scientific Commi ttee Meeting The Hague, March 2000. J Orthop Med 200 1 ;2 3 :33-35 .

Chapter One: Active Care: Its Place in the Management of Spinal Disorders

fOt"mance is l i m i ted by psychological as well as phys" ical factors. Stress, m uscle tension, and pain are i nt er­ related (147,171). It is the physician's role to i n form the patient that fear and/or stress i ncrease m uscle ten­ sion, which in turn can exacerbate pain (94). Insight i nto this relationship helps to reassure patien ts that their pain is largely caused by factors that are poten­ tially controllable. Active care adheres to biomechanical principles by advising when and how to stabilize the back. LBP is j ust as l ikely to occ ur i n i ndividuals who move their back too l i ttle as in those who move too m uch. In fact, a trivial load encountered at a tim e of vul n erabi l i ty such as i n the early morning or after prolonged sitting is a typical mechanism of inj ury (71,162,225, 226). Active care adheres to n europhysiological princi­ ples by trai n i ng motor control patterns that are protec t ive of the spine. Spinal instab i l i ty h as b een shown to res ul t from poor end urance and coordi ­ nation of t he trun k flexors a n d · extensors (31,32, 61,66,193). In particular, low-intensity activation of key stabilization m uscles has b een shown to enhance joint sti ffness and thus s tabil i ty (31,209). Recent research shows that agonist-antagonist m uscle co­ activation is disturbed in LBP patients, thus compro­ mising stability m ec hanisms i nvolved i n reacting to unexpected loads or perturbations (33,204,205,272). Active care adheres to bioc hemical pri nciples by advising pati en ts to avoid the debilitation of bed rest and i nactivity while encouraging them regardi ng the safety and value of res um i ng activities with simple biomechanical modifications. Pain and tissue heali ng are related to metabolic and n utri tional issues. The disc is a relatively hypovascular tissue that contributes to i ts poor healing ability (87). In fact, som e p a i n treatments such a s epidural i njections, although they clearly de-inflame the n erve root and i n i tially reduce pain , have recently been shown to cause a rebound pai n later, perhaps as a result of i nterfering with the body's natural resorption process for the herniated disc (106). R esorption or regression of herniated discs-even i n large disc herniations-is a common finding and is consisten t with the normal process of tissue repair and remodel i ng (28,29,107,116,172,203). Further evidence for this is the fi nding that macro­ phages are presen t i n high concentration with d isc herniations (72,78,93). Inactivity slows the recovery process because the disc is dependent o n diffusion for its n utrition. Rest, inactivity, or overly "guarded" movements are del eterious to the recovery of activity tolerance. Con­ versely, reassurance that the spine i s not inj ured or damaged and that gradual reactivation will actually speed recovery is n ecessary to dispel the patien t's dis­ abling feeli ngs and cogni tions (i . e. , worry, anxiety, and fear) (94,95,197,262).

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7

The Deconditioning Syndrome­ Functional and Cognitive-Behavioral Aspects The Clinical Examination of Function and Performance

LBP is a subjective symptom that unfort unately cor­ relates poorly with most pathoanatomical (MRI, x-ray) i nvestigations including disc bulges, facet joi n t d egeneration, endplate changes, a n d m i l d spondy­ lolisthesis (97). Notable excep tions are disc extru­ sions, moderate or severe canal stenosis, and nerve root compression (97). In fact, most back problems are not caused by struc t ural pathology (arthritis, her­ niated disc) or s erious d isease (tumor, i n fectio n , fracture) and b en efi t [Tom prompt reassuran c e a n d early, reactivati o n advice. Therefore, one o f t h e pri ­ mary goals of care is to reassure patien ts about the b en ign n ature of their pain and the safety and value of res um ing normal activi ties. Preven tion of d econ­ d i ti o n i ng, both p hysi cal and psychological, i s a fun­ damen ta l goal of the m odern managemen t of spi nal disorders. What is deconditioning? D econdi tioning is the d i m i ni shed abi l i ty or perceived ability to perform tasks involved i n a person's usual activiti es of daily l iving. In the Agency for Heal t h Care Pol i cy and Research (AHCPR) low back pain guidel i n es (2), i t is stated that "the main goal for treatment of back pai n has shifted from treatmen t of pain to treatment of activity i n tolerances related to pain . " The plight of clinicians in this field i s that because pathoanatomy only weakly correlates with symp toms, there i s a dearth of objective findi ngs to aid the clinician i n nav­ igating a safe and speedy course for the pati en t who is recovering slowly. This has l ed spine sci en tists to search for relevan t, q uanti fiable features of LBP. M easurable abnormalities w hether s tructural or functional are considered i mpairm en ts (275). His­ torically, i mpairment was viewed as objective and disab i l i ty as primarily s ubjective. However, it is now recognized that i mpairments (isolated strength/ mobility m easures) are also related to psychological (cognitive-behavioral) iss ues s uc h as sel f-efficacy, fear-avoi da nc e, or pain expectan c i es , and that dis­ abil i ty can at l east i n part b e m easured with "sub­ j ective" q uesti o n na ires (Oswestry, Neck Disabi l i ty I ndex) or tests of act ual activi t i es (i . e. , walki ng speed, reaching tests, si t-to-stand tests) (222). The World Heal t h Organization (WHO) has been classifying the consequences of disease, from a bio­ m ed ical perspective, as i m pairmen ts , disabi l i ty, and handicap since 1980 (92). This work was updated recently as the International Classi fication of Func­ tio n i ng, Disab il i ty, and Health (ICF) document, from

8

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Part One: Overview

a biopsychosocial perspec tive, to take better account of the functional status of t h e i ndividua l (275). The ICF classi fies f unct ional status i n t h ree i nterrelated dimensions: a. Functions-specific s tructural and functional i m pa i rm ents b. Act ivi t i es-actions that a person performsl functional l i m i tations c.

Participation -social or work i nvolvement

Act i vi ty level pert a i n s to fun c t i on a l l i m i tations wh i le i m pa i rm en t s are isolated functional defjc i t s (Table 1. 3). Fun c t i o na l activi t i es or l i mi tations are furth er defi n ed as what t h e patient can or can't do (or perceives he or she can't do!) i n his or h er daily life (Fig. 1.3). In con trast, specific fun c t i onal defjcits a re ro und o n ly wi t h c l i n ical exa m i na t i o n a n d are o ften unrelated to t h e patien t's symptoms or actual fun c t i on a l a b i l i t i es (activi ty l evel and l i m i tations) (Fig. 1. 4). Participation is dependent on t h e physical ability to perform an activi ty, but i t also encompasses social and attitudinal factors. It can be measured w i t h a sub­ set of questions from the Chronic Pain Grading Scale (232,263,275). 1.

2.

To what extent did you perform any activities i n or around your home during this episode of low back pain (not being work or household activities)? To what extent did you part i c i pate i n any work andlor household activi t i es d uring this episode of low back pain ?

3. T o what extent d i d you participate i n sport activ­ i t i es d uri ng t h i s episode o f low back pai n ?

Table

1 .3

Im pai rm en t vs D isabil ity

Impairments­ Specific functional deficits ROM Strength Endurance Cardiovascular fitness Balance M uscle reaction time Fatigue-ab i li ty M easurable with physical performance testing

Disability­ Functional abilityl limitations Walking tolerance Sitting tolerance Standi ng tolerance Lifting abil i ty Carrying ability M easurable with activity i ntolerance questionnai res or sim ulated activity testing

Figure 1 .3 Spinal function sort-carrying a 30-lb bucket

30 feet. Reprinted with permission from Matheson L , M atheson M . S p i n a l Fu nction Sort. Wildwood, MO: Employment Potential I mprovement Corporation, 1 989.

4.

To what extent did you participate in any leis ure time activi t i es, besides sports, d uri ng this episode of low back pain ?

5.

T o what exten t d i d you participate in any social andlor family activities d uring t h is episode of low back pain ?

Each question was answered o n a 0-10 scale, w i t h 0 i ndicating "no participation" and 10 indicati ng to "full normal partici pation . " What I s The Relationship Between Symptoms, Impairments, Disability, and Distress?

Impairments show a ten uous correlation to both pain and activi ty i n tolerances (e.g. , disability) (115)80, 183,265). Far from being t h e so-called objective med­ ical factors, t h ey are related as m uc h to an individ­ ual's motivation to perform as to t hei r actual physical performance ability (34,37,119,120)! The American M edical Association's (AMA) (6) guide for assessing physical i m pairm en t allows only spinal range of motion (RO M ) , even though i ts reliability (185) and validity (180,196,279) are questionable and i t doesn't discrim i nate c hron i c LBP patients [Tom asympto­ matic i ndividuals (115,194). Fortunately, newer more promising methods have emerged (Table 1. 4).

Chapter One: Active Care: Its Place in the Management of Spinal Disorders

I

Figure 1.4 MedX l u mbar extension machine.

Practice-Based Problem

The patient's goal is to resume activity w i t h less pai n . Can t h e cl i nician i den t i fy i mpairments t h a t are rela­ ted to the pat ient's symptoms

01-

funct ional a b i l i ties

(i.e., di sab i l i ty ) ? Im pairments ( i .e . , spec i fi c dysfunc­ t ions) such as hypo mobile j o i n ts, t rigger po i n ts , and weak or t ight m uscles are [Tequen t fi n d ings. H ow do we determ i ne which i m pairments are c l i n ically releva n t ? For i nstance, c a n i t b e determi ned which impairments are responsible for biomechan ical overload ( patho­ mechanics) or are part ic i pa t i ng i n c l i n i cally significant functional adaptations or compensations (pathophysi­ ology)? Making t h i s determ i nation is at the heart of s h i fting care [Tom one that is symptom-based ( rest,

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9

not m easure fundamen tal work behaviors important for vocational quali fication (participation) or speci fic work behaviors relevan t to t h e question of return to previous work ability (participation) (62,157). Thus, questionnaires, although val uabl e outcomes of care, may not be suf£cien t guides for determi ning appro­ priate treatment strategies or ability to return to work. Recently, actual t esting of functional abilities has been st udied (186,222) (see Chapter 12). Simmonds and coll eagues have shown how general functional abi l i ty can be m easured wit h simple, reliable, i n ex­ pensive, t i m e-efficient t ests (186,187,222). Examples of such tests include sit-to-stand, rollover tasks, func­ t ional reach , loaded reach , distance walked, etc. These tests are proving to be val uable tool s for both identi­ fying functional limi tations and establishing realistic goals in the management of LBP pati en t s (60). M a t heson and colleagues have shown t h e contin­ uum from observed signs and symptoms to structural diagnosi s, impairmen t s, and t h e inability to perform specific work behaviors (62,157). Figs. 1. 5 and 1. 6 show t h e feat ures of t h i s model along with spec i fic m easurements used. Th e relationsh ip b etween i m pairm en t (specific functional defici ts) , disabili ty (general functional abil­ ity, perceived or actual) , and pain is poorly under­ stood. Every clinician can t hink of patients wi th sevel-e pain and disability who have m inimal i m pairment and others who are very i mpaired and yet avoid being disabl ed. Unfortunately, test i ng ability is more a test of one's performance t han t heir true capacity, because effort is influenced by pain (actual or expectancy) and psychological fac tors (fear-avoidance, self-efficacy) (36,51). Human performance literature i ndicates that the goals one sets for task performance inf luence t h e performance i t self (19). Waddell was t h e first to qua n t i fy t h e relationsh i p b etween t h ese vari a b l es (Fig. 1. 7) (265). More re­ c ently, M a n n ion showed t h a t 51.4% of an i n divid­ ual's d i sability could b e explain ed by performance,

medication, etc. ) to one that i s functionally oriented (reassurance, reactivation) (see Chapter 3 2 ) . The clinician m u s t b e careful n o t to make the goal of finding and correcting i mpairments an end in itself. This should be used as a means to achieving the end of symp­ tom reduction and activity restoration.

Table 1 .4 Performance Attribut es Related to C h ronic LBP • • •

The most popular measurement of disability (or abil­ i ty) is a patient's self-report of activi ty limitations or perceived f -tmctional abili ty (i. e. , Oswestry, Roland­ Morris, Neck Disabili ty Index). Whereas such ques­ tionnaires may be rel iable and responsive, t h ey do not correlate well with actual measurement s of functional performance abili ty (49,222). Furth ermore, t h ey do

• • •

•

•

Trunk extensor end urance Flexion-relaxat ion p h en o m ena Spinal motio n Back m uscle fat ig ueabil i ty (E MG) Posi ti o n sense Reaction t i m es w h en exposed to unexpected per­ t urbations Reaction t i m es o f trunk m uscles with voluntary upper or lower limb movem en t s Balance abi l i ty

J0

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Part One: Overvie\N

Work Disability Model Pathology & Diagnosis

I I I

Track A

-

---

Track B

-

---

Structural Impairment

-

-�

---

Functional Impairment

------�

Functional Limitation

Vocational NonFeasibility

Occupational Disability

--- --�

----- - �

---

-- �

---

--- ---�

---

---

--�

Bureaucratic ------------�

--�

----

--.-

Work Disability

Track C

-

---

Observed signs & reported symptoms

---

------------�

Loss or restriction of person component

---

-------

--�

Restriction of person component function

Inability to perform component actions & tasks

----

---- ---�

Inability to perform fundemental work behaviors

--�

Inability to perform specific work behaviors

Figure 1 .5 Work disab i l i ty model. Reprinted w i t h perm ission from M a theson LN. A

new model for disabi l i ty determi nation. Keynote Address, U n i ted Kingdom Society of OCCupalional Medicine Annual Scientific Meeting. Bel fast Northern Ireland, June, 200 1 .

psychologi cal, and pain factors (Fig. 1.8) (152). Th e performance factors alone accoun t ed for 24. 5% of the variance. O t h er studies have shown a si m ilar rela­ t i o n sh i p between fun c t i o nal p er formance d efi c i t s and disability (67,168,211,265). Turner e t a l recently showed that pain i ntensi ty scores m easured with a vi sual analog scale (VAS) predicted disabi l i ty as m ea­ sured with t h e Roland-M orri s q uestionnaire (246).

The authors concl uded that back pain rated as 5 or h igher is m uch more li kely to be disabling. Swinkels also found t hat pain i n t en sity along with specific pain­ related fear significantly predict disability (232). Mann i o n suggests that because one-half of self­ reported disabil ity before trea t m en t and more than half of i t afterwards i s unaccounted for by structural, psychological, volUlltary performance, or electromyo-

Who's ICF Hierarchy Unit of Analysis

Impairment

• •

Activity

Participation

Case Example

Effect on Person

Structural Functional

•

Disc herniation with

•

Strength/ROM deficits

nerve root compression

Functional

Walking, standing,

Limitations

sitting

Vocational

Operating equipment

Figure 1 .6 World Health Organizalion's IeF h ierarchy. Modified [Tom

M atheson LN. A new model for disab i l i ty determ ination. Keynole Address, Work Special Interset Section, American Occupational Ther­ apy Association, Indianapo l is, Apri l , 1999.

Chapter One: Active Care: Its Place in the Management of Spinal Disorders

r = 0.39/ Pain

<'

r= 0. �9

"

,,,,,,

!

Disability ADL

,·044

Time off Work

Figure 1.7 The quanti tative relations h i p between the

clinical presentation of pain , d isab i l i ty, and objective physical i m pairment and the correlation coefficients (r)

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11

successfully ret urned many o f t h es e individuals to work. (161) Phenomena T h e rIexion ­ relaxation p h enomenon occurs w h en the erector spinae muscles relax i nvolu ntarily in term i nal stage of a standing t ru n k f l exion m a n euver. It h as been s hown t h rough E M G recordings to correlate with low back pain (153,220,245,267). However, desp i t e sign ificant reductions i n pai n rat i ngs a ft er act ive t herapy, n o improvemen t in Hexion-relaxaLion was fou n d by M an nion (153).

Flexion-Relaxation

between them when 0 is no correlation and I is complete

Spinal Motion ROM is an integral component in the

correspondence. Reproduced w i t h perm ission from

evaluation of LBP pati ents (6). Although reliable, its validity is questionable. Various studies have failed to find a con-elation between ROM deficits and pain or disabi li ty (67,194). The quality of motion seems more i m portant than its quantity (164). In particular, veloc­ ity m easurements h ave shown to be a more val id m easure of LBP i mpairment (156) and to correctly predict whic h asymptomatic manual material han­ dlers would have future LBP (231).

Waddell G. The Back Pai n Revol ution. E d i nburgh : Churchill Livingstone, 1 989.

graphic (EM G ) fatigue findi ngs, then new aspects of physical function relat ing to motor. control are worthy of future investigation ( 152). Th ese i nclude those aspeClS of function involved in non-volun tary, reflex control of movem ent such as position sense, delayed react ion times, and balance tests listed i n Table 1.4 (153,163). Th e next section of t h is c hapter discusses the evidence lin king motor control and other func­ tional deficits to spinal disorders.

Correlation Between Specific Performance Deficits and Low Back Pain

The relation between functional deficits or i m pa i r­ ments and LBP has been studied extensively. M any features are iden t ified by cross-sectional analysis to be present i n greater incidence i n pain patients than in asym ptomatic patients. However, i n such cases the associated impairment may be a result of pain rat h er than its cause. A b etter type of research uses prospective longi tudinal analysis, thus provi ding evidence of t h e risk o f future low back or n eck pain when a certain dys f-t.ll1ction is present . Anoth er valu ­ able type of research is to determ i n e i f treatmen t o f a specific dysfunction alt ers pat i ent outcomes. Such research is ideal ly performed as a random i zed con­ trolled trial. Isokinetic Strength A reduced ratio o f trunk ex t en ­

sor t o flexor strengt h/endurance d iscrim i n a t es be­ tween L BP pa t i en t s and control subj ects. Th e normal ratio is approxim a tely 1. 3:1, with t h e ext en­ sors being stro nger ( 158). M ayer and colleagues demonstrated that patien ts chronically disabled with L BP frequently h ad a decreased trun k exten­ sorlflexor st rength rat i o and that a comprehen sive, multidisc ipl i nary f-m t (including an em phasis on tru n k ext ensor t ra i ni ng)

Back Muscle Fatigueability With EMG This is a

u n ique fun c tional m easure b ecause it is i nvolun tary and theoretically not subject to psychophysical issues such as pain expectancy or motivation. Chronic L BP patients show a median fyequency s h i ft (i ncreased rat e of decli n e) during susta i n ed con tract ions that con trol subjects do not (12,115,214,215). Reliability has been shown to be h igh when 80% of t h e maxi­ mum voluntary con traction (M VC) is perform ed (45). This sam e fin d i n g i s reported to correctly predict w h ic h asym p tomatic m anual material handlers will report future LBP (231). It has been shown i n certai n studies t hat these pro­ files can be improved with rehabili tation (103,104,

Performance

Pain

;/ ~ ""

20%

Psychology

~ /)

Disability

Figure 1 .8 I nterrelationship between performance, psy­

chologica l , pain factors, and d isab i l i ty (explai ned propor­ tion of variance using m u l t i ple regression analyses). From Mannion AF, J unge A, Taimela S, M u n tener M , Lorenzo K , Dvorak J . Active therapy for chronic low back pain . Part 3. Factors i nfluencing sel f-rated disabi l i ty and its change fol lowing therapy. Spine 200 1 ;26:920-929.

J2

--

Part One: Overview

1 1 5,1 59,2 1 6,24 1 ). However, i n other stud i es no improvement was found (153,174,198,274). Position Sense Kines t h etic awareness of posi t ion

sense (24,64,1 82,235) has been shown to be compro­ mised in LBP i ndividuals and in those with spinal stenosis ( 127). This is t h e abil ity to reproduce posi­ tions i n space and is called repositioning abi l i ty or error. Similar resul ts are also seen in t h e cervical spine (81 , 1 4 1 ,208,230,244). Delayed Reaction Times

a) When exposed to unexpected perturbations Lik e

t h e E M G studies m entioned, reactions t o unexpected perturbations are largely i nvol untary. Altered reac­ tion l i m es of m uscles have been cOlTelated with LBP. Wilder showed that slow reaction time, decreased peak o ut p ut , and i ncreased peak o ut p ut after dis­ c harges when irregular load is handled is typical of LBP s ubj ec ts (272). After treatment, t he reactions i m proved. Silting was shown to d i s t urb these vari­ ables and a bri ef wal k i ng break was shown to im prove t h em aga i n . A recent s t udy b y Leinonen using sim ilar m et hods as Wilder reported that t h ere was a slower reaction t i m e to anticipated, s udden load i ng in pat i en t s wit h sciatica than i n h ea l t h y con trols ( 126). T h i s was t h eori zed because of an i m pairmen t in t h e patien t 's central processing of i n formation. It was concluded that c hronic sciatica can i mpair l umbar feed-forward control. Radebold and colleag ues also found t ha t a motor con trol signat ure d i scri m i nates LBP patien ts fyom asym ptomatics-n a m ely a slow reaction t i m e, increased m uscle activation, and slow relaxation of muscles after unexpected perturbations (33,204,205). b) With voluntary upper or lower limb movem.ents

A delayed activation o f t h e transverse abdom i n us m uscle duri ng arm or leg movements has been found to disti nguish LBP patients [yom asymptomatic indi­ viduals (85,86). A rehabilitation program designed to improve this dys[·unction has been shown to be effective for chronic LBP patients (1 90). c) To extemal visual stimuli Reaction t i m es to visual

stim uli h ave been shown to be slower i n c h ronic LBP patients t han in asymptomatic i ndividuals (143, 144,236). Incoordination Incoordi nation

is correlated with LBP. Paarnianpour showed that a loss of control of the cen t er of rotation during resisted trunk move­ ments in the sagittal plane OCCUlTed in LBP patien ts, but not in normal patients (193). I ncreases i n rotation and side-bending and a decrease in sagittal motion occ urred during the resisted m ovemen t. Similarly,

Grabiner reported that asymmetric m uscle output d uring isok i n etic-resisted trunk extension did not reduce torque production, but was abnormal (65). Arendt-Nielson found over- and under-activity in m uscl es during di fferent phases of gait in chronic LBP s ubj ects, but not i n asymptomatic patients (7). Over­ activity of back m uscles was found d uring the swing phase of gai t and decreased agonist peak m uscle activ­ i ty during the double-stance phase was found in LBP pati ents (7). Simmonds has reported t hat stride length is decreased during the gait of LBP individuals com­ pared to normal subjects (90,91). Lamoth and col­ leagues recently found that pelvis-thorax coordination in the LBP group differed signHlcantly fyom that in the control group (12 1 ). Spec i fi cally, t h ey reported t hat the gait o f LBP pati en t s was c haract eri zed by a m ore rigid, l ess flexible pelvis-thorax coordination and slower gai t veloci ty than in asymptomatic sub­ j ects. In asymptomatic i ndividuals at gait velocities more than 3. 0 km/h, coupled transverse plane rotation of t h e pelvis and t horacic regions becomes uncoupled because of coun t er-rotation. However, in LBP sub­ j ec ts this uncoupling did not occur. O'Sullivan found that an increased ratio of rectus abdominus to transverse abdominus/obJique abdomi­ nal activation is correlated with LBP (190). Control subjects were able to preferentially activate the inter­ nal oblique and transverse abdominus m uscles with­ out significant rectus abdominus activation, whereas LBP patients could not do this. Individuals who auto­ matically perform a trunk curl fast instead of slow also showed a greater ratio of rectus abdominus to trans­ verse abdominus/oblique abdominal activaLion ( 1 91). An active straight leg raise test (ASLR) has been s hown to be associated with postpartum sacroiliac (SI) pain . The test involves lift ing one l eg 20 cm up from a relaxed supine position. It is positive i f signif­ icant h eavi n ess of t h e leg is noted and i f on repeti ti on when a manual compressive force is appl i ed through the ilia, or wit h a belt Lightened around the pelvis, the abi l i ty to raise the l eg i mproves (169 ,1 70). It has been shown that altered kin ematics of the diaph ragm and pelvic floor are present i n those with a positive t est (1 92). Addi tionally, manual compression through the ilia normalizes t h ese al tered motor control strategies (192). Edgerton found that an altered muscle activation rati o of synergis t spinal m uscles d uri ng a variety of m otor t asks was common in c h ronic n ec k pain pat i en t s a fter w h i plash i nj ury (44). U nderact ivi ty of agonists and overactivity of synergists was able to dis­ criminate pain patients with 88% accuracy. He stated, "The n ervous system apparen tly can detect a reduced capacity to generat e force [yom a specific muscle or group of muscles and compensate by recru iting more motoneurons. This compensation can be made by

Chapter One: Active Care: Its Place in the Management of Spinal Disorders

recru i t i ng motor u n i t s fTom an u n i nj ured area of the m u scle or from other m uscles capable o f per­ forming t he same tasks . . . " Nedherhand found that a decreased ability to relax the upper trapezius muscles during static tasks and after exercise dist inguished between chronic whiplash-associate disorder (WAD) classification II patients and healthy control subjects (181). Jull has shown that a cranio-cervical f lexion test can di fferentiate both chronic headache and c hronic neck pain patients after whiplash fTom asympto­ matic individuals ( 1 00,101). During t he test, patien ts showed over-activation of the superficial neck m us­ cles (sternocleidomastoid), an i nability to hold a con­ stant pressure with the head against a pressure sensor at all test levels, and an i nability to target h igher pres­ sure levels (26-30 m m Hg) (230). Individuals with mild or moderate/severe pain and disability had sig­ ni ficant overactivi ty of the superficial neck m uscles during the f lexion test at 1 month (230). This persisted at 3 months regardless of whether pain persisted (230). Treatment directed at improving cranio-cervical f lexion has recently been shown to ach ieve lasting results in terms of improved function and reduced symptoms (102). Endurance Endurance has been shown to correlate

with LBP. Decreased endurance of the t ru n k exten­ sors has not only been shown to correlate with pain (13, 124, 184) but also prospectively to predi c t recur­ rences (13), as well as f irst time onset of episodes i n healt hy i ndividuals (88,1 42). Some studies have dis­ puted that this test correlates with low back trouble (238). The test, if performed in the manner described by Biering-Sorensen, has been shown to be reliable i n various populations-asymptomat ic (124), sympto­ matic (175), and those wi t h a past history of LBP ( J 24). One study clai med t he test was unreliable, but a small sample ( 1 2 subjects) and a differen t procedure using a Roman Chair was used (160). Decreased endurance of t he deep neck flexors has been correlated with chronic neck pain and headaches (10,221,243,268). Balance Ability Balance deficits have been demon­

strated to be related to LBP (30 , 1 45,238,176). Byl showed t hat excessive anterior to posterior body sway on an unstable surface or poor single-leg stand­ i ng balance ability is correlated with LBP (30). Mok has shown that when compared w i t h age- and gen­ der-matched pain-fTee con troIs, study participants wit h LBP had poorer balance (176). Poor balance was also prospectively correlated with future LBP by Takala (238). Structural Characteristics of Muscles Structural char­

acteristics of the back such as fat content of t he lower

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13

erector spinae accoun t s for 30% of the variance in severely disabled men (3). Atrophy, demonstrated as a decreased cross-sect ional analysis, of t he multifidus in the low back has been shown to occur in patients with acute LBP (82), those recovered from acute LBP (84), and those having surgery for nenre root com­ pression caused by a herniated d i sc (277,278). The acute patient 's atrophy was ipsilateral to the pain and at the same segmental level as palpable joint dysfunc­ tion (82). Recovery from acute pain did not automat­ ically resul t in restoration of the normal girth of the muscle (84). However, spinal stabilization exercises successfully restored the muscle's size in one study (84), whereas in another various exercise strategies did not (108). In the study t hat showed that the exercise did restore the muscle's girth, follow-up data demon­ strated a decreased recurrence rate in t h ose who per­ formed the exercises versus t h ose who did not (83). Similarly atrophy has been shown in the suboccip­ i tal muscles of chronic neck pain patients (76,167).

Cognitive-Behavioral Components

Patie n ts who equate h u rt w i t h h arm h ave a d i sabling form o f t h i n k i ng. This i s part of fear-avo idance behavior that promotes decondi tioning (Fig. 1.9) (258,259). It is important to i dentify the patient who is fearful and avoid encouraging them to take on a "sick role" (147). Fear-avoidance beliefs (FAB) and di stress h ave recently been shown to account for approxi­ mately 5 0% of the variation in self-rated disability (Oswestry Disability Index) i n acute and c hronic LBP patien ts (69). FABs were shown to be much higher in chronic than acute patients (69). In another study, psy­ chological variables were demonstrated to account for 26% of self-reported pain and 36% of self-reported dis­ abil i ty (Roland-Mon-is scale) (152) (Fig. ] .8). The most i mportant psychological characteristics in this study were t he use of negative coping strategies, self-efficacy beliefs, fear-avoidance behavior, and di stress. Inter­ esti ngly, in t hi s study of t h ree d i fferent active care approaches, none of which consisted of psychologi­ cal or cogn itive-behavioral approaches, all three im­ proved the patient 's psychological coping strategies, as well as t heir pain and disability (152). FABs i mpact performance by limiting effort. Indi­ viduals who perceive that an activi ty will be pai n ful have been shown to have reduced physical perfor­ mance abili ties (119,120). In fact , the cogni t ive asso­ ciation of activity w i t h pain or anticipation of pain has been shown to be more predictive of physical perfor­ mance than purely nociceptive factors (7). Cou ncil et al exami ned the association between pain expectan­ cies and i l lness behavior by asking patients to antici­ pate how much pai n t hey would experience when

14

--

Part One: Overview

Injury

Diffuse Depression Disability Avoidance Hypervigilance

\

Recovery

1 A ) Pain Experience

Pain-Related Fear

�

Pain Catastrophizing

t

Confrontation

No Fear

Negative Affectivity

Threatening Illness Information

Figure 1 . 9 Fear-avoidance behavior. Reprinted with

perm ission from Vlaeyen JWS, Linton S. Fear-avoidance and its consequences in chronic m usculoskeletal pain. A state of the art. Pai n 2000 ; 8 5 : 3 1 7-33 2 .

perform i ng a number of simple motor tasks (36). They found substantial correlations between pain expectancies and self-rated physical disab i l i ty (58). It is well accepted that psychosocial variables such as depression are significantly correlated with illness behavior in pati ents with chronic pain (34,35,114, 146). H owever, of even greater i m portance are Cic­ cione's find ings that show that pain expectanci es accoun ted ror 33% of the variance i n acute subjects (P < 0.00 l ) but for only 16% of t h e variance in t h e c h ronic pat ien ts ( P < 0.00 1) (34). Fri t z et al h as also confi rm ed that i n i t i al rear-avoidance b el i efs were significant predictors o f subacute s ta tus at 4 weeks i n d ependen t of pain i n ten s i ty, physical i mpair­ m en t , disability, or t herapy received (54). Thus, fear­ avoidance b el i ds s uc h as p a i n expectan c i es are presen t even beFore acut e pain b ecomes c h ro n i c ! ! Psychosocial and physical deconditioni ng go hand­ in-hand because many i ndividuals have the bel i ef that t h ey will be unsuccess ful gai ning con trol over symp­ toms (locus of con trol) or rega i n i ng lost fun c t i o n (sel f-efficacy). Such beli efs have b een shown t o delay recovery (26,229,276). Asghari in a 9-month prospec­ tive trial in chronic pain patients demonstrated that sel r-efficacy beli efs-confidence i n the ability to per­ form a variety of tasks despite pain -was predictive of pain behavior and avoidance behavior i ndependent of pai n, distress, or personali ty variables (8). How a patient copes with acute pain has a lot to do with whether t h ey will have a c hronic problem (110). They may tend to catastrophize t h eir ill ness and feel t h ere is not h i ng that t h ey can do themselves (26). Patients who fear pain or catastrophize it by feari ng

an i n evitable poor outcome are also less likely to per­ form exercise (258,259) and more likely to avoid activ­ i ties (63). Thus, patients with fear-avoidance behavior can easily become deconditioned through activity avoidance, rest, symptomatic care, etc. According to Vlaeyen (259), fear-avoidance behav­ ior leads to deconditioning in the following manner:

a) Negative views about pain (i . e. , viewing it as a t hreat rat h er than an an noyance) and i ts causes l ead to catastrophization

b) Fear and anxiety in turn lead to the tendency to avoid the perceived t hreat. •

Activities of daily living become restricted

c) Psychophysical react ivi ty (sympat hetic activa­ tion, m uscle tension) occurs when activi ties are encountered t hat are perceived as harm ful. d) Fearf-ul patients become hypervigilant because t h ey cognitively put i ncreased attention on pos­ sible sources of pain. e) Because avoidance behaviors are anticipatory, t h ey are self-perpetuated since the ind ividual rarely comes i nto contact with the actual (non­ h arm ful) consequences of t h e feared si tuation. •

•

"Guarded movements" such as an im paired flexion-relaxation phenom enon are cor­ related w i t h fear-avoidance beli efs, NOT actual pain (267) Anxious pati ents predict pain earlier during t h e performance of physical tasks such as ROM or straight leg raise tests (34,37,1 19,120)

f) Long-standing avoidance of physical activi ty l eads to t h e "disuse syndrome" or deconditioning syndrome affecting both m usculoskeletal and cardiovascular systems T h e FAB m odel may be less appli cabl e in repet i tive stra i n i nj uri es because o f overuse (261). DeFier did not observe a s i m i lar relationship between pain­ related fear and task perf-o rmance in fibromyalgia patien ts as in chronic LBP (39). Whereas some people catastrophize pain and avoid activities, others may try to ignore pai n and overexert (79). People use different "stop rules" with activit i es. Teach i ng patients what they can do for themselves is an essential part of caring for the person with pain. A simple techn ique for getti ng a patien t to become active in thei r own rehab i litation program is to shift t h em [Tom bei ng pain avoiders to pain managers (25,2 12). More comprehensive programs have tradi­ tionally involved cogni tive-behavioral approaches focus i ng on "graded exposure" to generali zed move­ ments (50,128,129) (see Chapters 14 and 31). This has

Chapter One: Active Care: Its Place in the Management of Spinal Disorders

recently been modified by exposing t h e patien t to the specific movements or activit i es avoided and address­ ing the fearful beliefs and emotions that accompany t h em (9,135, 178,249,260,262). According to Vlaeyen (259), "graded exposures" have t h e following effects: •

•

Pain expectancies are corrected with repeated performance of t h e movements/exerc ises o n subsequent days After m ultiple expos ures, over-predictions o f pain intensi ty tend to match actual pain experience

Anot h er progressive strategy t each es patients to approach LBP in a probl em-solving m a n n er by: (a) taking an active role; (b) reducing modifiable risk factors; and (c) avoiding impulsively seek i ng mainly symptomatic relief (219,250).

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15

E nzyme defect acqu ired d i sease viral i n fection mental depression I nactivity

/ �

Decreased content of m itochondria

M u scle pain

E x ercise intolerance

Figure 1 . 1 1 E ffects of musculoskeletal immobil i zation .

Reprinted with permission from Troup J OG , Videman T.

The Negative Effects of Immobilization and Bed Rest

I nactivity and t he etiopathogenesis o f musculoskeletal disorders. C l i n B iomech 1989;4: 175.

Immobilization

Why doesn't rest or i nactivity allow tissues that are i rri tated to become less pain ful? Prolonged immobi­ lization results in compromise of the m usculotendi­ nous, ligamentous-articular, osseous, cardiovascular, and central nervous systems (Figs. 1.10 and 1.11 and Table 1 . 5). Bed rest leads to a loss of m uscle strength of 10% per week (179). The loss is reversible; however, recondi tion i ng time is longer than deconditioning time (17).

E levated compression of articular carti lage

Figure 1 . 1 0 Biochemical changes associated with

reduced physical activity. Reprinted with perm ission from Troup J OG , Videman T. Inac t ivity and the etiopathogenesis of m usculoskeletal disorders. C l i n B iomec 1 989;4 : 175.

Prolonged i mmobilization after an i nj ury can lead to scar tissue formation and lowered fatigue tolerance of i nj ured tiss ues (Fig. 1. 12). Soft tissue h ealing has t hree p hases: i nflammation , repair, and remodel i ng. Some form of local t issue i m mobilization is us ually advisable during t h e i n flammatory phase, which usu­ ally peaks at approximately the third day after inj ury. Toward the end of the inflammatory phase, fibroblasts are found in i ncreasi ng n umbers in t h e inj ured area. These fibroblasts contribute to scar formation. I n a study of calf contusions i n rats, Lehto and colleag ues found that conn ective tissue scar formation will per­ sist and become fibrotic rat h er than be absorbed if the acute i n f lammatory reaction is allowed to persist (125). These a ut hors s uggest early, aggressive man­ agement of i nj uries to l i m i t enlargement of the inj ured area. During t h e repair phase, passive and active motion of the tissues positively affects the i nj ured tissues. Clas­ sic work on knee cartilage by Sal ter and co-workers showed that after 3 weeks of i m mobilization, i n tra­ articular adhesions complicate the repai r phase of soft tissue h ealing (218). Either i nterm i ttent active motion or cont i n uo us passive motion prevent ed such adhe­ sion formation. The remodeling p hase involves lysis o f ad h esions and reorientation o f collagen fibers along the l i n es of imposed stress. Again, prolonged im mobilization is a n egative factor in proper h eal i ng. I n s t udies o f rh e­ s us monkeys, Noyes studied t h e effects of 8 weeks of immobilization o n l igament s t i ffness and failur e rate

16

--

Part One: OvervielN

Table 1 .5 Negative E ffects of Im mobilizat ion Joints Shrin ks joint capsules Increases compressive loading Leads to joint contracture Increases synt h esis rate of glycosaminoglycans Increase in periarticular fibrosis Irreversible changes after 8 weeks of immobilization Ligamen t Lowers failure o r yield point D ecreased thickness of collagen fibers Disk biochem istry Decreases oxygen Decreases glucose Decreases sulfate Increases lactate concen tration Decreases proteoglycan content Bone Decreases bone density Eburnation Muscle Decreased t hicken i ng of collagen fibers Decreased oxidative poten tial D ecreased m uscle mass D ecreased sarcomeres D ecreased cross-sectional area D ecreased mi tochondrial cont en t Increased con nec t ive tissue fibrosis Type 1 muscle atrophy Type 2 muscle atrophy 20% loss of muscle strength per week Cardiopul monary Increased maximal h eart rate D ecreased V02 max Decreased plasma volume

was 2 days of bed rest as effective as 2 weeks but also were the n egative effects of prolonged i mmobilization l i m i ted (41). A Coc h rane Collaboration review con­ cluded t hat bed rest (74): •

has no posi tive effect for LBP

•

may have slight ly h armful effects

•

yields no i mprovement with 7 days over 2 to 3 days i n LBP or sciatica

This is similar to an earli er review that concluded t h ere was no evi dence i n favor of bed rest (256). The Danish guidel i n es concluded that there i s i nsuffi­ c i en t evidence of a positive effect in relation to the resources used for t h e bed rest (38). Vroomen found t hat t h ere was no evidence of effectiveness of bed rest for sciatica (264). T h e Paris Task Force on Back Pai n recommended that "bed rest should n ei t h er be enforced nor pre­ scribed, but may be authori zed i f pain i ndicates i t (1). I f authori zed, i t should be o f a s short a duration as possible and s hould be i nterm i t t en t rather than continuous. After 3 days of bed rest, pat i en ts must be strongly encouraged to progressively resum e t h ei r activi ties." T h e Danish guidelines concurred, suggest­ ing that bed rest can be considered a pain-relieving m easure for 1 to 2 days for severe pai n (38). When recomm en d ed for severe pai n , it should be made clear that bri ef bed rest is recommended as a consequence of t h e pai n , but n ot a treatmen t for t h e pain (217).

2 50

From Liebenson C. Pathogenesis of chronic back pain . J Manipulative Physiol Ther 1 99 2 ; 1 5 : 303.

200 LOA D

(N) (188). Ligamen t stab i l i ty was only 31% of normal after 8 weeks. After 5 months of recondition i ng, sta­ b i l i ty recovered to 93% of normal l evels. Five months of reconditioning i mproved the tissue fai lure rat e to 80% of normal, and after 12 m o n t hs o f recondition­ i ng, t h e rate was complet ely normal.

1 50 1 00 50 1

2

3

4

DEFORM A T I O N

5

6

(mm)

Figure 1 . 1 2 The strength o f )-ested t issue deteriorates

dramatically compared to normal t issue. I n t h is medial collateral ligament of a rab b i t knee that rested Bed Rest

O f all t h e traditional treatmen t m et hods, none has fared worse than bed rest. D eyo performed a con­ t ro l l ed c l i n ical trial t h a t compared 2 days o f bed rest aga i n s t 2 weeks and conclud ed t hat not only

for 9 weeks, two- t h i rds of the strength has been lost. From M ooney V. The subacute patient: To operate or not to operate. I n : Mayer TG, M ooney V , Gatchel RJ , eds. Con t e m porary Conservative Care for Pai n fu l Spinal D isorders. Bal t i more: Lippincott, W i l l iams & W i l k i n s , 1 99 7 .

Chapter One: Active Care: Its Place in the Management of Spinal Disorders

A Patient-Centered Approach

The func l i onal re-act i vat i on model i s "pa t i en t­ cen t ered," because t h e patien l's symptom s, dysfunc­ Lion (i mpairment, abi lit ies, and participation), and di stress are all addressed (Table 1. 6 alid Fig. 1. 13). If a pati ent's recovery is unsalisfaclory, eval uation of each of th ese componen ls i s i ndicated. Symptoms do not arise in a vacuum . Injury or pathology i s c ertai n ly a fac tor, b ut one t h at i s not nearly as importanl as has been assumed. The fact that advanced imaging modal i t i es show l h a t a l arge percenl of asym ptomatic i n dividual s h ave h erniated discs m eans l hat l h eir presence i n symptomatic individua l s i s oflen coincidental. C l early, individu­ als can com pen sale for t h em . As Figure 1. 13 shows, each of t h e major com pon en t s can i n fl uence t h e o t h er. Sym ptoms can be di stressi ng (26,50 ,94, 129) and l ead lo changes i n h ow one performs activi t i es such as wal king (90,91) and spec i fi c functions (i mpairm ents) such as t h e body's· abil i ty to respond lo a sudden load ern c i ently (272). In t urn, psyc h o ­ logical di stress such as fear-avoidance behavior negalively in fl uences impairmen t s (119,120), activ­ i ty tolerance (34), and pain reporti ng (249). Fi nally, spec i fic dysfunctions such as poor l runk extensor end urance h ave been shown to be prospec lively l i n ked lo t h e developmen t of acule LBP in asympto­ matic individua l s (88,142,238) and recurrent LBP i n ac ut e LBP subj ec l s (13). T h us, t h e relationsh i p between func lion, p sychological wel l n ess, and symploms i s an i mporlant one to appreciate wh en caring for sufferi ng indivi d ual s. A lypical L B P scenario i n volves a pat i en t w i t h persi stenl pain expecting t h a t i maging be performed so t h ey can l ea rn whal " t h e ca use" of t h e p a i n i s (47,98, 111). Predic lably, l h ere i s n o dearth of struc ­ t ural pathology present lhat can easil y be ascri bed a s being "th e ca use of t h e pain" (16, 40). The pat i en t i s

• •

Symptom s-Pain Dysfunction Impairmen t s-ROM Functional abi l i t i es-wal ki ng tolerance Participation-work activi ty P sychosocial-distress, fear, anxiety, d i sabi l i lY

o o o

•

t h en given t h e label of h aving a h ern i at ed d i sc or d egenerative arthritis and i s i n form ed t h at l h ey have t h e option to l earn to l ive wi l h l h ei r pain wi t h t h e h el p of m edication, manipulation, o r i nj ections o r to have surgery to correct t h e problem. U n fortunately, if a patien t does not recover, after ei l h er sym plo­ matic or surgical managemen t , t h eir d i stress in t h e form of fTIlslration increases a n d t hey are now labeled as having psychogenic pain (43). In such cases, whose fai l ure is t h i s-t h e pati en t 's or t h e h ea l t h care sys­ t em's? LaRocca (122) i n h i s Presidential address lo t h e C ervical S p i n e R esearch Society sa i d , "An assumplion i s made t h at t h ere i s a pathological en t i ly operating i n t h e spin e to produce pai n w h i c h , i f el i m ­ i n a l ed or con troll ed , shoul d resul t i n pa in relief i n every i n stance . . . T h e error h ere i s t h e aUlomatic l eap to psych ology. IL assumes thal all organic fac­ tors have b een considered, w h en in rea l i ty t h e c l i n i ­ cian's appreciation o f t h e com p l exilY of suc h factors is often severely l i m i l ed." In a pat i en t-cen t ered, self-managemen t approach, n o n -responsive pat i en t s would rec eive an eva l ua­ t ion to rul e o ut rel evant path oanatomy ("red flags" ) com b i n ed w i t h a n evaluation of psychosoc ial ("yel­ low flags") and functional/physiological faclors. I ro n i ca l ly, fun c t i o n -i f evalua l ed al all-i s usu­ ally l i m i t ed to l ess val i d m easures such as RO M . A

Activity

�

Dysfunction

� !J

17

Table 1 .6 The Pat i en t-Cen t ered Approach

Distress

Symptoms

--

D;,,,...

Figure 1. 1 3 The patient-centered approach.

Intolerance Poor Participation

Symptoms

Impairment

18

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Part One: OvervielN

dichotomy exists i n which function i s eit h er ignored com pletely or given too m uc h credit for causing pai n . Most parameters of dysfunction iden t i fi ed i n LBP patients have not been shown to precede t h e pai n , b ut rat h er only to accompany i t . In other words, many dysfunctions are adaptive to the problem rat h er than part o[ its source. Important exceptions are trunk ex tensor end urance and balance [unction, which can predict future LBP in asymptomatic i ndividuals (88, 1 42,238). The challenge for clinicians i s to strike a balance between ignoring function and blindly bel i eving that every hypomobile joint, trigger poi n t , or weak muscle requires treatmen t .

control group receiving no education or exerci se advice (33% vs 51%) (123) o

•

•

Adolesc en t s who walk or bike more t han 8 km per week were significantly less lik ely to have future LBP than those who were less active (223).

There i s strong and consi stent evidence that back schools are not effective i n preven t i ng nec k and back pai n. There are no good-quality studi es evaluating the effect iveness of ergonomics.

Acute Phase ( First 4-6 Weeks) Evidence of Active Care's Effectiveness: Does I t Exist?

Presented h ere i s a summary of some evi dence com­ paring active care to "tincture of t i m e" or oth er modal­ i t i es for t h e treatmen t of spi n e-related conditions. The most common criteria for recovery are sym ptom reduction and return to work. However, other crit eria such as sati sfaction, h ealth care uti li zation, activity i n to lerances, participation, and d i stress h ave also been appli ed. Active care i n c l ud es a vari ety o f approach es, [To m basic advice to stay active t o supervi sed mac h i n e-based exerci se ro ut i n es.

Prevention

A recent revi ew o[ the preventive l i t erature by Lin ton and van Tulder o ffered the following conclusions (1 30): •

•

•

•

Education including i n formation orien ted toward preven ting fear-avoidance and promoting coping abili ty was m ore effec tive than no in terven tion (233). Advice to exerci se and a free m embersh ip to a h ealth club were at least as effec t ive as an exerc i se program ( 1 31). Exerci ses were found by one st udy to be more effec tive than a back school (42). Exercises seem to be t h e only consi st en t ly proven effective preven t ive i n t erven t i o n , although most studies o n which t h i s i s based are m et hodologically flawed, and t h e effects are only weak (42,70,109,237). o

A high-quality study demonstrated with a randomi zed, contro ll ed trial that an i n t erven tion group that received a 40- m i n ute l esson on back probl em s and ergonomics and t h en performed passive pro n e ext en sions daily report ed fewer back problem s in t h e subsequent year than a

Advice to Stay Active

Information and advice emphasizing the value of fit­ n ess and t h e safety of resum ing activi ties ach ieved superior outco m es to advice that reinforced rest, activity restrictions, and the notion that the spine was i nj ured or damaged (arthri ti s, h erniated disc) (25). Reassuring workers and encouragi ng resumption of ordinary activi ties was superior to m edication, bed rest, or mobi lization exerci ses (148). Li ttle et al recen t ly d em o n strated t hat educational advice t hat enco urages early exerc i se (not j ust advice to stay active) or endorsem en t by a physician of a self-man­ agem en t booklet h a s been shown to i ncrease patient satisfaction and function while red uc i ng pain (137). Interesti ngly, combining advice to exerci se with a take-home booklet was less effect ive t han ei ther inter­ vention by i tself. Thi s i s beli eved to be because of the fact that t h e wri tten and verbal infon11ation present ed was not consistent (27).

Exercise

The role of exerci se in acute LBP is controversial. In a Coch rane Collaboration (257), systematic analysis it was concluded t hat "there is strong evidence that exer­ cise th erapy is not more effective than inactive treat­ m en t s or other treatments [or acute low back pai n. Specific exerci ses are not recom m ended [or acute low back pain patients . . . " One notable st udy that i n n u­ enced these conclusions was by Faas et aI, who reported that exerci se was no better than usual care by a general practitioner in the treatment of uncom­ pli cated, acute LBP (48). It has been argued t hat the Coch rane Collaboration research ers believe t h e n ul l hypothesi s h a s been fulfill ed on the basi s o f results from only three studi es, yet the n ull hypothesis requires m uch stronger evidence and thus appears spurious (151). Th e st ud i es con sidered to be of h i gh m et hod­ ological quali ty by t h e Coch ra n e Collabora tion eval-

Chapter One: Active Care: Its Place in the Management of Spinal Disorders

uated exerc i se t ha t was prescribed on a "gen eric" basi s rather than bei n g customi zed to t he n eeds of each pa t i en t . Such an approach to exerci se pre­ scription is not considered hi g h-quali ty by m ost expert s in the rehabi l i tation fi eld (57,151,228). If a spec i fi c type o f exerci se i s given to a l arge, het­ erogenous group and i t fai l s to outperform other treatmen t s, t hi s may not suggest t he exerci se i s i n ef­ fec t ive for LBP (1 17). For i n stance, i f ext en si o n exerc i se i s given t o a l arge heterogenous group o f pat i en ts, som e of whom respond wel l to ext en sion and ot hers who respond bet t er to fl exion, the exer­ c i se will not be shown to be effective (140). Evidence that customizing exerci ses to t he un ique functional needs of t he pat i en t enhances outcomes was shown by researchers studying the McKen zie approach (228). The study had certain m ethodologi­ cal flaws t hat weakened i t s conclusions, but the value of customization i s not m i n i m ized. The Dan i sh guidelines-based on technology assessment , ethical i ssues, and evidence-based review gave a favorable rating for McKen zie type exerci ses, generally recom­ mending them for acute LBP (38). Studies t hat com pared individuals perform ing exercises matched to t hem versus u n matc hed con­ cluded t hat the matched groups achieved significantly better results (46,140). A recen t study found that the general reactivation recom mendations of the AHCPR guidel ines yielded i nferior results to matched treat­ ment (including exerc ise groups) based on a h.mc­ tional subclassification scheme (57). Other recent studies not evaluated in the Cochrane review show that future meta-analysis wil l li kely strengthen the place of exercise as a treatment for acu te LBP. Little et aI's study shows the value of exer­ cise early on ( 1 37). An Austral ian study has shown that if acute L B P patients perform specific spinal stabiliza­ tion exerci ses, mul t i fidus m u sc l e a trophy can b e prevented (84). Al though i n itial symptomatic and functional recovery (Oswestry) is not i mproved as a result of this in terven tion, the training has a secondary preventive effect by reducing future recurrences (83). Studies evaluating behavioral strategies have also shown substan tial improvemen ts with early active care approaches. Early behavior modification through exercise reduced disability 1 year later than it did in the control group (50). An eight-fold reduction in the risk of becoming chronic was achieved [To m i n formation designed to reduce fear and anxiety and provide self­ care advice (129). A recent randomized, controlled trial verified the results of these early studies (134). What each of t hese cognitive-behavioral approaches has in common is t hat return to activi ty was quota­ based, rat her than being cont i ngent o n absence of sym ptoms. Quo ta-ba sed exerc i se i s exerci se per­ formed for a spec i f ic duration or frequency indepen­ dent of symptoms.

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19

It i s striking t ha t early act ive care m ethod s have been put i n suc h a n egative l ight when such weak evi dence of their i neffectiveness exi st s. On t he con­ trary, when new evi dence is considered and all o f the l i t erature i s evaluated from a fresh perspec t ive, t he value o f properly recom m ended exerci ses from t he very beg i n n i n g of care b ecomes overwhel m i ngly c l ear.

Passive Modalities

Many of t he most popular treatmen t s for acute L B P l a c k evi d en c e o f effectiven ess. The recen t Dan i sh guidelines (38) (page 60) state, "One of the greatest errors in the treatmen t of LBP in thi s cen tury has been the unquestioned usage of passive treatments, often­ times initiated when spontaneous recovery has already begun . " Passive m odalities such as electrical muscle sti m u la t i o n were recom m ended only as optional. Such passive modali t i es may engender higher level s of patien t sat i sfaction, but t hey have not been demon­ strated to improve outcomes related to recovery (89). Thus, si m i lar to taki ng x-rays, patients may like it but because it doesn't improve outcomes, better patient education about appropliate management techniques for acute LBP are needed (47,98,11 1).

Subacute Phase Reactivation and Exercise (From 4-1 2 Weeks)

The su bacute phase i s t he i deal t i m e for both ac tive and aggressive trea t m en t (52,132,266). In cases of d i sabi l i ty, t he return to work c u rve decl i n es steeply between 6 and 20 weeks (227,266). The longer patients w i t h L BP are off work, t he m ore d i ffi c u l t i t is for t hem to return to work (227,266). For this reaso n , most guidel i nes recomm end exercise t herapy/fit ness for LBP of more than 6 weeks (38). In pati ents with subacute LBP, light multidisciplinary treatment pro­ grams have been shown to be more effective than t reatmen t as usual for return to work (73,94,95,128, 138). A Cochrane Collaboration review concluded that there i s moderate evidence that mul tidiscipli nary rehabilitation is effec tive for subacute L B P ( 105). Two studies fou nd t hat ei ther lay-led or profes­ sional-led i n struction i n self-care and worry reduction were both successh.I I in reduci ng back-rel ated worry, fear-avoidance beliefs, pain severity, and activity i n tolerances (173,260). A long-term fol low-up study led by Indahl focused on education designed to reduce fear (94,95). Patients were i n formed t hat light activity would not i njure the disc, but instead speed recovery. The return to work rate was double t hat of the control group. Hagen reported at I -year follow-up that l ight activity, education about t he benign nature of pa i n , and encouragem en t to stay active achieved a sign i f-

20

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Part One: Overview

icantly greater return to work rate t h an for t h ose who received more trad i t i o nal m a nage m e n t (73). These studies used graded exposures, which means that patients exercise included m ovements that were perceived as threatening by the patient. Loisel's group demonstrated that a work site visi t improved the suc­ cess of the program (138,139). A recen t randomized, con trolled trial of 160 LBP patients found that add i ng manual t herapy to reacti­ vation advice was s hown to be superior to reactivation advice alone (68). Similarly, a pragmatic study of "best care" versus manipulation followed by exercise, exercise alone, or manipulation alone for 1334 sub­ acute L B P patients in England was recently published (247). " Best care" i nvolved giving advice to gradually resu me near-normal activi ties along with a copy of The Back Book. Relative to "best care," the manipula­ tion followed by exercise group had the best patient outcomes (disability, pai n , adverse back pain beliefs, and general physical heal t h ) at both 3- and 12-month follow-up, whereas the m anipulation alone group was the most cost-effective (247, 248).

Chronic Phase Reactivation and Exercise (After 1 2 Weeks)

A large nu mber of well-controlled studies h ave shown that exercise is an effective treatment for chronic LBP. A Cochrane Collaboration review of exercise (257) concluded that, " . . . there is strong evidence (Level 1) that exercise therapy is more effective than usual care by a general practi tioner for chronic low back pain . " Two recent studies strongly suggest t h a t exercise has a long-term beneficial effect i n t he m anagement of chronic LBP (83,234). Both studies used exercise pro­ grams that focused on training coordinated move­ men ts and i ncluded evaluation of results during a prolonged follow-up period. O'Sullivan et al showed that specific spine stabil i za­ tion exercises ach ieved superior outcomes to isotonic exercises i n c hronic patients wit h spondylolisthesis (190). M a n n i c h e et al demonstrated that an i so­ tonic regime emphasizing e ndurance trai n i n g was successful in i m proving ou tcomes (150). I n a large, randomi zed con trolled cli n ical tri al, Timm s howed that exercise was superior to passive care in treating failed back surgery patients (242). I n this study a fur­ ther comparison of exercise types showed that low­ tech nology exercise (McKenzie and stabilization) was superior to h igh-technology exercise (isotoni cs & Cybex). The M c Kenzie m e t h od was shown to be as effec­ tive as an isotonic strengthening program in a recent randomized, controlled trial of subacute and chronic patients (pa i n duration o f at least 8 weeks) (199). The course of treatm ent was 8 weeks of supervised

tra1l1 1l1g. M c Kenzie was superior at a 2-mon t h follow-up, b u t no differences were noted at 8-month follow-up. Mannion reported that low-cost exercise programs are more effective than one-on-one physical t herapy for chronic L B P at 12-month fol low-up (154). The key is "challenging the patient's m isconception that exer­ cise is contrai ndicated in LBP" (155). Aerobic exercise was one-sixth the cost. Dependence on the physical therapist was believed to be the cause of regression to the mean at 12 months (154). General exercise programs using a cogni tive­ behavOlial approach have been shown to be effective i n both hospital and primary care settings (58-60,11 3, 134-136). Each of t hese programs encouraged reac­ t ivation and addressed fear-avoidance beliefs and behaviors by progressing exercises by quota indepen­ dent of pain as well as used "graded exposures" to feared stimuli. Another publication regarding a light multidisciplinary program with a similar emphasis not only reduced chronic LBP but also showed it enhanced return to work in males (224). This was demonstrated to be superior to a m ore traditional and expensive m u l tidiscipli nary pain man agement-rehabilitation approac h . Mul t idiscipli nary fu nctional restoration programs h ave demonstrated that t hey can enhance return to work in chronically disabled individuals with LBP, but their costs are generally h igher (4,11,161). The common denom i nators of care for chronic LBP t h at h ave been demonstrated to opti m i ze out­ comes are sum marized in Table 1. 7.

Active Care and the Neck

The Quebec Whiplash-Associated Disorders (WAD) guidelines recomri1ended early, active intervention (including manipulation) (227) (Table 1.8). Treatment fol lowing these guidelines has recently been show n to be much more e ffective than tradi­ t ional passive-based care (213). Clinically important

Table 1 .7

Common Denom i nators of Successful Care for Chronic Patients (132) •

• • •

•

•

Thorough physical and functional exami nation performed Report of findi ngs given Emphasis on self-care Reduce any u n founded fear or anxiety about pai n Crystal-clear recom mendations about ac ti vi ti es/exercise Avoidance of excessive " h igh-tech " testing or bed rest prescri ption

Chapter One: Active Care: Its Place in the Management of Spinal Disorders

Table 1 .8 WAD Guidel i nes • • •

• •

•

Cli nical diagnosis Reassurance ImmobilizaLion « 4 days for WAD classifications n & III) Activation Manipulation, mobilization/traction, exercise, postural advice, passive modali ties (first 3 weeks only) Multidisciplinary team management (between 6 and 1 2 weeks)

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21

Audit Process

Self-Check of the Chapter's Learning Objectives •

What l ines of evidence suggest that the "non­ specific" LBP classification can be more clearly defined?

•

What specific functional disturbances are prospectively related to spinal d isorders?

•

How is fear-avoidance behavior related to decon d i t i o n i ng?

•

What i s quota-based exercise or graded-exposures and is it shown to be effective?

•

symptoms at 6 months after accident were present i n only 10% of properly managed patients (early active i ntervenLion with submaximal movements identi fied by McKenzie evaluation) as compared w i t h greater than 50% of t hose given s tandard care (soft col lar, ini tial rest, gradual mobilization). Similar positive results for early activaLion were found in two other studies. Encouragement to con­ t inue with activi t ies of daily living had a superior outcome than prescription of sick leave and immo­ bili zation (18). Physical t herapy or exact i nstruction in sel f-mobi l i zation was better t ha n 2 weeks o f rest with a soft collar at l -mon t h , 2-mon t h , and 2-year follow-ups (166). Jull has recently demonstrated t hat a combination of manual t herapy and exercise tra i n i ng that improves deep neck flexor function correlates with improved recovery in c hronic neck pain patients after a whiplash i njury (102).

• CONCLUSION The patient-centered reactivation approach is focused on the patient's dysfunction and distress rather than valious signs of often coincidental structural pathology or the patient's subjective symptoms. A paradigm shi ft from a traditional biomedical model to a biopsychoso­ cial one has taken firm hold in the spine field. The biopsychosocial approach teaches us that the old adage "let pain be your guide" can actually reinforce illness behavior such as fear-avoidance behavior. The more modem report of findings reassures patients that t hey do not have a disease (tumor, infection, and fracture) and that staying active will actually speed recovery. Learning that pain does not always warn of impending harm or damage can empower patients to remain active, avoid disability, and preven t the transi tion from acute to chronic pain.

Describe the controversy over the effectiveness of active care (or acute LBP patients?

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Chapter One: Active Care: Its Place in the Management of Spinal Disorders

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1 32 . Linton SJ. The socioeconomic impact o f chro n ic back pain: is anyone benefiting? Editori a l . Pain 1 998 ; 7 5 : 1 63- 1 68 . 1 33 . Linton SJ, B uer N , Vlaeyen J , Hellsing A L . Are fear­ avoidance beliefs related to a new episode of back pain ? A prospective study. Psychology and Healt h , 2000; 1 4: 1 05 1 - 1 059. 1 34 . Li n ton SJ, Andersson T. Can chronic disab i l i ty be prevented? A rando m i zed trial of a cognitive­ behaviora l i ntervention for spinal pai n patients. Spine 2000; 2 5 : 2 82 5-2 83 1 . 1 35 . Linton SJ. Cogni t ive-behavioral therapy i n t he pre­ vention of musculoskeletal pain: description of a program. I n : L in ton SL, ed. New avenues for the prevention of chronic musculoskeletal pain and disabi l ity. Amsterdam: Elsevier, 2002 . 1 36 . L inton SJ, Ryberg M . A cognitive-behavioral group i n tervention as prevention for persistent neck and back pain i n a non-patient population: a random­ i zed controlled trial. Pain 200 1 ;90:83-90. 1 37 . Little P , Roberts L, B lowers H, et al. Should we give detailed advice and i n formation booklets to patients with back pai n ? A randomized controlled factorial trial of a self-management booklet and doctor advice to take exercise for back pain. Spine 200 1 ;26:2065-2072. 1 38 . Loisel P , Abenhaim L , Durand P , e t al. A population-based, random i zed c l i n ical trial o n back p a i n management. Spine 1 997;22:29 1 1 -29 1 8 . 1 39. Loisel P , Gosseli n L , Durand P, Lemaire J , Poitras S, Abenhaim L. Implementation of a participatory ergonomics program in the rehabilitation of work­ ers suffering from subacute back pain . Appl Ergon. 200 1 ; 3 2 ( 1 ) : 53-60. 1 40 . Long A , Donelson R, Fung T. Does i t matter which exercise? Spine 2004;29:2593-2602. 1 4 1 . Loudon JK, Ruhl M, Field E . Abi l i ty to reproduce head position after whiplash i nj ury. Spine 1 997;22: 865-868. 1 42 . Luoto S, Heliovaara M, H urri H, Alaranta H . Static back endurance and the risk o f low-back pain . Clin Biomech 1 995; 1 0:3 2 3-324. 1 43 . Luoto S, Taimela S, H u rri H, et al. Mechanisms explaining the association between low back trou ble and deficits i n i n formation processing. A controlled study w i t h fol low-up. Spine 1 999;24 ( 3 ) : 2 5 5-26 1 . 1 44 . Luoto S, Taimela S, H urri H , et a l . Psychomotor speed and postural control i n chronic low-back pain patients: A controlled follow-up study. Spine 1 996;2 1 :262 1 -2627 . 1 45 . Luoto S, Aalto H , Taimela S, et aJ. One-footed and externally disturbed two-footed postural con trol in chronic low-back pain patients and heal thy con­ trols: A controlled study with fol low-up. Spine 1 998;23:208 1 -2090. 1 46. M acfarlane GJ, Thomas E , Croft PR, Papageorgiou AC, Jayson M IV, Silman AJ . Predictors of early improvement i n low back pain amongst consulters to general practice: The i n fluence of p l-e-morbid and episode-related factors. Pain 1 999;80: 1 1 3- 1 1 9. 1 47 . M a i n CJ, Watson PJ. Psychological aspects of pai n . M anual Therapy 1 999;4:203-2 1 5 . 1 48. Malmivaara A, Hakkinen U, Aro T, et al. The treat­ ment of acute low back pai n-bed rest, exercises, or ordinary activity? N Engl J Med 1 99 5 ; 3 3 2 :3 5 1 -3 5 5 .

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1 49. Mal u f KS, Sahrmann SA, Van D il le n LR. U se of a classification system to guide non-surgical treat­ ment of a patient with chronic low back pain . Phys Ther 2000;80: 1 097- 1 1 1 1 . 1 50 . Manniche C, Lundberg E, Christensen I, et al . I n ten­ sive dynamic back exercises for chronic low back pai n . Pain 1 99 1 ;47:53-63 . 1 5 1 . Manniche C , Jordan A . Letter t o the editor. Spine 200 1 ;26:840-844. 1 52 . Mannion AF, J unge A, Taimela S, M un tener M , Lorenzo K , Dvorak J . Active therapy for chronic low back pain. Part 3. Factors i nfluencin g self-rated dis­ a b i l i ty and i ts change fol lowing therapy. Spine 200 1 ;26:920-929. 1 53 . Mannion AF, Tai mela S, Muntener M, Dvorak J. Active therapy for chronic low back pain . Part 1 . Effects on back m uscle activation, fatigab i l i ty, and strength. Spine 200 1 ;26:897-908. 1 54 . Mannion AF, M u n tener M, Taimela S, et al. A ran­ domized clinical trial of three active t herapies for chronic low back pain [ I n Process C i tation]' Spine 1 999;24: 2435-2448. 1 55 . Mann ion AF, et al. Changes in pain and d isabi l i ty one year after active therapy for chronic low back pain . I nter Soc Study o f Lumbar Spine, Adelaide, Australia, 2000. 1 56. Marras WS, Ferguson SA, Gupta P , et al. The quan­ t i fication of low back disorder using motion mea­ sures. Methodology and validation. Spine 1 999;24(20) :209 1 -2 1 00. 1 57. Mat heson LM, Gaudino WA, Mael F, Hesse BW. I m p roving the vali d i ty of the i m p airment evaluation process: A proposed theoretical framework. J Occupa Rehabil 2000; 1 0: 3 1 1 -320. 1 58 . Mayer TG, Smith S, Keeley J , Mooney V . Quantifi­ cation of l umbar function part 2: Sagittal plane tru n k strength i n chronic low back patients. Spine 1 98 5 ; 1 0:765-77 2 . 1 59. Mayer TG, Kondraske G , Mooney V, et al . Lumbar myoelectric spectral analysis for endurance assess­ ment. A comparison of normals w i t h decon d itioned patients. Spine 1 989; 1 4( 9 ) : 986-99 1 . 1 60. M ayer TG, Gatchel R , Betancur J, Bovasso E. Tru n k m uscle endurance measurement: Isometric con­ trasted to isokinetic tes t i ng i n normal subjects. Spi ne 1 995 ;20:920-927. 1 6 1 . Mayer TG , Gatchel RJ, Mayer H , e t al. A prospective two-year study o f functional restoration in i n dus­ trial low back i nj ury. JAMA 1 987;258 : 1 763- 1 767. 1 62 . McGill SM. I S B Keynote Lecture-The biomechan­ ics o f low back injury: I m pl ications on current prac­ tice in i ndustry and the c l i n ic . J B iomech 1 997;30:465-4 7 5 . 1 63 . McGill S M . Study i n progress 1 64 . McGregor AH, McCarthy I D , Dore CJ, et al. Quanti­ tative assessment o f the motion of the l umbar spine in the low back p a i n population and the effect of di fFerent spi nal pathologies of this motion. Eur Spine J 1 997;6( 5 ) :308-3 1 5 . 1 65 . M c I n tosh G, Frank J, Hogg-Johnson S, Bombardier C, Hall H. Prognostic factors for time receiving workers' compensation benefits i n a cohort of patients with low back pain . Spine 2000; 2 5 : 1 47- 1 5 7 .

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Chapter One: Active Care: Its Place in the Management of Spinal Disorders

mental eval uation o[ t h e Cybex II Back Testing Sys­ tem in normal subjects and patients with chronic low back pain. Spine 1 993; 1 8( 7 ): 8 1 2-824. 1 84. N icolaisen T, Joregnesen K. Trunk strength, back muscle endurance and low back trouble. Scand J Rehabil Med 1 985; 1 7 : 1 2 1 - 1 27. 1 85 . N i tschke J E , Nattrass CL, D isler P B , et a l . Reliabil­ ity of the American Medical Association Guide's model [or measuring spi nal range of motion. Spine 1 999;24( 3 ) : 262-268. 1 86. N ovy D M , Simmonds MJ , Olson SL, Lee E, Jones Sc. Physical performance: D ifferences i n men and women with and without low back pai n . Arch Phys Med Rehabil 1 999;80: 1 95- 1 98. 1 87. Novy DM, Simmonds M J , Lee E. Physical perfor­ mance tasks: What are the underlying constructs? Arch Phys Med Rehabil 2002 ;83:44-47. 1 88 . Noyes F: Functional properties o [ knee l igaments and al terations induced by immobil ization. C l i n Orthop 1 97 7 ; 1 23 : 2 1 0-242. 1 89. O'Reilly SC, Muir KR, Doherty M. Effect iveness of home exercise on pain and disability [Tom osteoart hritis of the knee: a randomized controlled trial. Ann Rheum Dis 1 999; 5 8 : 1 5- 1 9. 1 90. O'Sull ivan P, Twomey L, Allison . G . Evaluation o[ specific stabilizing exercise i n the treatment of chronic low back pain with radiologic diagnosis o f spondylolysis or spondylolisthesis. Spine 1 997;24:2959-2967. 1 9 1 . O'Su ll ivan P, Twomey L, All i son G , et al . Altered pallerns of abdom i nal muscle activat ion i n patients with chronic low back pai n . Aust J Physio 1 997;43 :9 1 -98. 1 92 . O'Sull ivan P B , Beales D J , Beetham JA, et al. Altered motor control strategies in subjects with sacro i liac joint pain during the active straight-leg-raise test. Spi ne 2002 ;27:E l -E 8 . 1 93 . Paarnianpour M , Nordin M , Kahanovitz N , Frank V. The triaxial coupl ing o[ torque generation of trunk muscles duri ng isometric exertions and t he effect of fa tiguing isoinertial movements on the motor output and movement pallerns. Spine 1 998; 1 3 :982-992. 1 94. Parks KA, Crichton KS, Goldford RF, M cG i l l S M . A comparison of l umbar range of motion and func­ t ional abi l i ty scores in patients with low back pain. Spine 2003 ; 2 8 :380-384. 1 95 . Pate R , Prall M, Blair SN, et a!. Physical activity and public heal t h . A recom mendation from the Centers [or Disease Control and Prevention and the Ameri­ can College o f Sports Med ic i ne. JAMA 1 995;273 :402-407 . 1 96. Pengel L H M , Refshauge K M , Maher C G . Respon­ siveness of pain , disabi l i ty, and physical i m pair­ ment outcomes i n patients with low back pain . Spine 2004;29:879-883. 1 97 . Pfingstein M , Kroner- Herwig B, Harter W, et a l . Fear-avoidance behavior a n d anticipation o f pain i n patients with chronic l o w back pain-a randomized controlled study. Pai n Med 200 1 ; 2 : 259-266. 1 98 . Peach J P, McGill S M . Classification o[ low back pain with the use o[ spectral electromyogram para­ meters. Spine 1 998;23: 1 1 1 7- 1 1 23 . 1 99. Petersen T , Kryger P, Ekdah l C, O lsen S, Jacobsen S. The effect o f McKenzie Therapy as Compared

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with that of i ntensive strengthening tra i n i n g for the treatment of patients with subacute or chronic low back pain : A randomized cli n ical trial. Spine 2002 ; 2 7 : 1 702- 1 709. 200. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and H uman Services, Centers [or Disease Control and Prevention, National Center [or Chronic Disease Prevention and Health Promotion, 1 996. 20 1 . Physical activity and cardi ovascular heal t h . N I H Consensus Development Panel on Physical Activity and Cardiovascular H ea l t h . JAMA 1 996;276:24 1 -246. 202. Pincus T, Burton AK. Vogel S, Field AP. A system­ atic review of psychological [actors as predictors of chronicity/disabil ity in prospective cohorts of low back pai n . Spine 2000;2 7 : E I 09-E I 20 . 203 . Postacchi n i F. Management o f herniation of t he l u m bar disc. J Bone Joint Surg [ BI-] 1 999;8 1 : 567-576. 204. Radebold A , Cholewicki J , Panjabi MM, Patel TC. M uscle response pattern to sudden trunk loading in healthy i n d ividuals and i n patients with chronic low back pai n . Spine 2000;25:947-954. 205. Radebold A, Cholewicki J, Polzhofer BA, Greene HS. I m paired postural control of the l u m bar spine is associated with delayed m uscle response t i mes i n patients with chronic idiopathic l o w back pa i n . S p i n e 200 1 ;2 6 : 724-730. 206. Razmjou H, Kramer JF, Yamada R. l n tertester reli­ ability o [ the McKenzie evaluation in assessing patients w i t h mechanical low back pain. J Ort hop Sports Phys Ther 2000;30:368-3 8 3 . 2 0 7 . Rei s S, Hermoni D , Borkan J , e t a ! . The RAM BAM­ Israeli Sentinel Practice Network The L B P PATIENT PERCEPTION SCALE. A new predictor of chronici ty and other episode ou tcomes among pri mary care patients. ( I n Preparation ) . 208. Revel M , M i nguet M , Gergoy P , Vai l lant J , Man uel JL. Changes in cervicocephalic ki nesthesia after a proprioceptive rehabi l i tation program in neck pain: A randomized controlled study. Arch Phys Med Rehabil 1 994; 7 5 : 895-899. 209. R ichardson CA, Snijders CJ , H ides JA, Damen L, Pas MS, Storm J. The I-elation between the transver­ sus abdomi nis m uscles, sacroil iac joint mecha n ics, and low back pain . Spine 2002 ; 2 7 : 399-405. 2 1 0. Riddle D L , Rothstei n J M . I ntertester rel iabi l i ty of M c Kenzie's classificat ions o[ the syndrome types present in patients w i t h low back pai n . Spine 1 993; 1 8 : 1 333- 1 344. 2 1 1 . Rissanaen A, Alaranta H, Sainio P, et al. lsokinetic and non-dynamometric tests i n low back pain patients related to pain and disabil ity i ndex. Spine 1 994; 1 9( 1 7 ) : 1 963-1 967. 2 1 2 . Roland M, Waddell G , M offell JK, Burton K , Main C, Cant rell T. The Back Book. London: The Station­ ary O ffice, 1 996. 2 1 3 . Rosenfeld M, Gun narsson R , Borenstein P. Early i n tervention in whiplash-associated disorders: A comparison of two treatment protocols. Spine 2000;25( 1 4) : 1 782- 1 7 8 7 . 2 1 4 . Roy S H , De Luca CJ, Casavant DA. Lumbar muscle fatigue and chronic lower back pain. Spine 1 989; 1 4: 992- 1 00 1 .

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Part One: Overview

2 1 5 . Roy S H , DeLuca CJ , Em ley M , et al. Spectral elec­ tromyographic assessment o f back muscles i n patients with low back pai n undergoing rehab i l i ta­ tion. Spine 1 995;20: 38-48. 2 1 6. Roy SH, DeLuca CJ , Snyder-M ackler L, et al. Fatigue, recovery and low back pain i n varsity row­ ers. Med Sci Sports Exer 1 990;22 :463-469. 2 1 7 . Royal College of General Pract i t ioners ( RCGP ) . C l i n ical G u i del i nes for t he M anagement o f Acute Low Back Pai n . London , Royal College or General Practit ioners (www.rcgp.org.uk), 1 999. 2 1 8 . Sal ter R, Sim monds DR, Malcolm BW, et al . The biological dfect o r continuous passive motion on the hea l i ng o f full-th ickness defects i n articular car­ ti lage. 1 980;62A: 1 23 2- 1 2 5 1 . 2 1 9. Shaw WS, Feuerstein M , H aufler AJ, Berkowitz S M , Lopez M S . Worki ng w i t h low back pai n : problem­ solving orientation and h.ll1 c tion. Pain 200 1 ;93: 1 29- 1 37 . 220. Sh i rado 0 , l to T, Kaneda K. e t al . Flexion-relaxation phenomenon in the back muscles: A comparative study between healthy subjects and pat ients with chronic low back pai n . Am J Phys Med Rehabil 1 99 5 ; 74 : 1 39- 1 44 . 22 1 . Si lverman J L, Rodriguez A A , Agre Jc. Quantitative cervical flexor strength i n healthy subjects and i n subjects w i t h mechanical neck pai n . AI"ch Phys Med Rehabil 1 99 1 ;72:679-68 1 . 222. Simmonds M J , Olson SL, Jones S, et a l . Psychomet" ric characteristics and cli nical usefulness of physi­ cal performance tests in patients with low back pai n . Spine 1 998;23(22 ):24 1 2-242 1 . 2 2 3 . Sjolie AN. Active or passive journeys and l ow back pain in adolescents. Eur Spine J 200 3 ; 1 2 : 5 8 1 -588. 224. Skouen JS, G rasdal AL, Haldorsen E M H , U rs i n H . Relative cost-e[fectiveness o f extensive and l ight mult id iscipli nary treatment programs versus treat­ ment as usual for pat ients w i t h chronic low back pain on long-term sick leave: randomized controlled study. Spine 2002;27(9) :90 1 -909. 225. Snook S H , Webster BS, McGorry RW, Fogleman MT, McCann KB. The reduction of chronic non­ speci fic low back pai n through the con trol of early mom i ng l u m bar flexion, Spine 1 998;23 :260 1 -2607. 226. Snook S H , Webster BS, McGorry RW. The reduc­ tion or chronic , nonspeci fic low back pain through the control or early mom ing l u m bar flexion: 3-year rollow-up. J Occupa Rehabil 2002; 1 2 : 1 3-20. 2 2 7 . Spi tzer WO, Skovron M L, Salm i LIR, et al. Scientific monograph or the Quebec Task Force on Whiplash­ Associated D isorders: Redefining "Whiplash" and i ts managemen t. Spine 1 995;20(Su pp):S I -S73. 228. Stankovic R, Johnell O. Conservative treatment of acute low-back pain . A prospective randomized trial. McKenzie method of treatment versus patient educa­ tion in "mini back school." Spine 1 990; 1 5: 1 20- 1 23 . 2 2 9 . Stenstrom C H , Sandberg A. H o m e exercise a n d compl iance i n i nflam matory rheumatic d iseases-a prospective clinical trial . J Rheumatol 1 997;24(2) :470-476. 230. Sterl i ng M, J u l l G , Vicenzino B, Kenardy J, Darnell R. Development of motor system dysfl.lIlcLion fol­ low i ng whiplash injury. Pain 2003 ; 1 0 3 :65-7 3 . 2 3 1 . Stevenson J M , Weber CL, S m i t h J T , D umas GA, Albert WJ . A longitudinal study of the development

o[ ]ow back pain in an i ndustrial population. Spine 200 1 ;26: 1 3 70-1 377. 232. Swinkels-Meewisse IEJ , Roelofs J, Verbeek ALM, Oostendorp RAB, Vlaeyen JWS. Fear of move­ ment/(re)injury, disabi l i ty and participation i n acute l o w back pai n . P a i n 2003 ; 1 05 : 37 1 -379. 2 3 3 . Symonds TL, B urton AK, Ti l lotson KM , et al. Absence res u l t i ng from low back trouble can be reduced by psychosocial i ntervention at the work place. Spine 1 995;20:2738-2745. 234. Taimela S, Diederich C, H ubsch M, Heinricy M . The role of physical exercise and i nactivity in pain recurrence and absenteeism fTom work after active outpatient rehab i l i tation ror recurrent or chronic low back pai n . A fol low up study. Spine 2000 ; 2 5 : 1 809- 1 8 1 6. 2 3 5 . Taimela S, Kankaanpaa M , Luoto S. The dfect or l u m bar fatigue on the ability to sense a change in l u m bar position. A contro l l ed study. Spine 1 999;24 ( 1 3 ) : 1 322- 1 327. 236. Taimela S, O sterman K. Alaranta H , et al. Long psy­ chomotor reaction time in patients with chronic low-back pai n-pre l i m i nary report. Arch Phys Med Rehab 1 993;74: 1 1 6 1 - 1 1 64 . 237. Takala EP, V i ikari-Juntura E, Tynkkynen E M . Does group gymnastics at the workplace help in neck pain ? A controlled study. Scand J Rehabil Med 1 994;26: 1 7-20. 2 3 8 . Takala EP, Vikari-Juntura E. Do functional tests pre­ dict low back pain. Spine 2000;25( 1 6):2 1 26-2 1 32. 239. Teresi LM , Lufkin RB, Reicher MA, et al. Asympto­ matic degenerative disk d isease and spondylosis or the cervical spine: MR I magi ng. Radiology 1 98 7 ; 1 64: 83-88. 240. Thomas E, S i l man AJ , Croft PR, Papageorgiou AC, Jayson M IV, M acfarlane GJ. Predicting who devel­ ops chronic lo.w back pain in primary care: A prospective study. B MJ 1 999;3 1 8 : 1 662- 1 667. 24 1 . Thom pson DA, Biedermann H-J, Stevenson J M , et al. Changes i n paraspinal electromyographic spec­ tral analysis with exercise: two studies. J E M G Kinesiol 1 992;2(3): 1 79- 1 86. 242. Timm KE. A randomized-control study or active and passive treatments for chronic low back pain following L5 lami nectomy. JOSPT 1 994;20:276-286. 243 . Treleavan J, Jull G , Atkinson L. Cervical muscu­ loskeletal dysfunction in post-concussion headache. Cephalalgia 1 994; 1 4:273-279. 244. Treleaven J, Jull G , Sterl i ng M. Dizzi ness and u nsteadi ness fol lowing w h i plash injury: Character­ istic features and relationsb i p with cervical joint posi tion error. J Rehabil Med 2003 ; 3 5 : 3 6-43 . 245 . Triano n , Schultz A B . Correlation or objective mea­ sure or t ru n k motion and m uscle function with low­ back disabil i ty ratings. Spine 1 98 7 ; 1 2 : 56 1 -565. 246. Tumer JA, Frankl i n G , H aegerty PJ, et al. The association between pain and di sabi lity. Pain 2004; 1 1 2 : 307-3 1 4. 247. UK B EAM Trial Team. U n ited Ki ngdom back pai n exercise a n d mani pulation ( U K BEAM ) random ized trial: Effectiveness o r physical treatments for back pain in primary care. B MJ 2004;doi: 1 O. I I 36/bmj . 38282.6692 2 5 .AE.

Chapter One: Active Care: Its Place in the Management of Spinal Disorders

248. U K BEAM Trial Team. U n ited Kingdom back pai n exercise and mani pulation ( UK B EAM ) randomi zed trial: Cost effectiveness of physical treatments for back pain in primary care. B M J 2004;doi : l 0. 1 1 36/ bmj .38282.607859.AE. 249. van den Hout J HC, Vlaeyen JWS, H ouben RMA, Soeters APM , Peters ML. The effects of failure feed­ back and pai n-related fear on pain report, pain tol­ erance, and pain avoidance in chronic low back pain patients. Pain 200 1 ;92:247-257. 250. Van den Hout JHC. V1aeyen JWS. Problem-solving therapy and behavioral graded activity in the preven­ tion of chronic pain disability. In: Linton SL, ed. New avenues for the prevention of chronic musculoskele­ tal pain and disability. Amsterdam : Elsevier, 2002. 25 1 . Van Dillen LR, Sahrmann SA, Norton BJ , et a1. The effect of active l i m b movements on symptoms i n patients w i t h low back pain. J Orthop a n d Sports Phys Ther 200 1 ;3 1 :402-4 1 3 . 252. Van Di l len LR, McDonnell MK, Flem ing DA, Sahrmann SA. The effect of hip and knee position on h i p extension range of motion measures i n indi­ viduals with and without low back pai n. J Orthop and Sports Phys Ther 2000;30:307-3 1 6. 2 5 3 . Van Dillen LR, Sahrmann SA, Norton BJ , et a1. Rel i ­ abi l i ty of physical exam i nation i tems used for clas­ sification of patients with low back pai n . Phys Ther 1 998;78:979-988. 254. Van Di llen LR, Sahrmann SA, Norton BJ , Caldwell CA, McDonnell MK, Bloom NJ. Movement system i m pairment-based categories for low back pain : Stage I validation. J Orthop Sports Phys Ther 2003 ; 3 3 : 1 26- 1 42 . 2 5 5 . van Tulder M W , Assendelft n , Koes BW, Bouter LM. Spinal radiographic findings and nonspecific low back pai n : A systematic review of observational studies. Spine 1 997;22 :427-434. 256. Van Tulder MW, Koes BW, Bouter LM. Conserva­ tive treatment of acute and chronic nonspeci fic low back pain: A systematic review of rando m i zed con­ trolled trials of the most com mon i nterventions. Spine 1 997;22( 1 8 ):2 1 28-2 1 56. 257. Van Tulder MW. Malm ivaara A, Esmail R, Koes B . Exel-cise therapy for low back pai n . A systematic I-eview within the fTamework of the Cochrane Collaboration Back Review Group. Spine 2000;25(2 1 ):2 784-2796. 258. Vlaeyen JWS, Crombez G . Fear o f movement/ ( re)injury, avoidance and pain disabil i ty in c hronic low back pain patients. Manual Therapy 1 999;4: 1 87- 1 95. 259. Vlaeyen JWS, L inton S. Fear-avoidance and i ts con­ sequences in chronic musculoskeletal pai n . A state of the art. Pain 2000;8 5 : 3 1 7-332. 260. Vlaeyen JWS, De Jong J , Geilen M, Heuts P HTG, Van Breukelen G. Graded exposure i n the treatment of pain-related fear: a replicated s i ngle case experi­ mental design in four patients with chronic low back pai n. Behav Res Ther 200 1 ;39: 1 5 1 - 1 66 . 26 1 . Vlaeyen J W S , Morley S. Active despi te pain : t h e putative role of stop-rules and current mood. P a i n 2004; I 1 0:5 1 2-5 1 6. 262. Von Korff M, Moore JE, Lorig K, et al . A random­ ized trial of a lay-led self-management group i nter-

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vention for back pain patients in primary care. Spine 1 998;23:2608-26 1 5 . 263. Von Korff J, Ormel FJ , Keefe SF, DWOl- k i n . Grading t h e severity o f chron ic pain . Pain 1 992;50: 1 33- 1 49. 264. Vroomen PCAJ, de Krom M CTFM, W i l m i n k JT, Kester A D M , Knottnerus JA. Lack of effect iveness o f bed rest for sciatica. N Engl J M e d 1 999;340:4 1 8-423. 265. Waddel l G , Somerv i l l e D, Henderson I, et al. Objec­ tive cli n ical evaluation of physical i m pairment in chronic low back pai n . Spine 1 992; 1 7:6 1 7-628. 266. Waddell G . The Back Pai n Revol ution. Edinburgh: Churc h i l l Livingstone, 1 998. 267. Watson P , Booker CK, M a i n CJ , et al. Surface elec­ tromyography in t he i dentification o f chronic low back pain patients: The development o f the nexion relaxation ratio. Clin Biomech 1 997; 1 2 : 1 65- 1 7 1 . 268. Watson D H , Trott P H . Cervical headache: An i nves­ t igation of natural head posture and cervical nexor muscle perfol-mance. Cephalgia 1 993: 1 3 ;272-2 84. 269. Wennberg D E , Kellet MA, D i ckens J D , M alenka OJ , Kei lson L M , Keller RE. The associat ion between local diagnostic tes t i ng i ntensity and invasive car­ diac procedures. JAMA 1 996;275 : 1 1 6 1 - 1 1 64 . 2 7 0 . Werneke M , H a r t D L . Discrim i nant val i d i ty and relative preci s i on for classifying pat ients with nonspecific neck and back p a i n by anatomic pain patterns. S p i ne 2003 ;28: 1 6 1 - 1 66 . 27 1 . Wiesel S E , Tsourmans N , Feffer H L, e t al. A study of computer-assisted tomography. I . The i ncidence of positive CAT scans in an asym ptomatic group of patients. Spine 1 984;9:549. 272. Wilder DG, Aleksiev AR, Magnusson M L, Pope M H , Spratt KF, Goel VK. Muscul ar response to sudden load. A tool to evaluate fatigue and rehabi l i tation. Spine 1 996;2 1 :2628-2639. 273. Wilson L, Hall H, M c I n tosh G , Melles T. I n tertester rel iabi l i ty of a low back pai n classification system . Spine 1 999;24:248-2 54. 274 . Wood KA , Standell CJ , Adams MA, et al. Exercise tra i n i ng to i mprove spinal mobil ity and back mus­ cle fatigabi l i ty: A possible prophylaxis for l ow back pai n ? Physical Medicine Research Foundation Sym­ posi u m : C l i n ical Approaches to Spinal Disorders. Prague, 1 99 7 . 2 7 5 . World H ealth Organization. International Class i fi­ cation of Human Functioning, Disabil ity and Health: I CF. Geneva: WHO, 200 1 . 276. Yordi GA, Len t RW. Predicting aerobic exercise par­ t ic i pation: social, cognitive, reasoned action, and plan ned behavioral models. J Sports Exer Psychol 1 993; 1 5 :363-374. 277. Yoshihara K, S hirai Y , Nakayama Y , Uesaka S. H i stochemical changes in t h e multi fidus muscle in patients w i t h l u m bar intervertebral disc herniation Spine 200 1 ;26:622-626. 278. Zhao WP, Kawaguc h i Y , Matsui H , Kanamori M , K i m u ra T . Histochem istry and morphology o f the m u l t i fidus m uscle in l u m bar disc herniation. Com­ parative study between d iseased and normal sides. Spi ne 2000;25 :2 1 9 1 -2 1 99. 279. Zuberbier OA, Hunt DG, Kozlowski AJ , et a1. Com­ mentary on the American Medical Association Gu ides' l u m bar i m pairment val i d i ty checks. Spine 200 1 ;26:2735-27 3 7 .

The Role of Muscles, Joints, and the Nervous System in Painful Conditions of the Spine

Craig Liebenson

Introduction The Biomechanics of the Spine Stability System Spine Instability and Injury The Role of Agonist-Antagonist Muscle Co-activation in Maintaining Spine Stability Injury Prevention Neurophysiological Aspects of Stability and Pain

Learning Objectives

After reading this chapter you should be able 10 understand: •

The cli nical relevance of the concepts of spine stabi l i ty and i nstability

•

What the "neu tral zone" concept means scien tifi­ cally and c l i nically

•

How agonist and antagon ist muscle co-activation stabilizes the spine

•

How central sensitization can explain how an individual can perceive pain in the absence of tis­ sue damage or i n jury

•

H ow pain leads to predictable adaptations in the muscular system i nvolving muscle imbalance

Agonist-Antagonist Muscle Imbalance The Neurodevelopmental Basis for Muscle Imbalance Neuropathic Pain and Central Sensitization

"Yet all experience is an arch where through gleams that untraveled world whose margin fades, Forever and forever when I move. "

Lord AlfTed Tennyson

30

Chapter Two: The Role of Muscles, Joints, and the Nervous System in Painful Conditions

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31

Functional pathology is n ot just al tered biome­ chanics, i t also i nvolves motor control errors that are part of the central n ervous system's response to pain and dysfunction.

Structural

The Biomechanics of the Spine Stability System Functional

Psychosocial

Figure 2 . 1 The major sources of a patient's failure to

recover.

Introduction Musculoskeletal d isorders are related to structural, psychosocial, biomechanical, and neurophysiologi­ cal factors. Most patients recover with a m in imalist approach that de-emphasizes the i m portance o f structural pathology a n d prevents psychosocial i l l ­ ness behavior [Tom emergi ng. T h i s occurs m ostly as a resu l t o f the fai rly straightforward act of u n ­ ambiguously reassuri ng patients a n d re-activating them. U n fortunately, structural pathology has been the focus of the biomed ical model for generations. Clinicians and patients alike are mesmeri zed by modern i maging technology's abili ty to visualize the anatomic substrate o f the patient's pain . However, just as a picture of a phone does not tell you if it i s ringing, the ability of i m aging modali ties t o i n form us about the spine's function is l i m i ted. In fact , it i s a n individual's fun c tional abilities o r tolerances that are at the heart of the "patient-centered" approach . The modern goal of care is to restore function. The means to that end i nvolves overcoming any barriers to patient re-activation t hat may be present. T h i s i ncludes avoiding t h e type of overly aggressive m a n ­ agement, [Tom b o t h a diagnostic a n d therapeutic standpoin t , that erects new barriers! Recently, psy­ chosocial factors have been recogn ized as significant imped i ments on the road to recovery. This has revo­ lutionized spine care as the emerging biopsychoso­ cial model (5,29,128). Although structural factors exp l a i n far l ess o f spine pain tha n had been hoped for, t h i s does n o t mean that most pain i s b y default psychogenic. As chapter 1 demon strated, i n adequate function of the l ocomotor system, i n parti cular poor motor contro l , is int imately associated with pain of spi nal origin . Simple reactivation or sel f-care advice should be grounded i n an u nderstand i ng of what constitutes "safe back" ac t ivi t i es and exerc i ses. Add i tionally, pa tients not recoveri ng from an acute episode within a few weeks should be evaluated not only for structural and psychosocial problems but a l so for functional pathology of the motor system (Fig. 2 . 1) .

Management of patients with spinal disorders is built o n an understanding of how the spi ne is i n jured, how it responds to pain or i n jury , and how i t can be stabi­ lized (see Chapter 5). When t he emphasis is only on what the spi ne looks like anatomically, rather than how i t functions then patient and doctor alike tend to become frustrated lead i ng to psychosoci al i l l n ess behavior.

Spine Instability and Injury ...

..

: .

.. .

.

.. ..

How can we explain to t he patient what caused t he pain i f there is not a history of antecedent trauma or relevant i maging findings?

Spin al and whole-body stabil i ty are t wo d i s t i n c t , b u t related, phenomena. Whole-body stability is the body's abi l i ty to maintain equilibrium, especially after being subjected to external forces that temporarily destabilize it ( 1 14). Equili brium is the ability to main­ tain the body's center of mass over a stable base of support. The spine i s l i kened t o an i nverted pendu­ lum, and thus a highly unstable system ( Fig. 2.2). In

Figure 2.2 From a stability perspect i ve, the body and each vertebrae is an invel-ted pendulu m . Stability is i ncreased by widening the base of support. A larger value of 8, which is modulated by t he base width, i ncreases the abil i ty to survive a perturbation (P) and thererore i s more stable. From McGill SM. Biomechanical basis for stabil­ i ty: An explanation to enhance c l i nical u t i l ity. J Orth Sports Physical Therapy 200 1 ;3 1 :97.

32

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Part One: Overview

fact , i t has been suggested t hat each vertebrae is an inverted pendul um ( 10 , 17,77 ,114)! Accordi n g to Winter ( 131), "Because two-t h i rds of our body mass is two-thirds of body height above the ground we are an inherently unstable system , unless a control sys­ tem is operating." Both m uscle forces and l igamen­ tous tension operating w i t h i n a con trol system are necessary to maintain equil ibrium . Spine stab i l i ty i s defined more narrowly as the abi l i ty of the spinal colum n or i ts components to resist buckling when undergoing load. Various forces such as stretch, compression, shear, or torsion can be involved. According to Panjabi , three subsystems work together to maintain spine stability (94). They are the central nervous subsystem (control ), an osteoligamen­ tous subsystem (passive), and a m uscle subsystem (act ive ) ( F i g . 2 . 3 ) . H e says "The n e ural subsystem receives information from the transducers, determines specific requirements for spinal stab i lity, and causes the active subsystem to achieve the stability goal." Panjabi has shown that minor trauma can stretch tissues beyond their elastic limit without causing rup­ ture or tearing (95,96). Because there is no tissue fai l ­ ure, t h i s "injury" is undetected b y imaging procedures looking for hypermobili ty caused by l igamentous insufficiency (95,96). However, as a result of stretching of the passive-elastic components, an expansion of the joi nt's "neutral zone" occurs (Fig. 2 .4) (94-96). The "neutral zone" is defined as the inner region of a joint's range of motion (ROM) where minimal resistance to motion is encountered (94). This inner region's mobil­ i ty is restricted by passive ligamentous factors alone, and not by active muscular forces. When the "neutral zone" is expanded, joint instabil­ i ty is said to exist. This is because with an expanded zone of non-resisted motion greater demands are placed on muscles that must stabilize a joint. Thus, the most observable and measurable sign of instability is not joi n t hypermobility, but rather excessive agonist­ antagonist m uscular co-activation ( 18).

Control Subsystem

Neural

Figure 2.3 The spine stab il i ty syste m . From Panjabi

M M . The stab i li zing system of the spine. Part 1 . Func­ tion, dysfunction, adaptation, and e nhancement. J Spinal DisOl-ders 1 992;5:384.

Deformation

Elastic Zone

(EZ)

Range of Motion

(ROM)

Load

Figure 2.4 The neutral zone ( N Z). T h is is a region of high flexibility. The elastic zone (EZ) is a region of high stifflless. The two zones together consti tute the physio­ logical range of motion (ROM) of a joint. The NZ is where spinal motion encounters m i n i mal resistance. A joint with i ncreased l axity will have an i ncreased N Z . From Panjabi M M . T h e stab i l izing system of t h e spine. Part 2. Neutral zone and i nstabil ity hypothesis. J Spinal D i sorders 1 992;5:39 1 .

Clinical Pearl

M i n imal l igamentous tension is produced when move­ ment occurs i n a "neutral range." Gradually increasing tension occurs when movement enters an "elastic range." L i gamentous tension is greatest and so i s i njury when movement occurs at the anatomical lim i t of motion. Good motor control and appropriate activities maintain movements in the neutral or early elastic range. Poor motor control or inappropriate activi t ies allow move­ ment to repeti tively reach the terminal elastic range. McGi l l has defined t he "neutral posture" as "one where the joints and surrounding passive tissues are in elastic equilibriu m and thus a t an angle of m i n imal joint load."

Injury occurs when load exceeds tissue tolerance. The spinal column devoid of its m usculature has been found to buckle at a load of only 90 Newtons (approx­ i mately 20 pounds) at L5 (26,27). However, during routine activities,loads 20-times this are encoun tered on a routine basis. Panjabi (94) says, "This large load­ carrying capacity is achieved by the participation of well-coordinated m uscles sun-ounding the spinal col­ umn." Surprisingly, the m o tor control system func­ tions well when undergoi ng load. Muscles stabilize join ts by stiffen i ng, l i ke rigging on a ship. But when load is at a m in i m um , such as when the body is relaxed or a task is trivial, the motor control system is often "caught off guard" and inj uries are precipitated.

Chapter Two: The Role of Muscles, Joints, and the Nervous System in Painful Conditions

The Role of Agonist-Antagonist Muscle Co-activation in Maintaining Spine Stability

H ow does the body resist i njury? Accord i n g to Cholewi cki and McG i l l , spine stabi l i ty i s great ly e n h anced by co-con tract i o n o f an tago n i s t i c trun k muscles (17). Early work o n t h e elbow ( 1 1 0) and knee (9) showed that an tagonist muscle co-activation is necessary for a i d i n g l igaments in m a i n ta in i n g j o i n t stabi l i ty duri ng l oaded tasks. Even t hough energetically costly, such co-contractions have been shown to occur during most daily activities (74). Co­ contractions do i ncrease spinal compressive load, as much as 12% to 18% or 440 N, but t hey i ncrease spinal stability even more by 36% to 64% or 2925 N (44). Therefore, i f injury risk is viewed as the ratio of tissue tolerance to external load, then a substan tial increase in stability occurs as a result of co-activation. This mechanism is presen t to such an extent that wi t hout co-contraction the spinal column is unstable in upright postures (39)! In particular, t hese co-con trac t ions are most obvious duri ng react i o ns to unexpec ted or sudden load ing (66 , 7 5 ) . Cholewicki showed a n i ncreased electro myographic ( E M G ) activation of the rectus abdominus in upright postures versus flexed postures as a mechanism to mai ntain stabil i ty in neutral pos­ tures (18 ) . Stokes has described how there are basi­ cally two mechanisms by which t h is co-activation occurs (114 ). One is a pre-con tract ion to stiffen and thus dampen the spi nal c o l u m n when faced w i t h unexpected perturbat ions. T h e second i s a suffi­ ciently fast speed of con trac tion of the musc les to react qu ick enough to prevent excessive motion that would lead to buckling after either expected or un­ expected perturbations (16 , 2 4 , 6 6 , 75 , 114 , 1 2 2 , 12 9 ) . Wilder e t a l ( 1 29) concluded i n a study of body's reac­ tion to sudden , unexpected loads that "the muscles will respond rapidly to stabil i ze the body, i . e . , they will try to maintain bal ance and posture . " This has also been veri fied by Radebold and Cholewicki in a series of studies (19,20,100,101). Cholewicki et al demonstrated that antagonistic trunk muscle co-activation is necessary to provide mechan ical stabil i ty to the lumbar spine around a neutral posture (18 ) . The authors found t hat antago­ nistic muscle co-activation increased i n response to i ncreased axial load on the spine. EMG measurements were gathered h-om three flexors-external obli que, internal oblique, and rectus abdomi nus; and three extensors-m u l t i fidus, l umbar erector spinae, and thoracic erector spinae. The subjects were asked to perform slow trunk flexion and extension movements in a semi-seated position with hip motion restricted, bu t trunk motion free. Weights were then added to the torso. One conclusion was t hat " i ncreased levels of

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33

muscle co-activation may constitute an objective indicator of the dysfu nction in the passive stabilizing system of the l umbar spine."

Trunk Muscle Recruitment Patterns in LBP Patients Differ From Those in Asymptomatic Subjects •

Increased a ntagonist muscle activation is a sign or muscle co-contraction consistent with elevated spine stabil i ty requi rements

•

A variety of dynamic and static tru n k tasks were performed

•

The ratio of l u m bar erector spi nae ( i ntersegmental-antagonist) to thoracic erector spi nae ( m u l t isegmental) muscle activation was greater in LBP i ndividuals than in healthy subjects

•

Stabil ity index modeli ng showed that the observed patient recru i t ment pallerns en hanced spinal stab i l i ty

•

The authors cautioned that increased an tagon ist muscle co-activati on patterns in pat ients may not be the cause of LBP, but could be a compensatory adaptation.

van Dieen J H , Cholewicki J , Radebold A . Tru n k muscle recruit­ ment patterns in patients with low back pain e n hance t h e sta­ b i l i t y of the lumbar spine. Spine 2003;28:834-841.

Various studies have poin ted out h ow i m portant the motor control system is for preven t i ng spinal injury. Inappropriate muscle activation sequences during seemi ngly trivial tasks (only 60 N ewtons o f force ), such as bendi n g over to pick u p a penci l , can com­ pro m i se spi n e stab i l i ty and pote n t i ate buck l i ng o f t h e passive ligamentous restra i n t s ( 2 ) . Th i s motor control skill has also been shown to be compromised under challe nging aerobic circumstances ( 7 8 ) . When a spinal stab i l i zation and respiratory challenge is simul taneously encoun tered, the nervous system will natural ly select m a i n tenance o f respiration over spine stabil i ty. An example of this occurs when dur­ ing repetitive bend i ng or l i ft i ng act ivi t ies t h e back becomes vul nerable because of poor aerobic fi tness even if the m otor control sys tem is well-trai ned. Studies have shown during a mi ldly aerobic chal lenge such as repetitive limb movements that tonic activity of the diaphragm and transverse abdomi nus muscles can be mai ntained ( 5 3 ,54). Good abdominal strength without proper coordi­ nation between the abdomi nals and diaphragm can

34

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Part One: Overview

lead to spine i nstabi l i ty during c ha ll enging aerobic activities (92 , 5 5 ) . N ormally during exhalation, the abdo m i nals increase t he i r activity whil e the dia­ phragm decreases i t s activity. I t has been demon­ strated that this reci procal relationship can become dys funct ional if respiratory disease i s present or aer­ obic demand is too great ( 5 5 ) .

High c C!I a. :t! 0 C!I In

'0 :t! C/)

a:

Injury Prevention

Low

To avoid injury, condi t ioning or adaptation m ust keep pace as expos ure to external load increases ( Fig. 2 . 5 ) . Exposure to load must also be temporarily removed so that the normal healing/adaptation process can h.lllfill i ts objective of i ncreasing the fail­ ure tolerance of the tissues. Too l i ttle or in frequent exposure to external load and conditioning never raises the tissue fai l ure tolerance. Too much, frequent, or prolonged exposure and adaptation can't keep pace. McGill has shown this relationship between tis­ sue loading and risk of i njury as '\!"-shaped ( 1,8 2 ) ( Fig. 2 . 6 ) . Most l o w back i n juries are not t h e result of a s i n ­ g l e exposure to a high-magnitude load, but i nstead a cumulative trauma from subfailure magni tude loads ( Fig. 2 . 7 ) . For i nstance, repeated small l oads (e.g., bendi ng) or a sustained load (e.g., s i t t i ng). Accordi ng to McGill, l ow back i njury i s usually a resul t o f "a history of excessive l oadi ng which grad­ ual ly, but progressively, reduces the t issue fai lure tolerance" ( 7 9 ) . T h e lumbar spine has been shown t o b e particu­ larly vulnerable to repetitive motion at end range. Disc

Total Inactivity

Figure 2.6 Relationship between activi ty histol"y and injury. From Abenheim L, Rossignol M, Valat JP, et a1. The role of act ivity in the therapeutic management of back pai n : Report or the In ternational Paris Task Force on Back Pai n . Spin e 2000;25 : 1 S-33S.

herniation i s related to repeated flexion motion (15 ) , especially i f coupled w i t h lateral bending a n d twisting (4,42 ). Injuries to the posterior elements including the facet join ts and pars have been shown to be related to cyclic full flexion and extension (14,50), as wel l as excessive shear forces ( 2 5 , 132).

... : ... ... . . .. Should exercise be performed i n a "neutral" or end­ range? Accordi ng to M c G i l l "evidence rrom t issue" specific i njury generally supports the notion of a neutral spine (neutral lordosis) when perrormi ng load­ i ng tasks to m i n i m i ze the risk of low back injury . . . . Avoiding spine end range of motion, during act ivi ty, can reduce the risk of several types or i njury" (79).

High

A curre n t controversy involves whether to prescribe exercises in a "neutral" or ful l ROM. Some approaches such as the McKenzie model advocate biased end­ range movements, whereas other "stabi l i zat ion" sys­ tems suggest t ra i n i ng pat ients to control the "i nner range." In real ity, these approaches are not as much at odds as it appears. The evidencc poi nts to an i ntegrated approach based on evaluat ion or the patient's sensitiv­ i ty to d i fferent types of motion ( McKenzie approach) as well as a n understanding of the load profile of di fferent movements and activit ies (stabil ization approach).

-0 C co

E�

Q)-o -0 co - 0 co....J c�

Injury

Q; X

w

N on- inju ry

For those in acute pain or "at risk," l i m i ting ROM is preferred. For instance, a bias involving avoiding end­ range Oexion motions in younger d i sc patients and avoiding end-range extension motions in elder stenosis pat ients would be consistent with both McKenzie and

Low �_______________________________ Deconditioned

Highly trained Functional capacity

Figure 2.5 Relationship between external demand and

funct ional capac ity .

Intensity of Activity

Maximum Activity

L

(continued)

Chapter Two: The Role of Muscles, Joints, and the Nervous System in Painful Conditions

stabi l i zation approaches. As recovery progresses and return to normal activi ties occurs, trai n i ng must expand to a ful l RO M . However, as this occurs, periph­ eral mobi li ty gains should be achieved in concert with "core" or proximal stabil ity so that repetitive strain to key spinal joints can be avoided. Such "grooved motor programs" that promote "load shari ng" during func­ t i onal tasks (bending, kneel i ng, squalling, reac h i ng, pushing, pulling, l i fting, carryi ng, etc) are the u l t i mate I goal of trai n i ng designed to speed recovery, preve n t re-injury, a n d enhance performance.

Increased end-range flexion loading of the spine has been shown to occur as a resul L of a fatiguing repet­ it ive task such as l i ft i ng (112 ) . Increases in spinal flexion and decreases in knee and hip motion were shown to occur as a stoop- l i fting strategy repl a ced squat l i fting. Sixteen subjects performed with a sub­ maximal load at maximum l i fting rate to study the effects of fat igue. Fatigue was associated with a decrease in knee and h i p motion and an increa (see Chapter 14) se in peak lumbar flexion, i n d icating a change from a squat l i ft to a stoop l i ft s trategy. Decreased postural stabi l i ty documented by a greater an terior to posterior excursion o f the trunk center of mass was also noted. Etnyre et al showed that LBP patien ts alter their sit-to-stand motions by redu cing their h i p motion during this movement stereotype (34). In a t runk movement involving isoinertial resisted trunk m ove­ ments in the sagittal plane ( flexion/extension), Paar­ nianpour showed that loss of control of the center of rotation occurred in LBP patients, but not i n normal subjects (93). This l oss of control was observed as an increased rotation and side bending motions duri ng resi sted flexion/extension in the pain group versus non-pain group.

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35

a porci ne model , just 2 m i nutes o f fu ll flexion has been shown to lead to a substantial loss of the normal spinal l igamentous stiffness (46). According to Bogduk and Twomney, "After pro­ longed strain l igaments, capsules, and IV discs of the lumbar spine may creep, and they may be liable to injury if sudden forces are unexpectedly appl ied dur­ ing t h e vul nerable recovery phase" (12 ). Thel-efore, avoidance of h igh-risk activi ties early in the morning or after sitting or stooping i n ful l flexion is crucial to injury or re-injury prevention. Not surprisi ngly, Snook demonstrated that avoidance of early morning f l exion faci l itated recovery fTom acute LBP (108,109). Suggestions to teach workers to l i ft with their knees and not their backs are overly simplistic. Most workers have learned various tech n i ques to avoid i nj ury that are i n consistent wi th this advice. Bel ler advice is consistent with the following pri n ciples: avoid early morning l i fting; avo i d l i ft i ng after pro­ longed sitting or flexion activi ties; rotate jobs to vary loads; allow frequent rest breaks; m a i n ta i n lu mbar lordosis; and keep loads close to the spine ( 81).

Neurophysiological Aspects of Stability and Pain Agonist-Antagonist Muscle Imbalance

The rel a t i o n s h i p between speci fi c funct ions ( i . e . , i mpairme n t s ) , pai n , a n d activi ty i n tol era n ces i s unknown. If clues can b e obtained about how the body typically responds to pathology, injury, or repeti tive strain, this woul d aid cl inicians in detern1in ing if a patien t's impairments are a cause of pain or its con­ sequ e n ce . The evide n ce presen ted in "The Role o f Agonist-An tagonist M uscle Co-activation in Mai n­ t a i n i n g Spine Stabil i ty" shows that the signature

Patient Advice

Knowledge or when i njury is most l i kely to occur can also infl uence the type of advice cli ni cians give (see Chapter 16). The early morning or after prolonged sitting are particularly vu l n erabl e l i m e s . Reil l y et a l ( 102 ) s howed t hat 54% of t h e l oss o f disc height (water conten t ) occurs in the first 30 m i nutes after arisi ng. Disc bending stresses are increased by 300% and l igaments by 80% in the morning ( 2 , 3 ) . It has been shown that after just 20 m i n u tes of ful l flexion of t he spine, l igamen tous creep or laxity occurs, which persists even after 30 minutes of rest ( 110) ! I n

Repetition Figure 2.7 A fatigue curve i ll ustrates the importance of repetition and load to fatigue fail ure. Reproduced with permission fTom Andersson GBJ. Occupational Biome­ chanics. I n : Weinstein IN, Wiesel SW, eds. The Lumbal­ Spine. P h iladelphia: WB Saunders, 1 990.

36

-�

Part One: OvervielN

response of the motor control system to biomecha­ n ically chal lengi ng si t uations is agonist-antagonist muscle co-activation. Therefore, a clinical "shortcut" in determining whether an i mpairment is c l inically significant would be determ i ning if i t contributes to agon ist-antagonist muscle imbalance. Profi les of how individual muscles react to injury or inflammation are begin n i ng to emerge. Certain muscles h ave a predictable tendency to become i n h i bi ted, whereas others become tense. Speci fic muscles in the knee (vastus medialis obli que) (30, 1 13 , 115 ), l um bar spine (multifidus) ( 5 2 ,133 , 1 34 ) , or cervical spine ( deep neck flexors, suboccipitals) (49,6 1 , 6 2 , 8 3 ) respond to i n flam mation or inj ury by beco m i ng i n hibi ted and atrophying. O t her muscles suc h as the upper trapezius ( 7 , 8,47 , 7 1 ,90), stern­ ocleidomastoid ( S C M ) (61, 6 2 ) , i nfraspinatus ( 6 5 ) , or l umbar erector spinae (loss of flexion-relaxation phenomena) ( 3 7 , 7 3 , 1 07,12 4 ) respond to i njury or overload by tensing or becoming overactive. Lund proposed the pain adaptation t h eory to explain t hese m uscle i m balances (68). He hypothe­ sized that when pain is present, there is a decreased activation of muscles during movements in which they act as agonists and i ncreased activation during move ments in which they are antagon i sts (68, 91). This model is i n s tark con trast to the pain-spasm­ pain m odel, which suggests that muscle tension i s necessa rily i ncreased when painfu l s t i m ul i are presen t . Rather, it appears t h at m uscle i mbalance i s the rule, w i t h cert a i n m uscles t e n d i ng toward hyperactivity and o thers toward i n hibition. Arendt­ N ielson found that overact iv i ty of antagonist back muscles during the i ps il a teral swing p hase of gait and decreased agonist peak m uscle activi ty during the double-stance phase d i s t i nguished t hose w i t h chronic L B P from controls ( 6 ) . Graven -N i e l son showed that i f the lower leg m uscles are subjected to saline injection, gait coord ination i s altered by a decrease i n E M G activi ty i n agonist m uscles and i ncrease in EMG activity of antagonists (45 ) . S i milar dysfunctions i n coordi nated movement have been shown when experim en tal m uscle pain was pro­ duced by saline i njection i n the masseter m uscles ( 8 7 , 1 J 9- 1 2 1 ) . Vogt et al found t hat reduced h i p extension range of motion and early and prolonged activation of the glu­ teus maximus and lumbar erector spinae muscles can di sti nguish between back pain subjects and asymp­ tomatic individuals ( 126). Because of the difficulty with clinical assessment of gait, the authors proposed that landa's prone test of h i p ( hyper)extension should be evaluated to determine if it can be used as a val i d assessm e nt of pathological muscle coordination i n the lumbo-pelvic region.

Perhaps as a result of agonist-antagonist muscle imbalance, another common finding is synergist sub­ stitution. Edgerton reported that strength is not always decreased i n pain patients because synergists substi­ tute for inhibited agonists (33). He found that syner­ gist substitution, not muscle weakness, distinguished chronic neck pain patients from asym ptomatics after whiplash i nj ury (33). Sparto demonstrated that spinal load i ng forces were i ncreased during a fatigu­ i ng isometric trunk extension effort wi thout a loss of torque output ( 1 1 1 ) . Torque output remained con­ stant because as the erector spinae fatigued substitu­ t ion by secondary extensors such as the internal oblique and latissimus dorsi muscles occurred.

Muscle Response to Pain May Depend on Psychophysical Factors Nederhand et al reported i n a recen t study that acute patients who later had t he greatest amount of neck dis­ abi l i ty tended to mi n i m i ze the use or painfu l upper trapezius m uscles (9 1 ). In fact, there was an inverse relationship between E M G activity duri ng an isometric and a dynamic task and future (6 months later) d isabil­ i ty (measured with the Neck Disab i l i ty Index) (9 1 )! In contrast, i n a group with h igher levels or disability and chronicity ( 1 0-53 months), elevated levels of muscle react ivity wel-e recorded (90) . This was concluded by the authors to be caused by a psychophysical response to prolonged exposure to chronic pain .

Synergist substitution m a y b e a "sign" of compen­ satory strategies. Prospective studies are necessary to establish a causal relationship. Synergist substitution may be the bodies attempt to compensate for an inhibited muscle or agonist-antagon ist pair that is not adequately stabilizing a key joint. A myofascial trigger poin t demonstrates the problem of assu ming an area of tension or sensitivity is the "cause" of a problem. Treatment of a trigger point i n the upper trapezius muscle is unlikely to give lasting pain relief i f perpet­ uating factors responsible for maintaining the trigger poin t and possibly i ts existence in the first place, such as i nputting on a keyboard that is too high or inhib­ ited lower scapular stabilizers, are not addressed. Similarly, would repeated chiropractic adjustments or anesthetic i njections to a primary pain generator without identification and correction of the under­ lying source of biomechanical overload ( i.e., muscle i mbalance, fa ulty ergonom ics) or fear-avo idance behavior l i kely have a lasting effect?

Chapter Two: The Role of Muscles, Joints, and the Nervous System in Painful Conditions

I s the common clinical find i ng of tension i n t he l u m bar paraspinals t he cause or effect of pai n ? M usculoskele­ tal health care specia l ists commonly find and treat erector spi nae tens ion. Yet soft ti ssue work and phys­ I ical therapy modal it i es appl ied d i rectly to t h i s muscle may not be the "key" treatmen t . To determi n e if erec­ tor spi nae tension is a cause of pain prospecti ve, lon­ gi tudinal studies are req u i red . When prospect ive stud ies on this muscle have been performed, what has been discovered is that that poor trunk extensor endu rance i s correlated with fut u re or recurre n t L B P ( 1 1 , 57,69). The tension that i s commonly palpated o r observed is l i kely compensatory to the muscle being I fati gued. Thus, a t reatment that would address t h e primary dysfunction i s endurance tra i n i n g t o i m prove the muscle's fatigue res istance.

The Neurodevelopmental Basis for Muscle Imbalance

The fact that muscles respond predic tably to pain and/or injury offers clinicians a valuable way to sort out which hmctional pathologies are c l inically sig­ n i ficant. That some muscles tend to become tight and others weak has long been observed in both neu­ rological ( i . e . , cerebral palsy, stroke) and orthopedic (i.e., nerve root compression) problems. Rood was one of the first to propose classi fying muscles on the basis of their functional characteristics as stabilizers or mobilizers (41). Janda (59,60) and Sahrmann ( 1 04) have championed this way of thinking that finally came under scientific scrutiny with Bergmark ( 1 0) , who proposed that muscles could b e broadly classi­ fied as deep, local stabilization muscles or superficial , global mobil i zation muscles. Janda has suggested that there is a group of "pos­ tural" muscles (i .e., gastrocnemius, upper trapezius, SCM, erec tor spinae) that are i nvolved in static tasks such as standing or sitting (60). These muscles have a tendency to become overactive. He describes another group as "phasic" because they are involved in stabi­ lizing or producing dynam i c movements such as head flexion, arm elevation, or trunk curling ( i . e . , deep neck flexors, i n ferior scapular li xators, abdomi­ nals). These muscles have a tendency to become inhibi ted. Th is notion emerged fyom his observation among individuals with neurologic disease that spas­ ticity (e.g., cerebral palsy) usually favored certain muscles ( i . e . , extremity flexors, adductors, and inter­ nal rotators) and paralysis (e.g. , stroke) favored other muscles ( i . e . , extremity extensors, abductors, and external rotators). Janda described how the postural

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37

muscle system was needed for preservation of basic functions and its muscles were usually spared, whereas t hose required for m ore dynamic activities were more fragile and easi ly compromised. He also noted that these same tendencies were seen in i ndi­ viduals without neurological di sease, who either remained in constrai ned, sitting postures for pro­ longed periods of time or were trai ning t heir muscles inappropriately. This theory has a n eurodevelopmental basis (see Chapter 2 3 ) . In the infant younger than 1 month old, the fetal position is maintai ned by "tonic" contraction of trunk and extremity flexors along with extremity adductors and internal rotators. Reciprocal i n hibi­ tion (Sheni ngton's law) that is present in early i n fancy inhibits the antagonists of the "tonic" muscle chains. As the infant develops reciprocal inhibition becomes dampened, thus allowi ng the "phasic" mus­ cle system to activate ( fails in cerebral palsy). As the "reflex-bound" infant begins to develop its postural con trol system, "tonic" activity of muscles that main­ tains the fetal posture is superceded by agonist­ antagonist co-activation of muscles necessary [or movement control and production of the upright pos­ ture. Thus, extensors, abductors, and external rota­ tors co-activate with their fetal partners to stabi lize joints and allow neurodevelopment of posture. For instance, orie n tation m ovements of the head and neck begin between 4 and 6 weeks as the deep cervical flexors activate to coordinate m ovement with the cervical extensors ( 1 27). Similarly, the infe­ rior scapular fi xators begin to activate in t he fol low­ ing months to balance t he activity of the upper trapezius and levator scapulae and allow for scapulo­ t horacic stabilization during arm movements (grasp­ i ng, prehension, pushing, pull i ng, e tc . ) . A typical example of a failure of this agonist-an tagonist co­ activation occurs in Spre ngel's deformity in which the scapula fails to descend. Vojta, who developed a rehabi l itation system for treatment of neurological diseases such as cerebral palsy, stroke, and spinal cord injury, formulated the idea that the fetal muscles were more primitive and thus better insulated, whereas the muscles needed for development of the upright posture were younger phylogenetically and thus biologically m ore fragile (Table 2 . 1 ) ( 1 2 7 ) . Preliminary investigations suggest that imbalances between t hese systems of muscles may be presen t in 3 0% of young children without neurological disease ( 1 2 7 ) ! I t i s easy to s e e h ow t h e m odern posture o f slumping at a desk will influence muscles a n d joints. Brugger has described how the spinal col u m n is part of a mechanical linkage syste m . He showed how the slumped sitting posture bri ngs about changes i n lumbo-pelvic, thoracic, and head and neck post ure

38

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Part One: Overview

Table 2.1

Neurodevelopmental Kinesiology

Global-HTonic"

Local-HPhasic"

PhylogeneLically older Dominant • I n trauterine & early infancy • Sedentarism • Decond i lioning • I njury • Aging

Phylogenetically younger Not active intrauterine & early infancy Requires h igher CNS control Fragile, easi ly i nhibited

and function. I n parti cular, the m uscles associ a ted wi l h the fetal posi tion will be maintained in short­ ened le ngths, whereas their antagonists w i l l be lengthened ( Fig. 2 . 8 ) . Bergmark divided m uscles i n t o two broad cate­ gories based on their function one functioning to produce movement and the other to control it (10). Superficial muscles are responsible for producing volun tary movement or torque production, whereas deep muscles are responsible for maintaining joi n t stabi l i ty. The deep ( " intrinsic") muscles are respon­ sible for joint stabi l i ty on an i nvoluntary or subcorti­ cal basis, whereas m ovement production is largely a voluntary act. The following charts show the d ifferent d ivisions of muscles accord i ng to their dysfunctional tenden­ cies (Table 2 . 2 ) .

Table 2.2

Figure 2.8 Cog wheel model of j o i n t centration i n uprigh t posture. Reproduced with perm ission [Tom: B rugger A. Lehrbuch der fu nkt ionellen Stbru ngen des Bewegungssystems. Zol l i kon/Benglen: Brugger-Verlag, 2000: 1 50 .

During neurodevelopment, the i n fant learns to support his or herself using different points of sup­ port that facili tates a wide variety of postures and movements. The ensuing m uscle co-activation cen­ trates joints in a position of maximum congruence of joi n t surfaces. This allows for maximum load-bearing poten tial and thus facili tates further functional devel­ opment of the i n fan t. The first sign of this is in the head and neck by the end of the first month of life and progresses in the sagi ttal plane until the i n fant has

M uscle System Classifications (after Bergmark, 1989)

Global-Superficial Muscles:

Local-Deep Muscles:

Typically become overactive or shortened

Typically become inhibited or lengthened

Gaslro-soleus Adductors H amstrings Tensor fascia lata H i p nexors Piri formis Quadratus lumborum (lateral ) Rectus abdomi nus External obliques Lateral & t horaco-Iumbar erector spinae Upper trapezius Levalor scapulae Pectorals Subscapularis Suboccipi tals SCM Lateral pterygoids Masseter

Quadratus plantae Peronei Vastus medialis Gluteals Transverse abdom i nus Internal oblique M u l t i fidus Quadratus lumborum (medial) Medial & lower erector spinae Lower & middle trapezius Serratus anterior Deep neck f lexors Digastricus

Chapter Two: The Role of Muscles, .Joints, and the Nervous System in Painful Conditions

assumed a fu l l squat position, although not weight­ bearing, by t he end of the fourth month of l i fe ( Fig. 2 . 9). Between the fourth and sixth months of l i fe, obli que muscles begin to work together, which cross the midline and allow for creeping, �rawl i ng, and turni ng-over motions. Table 2.3 summarizes this neurodevelopment. As a rule, muscle and joint dysfunction are inter­ related. Various theories to explain this have been proposed. For instance, that there is decreased mus­ cle stretch sensi tivity when type III or IV high-thresh­ old, non-adapting pain fibers are stimulated by either painful i rri tation of muscles or joints (Fig. 2 . 1 0) . Also, that joint inflammation or pat hology initiates a com­ plex neuromuscular response in the dorsal horn of the spinal cord, resu lting in flexor faci l i tation and extensor inhibition (Figs. 2 . 1 1 and 2 . 1 2 ) . Muscle imbalance typically alters the performance of movement patterns, including activi ties of daily l iv­ ing, with the ul timate result being i ncreased instabil-

Figure 2.9 Posture of normal i n fant at 3 to 4 months.

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39

Table 2.3 Postural On togenesis and H igher CNS Function (see Chapter 2 3 ) •

• •

•

•

Muscle co-act i vation � functional joint cen tra­ tion � maximum load-bearing S tarts at head and neck (CO- 1 ) : 4 weeks By the fourth month the sagi ttal plane motor program is in place: ful l squat posi tion (supine) Months 5-7 t runk rotation: oblique muscle chains develop 4 years: bal anced u prigh t posture is ach ieved

i ty. Because of substitu tion patterns, the quality or movement at individual joints may be affected with­ out any l oss of strength (6,33,43,93, 1 1 1 ) . Mu scle i m balance brings abou t typical postures such as the slumped posture described by BrLigger ( Fig. 2 . 8 ) . Other examples of commonly observed patterns or

40

--

Part One: Overview

�

Descending pathways

Joint recePtors ( stimuli: noxious chemical mechanical )

Mu�cle receptor� . ( stimulI: metabolites electrolytes)

I I I , IV

!

G! i i .t!

<,: i: " , � J

, ,?' ), j>;� , ;I �--' 1 i f'...,\'� .-

ili "('/ ,r'; 'y r',

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PRIMARY MUSCLE

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Muscle spindle Muscle tone Static sensitivity Dynamic sensitivity

SECONDARY MUSCLE Figure 2. 1 0 Pathophysiologic model for mechanisms

possibly involved in the genesis and spread of muscul ar tension in occupational m uscle pain and chro ni c muscu­ l oskeletal pai n syndromes, Reproduced w i t h perm ission h-om Johansson H, Sokja p, Pathophysiological mecha­ nisms i nvolved in genesi s and spread of muscular tension i n occupational m uscle pai n and i n chronic muscu­ l oskeletal pai n syndromes, A h ypothesis, Med Hypothesis 1 99 1 ;35 : 1 96,

poor posture and muscle i m balance have been described by Janda, These include the lower crossed syndrome, upper crossed syndrome, and layer or stratification syndrome ( Figs. 2 . 1 3 , 2 . 1 4, and 2 . 1 5 ) .

Neuropathic Pain and Central Sensitization

Pai n cas ts a long shadow i n the nervous system . Pain can b e "learned" i n the nervous system s o that it is main tained i ndependent of i nj u ry, pathology, expectations, or dysfunction. Such pain is called neuropathic and i s an i mportant under-recogni zed di mension of the chronic problem. Failure to appre­ ciate when pai n has become conditioned will lead to an overemphasis on coincidental structural pathol­ ogy, fu nctional deficits , and psychosocial factors. N eu ropat h i c pain is centrally maintained and therefore does not require peripheral sources of pain-

ful irritation or injury. Typically, i t arises as a result of a prolonged, intensive afferent bombardment from peripheral nociceptive pathways (Fig. 2 . 1 6). However, because of central sensi tization, altered processing of input fTom secondary neurons (after exiting the dor­ sal horn) occurs so that pain can be experienced in the absence of peripheral injury, inflammation, or in-ita­ tion. The most obvious example of this is phantom limb pain where the painfu l source is not present, but the central pathways that carry nociceptive informa­ tion are not inhibited, so that even non-noxious stim­ uli are i nterpreted as painful ! Two i mportant aspects of neuropathic pain are hyperalgesia, an exaggerated pain response, and allo­ dynia, pain to non-noxious stimuli. Neuropathic pain is an i m portant construct that can explain the com­ mon clinical presentation of persistent pain , hyper­ sensitivity, and poor motor control in the absence of or disproportionate to pathoanatomical or neurologi­ cal d isorders. Hall and Quintner showed that in chronic pain patients, light pressure elicits a widespread i ncrease in E M G activity (47). Sunderland was the first to pro­ pose that i ncreased muscle tone would act to protect the nervous system from tensile forces ( 1 1 8) . Hall has shown that the flexor withdrawal response is easier to activate i n chronic pain patients (48). Increased upper trapezius tension has been demonstrated when stretch is applied to the brachial plexus (7). Upper trapezius and levator scapulae have been reported to have increased E M G activity in subjects with neck pain ( 8 ) . Such elevations in muscular tension are con­ sistent with the central sensitization syndrome. Because of the poor correlation between presenting symptoms and objective physical signs chronic pain, patients are comm only m islabeled as psychogenic. Accordi ng to Merskey (85 ,86), "There is i ncreasing evidence that signs and symptoms that were taken to be proof of hysteria-or of behavioral disorder-

Practice-Basea Pt'ol::le l m ='"'"

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Many patients have pain long after an acute episode or i nj ury has resolved. These patients typically befuddle cli n icians by having sensi tivi ty to daily activities, exam­ i nation procedures, manual therapies, and exercises that seems d i s proport ionate t o the i m posed demands. Should such exaggerated responses be considered signs of abnormal i l l ness behavior or i rreversi ble structural pathology? Or, l i ke "phantom l i mb pain" in an amputee, could such over-reactions be part of a conditioned response in the central nervous system caused by pro­ longed, i ntense afferent (nociceptive) bombardment?

Chapter Two: The Role of Muscles, JOints, and the Nervous System in Painful Conditions

Enhancement of the effectiveness of descending nhibitory influences

--

Increased afferent inftow (group II, III, IV sensory fibres)

Release of transmitters and modulators

Release of neuropeptides from afferenl � fibres

Increased synthesis of neuropeptides Gene expression

Hyperexcitability of spinal neurons with articular input

Ascending fibres e.g. spinothalamic Iract , " ,- _ _

Sympathetic reflexes

/

/

I

I

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Motoreflexes

Figure 2. 1 1 Overview of neuronal events i n the course o[ inflammation i n the joint.

Reproduced with perm ission from Schaible HG, Grubb B D . Affel-en t and spinal mech­ anisms or joint pain . Pain 1 99 3 ; 5 5 : 5 . fear

IMMOBILIZATION

\

Synthesis and release of inflammatory mediators

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Figure 2. 1 2 Suggested network of factors cont ri buting to fixed flexion of a dam­

aged joint. Reproduced with permission [Tom Young A, Stokes M, I les JF. Errects o[ joint pathology on muscles. C l i n Orthop 1 987;2 1 9:2 1 .

41

42

--

Part One: Overview

Erector Spinae

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,

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Gluteus M a x lmus

Abdominals

Iliopsoas

Tight

W eak

or

Weak or Inhibited

Inhibited

Tight

(98) and Kenshalo (63) made the ini tial experiments that showed t hat noxious sensory stimuli produced heightened sensitivity of dorsal horn neurons to future stimuli . Osteopaths termed this neuro-m echanical phe­ nomenon the "facilitated segment." Pat terson (97) says of the fac i l i tated segment t hat " . . . because of abnormal afferent sensory i nputs to a particular area of the spinal cord, that area is kept in a state of constant i ncreased excitation. This fac i l i tation allows normally ineffec tual or subli m i nal stimuli to become effective i n producing efferent output from the fac i l i tated segment . . . " ( Fig. 2 . 1 7). The myofas­ cial trigger point, osteopathic lesion, and chiroprac­ t i c subluxation hypotheses l ong attacked on the basis that they were not scientifi c are now better­ appreciated in this context ( 8 5 ) . This includes pain often considered psychogenic because iL does not correlate w i th pathoanatomy, the heal ing ti me for an injury, or does not match derma tomal referred pain p a thways. Neuropat h i c pain is well-accepted in causalgia, reflex sympathetic dystrophy, post-herpeLic neuralgia, stroke, syringomyelia, syringobulbia, mul tiple sclero­ sis, "phantom l imb" pain, and spinal cord injury. Neu­ ropathic pain has also been proposed to result from a repeti tive strain i n i tiating strong afferent nociceptive barrage to dorsal horn neurones, eventually leading

Figure 2. 1 3 The lower crossed syndrome. Reproduced with perm ission fTom J u l l G, Janda V. M uscles and motor cont rol in low back pain . In: Twomney LT, Taylor JR, eds. Physical Therapy for the Low Back, C l i nics i n Physi­ cal Therapy. New York: C hurc h i l l L ivingstone, 1 987.

such as a fai lure of complaints to observe anatomical boundaries, may have a physical basis . . . Regional pain syndromes and regional loss of sensitivity can have a pathophysiological origin related to expan­ sion of receptor fields through the responses to peripheral injury of spinal cord neurones." According to Nachemson (89), "various pools of nerve cells in the dorsal columns can be hypersensitized and t h us can signal a painful condition even though there is very lit­ tle peripheral input." As long ago as 1 88 3 , Sturge suggested that an injury could trigger a change in the central nervous system such that normal i nputs would evoke an exaggerated response ( 1 1 6) . MacKenzie in 1 893 pro­ posed that referred pain could resul t after sensory impulses [yom i nj ured tissue have created an "irrita­ ble focus" in specific spinal cord segments (70). Perl

1

'j

Weak Deep Neck Flexors

Tight Pectorals

Tight Upper Trapezius and Levator Scapula

Weak Lower Trapezius and Serratus Anterior

Figure 2. 1 4 Upper crossed syndrome. Reproduced with

permission from L iebenson C . Man ual Resistance Tech� n i ques i n Rehabi li tation in M uscle Energy Techniques, 2nd ed. Chai tow L. E d i nburgh: C hurc h i ll Livingstone, 200 1 .

Chapter Two: The Role of Muscles, Joints, and the Nervous System in Painful Conditions

Muscle Hypotrophy

Muscle Hypertrophy

Cervical Erector Spinae Upper Trapezius Levator Scapulae Lower Stabilizers of the Scapula Thoracolumbar Erector Spinae Lumbosacral Erector Spinae Gluteus Maximus

Hamstrings

Quadratus Plantae

43

structures. Stimulation of viscera does not always pro­ duce pai n, but visceral aHerents projecting into the dorsal horn do typically converge with skin and/or deep somatic structures ( 3 8,40). Convergence and central neural plasticity provide the neuroanatomical basis for pain referral . It has been reported that m any aHerent units when noxiously stimulated elicit pain in two distinct RFs (84). Branch i ng of the aHerent fiber near its termi nation point is the likely anatom ical explanation. According to Mense (84) this would, "reduce the spatial resolution of the nociceptive sys­ tem and thus could contribute to the di ffuse nature of deep pain . " Dorsal horn neurons have been found to be able to c hange the size, number, and sensitivity of t heir RFs u nder t h e i nfluence of noxious stimuli (56,58). Under noxious stimuli, referred pain into new RFs has been s hown experim e ntally to typically take a few m i n u tes to occur ( 3 5 ) . Neuroplasticity seems to be operating as new central nervous connections are formed after peri p heral i nj u ry. It has been shown that v isceral pain such as from a coronary i n farct can be referred to a m uscle l i ke the pectoralis major ( 1 23 ) . The muscular target for referred pain may also show signs of hyperalgesia ( 1 2 5 ) .

Figure 2. 1 5 The layer or stratification syndrome. Reproduced wilh permission from J u l l G , J a nda V. M uscles and molor control in low back pain. I n : Twom­ ney LT, Taylor J R, eds. Physical Therapy for lhe Low Back, Clinics i n Physical Therapy. New York: Churc h i l l Livingstone, 1 987.

to sensi tization o f those neurones caused by cen tral nervous system plasticity ( 2 3 ) . As a result of sensi­ tization of secondary dorsal horn neurones or a decreased threshold for primary peripheral afferents­ including normally pain-i nsensitive groups I and I I aHerents-normal mechanoreceptor afferent i nput can be in terpreted as nociceptive (23). This results i n aJlodynia, deep hyperalgesia, and an expansion o f the receptor field (RF). The RF is dermatomal represen­ tation zone where nociceptive irri tation of a spinal nerve is felt . Neuropathic pain is n o t simply a sensory phenom­ enon. With increased tissue sensitivity and i ncreased muscle tension, motor con trol will also be aHected. Movemenl patterns may change to reduce strain on the sensitive tissues. This process occurs on an invol­ untary basis but can have a large impact on body's abil i ty to recover. Neuropathic symptoms have been shown i n part to be caused by convergent input in the dorsal horn from skin and/or deep somatic (visceral and non-visceral)

--

Somatosensory Cortex

Hypothalamus

Mesencephalon

A

B

C

Noxious Stimulation

Figure 2 . 1 6 M u l tiple pathways of corticopelal nocicep­

tive transmission (A, spinoreticul ar; B, spi nothalamic; C , spinomesencephalic; D, spinohypothalamic tracts). From Chapman C R. The psychophysiology o f pain i n Bonica's M anagement of Pai n , Third e d . I n : Loeser JD, ed. P h iladelphia: L i pp incott W i l l iams & W i l k i ns , 200 1 .

44

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Part One: Overvievv

Descending systems

Large diameter input

also occur as in cardiac pain referring to the ear ( 1 3) . A decrease i n t h e flexion wi thdrawal reflex threshold has been demonstrated in women after gynecological surgery ( 2 8 ) .

Small diameter input

Central Sensitization Demonstrated in Fibromyalgia Patients •

Fibromyalgia patients had lower cold t h reshold tolerance along with an increased nociceptive flexion reflex compared to control subjects.

•

Cold threshold-immersion of the hand in an ice water bath . M i n i m u m amount of stimulat ion that caused pai n

•

Cold tolerance-the t i m e a con ti nuous pai n fu l i m mersion ion ice water bath could b e endured

•

Nociceptive flexion reflex-surface electrode stimulated sural nerve near lateral malleolus. EMG

Skin

used to measure biceps femoris muscle contraction Desmeules JA, Cedrasc h i C , Rapi t i E, et al. N e u rorphysiologic evidence for a central sen s i t i zation i n pat i e n ts w i t h fibromyal­ gia. Art h ri t i s Rhem 2003;48: 1 420- 1 429.

Deep somatic and skeletal afferent impulses B

Figure 2. 1 7 Physiologic mechanism of t he "irritable focus" i n the grey maller of the spi nal cord. Reproduced with permission from Grieve G P . S i mu lated visceral dis­ ease. In: G rieve G P, ed. Modern Manual Therapy of t he Vertebl-al Col u m n . Edinburgh: Churc h i l l Livingstone, 1 986.

The presence of non-dermatomal referred pain and hyperalgesia i mplies that central changes i nde­ pendent of convergence are operative ( 2 2 ) . An exam­ ple is the si tuation in which referred pain spreads to the s i te of an old i nj ury. An angina a ttack has been shown to refer pain directly to an old vertebral frac­ ture (5 1 ). It has also been demonstrated that 1 week a fter dental surgery, pin prick of the nasal m ucosa can produce referred pain to the treated teeth ( 1 03 ) . Distan t referral o f pain t o a non-dermatomal area can

What is Sensitization?

Sensitization is a change in the stimulus-response profile of dorsal horn neurones so that they respond to normal mechanoreceptive afferents as if they were n ociceptors (65,76, 1 30 ) . Wi llis explains that a noci­ ceptive barrage leads to central sensi tization of dorsal horn neurones ( 1 30), "If these nociceptive neurons have convergent input from mechanoreceptors, their responses to both i nnocuous and noxious mechanical stimuli will then be i ncreased . . . . Sensi tization t hen causes formerly subthreshold responses to reach t h reshold and trigger d i scharge s . " Accord i ng to M ayer (76), "Overwhelming evidence supports the conclusion that a c hange i n the cen tral processing of input fyom low-threshold mechanoreceptors i s responsible for secondary hyperalgesia t o l ight touch." S i l e n t nociceptors that are mechano-insensi tive can become mechano-sensitive once sensitized ( 1 05 ) . Table 2 . 4 l ists the neural changes associated with sensi tization . How Do Mechanoreceptor Afferents Cause Pain? The Neurochemistry of Neuropathic Pain The patho­

physiology of neuropathic pai n involves peripheral and central neural events (Fig. 2 . 1 8). Sustained activ­ i ty in type III and IV (small diameter) plimary affer­ ents leads to a release of exci tatory amino acids (glutamate) and neuropeptides (substance P) in the

Chapter Two: The Role of Muscles, Joints, and the Nervous System in Painful Conditions

Table 2.4 •

•

• •

--

45

deac t ivated by t h e flood o f exci tatory a m i no acids (3 1 ,99). Long-lasting changes appear to be the resu lt of oncogene activation by strong nociceptive in put ( 1 30). Oncogenes such as c-fos enter the nucleus of the neuron and regulate other gene activi ty. Accord­ ing to Willis ( 1 30), "The impl icati ons of this chain or events are still unclear, but a poten tial result could be long-term changes i n the responsiveness of nocicep­ tive neurons. "

The pathophysiology of sensitization

Increased spontaneous activi ty of types III and IV primary afferents Prolonged after discharges of a fferents to repeated stimul at ion Decreased threshold to a fferent i nput Expanded receptive fields of dorsal horn neurons

Pathoanatomical Changes in Neuropathic Pain Peri­

dorsal horn. Increased concentration of these neuro­ chem ical mediators w i l l lower the firing t hreshold for pri mary sensory afferents (65 , 1 3 0 ) . In the pres­ ence of certain neurotransm i t ters, secondary dorsal horn neurons may become hyper-responsive because of excitatory amino acids acting at N-methyl-D­ aspartate ( N M DA) receptor si tes and activating dor­ sal horn nociceptive neurons ( 6 5 , 1 3 1 ) . Secondary neuron hyper-responsiveness a ft e r repeated s t imu­ lation is called "wind-up" and is o ften short-term . I n hibi tory amino acids l i ke GABA are present to dampen this but, over time, segmental i n hibition is

p heral nerves can sprout after peripheral nerve injury so that low t h reshold mechanoreceptors can extend to termi nate within the superficial dorsal horn and make direct connection with nociceptors (3 1 ,99). Peripheral nerve damage according to Dubner leads to an expansion of the low threshold portion or wide dynamic range (WDR) neurons caused by a l oss or surrounding i n h i bi tion ( 3 1 ) . Increased exc i tabi l i ty leads to excitotoxicity (32,76, 1 1 7 ) . The most sensitive neurons are small local circuit inhibitory neurons (3 1 ) . Morphological changes have been demonstrated in the rat dorsal h orn a fter part ial nerve inj u ry ( 3 1 , 1 1 7) .

Neurotransmitter Release

Projection Neuron

r

?CeIl Dea'h

Nitric Oxide/Arachidonic Acid

�zation

Autonomic & Motor Effects

Immun e

��

�ell Factors

' Cytoklnes • Endorphins

Vascular Agents . ns

: ��

+ • NItriC OXide

Tissue Injury • Bradykinin

: ��T

• Prostanotds

Neurokinins

�/ � �

Peripheral

Nociceptor

\

Neurotrophins

Sympathetic Influences

Thermal and

Cytokines and

Mechanical

Neurolrophins

�

Stimuli

Figure 2. 1 8 Pharmacologic systems thought to contribute to t ransmission and modu­

lation of nociception i n the dorsal horn of the spinal cord. From Terman GW, Bonica JJ. Spinal mechanisms and t heir modulation. Bonica's Management of Pai n , Third ed. I n : Loeser JD, ed . P h iladelphia: Li ppincott Will i ams & W i l k i ns , 200 1 .

46

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Part One: Overview

M agnetoencepha lograp h i c a n d evoked poten t i al studies i n c h ron i c l ow back p a in patients have demonstrated central nervous system (CNS) hyper­ responsiveness i n the pri m ary somatosensory cor­ tex ( Fig. 2 . 1 6) ( 3 5 , 36 ) . M agnetoencephalography has also shown somatotopic cortical map reorganization i n patients who underwe n t reconstructive surgery ( 8 8 ) . That the spinal cord and C N S are i nvolved i n pai n ful musculoskeletal di sorders i s n o l onger a question.

Neurophysiologic (Neuromagnetic) Abnormalities Documented i n Chronic Upper Limb Pain C l inical Findings •

aIJodynia

•

decreased strength

•

decreased mobil i ty

Neurophysiologic Findings

From whole head magnetoencephalography •

termed neuropathic pai n . Alongside the long-lasting spinal cord excitabi l i ty produced by sustained, i n tense nocicicep ti ve activity, depression of spinal cord exc i tabil i ty has been s hown to be possible via descen d i ng serotonergic pathways ( 2 1 , 1 06 ) . I n particular, 5-hydroxyt ryptamine ( 5 - HT) exerts a descendi ng control on nociception via presynaptic i nh i b i t i o n of primary afferen t s ( 6 4 ) . Shay and Hochman have also demonstrated l hat serotonin (5-HT) depresses multi-segmental sensory convergent input or receptive field size i n lami nae IV-VII spinal neurons ( 1 06). The descending modulation of neuropathic pain by serotonergic strategies is a promising new approach for m a nagi ng neuropat h i c pain . Other strategies designed to disinhibit the spinal cord excitabilily i nclude cogni tive-behavioral training and affecl ive m e t h ods ( i . e . , medi t a t i o n , relaxa t i o n trai n i ng ) , w h i c h intluence t h e hypothalamic-pitui tary axis and limbic centers. Addit ionally, stabilization approaches designed to improve function of agon isl-antagonisl muscles duri ng daily tasks may reduce nociceptive input to the dorsal horn, and over time help to re­ establish more normal stimulus-response profiles in the pain system.

I ncreased pri mary somatosensory (SI) responses to tactile sti mulation of the affected side

• CONCLUSION

•

2 5%-55% greater than on non-affected side

•

Shortened distance between thumb and l i ttle 6nger

Co-activation of agonist and antagonist muscles is an essential motor control trail t hat develops over time in the i n fant and allows for a balanced, upright posture to be achieved by 4 years of l i fe ( 1 2 7 ) . In adults, this muscular co-activation is an essential feature of joint stability ( 1 7 , 1 8) . Poor molor control-as demon­ strated by synergist subsl itution (6,33,43, 1 1 1 ), slow reaction time of muscles ( 1 9, 1 00, 1 0 1 , 1 29), or inade­ quate agoni st-a n tagonist co-activalion ( 1 7 , 1 8 )­ goes hand-in-hand w i t h decreased j o i n l stab i l i lY. M a n n i o n suggests that lhis fau l ty motor con trol is the m ost l i kely source of the approxi mately 50% of L B P syndromes that are still unexplai ned ( 7 2 ) . Lewit said t h a t t h i s functional palhology of l h e motor system i s t h e most common c l i n i cal fi nding i n pain patients present i ng to orthoped ists, rheuma­ tologists, and n eurologists, yel it is routi nely over­ l ooked ( 6 7 ) . A study of the biomechanics a n d neurophysiology of spine stabil i ty demonstrates that rehabil i tation approaches should focus on developi ng coordination between agonist and an tagonist muscles, a fast speed of contraction of s tabi l i zers, aerobic conditioni ng, and muscle endurance. The final common pathway of rehab i l i ta t i o n of t h e motor system is to train i mproved motor control i n a patienl's aClivities of daily living.

SI representation zones corresponding to t he affected hand •

Shortened duration of the tactile evoked 20-Hz rebound in the motor cortex (reflective of functional state of the motor cortex)

Conclusion •

Chronic pain patients typicall y have altered central tacti Ie processi ng

•

Somatosensory c hanges are l i kely to be related to m otor findi ngs as well

J uo t L onen K , Gockel M , S i Jen T, H urri H , H a r i R, Forss N . Altered central sensorimotor processi n g i n p a t i e n ts w i t h com­ plex I-egional pai n syndrome. Pa i n 2002;98:3 1 5-323.

Can Central Sensitization and Expanded Receptor Fields be Modulated? The i nteraction of descending

neuromodulatory and segmental activity o n s p inal cord n eurons i n dicates there is a h igh degree o f modi fiabil i ty of the sensory i ntegration phenomena

Chapter T\No: The Role of Muscles, JOints, and the Nervous System in Painful Conditions

Audit Process

Self-Check of the Chapter's Learning Objectives •

Describe how agonist-antagonist muscle co­ activation stabi l izes the spi ne.

•

What is the di fference between whole body and spinal stability?

•

How can chronic pain patients feel pain from non­ noxious s t i m u l i ?

•

Wh ich muscles have a tendency t o become i n h i b i ted and which overactive?

•

How does neurodevelopmental kinesiology shed l ight on the problem of agonist-antagonist co-activation i n adul ts ?

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in vitro: The effects of neonatal capsaicin treatment. Brain Res 1 998;789:339-342. LaMotte RH. Subpopulations of "noci fensor neu­ rons" con tributing to pain and allodynia, itch and allokinesis. APS J 1 992;2: 1 1 5- 1 26. Lavender SA, M i rka GA, Schoenmark l i n RW, Som­ merich C M , Sudhakar LR, Marras WS. The effects of preview and task symmetry on t ru n k muscle response to sudden loading. Human Factors 1 989;3 1 : 1 0 1 - 1 1 5 . Lewi t K. Man ipulat ive therapy i n rehabil i tation of the motor system , 3rd ed. London : B u tterworths, 1 999. Lund JP, Donga R, Widmer CG, e t al. The pain­ adaptation model : A discussion of the relationship between chronic musculoskeletal pain and motor activity. Can J Physiol Pharmacol 1 99 1 ;69:683-694. Luoto S, Heliovaara M, H u rri H , Alaranta H. Static back endurance and the risk of low-back pain . C l i n Biomech 1 995; 1 0:32 3-324. MacKenzie J . Some points bearing o n the associa­ tion of sensory disorders and visceral diseases. Brain 1 893 ; 1 6:32 1 -354. Madeleine P, Lundager B, Voight M , Arendt-N ielsen L. Shoulder muscle co-ord i nation during chronic and acute experi mental neck-shoulder pai n : An occupational pain study. E u r J Appl Physiol 1 999;79: 1 27- 1 40. Mannion AF, Junge A, Taimela S, M u n tener M , Lorenzo K, Dvorak J. Active therapy for chronic low back pai n . Part 3. Factors i nO uencing self-rated dis­ ability and its change fol lowing therapy. Spine 200 1 ;26:920-929 . Mannion A F , Taimela S, M u n tener M, Dvorak J . Active therapy for chronic low back pain . Part 1 . Effects on back muscle activation, fatigab i l i ty, and strength. Spine 200 1 ;26: 897-908. Marras WS, M irka GA. M uscle activities during asymmetric tru n k angular accelerat ions. J Orthop Res 1 990;8: 824-832. Marras WS, Rangarajulu SL, Lavender SA. Trunk load­ ing and expectation. Ergonomics 1 987;30:5 5 1 -562. Mayer RA, Treed RD, Srin ivas NR, Campbell I N . Peripheral versus cen tral mechanisms for secondary hyperalgesia. APS J 1 992:2; 1 27- 1 3 1 . McG i l l SM . Bioillechan ical basis for stab i l i ty: An explanation to enhance c l i n ical u t i l i ty. J Orth Sports Phys Ther 200 1 ;3 1 :97. McGill SM, Sharratt MT, Seguin JP. Loads o n the spinal tissues during simul taneous l i ft i ng and ven t i ­ latory challenge. Ergonomics 1 995;38: 1 772- 1 792 . McGill S M . Low back exercises: prescription for the healthy back and when recovering [Tom i njury. Resources Manual for Guidel i nes for Exercise Test­ i ng and Prescription, 3rd ed. I nd ianapoli s , I n : American College o f SPOl-ts Medicine/Bal t i more: Lippincott, Will iams and W i l k i ns , 1 998. McGi l l S M , Brown S. Creep response o f the lum bar spine to prolonged ful l flexion . C l i n Biomech 1 992 ; 7 :43-46. McGi l l S M , Norman RW. Low Back B i omechanics i n Industry: The Prevention of I nj ury Through Safer L i ft i ng. I n : Grabi ner M, ed. Current Issues i n B i o­ mechan ics. Champaign, IL: Human K i netics, 1 993.

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8 2 . McGi l l S M . Low back d isorders: The scientific foun­ dation for prevention and rehabil i tation. Cham­ paign, I L : Human K inetics, 2002. 83. McPartland JM, Brodeur RR, Hallgren RC. Chronic neck pain , stan d i ng balance and suboccipital mus­ cle atrophy: A pilot study. J Manipulative Physiol Ther 1 997;20:24-29. 84. Mense S. Sensi t i zation o[ group I V muscle I-eccp­ tors to bradyki n i n by 5-hydroxytryptamine and prostaglandin E2. Brain Res 1 98 1 ;225 :95- 1 05 . 8 5 . Merskey H . L i m i tations o f Pai n Behavior. APS J 1 992;2: 1 0 1 - 1 04 . 86. Merseky H . Regional pai n is rarely hysterical. Arch Neur 1 988;45 :9 1 5-9 1 8 . 87. Michelotti A, Farella M, Martina R . Sensory and motor changes of the human jaw muscles during i nduced orthodontic pain . Eur J Orthop 1 999;2 1 : 397-404. 8 8 . Mogli ner A, Grossman JA, Ri bary U, et al. Somatosensory cortical plasticity i n adu lt humans revealed by magnetoencephalography. Proc Natl Acad Sci U SA 1 993;90;3593-3597. 89. Nachemson A L . Newest knowledge of low back pain. C l i n Orth ReI Res 1 992;279:8-20 . 9 0 . Nederhand M J , Ijzerman MJ, Hermens HK, Baten CTM, Z i lvold G. Cervical m uscle dysfunction i n the chronic whiplash associated disorder Grade n (WAD-I I) . Spine 2000; 1 5 ; 1 938- 1 94 3 . 9 1 . Nederhand MJ, Hermens H K, Ijzerman MJ, Turk DC, Zi lvold G . Chronic neck pain d isabil ity due to an acute whiplash i nj u ry. Pain 2 003; 1 02:63-7 1 . 92 . O'Sul l ivan P B , Beales D J , Beetham JA, et al. Al tered motor control strategies i n subjects with sacroil iac joint pain during the active straight-leg-raise tes t . S p i n e 2002 ; 2 7 : E 1 -E 8 . 93. Paarn ianpour M , Nord i n M , Kahanovitz N , Frank V . The triaxial cou pl i ng o f torque genera tion of trun k muscles during isometric exert ions and the effect of fatigu i ng isoinertial movements on the motor output and movement pattems. Spine 1 998; 1 3 :982-992 . 9 4 . Panjabi M M . T h e stab i l izing system of the spi ne. Part 1 . Function, dysfunction, adaptation, and enhancement. J Spinal Dis 1 99 2 ; 5 :383-389. 95. Panjabi MM, N i bu K, Cholewicki J. Wh i plash i njuries and the potential for mechanical i nstab i l i ty. E ur Spi ne J 1 998;7 :484-492. 96. Panjabi M M , M oy P, Oxland TR, Cholewicki J . Sub­ fai l u re injury affects the relaxat ion behavior of rab­ b i t ACL. C l i n B i omech 1 999; 1 4:24-3 1 . 97. Patterson M . Model mechanism for spinal segmen­ tal facil itation. Colorado Springs, CO: Academy of Applied Osteopathy Yearbook, 1 976. 98. Perl ER, Dumuzawa T, Lyn n B , Ken i n s P. Sensi t i za­ tion of h igh t h reshold receptors with u n myel inated ( C ) afferen t fibers. I n : Iggo A, Liynsky I, eds. Somatosensory and V isceral Receptor Mechanisms, Progress in B rain Research 1 974;43:263-2 7 8 . 99. Perl E R . M u l t i receptive neurons a n d mechanical allodynia. APS J 1 992: 1 ;37-4 1 . 1 00. Radebold A, Cholewicki J , Panjabi M M , Patel TC. Muscle response pattern to sudden tru n k loading i n healthy i ndividuals a n d i n patients w i t h chronic low back pai n . Spine 2000;25:947-954.

50

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Part One: Overview

1 0 1 . Radebold A, Cholewicki J , Polzhofer BA, Greene HS. I m pa i red postural contml of the l u mbar spine i s associated with delayed m uscle response t imes in patients with c hron ic i d iopathic low back pain. Spine 200 1 ;26:724-730. 1 02 . Rei lly T, Tynell A, Troup J DG. C i rcadian variation i n the human stature. Chronobiol I t 1 984 ; 1 : 1 2 1 . 1 03 . Reynolds O E , Hutchins He. Reduct ion of central hyper- i rr i tab i l i ty fol lowi ng block anesthesia of peripheral nerve. A m J Physiol 1 94 8 ; 1 52 :658-662. 1 04 . Sahrmann S. D i agnosis and Treatment of Move­ ment l. m pa i rment Syndmmes. St. Louis, MO: Mosby, Inc, 200 1 . 1 05 . Schiable HG, Grubb B D . Afferent and spinal mech­ anisms o f joint pai n . Pain 1 99 3 ; 5 5 : 5-54. 1 06. Shay BL, H ochman S. Semto n i n alters m u l t i ­ segmental convergence patterns i n spi nal cord deep dorsal horn and i ntermed iate l am inae neurons i n an i n vitm young r a t preparation. P a i n 2002 ;95:7- 1 4. 1 07. S h i rado 0, I to T, Kaneda K, et a l . Flexion-relaxation phenomenon in the back muscles: A comparative study between healthy subjects and pati ents with chron i c low back pai n . Am J P hys Med Rehabi l 1 995;74: 1 39- 1 44. 1 08. Snook S H , Webster BS, McGorry RW, Fogleman MT, McCann KB. The reduction of chroni c nonspe­ cific low back pain t hmugh the cont rol of early morning l u m bar flexion. Spine 1 998;23 :260 1 -2607. 1 09. Snook SH, Webster BS, McGorry RW. The reduc­ tion of chmnic, nonspeci fic low back pain t h rough the control of early morn i ng l u m bar flexion: 3-year fol low-u p. J Occup Rehab 2002; J 2 : 1 3-20. 1 1 0. Solomonow M, G uzzi G, Baratta, et al. E M G-force model of the el bows an tagonistic muscle pair. The effect of joint pos i tion, gravity and recru i tment. Am J Phys Med 1 986;65 : 2 2 3-244 . I I I . Sparto PJ , Paarn ianpour M, Massa WS, Granata

1 1 2.

1 1 3.

1 1 4.

1 1 5.

I 1 6.

1 1 7.

KP, Reinsel TE, S i mon S. Neuromuscular t ru n k performance and spinal loading during a fatigu i ng i sometric t m n k extension with val-ying torque req u i rements. Spine 1 997; I 0: 1 45- 1 56. Sparto PJ , Paarni an pour M, Rei nsel TE, Simon S. The effect o f fatigue on m u l t ijoint k i nematics and load sharing during a repe t i tive l i fting test. Spine 1 997;22: 2647-2654. Spencer J D, Hayes KC, Alexander U. Knee j o i n t effusion a n d quadriceps reflex i n h ib i tion i n man, Arch Phys Med Rehab, 1 984;65: 1 7 1 - 1 77 . Stokes IAF, Gardner-Morse M , Henry SM, Badger GJ. Decrease in Tru n k M uscul ar Response to Per­ turbation W i t h PI-eactivation of L u m bar Spinal M u sculat ure. Spine 2000;25: 1 957- 1 964. Stokes M , Young A. I n vest igations of quadriceps i n h i bition: I m p lications for c l i nical pract ice. Phys­ iotherapy 1 984;70:425-428 . Sturge WA. T h e phenomena of angina pectoris and their bearing upon the theory of counter i lTitation. B ra i n 1 88 3 ; 5 :492-5 1 0. Sugi moto T, Bennett G J , Kajander Ke. Transsynap­ tic degeneration in the superficial dorsal horn after sciatic nerve i nj ury: Effects of a chron ic constric-

1 1 8.

1 1 9.

1 20.

121.

1 22 .

1 23. 1 24.

1 25.

1 26.

1 27 . 1 28. 1 29.

1 30.

131.

1 32 .

1 33 .

1 34 .

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Quality Assurance: The Scope of the Spine Problem and Modern Attempts to Manage It _.

Craig Liebenson

Introduction

Learning Objectives

Scope of the Problem

After reading this chapter you should be able to:

Epidemiology and Natural History Risk Factors: Etiology and Prognosis

• •

Evolution of Evidence-Based Healthcare What Is Evidence-Based Healthcare? Implementation of New Evidence Limitations of Evidence-Based Healthcare Improving the Quality of Evidence-Based Guidelines

•

Understand the course of spinal disorders Understand the risk factors for both acute and chronic low back pain Understand the benefits and limitations of man­ agement guidelines for low back pain and w hiplash-associated disorders "] am merely picking up pebbles from the

seashore of knowledge"

Sir Isaac Newton

51

52

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Part One: Overview

Introduction Specialists in the management of spinal disorders have seen tremendous changes in the past decade. Whereas the low back pain (LBP) problem is acknowledged as an epidemic, a consensus has gradually emerged as to why this happened and what can be done about it (2,31,39,76,129,130,142). An overemphasis on the simplistic biomedical approach of identifying and treating the structural cause of pain has led to excesses in diagnostic testing, bed rest, narcotic analgesics, and surgery (29,52,65,167). Meanwhile, an underemphasis on illness behavior has led to an underuse of functional (reactivation advice, manipulation, and exercise) and cognitive-behavorial approaches (173). A wide varia­ tion in practice habits-not justified by evidence of effectiveness-has been the major motivation of the guidelines development players (2,29). Patients wit h acute spinal problems tend to improve quickly, although recurrence is t he norm and dissatisfaction is high (30,165). Those who have chronic, persistent pain or become disabled are failed by a healt h care system that characteristically falls into the trap of overemphasizing the structural cause of pain rather than early on p roviding reassurance that there is no serious disease and t hat the road to recovery is through gradually resuming normal activities and restoring function (19,74,104). Unfor­ tunately, implementation of guidelines summarizing this modern self management approach has been poor (18,62). One possible explanation is that guidelines take an overly aggressive tone (1). Another proposed reason is that back pain lacks a defined specialty group such as cardiology that can be educated and partnered with to change practice behaviors (124). Finally, a third possibility is that it may be easier to educate patients who then will influence physician behavior rather than vice versa (18,21,134). Acute LBP is one of the leading symptoms that leads an individual to seek health care services. From diagnostic triage to rehabilitation, the modern goal of care is to maintain or resume normal func­ tional activities (2,23,167). Certain benchmark "tools of the trade" include diagnostic triage (with­ out imaging unless "red flags" of serious disease are present), appropriate referral if there are "red flags," or reassurance that nothing serious is wrong, simple reactivation advice, and pain relief options such as medication (usually over the counter) and spinal manipulation. The subacute patient has reached a different deci­ sion point. Beginning at the 4-week mark, a patient who has not significantly improved is "de-facto" at high risk for chronicity and thus requires a differ­ ent "tool set." Structural (i.e., imaging), functional (physical performance ability), and psychosocial re-

evaluation is necessitated. At this stage, exercise guided by a rehabilitation specialist is appropriate (167). This may include cognitive-behavorial educa­ tion or exercise (i.e., McKenzie, stabilization, or iso­ tonic), with no particular approach having been clearly s hown to be superior to any other at present. New research has reinforced that it may not be so important exactly what is offered so long as it is matched to the patients activities and orfered with worksite involvement if related to occupation (52, 99,100). Certainly, so long as appropriate indica­ tions, progressive neurologic deficit or significant non-responsive leg symptoms and confirmatory imag­ ing findings, are present spinal surgery is an option at this stage (85). A key question remains as to whom should receive which components of this "benchmark" and when. Because of the high prevalence and limited effective­ ness of primary prevention, universal preventive care is not appropriate (136). Generally, too much care is with held until patients have well-established chronic pain syndromes when costs are extremely high and effectiveness is low (97,106,136,167). However, can we afford early, aggressive strategies for everyone, or is it possible to stratify individuals into groups of who is either more or less likely to recover so that aggressive care can be targeted to those who need it most (25,26,52,53,57,76,89,90,93,94,95,97,104,109, 136,155)? The identification of psychosocial "yellow flags" indicative of a decreased likelihood of recovery have been proposed as a technique for early identifi­ cation and thus matched appropriate management of those with a poorer prognosis (76,92,93,129,130,151).

Scope of the Problem Epidemiology and Natural History

..

: ..

.. .

.

..

...

A common myth is that pain and activity intolerances are usually eli m inated within 4 to 6 weeks of the onset of a typical low back pain episode. Alt hough it is true that sig­ n ificant improvement is usually achieved quickly, pain and activity restrictions tend to persist and recur indefi­ n i tely. This being the case, what type of expectations should patients be given regarding their recovery in tel-ms of pain, retum to work, activity intolerances, and the like-

�ood of I-e�un-ence? Incidence

Acute low back pain (LBP) affects most of the popu­ lation at some time or another. By the age of 30,

Chapter Three: Quality Assurance

nearly one-half o[ the population will have experi­ enced a significant episode of LBP (\18). The likelihood of someone having pain at any given time-the point prevalence-is between 15% and 30% (107,111). The Nuprin Pain Report found that LBP was second only to headache as the most common pain symptom affecting American adults over the previous year (149). This report showed that the 1-year prevalence rate (chances of having LBP in t he past year) was 56% and the lifetime prevalence rate (chances or having LBP in one's lifetime) was 70% (64,149). Similarly, European studies have demon­ strated I-year prevalence rates of 35% to 40% (7, 71,79,107, 1 19,169) and lifetime prevalence rates of between 60% and 80% (107,119,111,141,169). Most patients with acute LBP have had it before (165). It typically runs a self-limiting course only to recur again in the future. Carey et al reported t hat only 5% of acute low back pain episodes become chronic (23). The General Survey on Living Conditions in Sweden and the General Household Survey in Britain came to similar conclusions (132,157). Unfortunately, even though the chronic problem affects a small per­ centage of individuals, it consumes the majority of the costs associated with this problem (68,142).

Course of Low Back Pain

It has been traditionally taught that for the majority of individuals (750/0-90%), acute LBP episodes resolve within 4 to 6 weeks (65,142) (Fig. 3.1). This is based on insurance surveillance data that mostly tracked disability. Such an excellent natural history has led to the mistaken belief that acute LBP can be managed symptomatically (bed rest and medication) and left alone. However, there are two problems with this per­ spective. First, the view that most acute episodes resolve quickly and completely is disputed by a num­ ber of studies of primary care patients (36,165). Sec­ ond, there is a growing body of evidence that it is more

C

l------_ � Intervention

.� a;

(j) c

&

Outcome Assessed --

Time Figure 3.1 Presumed natural h istory of LBP. Repro­

duced from Deyo RA. Practice variations, treatment fads, risi ng disabil ity. Do we need a new c l i n ical research para­ digm? Spine 1993 ; 1 8:2 1 53-2 1 62.

--

53

c

.�

Q) (j) c

& Time Figure 3.2 Actual course of L B P here. Reproduced from

Deyo RA. Practice variations, treatment fads, ris i n g d is­ abi l ity. D o we need a new c l i nical research paradigm? Spine 1993 ; 1 8:2 1 5 3-2 1 62 .

cost-effective to attempt to prevent chronicity i n those at risk for it rather than waiting to treat only those in whom it becomes fully apparent (97,106,122,136, 151,167). One of the first studies that cast doubt on the often suggested rosey natural history for LBP was by Lloyd and Troup who presented evidence that s howed that 70% of people continued to have have residual symp­ toms even after they returned to work (98). Berquist­ Ullman and Larsson found t hat 62% of acute back pain patients had at least one recurrence during a I-year follow-up (6). Similarly, Butler et al demon­ strated that even though most disabled workers with LBP return to work within 1 month, 50% o[ t hem relapse within 1 year (20). Von Korff et al demon­ strated in a non-occupational setting that after 1 month only 30% of neck and low back pain patients had achieved pain-free status and after 1 year one­ half still reported recurrent or persistent pain (165)! Although this study is often criticized for not exclu­ sively limiting itself to patients havi ng their fi rst-ever episode of acute LBP, it nonetheless served as a wake up call t hat the presumed natural history o r LBP episodes was not what "experts" claimed. I n fact, it could be said that because most of our acute patients have had symptoms before Von K orff's study is a more realistic look at the natural history clinicians in the trenches actually see! In the past few years, a number of high-quality, prospective studies (23,30,36,160) have looked at the course of first-time acute LBP in non-occupational settings. These studies show that most acute episodes tend to improve rapidly, although not completely, and then run an intermittent, chronic course with less severe "flare-ups" (Fig. 3.2). The original episode rTe­ quently lasts for as long as 3 months, not 4 to 6 weeks, before it can be said to have remitted (30,36). The pre­ dictable "flare-ups" are mild to moderately activity­ limiting and painful and lead to general dissatisfaction with the symptoms (30,36,165).

54

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Part One: Overview

When looking at the literature regarding t he nat­ ural history of LBP, two important sources of error should be avoided. First, are the inception cohorts (study population) of each study similar enough to compare? Second, what criteria are being used to conclude that recovery has occurred? Evaluating if inception cohorts are similar is per­ formed to see if are we are comparing apples to apples. Some studies of recovery include in their inception cohort a mixed group of new-onset cases with pre-existing cases. Von Korff's study mixed the two (like in a real practice!), so naturally he shows a poorer natural history because he was already includ­ ing in his cohort individuals with previous histories (165). Other studies like Carey's use very strict crite­ ria to limit the cohort to only first-time sufferers, which is quite different than the make-up of most practices (23). Another crucial difference in many studies is that they often use different outcomes to define "recovery." Symptoms, care-seeking, activity limitations, satisfac­ tion, or disabilit), have all been used and each consti­ tutes something quite different. Cherkin performed a prospective study with an inception cohort of 219 patients presenting to a pri­ mary care health maintenance organization (HMO) clinic in the state of Washington for care for the first time for a new episode of LBP (30). The criteria used for recovery included a novel measurement of how satisfied with care a patient would be if the current level of symptoms persisted. At 1 week, one-third were satisfied; at 3 weeks one-half were satisfied; at 7 weeks two-thirds were satisfied; and at 1 year 85% were sat­ isfied. T his certainly did not equate with traditional wisdom that 90% of LBP patients were recovered in 4 to 6 weeks. In fact, at 7 weeks, only 46% were symp­ tom-free, 38% were free of dysfunction, and only 31% were both symptom-free and without dysfunction. Even at 1 year, only 39% were both symptom-free and without dysfunction, and fully 29% were considered to have poor outcomes. In a related study, Croft et al performed a prospec­ tive study with an inception cohort of 463 adults pre­ senting to general practitioner (GP) in England (36). These were patients having their first consultation for LBP in the past year. They could have had LBP, but not any consultations, within 1 year. The crite­ ria for recovery were reduced pain and disability. At 3 months, although 9 ]% stopped consulting, only 21% had completely recovered. At 1 year only 25% had completely recovered. Jacob conducted a longitudinal, community-based study of 3350 individuals from a single town in Israel (75). Of these, 555 met the inclusion criteria of self­ reported pain in the past month; 78.7% sought some health care at baseline. The outcomes of recovery

studied were persistence of pain after 2 or 12 months. More than three-fourths of the pain group continued to report pain after 2 and 12 months. The traditional view that mostLBP patients are recov­ ered in 4 to 6 weeks is not supported by the current litera­ ture (Table 3.1). Croft summarizes CWTent lhinking as, "The findings of our study are in sharp contrast to the fre­ quently repeated assumption that 90% of episodes of low back pain seen in primm)' care will have resolved within a month" (36). The Cherkin, Croft, and Jacob studies suggest that the I-year data indicate a significant unrecognized problem (30,36,75). Croft et al says, "We should stop characterizing LBP as acute problems which recover, but rather as a c hronic problem with frequent recur­ rences." Most striking is Croft's conclusion that more aggressive early treatment may be needed to address this rather non-benign natural history, "Since most consulters continue to have long term low back pain and disability, effective early treatment could reduce the burden of these symptoms and their social, eco­ nomic, and medical impact." Deyo and Weinstein agree saying, ". . . the emerg­ ing picture is that of a chronic problem with intermit­ tent exacerbations, analogous to asthma, rather than an acute disease that can be cured" (44). Dutch find­ ings confirm this by finding that at 12 months after initial consultation, even though only 10% of pa­ tients still had the same episode (chronic patients), 75% had reported at least one recurrence (160).

Table 3.1 for LBP

Summar), of the Natural History

The good news: • •

•

•

• •

For the majority, improvement begins rapidly Chronic, unremitting LBP affects a minority of patients Disability persists in a relatively small percentage of individuals, even in those with chronic LBP Most individuals don't seek care and when they do it does not last long Satisfaction with chiropractic care is very good The economic costs for managing most LBP is not that great

The bad news: •

• • •

Complete resoluLion of symptoms and activity intolerances does not occur rapidly The recurrence rate is high Satisfaction with medical care is not very good The economic costs related to the small minority of individuals with persistent, disabling occupa­ tional LBP are an enormous problem for society

Chapter Three: Quality Assurance

Carey's study sheds significant light on the impor­ tant question of what type of care is indicated by these data (23). Because persistent, chronic LBP occurs in less than 8% of new episodes of acute LBP and is usually not disabling, he suggests that the focus of care should be on disability prevention and functional recovery rather than symptom management, "The challenge for clinicians is to maintain patient func­ tioning in the face o[ persistent symptoms that are not easily resolved with treatment." Thus, ". . . preserva­ tion of physical hmctioning, rather than symptom eradication, should be the paramount goal of health care for patients with chronic LBP."

Systematic Critical Review Evaluates Epidemiologic Data on Natural History and Course of Back Pain •

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55

Table 3.2 Table Percentage of Costs by Type of Treatment and Compensation Back Pain Costs

Medical costs Physician's fees Hospital costs Diagnostic tests Physical therapy Drugs Appliances Disability Temporary Permanent Total costs

Percent

Percent

33 11 11 4 3 2 2 67 22 45 ]00

Adapted with perm ission from Pope M H , Frymoyer I W , Andersson G , eds. Occupational Low Back Pai n . New York: Praeger, 1984: 107.

Fi nds no evidence for the popular claim that 90% of back pai n episodes resolve spontaneously i n I month

•

Return to work does not equate with recovery because chronic pat i ents may "move" i n and out o f em ployment o r return t o less demanding jobs

•

Patients may stop consul t i ng with their medical physician , but this does not mean they are recovered

•

This study questions the value of s hort-term recovery as a val id outcome measure for a recurrent disorder such as back pain

•

The authors propose long-term preve n t ion o f recurrences a s a more relevant measure of the success of a therapeutic i n tervention

Hestbaek L, Leboeur-Yde C, Manniche C. Low back pain: what is the long-term course? A review or studies or general patient populations. Eur Spine J 2003; 12:149-165.

Costs

LBP is the second leading reason for visiting a physi­ cian after upper respiratory problems (40). Its cost represents a major under-appreciated health care failure. In the United States, the costs are estimated at $25 billion annually. This is approximately three­ times the cost of all types of cancer! Most of the costs related to back problems are asso­ ciated with occupational back pain and are caused by disability (Table 3.2). Williams has shown that physi­ cal therapy, surgery, and diagnostic testing are the biggest health care contributors, with mental health

and chiropractic representing surprisingly small over­ all costs (0.5% and 3.4%, respectively) (173). The most expensive patients are the 1% who undergo surgery (173). Freidlieb concluded that 44% of CAT scans (CT) or magnetic resonance imaging (MRI) studies were unnecessary (55). New information also sug­ gests medication abuse is a bigger cost problem than previously thought (158). Ursiny showed that narcotic use is the most significant cost factor fTom a treatment perspective (158). In a study looking at 98 randomly selected disabled workers, Mahmud et al (102) concluded, "Disability was significantly associated with increased utilization of specialty referrals and provider visits, use of MR I, and use of opioids for more than seven days." The study found that 27% of uncomplicated acute LBP patients had an MRI scan in the first month and 33% had a CT scan; 38% received a prescription [or nar­ cotic opioids. Even though only a small percentage (7%) of indi­ viduals with acute LBP develop chronic, unremitting pain and disability, this group demands our atten­ tion (68). They account disproportionately for the costs associated with the LBP probJem with 7.4% of patients estimated to account for 75% of all the costs and 85% of the disability days (68,142) ( Fig. 3.3). lL is for this reason that identifying potential risk fac­ tors for acute pain becoming chronic has become an area of intense LBP research (see Chapter 9). Care-seeking forLBP varies from country to coun­ try. In the United States, only 39% of acute patients sought care (23). In England 48% (174) sought care, in Belgium 63% (146) sought care, and in Israel 78% (75) sought care.

56

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Part One: Overview

PERCENT

Risk Factors: Etiology and Prognosis

70 60 50 40 30 20 10 0

< I

I

to 3

3 to 6

>

6

DURATION OF ABSENCE FROM WORK (months) Figure 3.3 Compensation costs ror back i nj u ry i n groups

w i t h di rferent dura t ions or absence from work. Quebec, 1 98 1 . From Spit zer WO, Le Blanc FE, D u puis M, et a l . Scien tific approach to t h e assessment and management or activity-related spi nal d i sorders: A m onograph for c l i n­ icians. Report of the Quebec Task Force on Spinal D isor­ ders. Spine 1 987; 1 2(suppl 7 ) : SI-S59.

Natural History for Spinal Disorders Other Than Low Back Pain

Sciatica is a common condition that typically lasts longer than LBP (44,156). The presence of leg pain has been shown prospectively to at least double the risk of a back problem becoming persistant (odds ratio, 2.55; 95% confidence interval, 1.3 to 5.1) (151). The lifetime prevalence for it is estimated to be between 14% and 40% (111,145,156). Surgery for sciatica is estimated to be necessary in between 1.3% and 3.1% of the population (41,86,156). In contrast, spinal stenosis does not have such a favorable prognosis (44). Approx­ imately 15% of patients improve, 15% worsen, whereas the remainder remain fairly stable. Neck and s houlder problems occur in nearly as many individuals as LBP, with a lifetime prevalence between 50% and 71% of the population (34,111). The I-year prevalence rate is nearly 14.6 % in Saskatchewan (34) and 17.9% in England (38); 48% of neck pain episodes persist at 1 year (70). According to Makela (105), the chronic problem is frequent, affect­ ing 9.5% of males and 13.5% of females. Like LBP, neck pain is generally persistant, with only one-third experiencing a complete resolution of symptoms (35). Headache has a high point prevalence of 16% to 22% and a lifetime prevalence of more than 90% (111). Whiplash injuries are common, but their duration is controversial (103). Many authors (59,102,117) esti­ mate it to last approximately 2 to 3 months, w hereas others have concluded that 20% to 70% of the time pain persists at least 6 months later (13,14).

Two quite distinct sets of risk factors can be identified in those with LBP. First are those that predict who will have acute LBP. Some of these may actually be pre­ disposing or etiologic factors. Second are those [ac­ tors that predict which acute LBP patients will have chronic pain. These can be thought of as perpetuating or prognostic factors. Prevention efforts are depen­ dent on accurate risk factor identification. Because the cost of such preventive approaches is usually a consideration, groups at high risk are those who would be the likely targets. Prevention of acuteLBP is considered primary prevention, whereas prevention of c hronic LBP in those already having acute LBP is termed secondary prevention. Primary prevention efforts have been notably unsuccessful, whereas sec­ ondary prevention has become the focus of most recent guidelines statements (2,39,76,129,130). The best studies of risk factors are those that are prospective, because they can infer more accurately causation. In contrast, cross-sectional or retrospec­ tive studies only reveal associations and often conse­ quences rather t han causes. There is a rapidly growing body of literature on risk factors for LBP, but very few for sciatica or neck pain.

Risk Factors Associated with the Onset of Acute LBP

. ..

.. .

.

.. ..

Can factors related to the development or spi nal pain and disabil i ty be ident ified so that better primary pre­ ventive efforts can be designed, investigated, and pro­ moted?

Risk factors for the development o[ acute LBP have been divided into two general groups-individual and external. If risk factors for acute LBP can be identified, perhaps workers can be better-matched to occupa­ tions so as to reduce the incidence of costly, disabling episodes. Additionally, primary prevention measures depend on accurate identification of risk factors to be efficacious. Individual The primary individual risk factors for

onset of back pain are related to age, socio-economic class, education level, long-term activity levels, and self-rated health. Gender, genetics, congenital anom­ alies, degenerative conditions, muscle strength, and cardiovascular fitness have all been found to be unre­ lated to LBP onset. Smoking has been shown to be

Chapter Three: Quality Assurance

related, but the causal link is tenuous. Evidence that fitness and higher levels of physical activity over the long-term are correlated with reduced incidences of back pain exists, but so does short-term evidence to the contrary. Strength has not been shown to be related toLBP, but endurance has, although it is weak and controversial. Flexibility's relationship to LBP is controversial. Height and weight are often referred to as related to LBP episodes, but there is evidence to support and to reject the hypothesis. Table 3.3 sum­ marizes the main categories of individual risk factors for acute onset LBP. Psychosocial Fear-avoidance beliefs have been found

to be prospectively related to the development of pain and dysfunction (96). The relative risk (RR) is 2.0 to 2.5 (96). The RR is the ratio of incidence rates for a condition in two distinct populations. Thus, individ­ uals with substantial fear-avoidance beliefs are two­ times to 2.S-limes more likely to have LBP than those without such beliefs. High levels of distress have been shown to strongly predict that future episodes of LBP would be more likely to become chronic (151). In an asymptomatic group of 23-year-olds evaluated and then re-evaluated again 10 years later, psychological distress increased risk more than 2-fold for future LBP (odds ratio, 2.52; 95% confidence interval) (123). Depression was found to be an inde­ pendent predictor of onset of an episode of neck or low back trouble (24). Self-rated health is a potent predictor of new episodes of LBP (37,78). The relative risk in men is 1.5, whereas in women it is 2.2 (37). Below-average self-rated health has also been shown to predict that future episodes of LBP would be more likely to become chronic ( 151).

Table 3.3 Major Categories of Individual Risk Factors for Acute Onset LBP • •

•

•

•

Psychosocial (self-rated health) Physical-functional (activity level-short-term and long-term, flexibility/motion characteristics, strength, endurance, balance, cardiovascular fit­ ness, lifting capacity) Physical-structural (congenital anomalies, degenerative conditions) Work-related (some are also psychosocial or physical)-job satisfaction, low social support in the workplace Socio-demographic (age, socio-economic class, education level, gender, genetics, smoking, anthropometric-height, weight)

--

57

Phys ical-Functional

Activity level The relationship between overall fitness

and LBP episodes is one of the more interesting potential risk factor. Cady showed in a large prospec­ tive study of 1652 fire fighters that higher levels of physical fitness were preventive ofLBP episodes (22). Leino found that men wHh lower baseline levels of physical activity were at greater risk [or LBP 10 years later (87). No such elevated risk was round in women. Harreby found that inactive teenagers were more likely to have LBP 25 years later than physically active ones (67). Similarly, Videman found that compared to elite athletes, matched controls had more LBP (163). In contrast, Croft (37) found that activity levels were not correlated with subsequent LBP in the short-term, over a 1-year period, except for the [ollowing: •

•

Regular sports activity in women is related to LBP: RR, 1.3 Do-it-yourself activities in men are related to LBP: RR, 1.8.

In a related study, low levels of physical activity level were found to be strongly correlated with future development of chronic LBP in asymptomatic indi­ viduals ( 151). Cardiovascular fitness Cardiovascular fitness has not been shown to be related to f-uture onset of LBP (3,125,154). Muscle strength and endurance There is some evidence that poor isometric endurance of lhe back muscles is predictive o[ LBP episodes (8,101). However, this has been disputed by Takala (148). Stevenson et al reported that the electromyographic median [Tequency shift (increased rate of decline) during sustained contractions of the erector spinae and quadriceps strength and endurance each pre­ dicted future LBP in workers involved in manual material handling (144). Lifting capacity Isomelric lifting capacily was nol shown to be correlated by Ballie (Baltie 1989) bUl was correlated by Chaffin, Liles, and Takala. (27,91, 148). Balance Poor balance was correlaled wilh fulure LBP by Takala (148). Flexibility Reduced flexibility was shown lo be related by Battie (4). However, increased range of motion (ROM) has been idenlified as a risk faclor in women and decreased ROM in men, according lo Biering-Sorensen and Takala (8, 148). A novel dimen­ sion of ROM is the patienl's nalural speed or accele­ ration during testing. Decreased thoracic acceleration

58

Part One: Overview

during ROM testing was shown to be positively asso­ ciated with future LBP (144). Physical-structural (congenital anomalies, degenera­ tive conditions) Spinal x-rays have been used for many years to screen workers in high-risk occupa­ tions for potential risk of disabling back conditions without finding any predictive value (146). The Occu­ pational Health Guidelines (OHG) (12,15,168) fyom England summarize current scientific opinion on this subject quite succinctly, "It is important to address a very commonly held misconception about the rela­ tionship between various structural findings and spinal disorders. Historically, the public and clini­ cians have assumed that congenital abnormalities such as tropism or spina bifida, degenerative changes in discs or facets, spondylolisthesis, and herniated discs were all structural changes which if present would predispose a person to future LBP, sciatica, or neck pain episodes. To date the con-elation is very weak. The likelihood of an asymptomatic individual with any of these structural pathologies developing clinical problems in the future is hardly greater than [or someone without them." Work-Related: Job Satisfaction, Low Social Support in the Workplace Job salisFacliol1 There is strong evidence for low job

satisfaction as a risk factor for LBP. The magnitude of risk estimate (relative risk) is 1.7 to 3.0 (9,10,72, 120,122,127). This risk also extends to future acute episode being more likely to become chronic (151)! Social sllpporl il1 Ihe workplace There is also significant evidence that low social support in the workplace correlates with future onset of disabling LBP (72). The magnitude of risk is estimated to be 1.3 to 1.9 (10,126). Sociodemographic (Age, Socio-Economic Class, Education Level, Gender, Genetics, Smoking, Anthropometric-Height, Weight)

Il can be said that LBP is more common in those between late adolescence and the early 40s. After the age of 60, incidence rates begin to decline. New evidence suggests LBP may be more common than thought in even younger individuals (112,167).

Age

Socio-economic class Lower socio-economic class is related, for a variety of reasons, such as external [actors including heavier manual labor (167). In fact, the relationship is stronger for the duration of disability than it is for actual incidence of episodes.

like socio­ economic class is more related to duration of disabil­ ity than actual incidence rates [or LBP (167). Educalion

level Low education level

Smoking Smoking has clear effects on the anatomic

structures of the low back. Decreased blood flow and nutrition to the disc, lowered pH of the disc, demin­ eralization of the vertebral bodies, altered fibrinolytic activity, and increased degenerative changes have all been described. However, epidemiologic studies show there is only a very weak correlation between smoking and LBP and no correlation with sciatica (80,112). An exception is Croft's recent study, which showed that current smokers have more LBP than non-smokers or former smokers (37). Height and Weight Anthropometric measures such as

height and weight have been looked at in numerous studies reviewed by Nachemson (112). An early study of US military recruits found that those hospitalized for LBP were significantly taller and heavier than control subjects (73). Croft found that women in the shortest quintile had reduced risk (37). Kopec el al found height was correlated with LBP in men, but not women, whereas weight was not a factor for either sex (78). Deyo and Bass found that there was an increased likelihood of the heaviest individuals having LBP when compared with the lightest indi­ viduals (42). Shekelle found no relationship between body mass index (BMI) and back pain in 3000 adults (137). Croft found that both weight and body mass index were related to subsequent LBP in the next 12 months with borderline significance (37). They also found increased weight in women increased the risk. Women in the heaviest quintile had a relative risk of 1.8 compared to those in lowest quintile. No similar association was found for men. In this study, the risk associated with BMI was the same as for weight. External Work activities have been studied exten­ sively for their possible association with f-uture onset of LBP. Whole-body vibration such as in truck and automobile drivers, as well as frequent bending (flex­ ion) and twisting, have been shown to be related to both LBP and sciatica (164). Both repetitive work tasks (arm or neck movements) and manual handling (carrying, lifting, pushing, and pulling) have been shown to be related to future onset of LBP. According to the Occupational Health Guidelines (OHG) (168) from England summary, "There is strong evidence that physical demands of work (manual ma­ terials handling, lifting, bending, twisting, and whole body vibration) are a risk factor for the incidence (onset) of LBP, but overall it appears that the size of the effect is less than that of other individual, non­ occupational and unidentified factors." Risk Factors for Neck Conditions Static load has

been shown to be related to neck pain (i.e., heavy exposure to visual display unit work is cOlTelated with neck pain) (164). Also, somewhat weaker evidence suggests that work tasks involving forceful arm move-

Chapter Three: Quality Assurance

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59

ments are correlated with neck pain (164). Fatigue, sleep problems, less sports activity, and high psycho­ somatic score in those 15 to 18 years old predicted f-uture neck and shoulder pain (7 years later) (140). Female sex, having given birth to more children, psy­ chological distress, previous LBP, and previous neck injury are other lisk factors for future neck pain (70). Depression has been prospectively linked to h.lture neck pain (24). There is a trend toward a greater inci­ dence of neck pain in women, and it peaks between the ages of 30 and 45 (34); 50% of all soft tissue neck injuries are related to automobile accidents, with a female preponderance (162). Other causes are acci­ dental falls (25%), sports injuries (24%), and bicycle injuries, with a male preponderance (162).

and cost-effective to substitute more aggressive treat­ ment for a less aggressive approach (52). Basically, because most individuals who are disabled by acute LBP have a low risk for chronic disability, it would be necessary to treat a very high percentage of all dis­ abled individuals to even make a small difference in the return to work outcomes. Frank explains "the number needed to treat" to make a signi ficant dif­ ference in outcomes declines quickJy after the first month. This is because of the [acts that : (a) the pool of individuals suffering is much smaller; and (b) these individuals' likelihood of spontaneous recovery is much smaller. According to Frank, there are three distinct stages in terms of risk of an acute episode becoming chronic (52) (Fig. 3.4):

Perpetuating Factors for Poor Recovery of LBP:

Acute-First 4 weeks : risk of chronicity is low

Prognostic Factors

Subacute-Weeks 4 to 12: risk is high "ipso facto" and the survival curve suggests aggressive treatment will be cost-effective here Chronic-After 12 weeks: recovery halts

Because many acute L B P patients recover with m i n i mal i ntervention, aggressive treatment or all acute L B P patients i n t h e hope o r reducing t h e expensive chronic problem is cost-inerficienl. H owever, can pri mary care providers iden t i ry a subgroup of acute patients at h igh risk ror chronicity so that an efficient allocati on of resources can be used to prevent chronic pain before i t i s establ ished?

_-.l

Although long-term disability affects a small percent­ age of patients, they consume a disproportionate portion of the overall costs. Once chronic pain and disability is established, it is very resistant to treat­ ment. Therefore, if it can be predicted who will be resistant to recovery, then more aggressive treatments given early on to those individuals may reduce the chronic problem. Frymoyer was one of the first to focus on identifi­ cation of high risk patients, "if a patient is identified early in the course of the low back pain episode to have a high risk for disability, early, aggressive reha­ bilitative efforts may be more successful and cost effective than permitting the patient to have a longer period of disability with its resultant economic, social and medical consequences" (45). Others have fol­ lowed in Frymoyer's footsteps (11,53,54,89,90,92, 93,151). To scientifically determine whom should receive more versus less aggressive care, Frank has presented the concept of the "number needed to treat" to deter­ mine the cutoff for when it would be more efficient

Frank warns that a risk factor for acute pain becom­ ing chronic is overly aggressive acute management (therapeutic or diagnostic) (52,102). Therefore, he states, "there is ample evidence that the prognosis [or m ost patients with LBP (who have only ordinary low back strain) is so good, even without any medically prescribed treatment, that only minimal investigation and treatment, together with substantial reassurance, is warranted" (53). Staging patients uncovers the patients at greatest risk for chronicity by the mere presence of continued disability after 4 weeks. Individual risk factors for acute pain becoming chronic are called "yellow flags" (Table 3.4). They are divided into those related to symptoms, examination, psychosocial, functional, and work-related factors. Most are subjective and they are predominately psy­ chosocial. In contrast to "red flags," which require urgent attention, further testing, and possibly s pecial­ ist referral, "yellow flags" only require a shift in the focus of care. These risk factors have been shown to predict future chronic pain or disability in acute LBP patients (19,30,54,69,76,92,93). Some have shown that they can predict future chronic LBP in individu­ als before they have an episode of acute LBP (151). It has been demonstrated that formal use of a question­ naire has higher sensitivity and predictive value for identifying distressed patients than simple history tak­ ing alone (63). In the context of disabling back pain, the individual lisk factors exist alongside health care provider, work­ place, and compensation risk factors (116). Williams et al showed that whereas psychosocial factors are

60

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Part One: Overview

1 00% (J)

C

CIS

80%

S .Y.

CIS � - 0

�0 :::: �

60%

01 _ CIS =

40%

a..

20%

GJ O

C U) GJ � GJ

II

III 15

o 3 to 4 weeks

12 weeks

20

25

40

35

30

45

50

Time (Weeks) Since Pain Onset

Figure 3.4 Three-phase model of low back p a i n natural history. From

Frank J W , Kerr M S , Brooker AS, et al . Disab i l i ty resu l t i ng from occupa­ tional low back pain . Part 2: What do we know about secondary preven­ t i o n ? Spine 1 996;2 J :29 1 8-2929.

Table 3.4

"Yellow Flags" Risk Factors of Chronicity

Symptoms

( 1 9,30,45,48,52,53 ,60,83, 1 09, 1 35, 1 5 1 , 1 59): • • • •

Duration of symptoms Sciatica Severe pain intensity Widespread pain

Physical Examination ( 1 9,33,66,77,84, 1 48, 1 49, 1 70): • •

•

Positive straight leg raise test Positive neurological examination (motor, sensory, reflex) Restriction in two or more spinal movements

Psychosocial Factors

significantly involved in those not returning to work, only 0 . 5% of workers disabled for 6 months had treatment that addressed these issues (173). Work­ place dissatisfaction is a key element in those who are disabled, yet proactive policies at the workplace to facilitate return to work are not commonly seen (10,151,116). The compensation system itself is adver­ sarial and this contributes to the problem (116). Perpetuating Factors for Persistant Neck Conditions

Persistent neck pain is predicted by co-morbid LBP, cycling as a regular activity, older age, and being out of work (70). Whiplash Associated Disorders classi­ fication II patients with neuropsychologic problems have a worse prognosis over a 3-year follow-up period ( 1 50).

( 30,43 ,45 ,66,77 ,92,93 , 1 09, 1 5 1 ) : • • • • • • •

Three or more Waddell signs of illness behavior Self-rated health as poor Fear-avoidance beliefs Anxiety Catastrophizing Self-efficacy Locus of control

Work-Related

( 25 ,26,30,33 ,66,69,72,92,93, 1 09, 1 5 1 , 1 73 ) • • • •

Involved in compensation or litigation Physically demanding job (or perception of) Job dissatisfaction Disability in the previous 12 months

Functional (92,93, 1 09) • •

Light work or activity tolerance Sleep negatively affected by pain

Evolution of Evidence-Based Healthcare ...

: ...

;. .

.

. . ..

C l i n ic i ans and consumers are [aced with the [Tll strating challenge of judging the veracity of orten contradictory cla i ms o[ effect iveness for a broad array or tests and trea t m e n t s for s p i n a l problem s. How can one s i ft through the widely varying empirical clai ms and vast sci­ entific l iterature t o detel-m i ne what i s appropriate care?

What Is Evidence- Based Healthcare? Introduction

Evidence-based health care (EB HC) is designed to evaluate the overwhelming volume of medical litera-

Chapter Three: Quality Assurance

ture and disseminate the most valid and important findings to prac titioners. EBHC helps clinicians to determine which management approaches (diagnos­ tic and therapeu tic) are proven effective, proven inef­ fective, or lacking in sufficient evidence to draw a conclusion. Those with evidence of effectiveness are typically ranked [rom weakest to strongest based on the quality of the studies, with RCTs given the great­ est weight. Those neither proven nor unproven are usually called experimental and viewed skeptically if they are either expensive or potentially dangerous. Those that are proven ineffective are debunked and their use discouraged! With the advent of EBHC, clinical or practice guidelines about the efficacy of different management approaches for a wide variety of health care condi­ tions (e.g., breast cancer surgery, hysterectomy, hyper­ tension, mammography screening) have emerged. The US Institute of Medicine (IOM) (5 1) defines such guidelines as "Systematically developed statements to assist practitioner and patient decisions about appro­ priate health care [or specific clinical circumstances." Low back pain guidelines have been released through­ out the world including Canada, the United S tates, England, Sweden, New Zealand, the Netherlands, and Denmark. According to Chapman-Smith "the primary goal of guidelines is to improve standards of care by bringing the most up-to-date knowledge to clinical practice in a form that is easy to use" (28). Wiesel recommends that we distinguish guidelines from standards of care by virtue of their being based on expert consensus opinion rather than scientifically strong evidence ( 172). A major goal of guidelines players is to produce diagnostic and therapeutic protocols or algorithms with scientifically sound decision points. Eddy esti­ mates that if strong evidence is present for all decision points that diagnosis and treatment will be appropri­ ately directed [or more than 95% of the patients of the specific disease entity (47). According to Wiesel, when only consensus-based decision points are available for algorithms, this figure decreases to 60% (172). He states that to use a guideline to influence management decisions, ". . . the physician must be prepared to modify the recommended care as the specific clini­ cal setting dictates." This echoes the sentiments of Sacket t (131) the pioneer of EBH C who says, "clini­ cal expertise should be informed but not replaced by evidence." The Agency for Health Care Policy and Research's (AHCPR's) introduc tion states the following reasons for LBP guidelines (2):

•

•

High prevalence of low back problems in society High cost of the low back problem to society

Widespread variation in practice habits

Growing body of scientific literature demon­ strating evidence of ineffectiveness [or certain commonly used assessment and treatment approaches

Cherkin et al surveyed a large group of medical phy­ sicians (nearly 1200 respondents) regarding their beliefs about the efficacy of different treatments [or LBP (29). The only treatment that a majority recom­ mended was physical therapy. Less than half of the physicians believed that spinal manipulation was effective, yet substantial minorities believed bed rest and narcotic analgesics were effective. The s tudy highlighted that physicians lack a consensus on what is appropriate care for LBP. Furthermore, the only treatment they generally agreed is effective is consid­ ered by most systematic reviews and guidelines to be merely supportive (physical therapy). Most alarming is that a substantial minority believed in treatments such as bed rest and narcotic analgesics, which have been demonstra ted to lack effectiveness, whereas missing fyom nearly half of the respondent's list was spinal manipulation-one of the only treatments that actually has evidence of effectiveness for LBP.

Summary of Major New Conclusions From Successive Guidelines

Many international teams of research methodologists, clinical scientists, and health care providers have been brought together to review the available "best evi­ dence" for the management of low back and neck pain. Their consensus opinions do NOT represent a new standard of care, but the guidelines that have emerged have proposed a revolutionary new para­ digm for managing spinal disorders. What follows is a brief summary o[ the most important of these inter­ national guidelines.

1 987: Quebec Task Force (1 42) •

•

• •

61

Increasing evidence that much of the care for low back problems is either inappropriate or suboptimal o

•

--

•

Specific diagnosis of acute LBP is possible in only 20% of cases Management different [or acute stage than for later stage: 7 weeks was the cutoff U tility of diagnostic imaging limited and not recommended routinely Iatrogenic effects of bed rest prescription discussed

62

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•

Part One: Overview

Early return of patient to normal activity recommended even if pain is present

•

Specific recommendations regarding manual therapy are given o

1 994: Agency for Health Care Policy

o

and Research (AHCPR) (2) •

•

•

Perform diagnostic triage with special emphasis on finding "red flags" requiring urgent attention Recommended very strict criteria be applied to the decision to have surgery Recommended spinal manipulation as one of the few primary treatment options for acute LBP requiring additional symptomatic relief

o

o

•

•

For patients with acute pain of more than 2 to 3 days For acute recurrences or flare-ups o f chronic pain As part of an overall approach to manage chronic LBP As part of the approach for nerve root problems

The GP and DC are recommended as the portals to the system The emergency room should not be a portal except for trauma patients because such physicians lack the necessary evaluation skills

1 994: Clinical Standards Advisory Group (CSAG) (3 1 ) •

•

Recommended biopsychosocial assessment at 6 weeks Described appropriate versus inappropriate use of medication

1 995: Quebec Whiplash Associated Disorders (WAD) Guidelines 1 995 (1 43) •

•

Recommended classification system based on signs and symptoms Recommended early, active intervention (including manipulation)

1 995, 1 999: Royal College of General Practitioners (RCGP) ( 1 29, 1 30) •

•

•

Recommended consideration of refelTal to specialists i[ primary care failed (4-6 weeks) Recommended early identification of psychosocial risk factors of chronicity

2002: Dutch Royal Physical Therapy Association and the Dutch Society of General Practitioners (1 33) • •

Recommended exercises for those not returning to normal activities within 6 weeks

Guidelines for WAD grades 1 and 2 Active interventions such as education, exercise therapy, training of functions, and activities are recommended according to the length of time since the accident and the rate of recovery.

1 997: New Zealand (76) •

•

Described the psychosocial aspects of pain and how to uncover them [Tom history Provided a screening questionnaire for identi fying psychosocial "yellow flags" risk [actors of chronicity

2003: Dutch Physiotherapy Guidelines for Low Back Pain (5) •

•

1 999: Denmark - Danish Institute for Health Technology Assessment (39) •

•

First guidelines to include a health technology assessment that considered ethical issues, health care organization, and economics Recommended advice that emphasizes overcoming fear-avoidance behavior and that hurt does not equal harm, rather than traditional "back school" with more "careful" advice

Distinguished between impairments, disabilities, and participation based on the International Classification of Human Functioning, Disability, and Health (171). Behavioral therapy incorporating a time­ contingent rather than pain-contingent approach is recommended

2005: European Guidelines for the Management of Acute Nonspecific Low Back Pain in Primary Care - Preliminary Draft (50)

For Prevention of LBP •

There is limited evidence for prevention of LBP

Chapter Three: Quality Assurance

•

•

The most exists for physical activity/exercise and biopsychosocial eduction The emphasis should be on prevention of the consequences of LBP-care-seeking, disability, recurrence, work loss

For Acute LBP •

•

Be aware of psychosocial factors, and review them in detail if there is no improvement Mul tidisciplinary treatment programs in occupational settings may be an option for workers with subacute low back pain and sick leave for more than 4 to 8 weeks

•

•

•

•

Prognostic factors including psychosocial distress, depressive mood, severity of pain and functional impact, prior history, and patient expectations should be assessed Cognitive-behavioral, exercise, educational, and multidisciplinary (bio-psycho-social) treatmen t can be recommended; also, back schools and short courses of manipulative therapy Physical therapy modalities cannot be recommended Acupuncture, injections, intradiscal electrothermal therapy, spinal cord stimulation, radiofrequency lesioning of the dorsal root ganglion cannot be recommended Surgery cannot be recommended unless after 2 years of all other conservative measures have failed or are unavailable

Implementation of New Evidence .

: .

.. .

.

. . .

Guideli nes have been publi shed throughollt the world, which sum marize the scientinc evidence and m u l ti d isci ­ plinary expert consensus opinion about recen t changes in cl i n i cal managemen t . Has publication of guidelines actually i mproved the qual i ty of heal th care [or spinal disorders and if not, why not?

Although guidelines have nourished, practitioner's implementation of the suggested changes in practice has not occurred. The Fourth International Forum on Low Back Pain Research in Primary Care, in Israel in March 2000, recognized this problem and was thus entitled, "Implementation and Dissemination: Getting

63

Research into Practice" (16). The focus of this meet­ ing was on hO\", to change behavior of health care providers ( R CPs). Rainville showed that physician recommendations for activity restrictions and dis­ ability with chronic LBP patients vary widely and are fTequently more restrictive than is recommended in consensus guidelines (124). The Paris Task Force ( J ) identified the following obstacles to clinical util ization of the guidelines: •

•

For Chronic LBP •

--

•

•

•

The primary care physicians seeing back patients are a diverse group difficult to reach with educational outreach Guidelines do not differentiate types of activity or define activity yet they all recommend it No discussion of tools that evaluate Functional capacity Guidelines take a very aggressive tone with physicians in that they recommend physicians to alter behavior and admit failure No description of the clinical profile of the necessary specialists is given

Revolutionary changes in cardiac care incorporating early activation were readily incorporated into prac­ tice because heart patients are seen by a single spe­ ciality of physicians. In contrast, less than one-third of all patients with LBP seek care and when they do, they go to a diverse array of RCPs. In fact, the largest grou p are GPs who have widely differing views about proper management of LBP (29) and in whom education measures will not be nearly so simple as in cardiology ( 1 24). According to Rossignol education must be part of a new system of care that is easy for the doctor (128). Most valuable is better explanations to patients and their participation 111 decision-making. Guidel ines by themselves are not likely to improve quality; however , it is not because they are unnecessary. Rather, they are necessary just not suFficient. The Danish guidelines emphasize for the first time that it is not just provider behavior that must change, but the entire health care milleau must undergo a transformation (39). Specifically, they endorse better interdisciplinary cooperation between different R CPs. They recommend that management methods should not differ substantially from RCP to R CP. To encour­ age these paradigm shifts common postgraduate courses should be offered [or different R CPs involved in managing LBP. Goldberg has "benchmarked" a novel approach to using education to reduce surgery rates (61). By tar­ geting areas with high surgery rates and using a non­ coercive approach, a 9% reduction in surgery rates was achieved. Surgeon study groups were used to

64

Part One: Overview

review the scientific evidence on surgical indications and the implications of different rates of surgery. Surgeons and t heir patients participated in out­ comes research to assess indications and outcomes of surgery. A 6-month follow-up was included and the surgeons received a report showing how they com­ pared with their peers. Conferences for primary care providers were offered that explained what evidence­ based spi ne care entailed. Emphasis on minimal bed rest, early return to normal activity, avoidance of early imaging, and appropriate criteria for surgical referral were all discussed. A local general physician pre­ sented essential facets of this new approach i n w hat is called "academic detailing." Videodiscs were used for patient education of surgical candidates. An over­ view of the results of surgery were presented along with interviews of bot h satisfied and dissatisfied patients after a variety of surgical and non-surgical procedures. Lastly, a hospital intervention led by a health care economist was directed at administrative personnel and emphasized cost-effectiveness issues. A recent Australian study revealed that significant changes in physician behavior could be achieved by a mass media campaign (18). Physicians appeared motivated partially by their more informed patients. They were found to give more reactivation advice and less prescribed bed rest than t heir peers who were not in a province exposed to t he mass media campaign. Similar education, in Scotland, aimed directly at the consumer has shown promise (134). Frank and Loissel have s h ow n t hat in a highly complex and costly occupational setting, it may not malleI' as much what different strategies are offered as it docs t hat the worksite is involved. Explicit in­ volvement of the workplace includes workplace visits by rehabilitation specialists to negotiate individual­ ized job modifications (52,99,100). Shared decision-making is another proposed solu­ tion to mee ting t he needs of t h e various players involved in back pai n . In s hared decision-making, the patien t is involved with the clinician i n c hoosing among different options. This empowers patients by giving them some control over the decision-making process. By involving t he patient in t his process, it has the potential to increase their satisfaction with the process regardless of outcome. Studies involving patients wi th heart disease have show n that through shared decision-making patients become both more kn owledgeable and confident (88,110). Such a n approac h was recen tly used with prospective surgi­ cal candidates for lum bar disc surgery. It was show n that a n in teractive video program facilitated patient decision-making about t heir treatment (121). Von Korff proposed that HCPs should negotiate with their patients their respective roles, responsibili-

ties, and expectations (166). The HCP is the trainer and the patient is the active participant. A key to the success of such active participation is mutually agreed on goals. Back problems with their recurrent natural histories are more like asthma or diabetes. Like such chronic illnesses, treatment is not likely to be suc­ cessful without a self-care component (166).

Is EBHC actually better than traditional care? E B H C may be based on t h e "best evidence," but is i t

itself evidence-based ? A recent Austral i a n tri a l com­ pared evidence based care to t rad i t ional care ( l 08 ) . Patients were assessed at base l i ne , 3 months, 6 months, and 12 months. X-ray u t i l i zation was 7% i n the experi­ mental group compared to 30% in trad i t ional care group . Bed rest was recommended only 2% of t he t i me i n t h e evidence-based group versus 40% i n the tradi ­ t ional group. T h e trad i tional care group recom mended o p iates 25% of t h e t im e . At J 2 m o n t h s , 7 1 % of the evidence-based patients were ful l y recovered, compared to 56% of t h e tradi t i onal care group. Most i m pressively, qual i ty was achieved at a reduced cost. The tradit ional care cos ted 7 1 % more than the evidence-based care.

Limitations of Evidence- Based Healthcare

Although guidelines have been a boon to clinicians and consumers alike, t hey are far from perfect. What if any are the specific limitations of low back pain guidelines? While they recommend the goal of increasing activity tolerance, t here is very little in the guidelines about h ow to improve patient's activity tolerance (1)! There is insufficient evidence t hat t hey i mprove the quality or reduce t he cost of care. In fact, in physical medicine there is often a scarcity of high-quality evidence. I n such an instance, there is a danger of giving too much weig ht to the evi­ dence and underestimating h ow little is actually known (152). The Quebec Task Force acknowledged that an accurate diagnosis of LBP is possible less than 20% of the time (142). However, merely because it is difficult to diagnose subtypes ofLBP does not mean they don't exist. Laboeuf-Yde has described how non-specific LBP is most likely made up of several specific sub­ types that are not yet identified (8 1,82). As discussed in chapter 1, new classification schemes are emerging that show that improved care results from identifica­ tion of the subclassifications of "non-specific" LBP patients (46,49,56).

Chapter Three: Quality Assurance

I mproving the Quality of Evidence-Based Guidelines

For EBHC to be the "benchmark" for quality in health care, a rigorous ongoing process called total quality improvement is needed. Of course, quality must be achieved at a reasonable cost. Frymoyer defined value as the ratio of quality to cost (58). Success depends on flexibility, ongoing review, and participation of all the "players." From the patient's perspective, effective guidelines must be clear, specific, and unambiguous (161). According to the I nstitute of Medicine (51) and U.K. National Health Service (114), good guidelines should adhere to certain criteria: •

Define their target disorder

•

Adhere to scientifically rigorous standards

•

Be user-fTiendly

•

Lend themselves to audit processes

•

Include distribution plans

•

I nclude implementation plans

•

I nclude regular, future reviews

Important outcomes to measure to determine the usefulness of guidelines include (161): a) Patient-centered outcomes such as pain reduc­ tion, [unction, return to work, and satisfaction b) Health care utilization costs c) Cost of developing, implementing, and updating guidelines To stay abreast of new knowledge groups, the Cochrane Collaboration provides updates of new evi­ dence (32). Periodic updates of guidelines are neces­ sary. No established criteria for guideline revision exists. Shekelle suggests guidelines should be revised when ( 138): •

Significant changes occur in the scientific literature

•

New methods emerge

•

New outcomes are deemed appropriate

•

There is a change in the availability of health care resources

On reviewing 17 different guidelines published by A HCPR between 1990 and 1996, Sheklle et al esti­ mated that half of the guidelines were outdated after 5.8 years ( 139). The authors suggest that guidelines should be evaluated [or validity every 3 years.

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65

The Institute for Musculoskeletal Research and Clinical Implementation (IMRCI) developed an audit for use in England to help HCPs provide the highest possible quality care in the first 6 weeks of a low back episode (17) (see Chapter 39). The audit offers evi­ dence-based recommendations on specific aspects of care. The audit may guide care or can be used retro­ spectively to see where changes could be made to opti­ mize future care. Action steps, supportive evidence, and chart review are all described in detail. Another British group has formed to help GPs learn how to identify appropriate decision points for refen-ing to specialists (115). Guidelines are considered by many HCPs as merely a current trend. Such thinking is prejudiced by those who hold to u ntested belief systems (113,153). It is the challenge of those who believe in an unproven approach to secure funding for the necessary research to demonstrate the validity of the methods. However, lack of evidence of effectiveness is NOT the same thing as evidence of i neffectiveness. I n fact, certain en-oneous conclusions can be reached if it is assumed that all patients are alike. Researchers may prefer homogenous populations o[ individuals, but clini­ cians know that each patient is unique.

• CONCLUSION LBP is an epidemic problem i n which certai n advances are known but not generally used. The nat­ ural history is not as brief as has been believed, with most patients suffering prolonged symptoms and activity intolerances after acute episodes. Although it is not clear why most i ndividuals have acute LBP, we now know that acute pain becomes chronic primar­ ily as a result of psychosocial factors. The focus in care has traditionally taken two con­ trasting paths. One path is typified by limiting care for acute and subacute patients (medication and rest). The other path involves maximizing care for chronic patients (i.e., diagnostic imaging and surgery). The evidence points us i n a differe nt direction. Namely, that secondary preventive efforts should tar­ get i ndividuals at "high risk" for chronic pain while they are i n the subacute phase. This management does not necessitate aggressive imaging or surgery on these patients, but rather orients care toward restoring function a nd addressing psychosocial problems such as fear-avoidence beliefs and distress/ depression. How to improve implementation of this new evi­ dence is a major question. Unlike cardiovascular problems in which only one specialty dominates care, patients with spine problems are seen by myr­ iad HCPs. To get all the "players on the same side of

66

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Part One: Overview

lhe baW-patients, HCPs, insurers, government, and employers-is a major challenge for those interested in solving this epidemic problem.

Audit Process

Self-Check of the Chapter's Learning Objectives •

What is t h e l i ke l i hood of your patient h aving achieved a satisfactory recover at 3 weeks and 7 weeks?

•

What are examples of speci fic "yellow flag" risk factors of c h ro n icity?

•

What new i n formation have t h e various i nternational low back pain management guide l ines given you regardi ng patient care?

•

Are you aware of commonly used assessm e n t and treatmen t approaches that are not recommended by the various guidelines? -For i n s tance, x-rays for acute LBP w i t hout "red flags"

•

Are you aware o f assessment and treatment approaches that you were not previously u s i n g or referri ng for t h a t are recom mended by t h e various gui de l ines? -For i nstance, man ip u l ation for acute LBP without "red flags"

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6 7 . H a rreby M , H esselsoe G , Kjer J, Neergaard K. Low back pain and physical exercise in leisure-ti m e i n 3 8 year old m e n and wome n : A 25 year prospective cohort study of 640 school c h ildre n . Eur Spine J 1 997;6: 1 8 1 - 1 86 . 6 8 . H ashemi L, Webster BS, Clancy E A , Voli n n E . Length of d isab i l ity a n d cost o f workers' compensa­ t ion low back pain claims. J Occ u p Environ Med 1 998;40:2 6 1 -2 6 9 . 69. H azard RG, H a u g h L D , R e i d S, Preble J B , MacDon­ ald L. Early prediction of c h roni c d i sab i l i ty aher occ u pational low back i nj ury. Spine 1 996;2 1 :945-95 1 . 70. H i l l J , Lewis M , Papageorgiou AC, D ziedzic K, Cro ft P. Predi c t i n g persistent neck pai n . A I -year follow­ up o f a popu lation cohort. Spine 2004;29: 1 648-1 654. 7 1 . H i l l man M, Wright A, Raujarat nam G, et a l . Preva­ lence of low back pain in the comm u n i ty: I m p l ica­ t ions fOI- service provision in BradFord, U K. J Epidemi l ol Com m un Health 1 996;50: 347-3 5 2 . 7 2 . H oogendoorn W E , van Poppel M N M , Bongers P M , Koes BW, Bouter L M . Systematic review of psy­ chosocial factors at work and private l i fe as risk Fac­ tors for back pai n . Spi ne 2000;25( 1 6 ) : 2 1 1 4-2 1 25 . 7 3 . H rubec A , Nasbbold BS Jf. Epidemiology of l u m bar disc lesions in the m i l i tary in World War II. Am J Epidem i ol 1 9 7 5 ; 1 02:366-376. 74. I ndahl A, H aldorsen EH, H o l m S, Rei keras 0, H ursi n H. Five-year Follow-up study of a controlled c l i nical trial using l ight mobi l i zation and a n i n for­ mat ive approach to low back pai n . Spine 1 99 8 ; 2 3 : 262 5-2630. 75. J acob T, Baras M, Zeev A, Epstein L . A longi tudinal, com m u n i ty-based study of low back pain outcomes. Spine 2004;29: 1 8 1 0- 1 8 1 7. 76. Kendall NAS, L i nton SJ, M a i n C J . Guide to assess­ i n g psychological yel low flags in acute low back pai n : Risk factors for long-term disabi lity and work loss. Wel l i ngton, New Zealand: Accident Rehab i l i ta­ tion & Compensation I nsurance Corporation of New Zealand and t he National Health Comm ittee, 1 99 7 . 77. Klenerman L, Slade P , Stanley I , et a l . T h e predic­ tion of c h ron i c i ty in patients w i t h an acute attack of low back pain in a general practice setting. Spine 1 995;20:4 78--484.

8 3 . Lancourt J , Ketteljut M . Predicting return to work for lower back pain patients receiving worker's compensati o n . Spine 1 992 ; 1 7 : 629-640. 84. Lani er DC, Stockton P. C l in ical predictors of out­ come of actue episodes of low-back pai n . J Fam Pract 1 98 8 ; 27:483-489. 85. Larequi-Lauber T, Vader JP, B u rnand B, et a l . Appropriateness of i ndications for surgery of lum­ bar disc hernia and spinal stenosis. Spine 1 997;22( 2 ) :203-209. 86. Lawrence JS. Rheumatism in popul ations. London: Heinemann, 1 97 7 . 8 7 . L e i n o P . Does lesiure t i me physical activity prevent low back d isorders? A prospective study of metal i ndustry employees. Spine 1 993; 1 8 :863-87 1 . 88. Liao L , et a l . Impact of an i n teractive video on deci­ sion making of patients with ischem ic heart disease. J Gen Intern Med 1 996; 1 1 : 373-376. 89. Liebenson C , Yeomans S. Identification of the patient at risk For persistent or recurrent low back trouble. I n : Yeomans S, ed. The c l in ical appl ication of outcomes assessment. Stamford, CT: Appleton & Lange, 1 999. 90. L iebenson CS, Yeomans SG. Yellow Flags: Early ide n t i fication of risk factors of chro n i c i ty in acute patients. J Rehabil Outcomes Meas 2000;4( 2 ) :3 1 -40. 9 1 . Liles D H , Deivanayagam S, Ayoub M M , Mahajan P. A job severity i ndex for the evaluation and control of l i fting i njury. H u m Factors 1 984;26:683-693. 9 2 . L inton SJ, Hallden K. Risk factors and the natural course of acute and recun-ent m usculoskeletal pain : Developing a sCI-een i ng i nstnlment. I n : Jensen TS, Turner JA, Wiesen feld-Hall in Z, eds. Proceedi ngs of the 8th World Congress on Pai n , Progress i n Pai n Research a n d Management, vol 8. e d . Seattle: IASP Press, 1 997. 9 3 . L inton SJ, Hallden BH. Can we screen for problem­ atic back pain? A scree n i ng questionnaire for pre­ d i c t i ng outcome i n acute and subacute back pain . C l i n J P a i n 1 998; 1 4: 1 -7 . 9 4 . L i n ton SJ. Psychological r i s k factors for n e c k and back pain. I n : Nachemson A, Jonsson E, eds. Swedi s h SBU report. Evidence-based treatment for back pai n . Stockhol m/Phi l adelphia, Swedish Coun­ c i l on Technology Assessment in Heal th Care ( S B U)/Lippi ncotl ( Engl ish translation ) , 2000:75. 9 5 . L i n ton SJ. A review of psychological risk factors in back and neck pai n . Spine 2000;9: 1 1 48-1 1 56 .

Chapter Three: Quality Assurance

96. L i n ton SJ, Buer N , Vlaeyen J, H e l l s i ng AL. Are fear­ avoidance beliefs related to a new episode of back pain? A prospective study. Psychol Health 2000; 1 4; 1 05 1 - 1 059. 97. L i n ton SJ . Cognitive-behavioral therapy in t h e pre­ ven t ion of m usculoskeletal pai n : Desc'rip t i o n of a progra m . In: Li nton SL, ed. New avenues for the prevention of chronic musculoskeletal pain and dis­ ability. Amsterdam : E lsevier, 2002. 98. Lloyd DCEF, Troup JDG. Recurre n t back pain and its prediction. J Soc Occup M ed 1 983;33 :66-74. 99. Loisel P, Abenhaim L , Durand P, et al. A popu la­ tion-based, randomi zed c l i nical trial on back pain management. Spine 1 99 7 ; 2 2 : 2 9 1 1 -29 1 8 . 1 00. Loisel P, Gosse l i n L, D u rand P, Lemaire J, Poit ras S, Abenhaim L. Im plementation of a parti c ipatory ergonomics program in the rehab i l i tation of work­ ers sufferi ng fTom subacute back pain . Appl Ergon 200 1 ; 3 2 ( 1 ) : 5 3-60. 1 0 1 . Luoto S, Heliovaara M, H urri H , AJaranta H . Static back endurance and the risk o f low-back pain . C l i n Biomech 1 995 ; 1 0:323-324. 1 02 . Mahmoud MA, et a l . C l i n ical management and the duration of disab i l i ty for work-related low back paLl. J Occup Environ Med 2000;42 : 1 1 78- 1 1 87 . 1 03 . Maimaris C , Barnes M R , Allen M J . 'Wh i p l ash i njuries' of the neck: A retrospective study. Injury 1 988; 1 9 : 393-396. 1 04. Malm ivaara A, Hakkinen U, Aro T, et al. The treat­ ment of acute low back pain-bed rest, exercises, or ordinary activity? N Engl J Med 1 99 5 ; 3 3 2 : 3 5 1 -3 5 5 . 1 05 . Makela M , Heliovaara M , Sievers K, Impivaara 0, Knekt P, Araomaa A. Prevalence, determi nants, and consequences of chronic neck pain in F i n l and. A m J EpidemioI 1 99 1 ; 1 34 : 1 3 5 6- 1 367. 1 06 . Marhold C, L i nton SJ, M e l i n L . Cog n i tive-behav­ ioral return-to-work program: Effects on p a i n patients w i t h a history of l ong-term versus short­ term sick leave. Pain 200 1 ;9 1 : 1 5 5- 1 63 . 107. Mason V. The prevalence of back p a i n in Great Bri t a i n . Office of Population C Censuses and Surverys, Social Survey D ivision ( now Office of National Statistics). London: Her M ajesty's Sta­ tionery O ffice, 1 994: 1 -2 . 1 08. McGui rk B , King W, Govind J, Lowry J, Bogduk N . Safety, efficacy, and cost-effectiveness o f evidence­ based guidelines for the management of acute low back pain in primary care. Spine 200 1 ;26:2 6 1 5-2 6 2 2 . 1 09. McIntosh G, Frank J , Hogg-Johnson S, Bombardier C, Hall H. Prognostic factors for time receivi ng workers' compensation benefits i n a cohort of patients with low back pai n . Spine 2000 ; 2 5 : 1 47- 1 57 . 1 1 0 . Morgan M W , Deber H A , Llewellyn-Thomas H , et a1. A randomized trial of the ischem ic heart disease shared decision maki ng program: An evaluation of a decision aid (abstract). J Gen I ntern Med 1 997; 1 2 (Suppl ) : 6 2 . I l l . Nachemson A, Waddell G, Norl u n d AI. Epidemiol­

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1 44. Stevenson J M , Weber CL, S m i t h JT, Dumas GA, Albert WJ . A longitudi nal study of the development of low back pain in an i n dustrial population. Spine 200 1 ; 2 6 : 1 370- 1 3 7 7 . 1 45 . Svenssson H O , Andersson G BJ. A retrospective study of low back pain i n 38 to 64 year old women: Frequency and occurrence and i m pact on medical services. Spine; 1 988; 1 3 : 548-55 2 . 1 46 . Symmons D P M , van Hemert A M , Vandenbrouke JP, Valkenburg H A . A longitudinal study o[ back pai n and radiological changes i n the l u m bar spines of m iddle-aged women.!!. Radiographic findings. Annals of the Rheumat i c D i seases 1 99 1 ;50: 1 62-1 66. 1 47 . Szpalski M, Nord i n M, Skovron ML, et al. H ealth care u t i li zation [or low back pain i n Belg i u m . I n flu­ ence of sociocultural factors and heal th bel iefs. Spine 1 995;20:43 1 -442. 1 48 . Takala EP, V i kari-J u n tura E . Do fu nctional tests predict low back pai n . Spine 2000 ; 2 5 ( 1 6) : 2 1 26-2 1 32 . 1 49. Taylor H , Curran N M . The Nupri n Pai n Report. New York: Loui s Harris and Associates, 1 98 5 : 1 -2 3 3 . 1 50. Tenenbaum A , Rivano-Fischer M , Tjell C , Edblom M , Sunnerhagen KS. The Quebec Classification and a new Swedish classification for w h i plash-associ­ ated d isorders in relation to l i fe satisfaction in patients at h i gh risk of c h ronic funct ional i m pair­ ment and d isab i l i ty. J Rehabil Med 2002 ;34: 1 1 4-1 1 8. 1 5 1 . Thomas E , S i l man AJ, Croft PR, Papageorgiou AC, Jayson M IV, M adarlane GJ. Predicting who devel­ ops chronic low back p a i n in primary care: a prospect i ve study. B M J 1 999;3 1 8 : 1 662- 1 667. 1 52 . Tonel l i MR. I n defense o[ expert opinion. Acade m ic Medic i ne 1 999:74; 1 1 87- 1 1 92 . 1 53 . Trial and error. Econom ist 1 998;93. 1 54. Troup J D G , Foreman TK, Baxter CE, Brown D . The percep t i on of back pai n and the role o[ psychophys­ ical tests of hf-ting capaci ty. Spine 1 987; 1 2 :645-657. 1 5 5 . Truchon M, F i l l ion L . B i opsycbosocial determ i­ nants of chro n i c d isabi l i ty and low-back pain: A review. J Occu p Rehab 2000; 1 0: 1 1 7- 1 42 . 1 56 . Tuback F, Leclerc A. Natural h i story of sciatica, pre­ sented at the annual meeting of the American Col­ lege of Rheumatology, Phi ladel p h i a , 2000. 1 57 . UK General Household Surveys. London: Office o[ National Statistics. 1 58 . Urs i ny J, et al. Manag i ng the costs of care for low back pain : Experience w i t h i n a large health care deli very system, presented at the annual meeting of the American Coll ege of Rheumatology, P h i ladel­ p h i a , 2000. 1 59. van den Hoogen H J M , Koes BW, Deville W, van E ij k J T M , Bouter L M . The prognosi s of low back pain in general practice. Spine 1 997;22: 1 5 1 5- 1 52 1 . 1 60. van den H oogen H J M , Koes BW, van Eijk JTM , Bouter L M , Deville W. On tbe course of low back pain in general practice: A I -year follow-up study. Ann Rheum Dis 1 998;57: 1 3- 1 9. 1 6 1 . Van Tulder W E , Croft PR, van Splun teren P, et al. D issem inati ng and i m plemen t i ng the results of back pain research in primary care. Spi ne 2002 ; 2 7 : E 1 2 1 -E I 27 .

Chapter Three: Quality Assurance

1 62 . Versteegen GJ, Ki ngma J , M iej ler WJ , ten D u i s H J . Neck spra i n n o t ari s i n g fTom car accidents: A retro­ spect ive study covering 25 years. Eur Spine J 1 998;7:20 1 -205. j 63. Videman T, Sarna S, Battie MC, et a l . The long-term

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on neck and low back pai n . I n : Nachemson A, Jons­ son E, eds. Swedish SBU report . Evidence-based treatment for back pai n . Stockholm/Philadelphia, Swed ish Coun c i l on Technology Assessment i n Health Care ( S B U )/L i p p i ncott ( Engl ish translati on ) , 2000. 1 65 . Von Korff M, Deyo RA, Cherk i n D, Barlow W. Back pain i n prim ary care: Outcomes at 1 year. Spine 1 993; 1 8 : 855-862. 1 66 . Von Korff M . Collaberative care. Ann I ntern Med 1 997; 1 2 7 : 1 87- 1 95 . 1 67 . Waddell G . The Back Pain Revolution, 2 n d ed. Edinburgh: Churc h i l l Livi ngstone, 2004. 1 68 . Waddell G, Burton AK. Occupational health guide­ l i nes for t he management of low back pain at

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Putting the Biopsychosocial Model into Practice

Craig Liebenson -

Introduction The Biopsychosocial Model Overemphasis on a Structural Diagnosis

Learning Objectives

After reading this chapter you should be able to: •

Overemphasis on Bed Rest Overuse of Surgery

•

Abnormal Illness Behavior Diagnostic Triage to Rehabilitation-The Benchmark

•

Reassurance/Diagnostic Triage Reactivation Advice Relief of Pain Re-Evaluation of Structural, Functional, and Psychosocial Contributors to Continued Pain or Disability Reconditioning Referral Practitioner Audit

•

Understand the limitations of a biomedical approach in managing spine pain patients Understand the importance of functional reacti­ vation as a guiding principle in spine patient care Understand the i mportance or psychosocial fac­ tors such as fear-avoi dance behavior in a patient when t here is failure to achieve a satisfactory outcome Understand the "decision points" of care when i m plementing the biopsychosocial model i nto clinical practice

"Let fear, then be a kind of pain or disturbance resulting from imagination of impending danger, either destructive or painful." Aristotle

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Chapter Four: Putting the Biopsychosocial Model into Practice

73

Introduction

Individuals with persistent activity limi ting low back pain (L BP) generally assume that structural factors play a decisive role in their pain and disability. H ow­ ever, it is now acknowledged that most structural pathologies are present in asymptomatic individuals in nearly equal degree as they are in those who are symptomatic. This fact combined with the generally unsatisfactory results of tradi tional care for LBP has led to the critical evaluation of the biomedical model (49,66,97). Accord i ng to the International Association for the Study of Pai n ( lASP), pai n is not simply the result of structural i nj ury or pathology but is "an unpleasant sensory and emotional experience associ­ ated with actual or potential tissue damage . . . " (63 ). Pain has its origi n i n peripheral activation from physical sources; however, it is also modulated in the dorsal horn, and by descend i ng influences largely of psychologic origin (57). Concurrent evaluation of both the sources of pain and the psycho-physical per­ ceptions that lead one to fear and t hus avoid activity should be addressed so that reactivation can occur (39,53,94). Thus, musculoskeletal pain patients in general and LBP patients in particular require an approach that addresses the physical (biological) and psychosocial dimensions of their problem. This modern approach is called biopsychosocial ( BPS) in that the total patient is our subject. Rather than focusing on structural causes and cures, this new paradigm emphasizes the goal of maintaining or restoring function. Such an approach is of value regardless of the pathoanatomic diagnosis. This BPS approach is the main subject of not only this chapter but also the entire book that follows. The Biopsychosocial Model

Less t han 20% of back pai n is caused by structural fac­ tors. Does t h is mean that most pai n is psychogenic?

Pain has been interpreted since the time of Descartes as signaling tissue damage ( Fig. 4. 1 ). The biomedical model of finding the structural cause and then treating it or "fixing" it to elicit a cure is based on this rather narrow view of pain. It is now acknowledged that a structural cause for pain does not usually exist and that a structural cure is not often successful. The Cartesian model leads one to assume if cure is not brought about, then t he problem must be psychogenic. The dualism inherent in the early Renaissance notion of pain suggests that pain is either in the mind or body, but not both ! According to the new lASP definition of

Figure 4.1 The Cartesian model or periphcral activat ion

of pain pathways. From Descal-tc's L'Hol11l11c (Paris 1 644).

pain, i t is associated with both a disagreeable physical sensation and an emotional experience (58,59). Thus, i t is sensorial (nociceptive) and affective (emotional) and should not be defined dichotomously as either physical or psychological . The biopsychosocial model views pain as involving ascending nociceptive input from the periphery ( Car­ tesian model), descending modu lation that inhibits or faci l itates nociception ( Gate Control Theory of Melzack and Wall ) , and central processes with neuro­ logical, affective, and cognitive dimensions ( Figs. 4.24.4) (57). Therefore, the perception of pain is heavily i nfluenced both by nociception and by one's attitudes, beliefs, and soci al environment ( Fig. 4.5). Even though most patients begin improving from back pain episodes quickly, both the recurrence rate and dissatisfaction with medical care is high. Addi­ tionally, the m inority in whom persistant chronic dis­ abling pain develops account for by far the greatest percent of costs (85%). Therefore, the traditional bio­ medical model should be re-evaluated in light of its failure to successfully address the low back problem. In patients who do not recover, the l i m i tations of the biomedical approach are even more evident. fn an attempt to find the structural cause o f LB P, overly sensitive tests are ordered, with high false-posit ive rates. The patient either is told nothing is wrong and labelled psychogenic or is told about the pathology and to rest, take medici nes, and learn to live with it. If they can't tolerate it anymore, then they are i n formed that t hey should have surgery. The incidence rate, cost of chron icity and disabil­ ity, general dissatisfaction, and high reCUlTence rate add up to a problem of epidemic proportions. Waddell

74

--

Part One: Overview

Inhibitory Large Fiber

Substantia Gelatinosa

Glands

A

TCel1

Cognitive Control

Descending I nhibitory Control

Large Fibers

I n put from Periphery Small Fibers B

Gate Control System

Figure 4.2 The gate control theory o f pain . (A) Ascendi n g pathways from small and large diameter fibers to the dorsal horn of the spinal cord and to h i gher centers. From Suchdev P K . Pathophysiology of pain. In: Warfield CA, Fausett J H, ed. Manual of Pain M anagement, 2 nd ed. P h i ladelphia: Lippincott Williams & Wilkins, 2002 . (B) The excitatory (white circle) and i n h i bitory (black circle) links [Tom the substantia gelati­ nosa (SG) to the transmission (T) celis, as well as descending i n h ibitory control from brainstem systems. The roun d knob at the end of the i n h ibitory l i n k i mplies t hat i ts act ions may be presynaptic, postsynaptic, or bot h . All connections are exci tatory, except the i n hi b i tory l i n k from SG to T cell. From Bon i ca JJ, Loeser J D . History of pai n concepts and t herapies. In: Loeser JD, ed. Boni ca's Managemen t of Pai n , 3rd ed. Philadelphia: LippincoLL Williams & W i lkins, 2 00 1 ( modified from Melzack R, Wall PD. The challenge or pai n . New York: Basi c Books, 1983.)

( 97) in his Volvo award-w i n n i ng paper stated, "Con­ ventional med ical treatment for l ow-back pain has failed, and the role of medicine i n the present epi­ demic must be critically examined." The low back epidemic is caused by a number of factors. The rea­ sons for this fai l u re are presented in Table 4.1.

Overemphasis on a Structural Di agnosis

Many doctors overuse diagnostic imaging as part of the initial evaluation of a LBP patient. This is per­ formed for two mistaken reasons. One is the belief that serious diseases (i.e., tumors, i nfections) can be missed

Chapter Four: Putting the Biopsychosocial Model into Practice

Central Sulcus

�(

75

Postcentral Gyrus (Somatosensory cortex)

�

Cortex

--

Social Environment

TO ASSOciation Cortex Illness Behavior

Thalamus

Psychologic Distress

Spinothala­ micTract

�

Spinoreticular Tract

Spino­ mesen-/ cephalic Tract Spinal cord

Nociceptor in Muscle

Figure 4.5 The biopsychosocial model. Reproduced with

Figure 4.3 Ascending nociceptive pathways. From

permission from Waddell G. The Back Pain Revolution. Edinburgh: Churchill Livingstone, 1998.

Mense S. Si mons DG. M uscle Pain: Understanding Its Nature, Diagnosis, and Treatmen t . Baltimore: Lippincott Williams & Wilkins, 2001.

From H ypothalamus

To Thalamus

+ �

En kephalinergic Neuron

--------... I nhibitory Synapse

PAG

--<J Excitatory Synapse

+ ROSTRAL

EAA/NT?

+

.....

MEDULLA

+

+

+

+

NE

5-HT

SP?

SPINAL CORD

�

Nociceptive I nput

Figure 4.4 Descending antinociceptive modulation. From M e nse S. Simons

DG. M uscle Pain: Understanding Its Nature, D iagnosis, and Treatment. Bal­ timore: Lippincott, Williams & Wilkins, 200 1 ( redrawn from Basbarum AI, Fields HL. Endogenous pain control system: brainstem spinal pathways and endorphin circuitry. Ann Rev Neurosci 1 984;7:309-338.).

76 -- Part One: Overvie\N

Medical Reasons for the Low Back Disab i l i ty Epidemic

Table 4.1

A) Overemphasis on a structural diagnosis B) Overprescription of bed rest C) Overuse of surgery

by a thorough history and physical examination. Sec­ ond, the belief that structural pathologies (e.g., herni­ ated discs, arthritis) that can only be identified with imaging are strongly correlated with symptoms. H istory and examination are more than 99% sen­ sitive for identifying "red flags" of serious d isease ( 2 1 ,56,97, 9 8 ) .

N o "Red Flags" o f Tumor, Infection, or Fracture Were Missed as a Result of Not Routinely Imaging Acute Patients •

Long-term follow-up of 437 patients revealed no serious di sorders were missed as a result of not performi ng routine i magi ng on acute pat ients

•

A "red n ag" checklist mostly fmm histOl-y alone was used

•

1 .4% of patients did have serious condi tions such as crush fracture, kidney carcinoma, and prostate carcinoma, but they were suspected on i n it i a l evaluation a n d referred for addi ti onal tests

Unfortu nately, even when using advanced i magi ng techni ques such as myelography, CAT scans, or mag­ netic resonance i magi ng, the same posit ive findings are also present i n 28% to 50% of asymptomatic indi­ viduals (4,9,38,43 , 74, 1 04). Similarly, in the neck, the false-positive rate for imaging has been reported to be as high as 75% in the asymptomatic population ( 5 , 81). Thus, imaging tests have high sensitivi ty ( few false-negatives) but low specificity (high false-posi tive rate) for identifying symptomatic disc problems. Furthermore, the presence of structural pathology i n an asymptomatic i ndivi dual does not predict a greater l i kelihood of future problems (6, 1 6) ! Boren­ stein et al performed MRI on 67 asymptomatic peo­ ple; 31% has abnormality of d isc or spinal canal (6). The MRI findings were not predictive of future LBP. Individuals with longest duration of LBP were not those with the greatest anatomical abnormali ties. Carragee et al studied discograms and reported that a painful disc injection did not predict LBP on follow­ up at 4 years ( 1 6). Though d iscograms have high sen­ sitivity for i dentifying tears in asymptomatic patients, it was the psychometric profiles that were found to strongly predict future L B P and work loss. Even when the diagnosis of disc herniation is rele­ vant , such pathology has a tendency to resolve with­ out surgical i n tervention. B ush et al ( 1 3 ) reported, "A h igh proportion of i ntervertebral disc herniations have the potential to resolve spontaneously. Even if patients have marked reduction of straight leg rais­ i ng, positive neurologic signs, and a substantial inter­ vertebral disc herniation (as opposed to a bulge), there is poten tial for making a natural recovery, not

McGuirk B, King W, Govind J, Lowry J, Bogduk N. Safety, effi­ cacy and cost-errectiveness of evidence-based guidelines fOl­

Disc Findings in Normal Subjects

the management or acu t e l ow back pain in primary care. Spine

2001;26:2615-2622

The false-posi tive rate for i dentifying clinically sig­ nificant herniated d iscs or degenerative conditions with imaging (e.g., x-ray, MRI) is so h igh as to make the tests clinically i nappropriate as screen i ng proce­ dures ( Fig. 4.6). The problem is that many individu­ als who have pain unrelated to the structural findings will be mislabeled and potentially receive unneces­ sary treatments. They may t h i n k of themselves as "sick" when in fact most of t hese changes are related more to age than to symptoms. After the discovery by Mixter and Barr that com­ pression of a nerve root by a herni ated disc could cause sciatica, t he belief i n the pathoanatomical basis for back and leg pain has been a fundamental dogma (1,64). Structural evidence of a l umbar disc hernia in a patient with appropriate symptoms i s presen t more than 90% o f t he t i me (4,3 8 ,74,104) .

100% 90% 80% 70% co E 60% 0 50% c .0 40%
0

40

50

60

70

Age in Years

Figure 4.6 False-posit ive rates for disc herniation with various i magin g modalities. I maging findings of disc abnormalities increase in frequency with age in patients w ithout symptoms. (CT, computed tomography; DID, degenerative join disease; M R!, magnetic resonance i mag­ i ng.) From Bigos S, M uller G. Primary care approach to acute and chronic back problems: Defi n i t ions and care. In: Loeser J D , ed. Bonica's M anagement of Pai n , 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 200 1 .

Chapter Four: Putting the Biopsychosocial Model into Practice

least due to resolution of the intervertebral disc herni­ ation." This group found similar resul ts in the cervical spine, concluding that most cervical disc herniations regress with time without resorting to surgery (14). Yukawa found that in sciatica patient� treated con­ servatively and followed-up for 3 years that 57% had a reduction in the size of disc hern iation and only 3% had an enlargement (107). Other structural pathologies have also been over­ stated as causes of back pain. There is little relation­ ship between radiological signs of degeneration and clinical symptoms (19,30,32,47,52,78,82,87). Nachem­ son (67) said, "Even when strict radiographic criteria are adhered to, 'disk degeneration' is demonstrated with equal incidence in subjects with or without pain." Accordi ng to a recent review by Jarvik and Deyo, the prevalence of disc degeneration among asymptomatic individuals of at least middle age ranges from 46% to 93% (41). They conclude that findings such as bulges, dehydration, and loss of disc height should not auto­ matically be viewed as abnormalities because they are strongly related to age. However, there are certain exceptions, such as disc extrusions, moderate or severe canal stenosis, and nerve root compression, which are significantly cOlTelated with symptoms (42). Van Tulder in a systematic evaluation of the l iterature concluded that spondylosis, spondylolisthesis, spina bifida, transi tional vertebrae, and Scheuermann dis­ ease are not associated with low back pain (87). Videman, in a study of cadaver specimens, found no correlation between structural pathology and a history of low back pain (91-93). Segmental instability and isolated disc resorption are other diagnosis that again cannot be validated (67). Recently Kendrick reported that patients who received x-rays were more likely to report a longer duration and greater severity of pain, reduced func­ tioning, and poorer health status than those who had not (44). They concluded that "radiography encour­ ages or reinforces the patient's belief that they are unwell and may lead to greater reporting of pain and greater limitation of activities." Nearly two-thirds of the patients who underwent x-ray were found to have structural pathologies, yet no significant differences in outcome were noted between patients with nor­ mal versus abnormal x-rays. Because patient satis­ faction was h igher if x-rays were taken, the authors concluded that patient education regardi ng the i n­ ability of radiography to improve therapy, decision­ making, or outcomes is important. Most low back patients do not have structural pathology that can be clearly diagnosed as being the cause of their symptoms (3). For this reason, most of these patients are classified with the label non­ specific back pain. According to Frymoyer (31), "most commonly, diagnosis is speculative and unconfirmed

--

77

by objective testi ng." An interesting exception to this involves patients with chronic pain i n whom, accord­ ing to Bogduk, the pain generator can be identified the majority of the time w i t h the use of a double anesthetic block tech nique (see Chapter 6).

Overemphasis on Bed Rest

Because of the failure to pinpoint the specific pain generators in low back pain, bed rest and analgesics have become the typical treatment. The generally positive early course of most low back pain episod �s has given justification to this practice of symptomatlc treatment. As it turns out, this seemingly benign pre­ scription of prolonged bed rest has now been shown to be one of the most costly errors in musculoskeletal care. Allan and Waddell ( 1 ) said, "Tragically, despite the best of i ntentions to rel i eve pain, our whole ap­ proach to backache has been associated with increas­ ing low back disability. Despite a wide range of treatments, or perhaps because none of them provi de a lasting cure, our whole strategy of management has been negative, based on rest. We have actually pre­ scribed low back disability!" Deyo performed a controlled clinical trial that com­ pared 2 days of bed rest against 2 weeks and con­ cluded that a shorter period of bed rest was as effective as a longer one (22). The negative effects associated with prolonged immobilization were not seen with brief bed rest. A more recent study confirmed Deyo's work by fi nding that 4 days of bed rest led to more sick leave than advice to continue normal activity (73). The Danish guidelines concluded that bed rest should only be used for severe pain and then only for 1 to 2 days (20). They found there to be i nsufficient evidence of a positive effect. Van Tulder found that there was no evidence i n favor of bed rest for acute LBP (88). Vroomen demonstrated that there was no evidence of effectiveness of bed rest for sciatica (96).

Cochrane Collaborations Review of Bed Rest Versus Advice to Stay Active •

"There is no evidence that advice to stay active is harmful for ei ther acute LBP or sciat ica"

•

". . . there are potential harmful effects of prolonged bed rest . . .

•

"

"

. . . i t is reasonable to advise people

w

i t h LBP and

sciatica to stay active. " Hagen KB, Hilde G, Jamtvedt G, Winnem MF. The Cochrane Review of advice as a si ngle tl-eatment for low back pain and sciatica. Spine 2002;27: 1736-1741.

78

Part One: Overvie\l\l

Randomized, Controlled Trial Demonstrates Limitations of Bed Rest Prescription •

2 81 acute LBP subjects (<72 hours)

•

Com pared 4 days o( bed rest versus con t inuation

I n surgical candidates i s t h e decision to operate a med­ ical question ? •

good prognosis with passage of t i me

of normal activities (insofar as pain allowed ) •

A t 7 days, I m o n t h , a n d 3 months, pain i n tensity,

•

functional d isab i li ty ( Roland-Morris scale), and

•

spinal mobili ty were s i m i lar (or both groups • •

Relapse rate was s i m i lar for both groups l ncreased days of sick leave i n bed rest grou p

Sciatica without sign i ficant neu rologic loss has a

Free fTagments are usually absorbed after 2 months Decision to operate may depend more on a patient's support system and financial resources t han medical issues

Caragee E. Point or view. Spine 2001;26:648-65 I.

Rozenberg S, Delval C , Rezvani Y , e t al. Bed I-est or normal activity ror patients with acu t e low back pain: A randomized cont rolled t rial. Spine 2002;27: 1487-1493.

Overuse of Surgery

The overuse of surgery has been one of the most problematic i nterventions in back pain. B igos and Battie (3) said, "Surgery seems helpful for at most 2% of patients with back problems, and its inappro­ priate use can have a great i m pact on i ncreasing t he chance o f chronic back pain d i sabil ity." Saal and Saal (75) supervised care for a group of patients referred by neurologists for surgery. They attempted rehabili tation for t hese patients and made the fol­ lowing observations, "Surgery should be reserved for those pat ients for whom function cannot be sat­ isfactorily i mproved by a physical rehabi l i tation program . . . Fai lure of passive non-operative treat­ ment is not su fiicient for the decision to operate." In 1970 Hakel i us performed a study that revealed that the majority of sciatica patients responded to conservative care (37). Bush (13) in 1992 published that "86% of patients with clinical sciatica and radio­ logic evidence of nerve root entrapment were treated successfully by aggressive conservative management." The Danish guideli nes recommend spinal surgery for disc herniation, cauda equ i n a syndrome, spinal stenosis, and stabilizing back surgery so long as appropriate i nd ications are present (20). Table 4.2 summarizes the Danish gu idelines i ndications for spi nal surgery.

Surgical Ind ications for Disc H ernia­ tion accordi ng to the Danish Guideli nes (20)

A Cochrane Collaboration systematic analysis found that there is considerable evidence on clinical effec­ tiveness of d iscectomy for carefully selected pat ients with sciatica caused by lumbar disc prolapse that does not resolve with conservative management (33,34). They found that 65% to 90% of sciatica patients whose symptoms lasted 6 to 24 months had good to excellent outcomes. In contrast only, 36% of conservatively treated patients had good to excellent outcomes. Al­ though this often is i nterpreted to defend the aggres­ sive recommendation for surgery, t h i s is not necessarily the case. A study of spinal stenosis patients found that there is no d ifference in surgical outcome i n patients who delay surgery by opting for a trial of conservative care (2). I n 1983, Weber reported that even in properly selected patients there is no difference in outcome between surgically and conservatively treated patients at 10 years (103). However, the study by Gogan and Fraser suggests the long-term results of surgery are superior to conservative care (35). Gibson et al (33) concluded, "There is a serious lack of scientific evidence supporting surgical management for degenerative lumbar spondylosis." They found no acceptable evidence for the efficacy of any form of decompression for degenerative lumbar spondylosis or spinal stenosis. Also, that there is no acceptable evi­ dence of the efficacy of any form of fusion for degen­ erative lumbar spondylosis, back pain, or "instability." Failure rates w i th spine surgery are estimated to be between 10% and 30%. The only RCT is more than 25 years old (103), and this has recently come under methodological cri t icism (85). I m proper selection of patients may be the most important factor. The most certain surgical criteria are:

Table 4.2

• •

• •

after 4-6 weeks of conservative care when there is a positive correlation between clin­ ical findings and i m aging reports and progressive weakness in the leg or severe leg symptoms in spite of medicati o n

•

Cauda equina syndrome

•

Paresis, rapidly progressive despite optimal treatment (trial of conservative care for 4 weeks to 3 months)

The RAND corporation convened a multidiscipl inary expert panel to review the scientific li terature and

Chapter Four: Putting the Biopsychosocial Model into Practice

come to a consensus regardi ng the criteria for spine surgery as appropriate, equivocal, or i n appropriate (Table 4.3) (86); 38% of surgeries performed i n two university neurosurgery departments were prospec­ t ively evaluated using this criteria and were deter­ mined to be i nappropriate (46). Agr�emen t w i th these criteria was reached i n dependently i n Switzer­ land (85). The notion that i f there i s a large disc extrusion that surgery is necessary is not supported in the l it­ erature. Bush et al (13) reported, "Indeed, the i n ter­ vertebral disc pathomorphology that m ight seem best suited to surgical resection is i n fact that which shows the most s ignificant i nc i dence of natural regression . . . These results confirm that if the pain can be controlled, nature can be allowed to run its course with the partial or complete resolution of the mechan ical factor. . . . Lumbar h erniated n ucleus pulposus can be treated non-operatively with a high degree of success." Carragee recently reiterated that preoperative MRI is not a h ighly rel i able predictor of disc surgery outcome (15). But it was still possible to conclude

79

that the larger t he disc herni ation the greater t he like­ l ihood of a surgical success. In [act, 57% of pat ients with anterior-posterior (AP) disc herniation dimen­ sions of less than 6 mm had poor cli nical resul ts, whereas only 2% w i th AP dimensions more than 9 mm were considered fai lures, although they did h ave the h ighest reherniation rate. Surgery clearly has its place for lumbar spine dis­ orders, but this should be only when appropriate cri­ teria are applied. Allan and Waddell (1) poi nt out that unnecessary surgery has been a major problem for some time, "The rapid and enthusi astic expan­ sion of disc surgery soon exposed its l imitations and fai lures. It was accused of leaving more tragic h uman wreckage i n its wake than any other opera­ tion i n history." Schneider and Kahanovitz noted t hat even i n patients who had an apparently success­ [-ul operation for sciatica, i f the problem is compen­ sable ( i . e . , workman's compensati o n or personal i njury), they are still at sign i ficant risk for recurrence and disabil i ty (76).

Abnormal Illness Behavior

Surgical I ndications for Disc Herniation or Spinal Stenosis accordi ng to the Rand Corporation (46) Table 4.3

Appropriate: • Pain i n lower limb, imaging positive for disc her­ n ia or spinal stenosis, major or m inor neurologi­ cal findings, restricted activity for more than 6 weeks Equivocal: • Pain in lower limb, imaging positive for disc her­ nia or spinal stenosis, major neurological fi nd­ i ngs, restricted activity for less than 4 weeks • Pain in lower l i mb, imaging equivocal for disc hernia or spinal stenosis, minor neurological findings, restricted activity for more than 6 weeks Inappropriate: • Pain in lower l imb, imaging positive for disc her­ nia or spinal stenosis, minor neurological find­ i ngs, restricted activity for less than 4 weeks M i nor neuro fi nd i ngs (2 or more items) • Asymmetric ankle reflex • Dermatomal sensory deficit • Positive ipsilateral SLR (straight leg raise) test • Sciatica Major neurologic findings • Progressive unilateral leg weakness, or • Positive contralateral SLR test

According to Dworkin (24), " Pain report often occurs i n the absence of pathophysiology or any d iscerni ble peripheral somatic changes.Thi s finding implies the need to reexam i ne our l im ited u nderstandi ng of pain, rather t han leap i ng to the conclusion that such pains must be psychogenic." LaRocca in his Presi­ dential Address to the Cervical Spine Research Soci­ ety Annual Meeting in December of 1991 explained that if physicians assume pathology is the major cause of symptoms, t hen if a patient has not recovered with treatment, they i ncorrectly assume t he problem must be psychogenic (48). Merskey (60) explained , "Slater & Glithero (77) showed that 60% of patients diag­ nosed by distinguished neurologis ts as having hyste­ ria d i d suffer fTom, or develop, relevant physical d isease that might account for their symptoms . . . " H e goes on to conclude that most regional pain syn­ dromes are not psychogenic i n origin and are often m islabeled as such (40,61,62). This is n o t to say that pain behavior does not accompany pain sensation. Dworkin (24) says "Finally, there is no i nconsistency i n accepting the likel ihood that chronic pain patients experience distress in the form of depression, anxiety, and multiple nonspecific physical symptoms, without having recourse to the d iagnosis or classification of their pain condition as psychogenic." Pain behavior is common and should be recognized and addressed. Whereas acute pain is directly related to painful sti muli, nociception, and tissue i nj ury chronic pain is due only in part to phys­ ical events (40,51,71,99,108). Chronic i llness behavior

80

Part One: Overview

and disability are only partia]]y related to nociceptive i nfluences (26,50,68,71). Psychosocial i ll ness behav­ ior, includi ng depression, inactivity, and pain avoid­ ance, is the rule with chronic pain sufferers (8,25,69,

Fear of Pain

Activity Avoidance

80,100).

Because the majority of patients do not have a diagnosable structural cause of their symptoms, a Fu nctional disorder should be assumed. Pain i n the locomotor system should be viewed as a sign of i m paired function. Non-specific or idiopathic back pain most likely has to do with m uscle or joint dys­ fl generation. Treatments designed for injury states or disc lesions will inevitably fail, thus causing depres­ sion, despair, and i llness behavior (27,28, 79,102,105). Abnormal illness behavior was defined by Pilowsky as a patient's inappropriate or maladaptive response to a physical symptom (Table 4.4) (72). This typically occu rs in back pain when no organic cause for a patient's symptoms can be i dentified.Descartes' view of pain as a warning signal of impending harm has led to the advice to "let pain be your guide." This is helpf'ul i n acute situations when nociceptive factors predomi nate. However, in chronic cases behavior should be encouraged that focuses on functi onal react ivation, not pain avoidance. In fact, it is neces­ sary [or the chronic pain patient to focus on increas­ ing their activities in spite of their pain. Abnormal illness behavior contributes to a slower or inadequate recovery. For instance, fear-avoid­ ance behavior leads to deconditioning (94). Patients who equate hurt with harm have a disabling form of thinking. They begin fear-avoidance behavior, which promotes deconditioning and thus leads to less stability in the low back patient (Fig. 4.7). I t is important to identi fy the patient who is fearful and avoid encouraging that patient to take on a "sick role." According to Troup (83), "If fear of pain per­ sists, unless it is spec i fically recognized and treated , i t leads i nexorably to pain-avoidance and thence to disuse."

Table 4.4

Abnormal illness behavior

Affective (emotional) • Anxiety • Depression Cogni tive (coping) • Fear-avoi dance behavior • Ignoring "stop rules" • Catastrophizing the low back problem ( labeling) o ruptured d isc o degenerative arthriti s

Acute Tissue Overload & Chronic Sensitization

�Deconditioning �

Figure 4.7 How fear-avoidance behavior leads to chron ic

sensi t i zation .

Diagnostic Triage to Rehabilitation-The Benchmark

The overarching goals of modern care for neuromus­ culoskeletal problems has been succinctly described by the recen t Clinical Framework document fTom the Victorian Workcover Authority in Australia (90). The aims and principles of care are summarized in the following goal statements: 1.

Treatment must be based on the best evidence available

2.

Treatment effectiveness must be demonstrated with outcome measurements

3.

A b iopsychosocial approach is essential

4.

Treatment must focus on self-care or manage­ ment skills

S. Treatment must be functional and focused on

return-to-work or activities Working Backs Scotland has focused on marketing a clear message to the public about how to manage back pain (106). The three key points are: 1.

Stay active

2.

Try simple pain rel ief

3.

If you need i t, get advice

An aggressive public media campaign (radio ads, free press); physician, employer, and union i nvolve­ ment; an informative web si te; and distri bution of brochures and posters led to a reversal i n health care beliefs ( rest vs. s tay active) within 1 to 2 months (99). With the help of follow-up booster campaigns, this continued to improve for more than 2 years.

Chapter Four: Putting the BiopsychosociaJ ModeJ into Practice

Does our railure to pin point t h e precise cause of L B P i n 80% o r cases mean t hat t here is n o decision-making process to guide care ror these pat ients?

81

--

Simple Backache or Nerve Root Complaint Yes

Yes

+

+

Referral

Time/ine: 1-3 Days

Reassurance: - No serious pathology

The first step in management is diagnostic triage. This establishes an algori thm or cri tical pathway for care ( Fig. 4.8). Patients have two basic goals (84). First, to receive i n formation about how to manage their LBP; and second, to receive advice on how to resume normal activi ties. The patient centered para­ d igm is goal-oriented, focusing on function, not j ust relief of symptoms. In t he report of findings, it is important to mutually establish the following goals of care: reduce pain, restore funct ion, and keep the patient i ndependent. This requires a strategic pro­ gram heedi ng "best practice" approaches i ncorpo­ rating reassurance, relief of pain , and reactivation (Table 4.5). Whereas this patient-centered approach

- Positive prognosis, but possibility of recurrence Symptom Control: -

Analgesics, NSAIDs

- Heat or Ice Activity Modification:

- Bed rest 1 -3 days «

7 days for nerve root pain)

- Avoid aggravation

Is pain settling within

the first 1 -3 days (2 weeks if nerve root pain),

Yes

even if still present?

-....j

Increase Activity

I No

+

Timeline: First 4-6 weeks

Pain Relief: Goal - to resume normal activities - Adjust analgesics - Manipulation (avoid if severe or progressive neurological deficit) - Active exercise, "hurt does not equal harm" (gradually increasing) - Physical agents (gradually decreasing) - Increase activity

- Early 10 of distress or depression

Is function improving

within the first 6 weeks (longer if nerve root pain),

Yes

even if still with some pain

...... 1

Return to Normal Activity

No

•

Sphincter disturbance •

Saddle anaesthesia

+ Yes

Timeline: 6 weeks

------+-

Reassessment: - Review diagnostic triage

t

"Red Flags" (See Table

- Psychosocial & physical performance assessment

4.6)

I

. Non-mechanical pain (constant, progressive, no relief with bed rest) - PH: carcinoma. steroids, HIV. drug abuse •

�

- Consider imaging & lab work

No

Weight loss

t

Negative

...

I

I

I

Timeline: 6-12 weeks

Continued Primary Management:

Yes -----.-

- Active Rehabilitation (active care > passive care)

- Malaise

- Id of factors which may predict a longer recovery

- Unremitting flexion restriction

(table

- Alternative symptomatic measures (muscle relaxants, antidepressant, injections, supports)

- Widespread neurology

- Objective outcomes utilized

t

Is function improving within

t

12 weeks, even if still with some pain?

- Leg pain > back pain - Radiates to lower leg

t

I

Refer or Change Management

I

3.4)

- Fever - Violent trauma

No

Positive

Yes

....1..

Return to Normal Activity

No

- Dermatomal numbness

t

& parasthesia

- positive SLR

Time/ine: 3-6 months

- Localised motor, sensory, reflex

Consider Second Opinion:

changes

- Active Rehabilitation Specialist (reconditioning, functional outcomes, behavioral principles)

No

+

Is function improving within

- Low back, buttocks, thigh pain - "Mechanical" pain (varies with

Yes---+-

I

Simple Backache

4-6 months, even if still

�

with some pain?

posture & movement)

Yes

......J

Return to Normal Activity

I

No

+ Time/ine: by the 6th month

PH - past medical history SLR - straight leg raise test

A

LBP - low back pain

(A) Diagnostic triage algorithm. (B) Treat­ ment guidelines algorithm

Figure 4.8

Secondary Referral to Multidisciplinary Rehabilitation Center

- Incremental exercise

- Behavioral medicine principles with functional objectives - Close liaison with the work place

Modified from CSAG Clinical Standards Advisory Group report on Back pain. London: HMSO.

1 994; 1 -89.

B

82

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Part One: Overview

Table 4.5

"Best Practice" Keys to Recovery­

The 7 R's 1 . Rule out

"red flags" of serious d isease

2. Reassurance that no serious d isease is present

and that improvement is l i kely to begin rapi dly (within a few weeks) 3 . Reactivation advice that normal activities can be resumed (walk, swim, b i ke, etc. ) and educa­ tion about simple activity modifications to reduce biomechanical strain ( i .e., h i p h inge, cats, abdominal bracing) 4. Relieve pai n with medication or mani pulation 5. Re-evaluation of those entering the subacute phase for structural, functional, or psychosocial pathology 6. Rehabilitate/Recondition/Reeducate muscles wi th McKenzie, slabil i zation, progressive slrengthening, or cognitive-behavorial ( i ndicated if high "yellow flags" score) approaches 7. Refer for specialist tests ( i . e . , "red flags") or treatments ( i.e., "yellow flags" ) when i nd icated

is goal-oriented, tradi tional approaches are technique­ or profession-driven (manipulation, i njection, sur­ gery). These traditional approaches have for the most part con fused and frustrated the health care consumer. The good natural history for acute problems neces­ sitates a minimalist approach (29). Unless there are "red flags," reassure and reactivate the patient. If needed, provide pai n relief treatmen ts. Avoid unnec­ essary surgery, overmedication, and overexamina­ tion, especially with d iagnostic imaging. In contrast, the subacute phase is a better t ime for more aggres­ sive management than is the chronic phase, because it is easier to prevent than to treat chronic pain . The key time frame is between 4 and 12 weeks (29). Those

Table 4.6 • • • • • • • •

•

with "yellow flags" ( i .e., fear-avoidance behavior) should be more aggressively managed, even as early as 3 weeks and certainly by 6 weeks. This still does not mean MRls for every patient, but it does mean a re­ habilitation specialist should be involved. The most important point is that when a full diagnostic workup is recommended, it should not be limited to M RIs or other structural evaluations. It should also include functional or physiological testi ng such as a func­ tional capacity evaluation and a psychosocial workup. Despite the fact that most patients begin improve­ ment rapidly, 20% to 25% of patients are dissatisfied w i th their care for back and neck pain (21). Cherkin found that despite the much publicized rosy picture for back pain, one-third of patients are dissatisfied with recovery even after 7 weeks, and one-half of t hese continue to be so at J year (18). Carey reported that even i n those who were returned to pre-injury functional levels, they were generally dissatisfied with their care (17). Thus, at least i n terms of customer satisfaction, there is much room for improvement. Patients require an approach that demonstrates empa­ thy with their situation. This is why prompt reassur­ ance and pain rel i ef options are important, along with education about the value of reactivation and possible recon d itioning.

Reassurance/Diagnostic Triage •

How-diagnostic triage

•

What- there

•

When-on

•

Why-to

is no serious disease and i mprovement is l i kely to begin rapidly (within a few weeks) day 1

d ispel the myth that imaging is needed or the spine is damaged

Diagnostic triage validates that nothing bad or sinister is going on (Table 4.6). Klassen reported that a chief

Red Flags of Serious D isease (tumor, infection, fracture, serious medical disease) (see Chapter 7)

Age younger than 20 or older than 50 years Traun1a History of cancer Night pain Fevers Weight loss Pain at rest Immune suppression ( i .e., significan t corticosteroid use) Recent i n fection

• • • • • •

Generalized systemic disease (diabetes) Failure of 4 weeks of conservative care Cauda equina Saddle anesthesia Sphi ncter disturbance Motor weakness lower lim bs

Chapter Four: Putting the Biopsychosocial Model into Practice

--

83

Australian Province of Victoria Demonstrates that the Message in "The Back Book" Can Change Social Behavior

A

•

M ultimedia campaign begun in 1 997 in Victoria, Australia advised patients with back pain to stay act ive and exercise, and not to rest fOI- prolonged

B

Referral

Figure 4.9 " Red Flags" action steps. A) Red flags negative.

periods or take time off fTom work. •

The campaign consisted of: o

B) Red flags positive.

o

purpose for visiting a doctor [or 43% of pain patients is the need for reassurance about the absence of seri­ ous disease (45). Those with "red flags" of serious dis­ ease require different action steps than t hose without them (Fig. 4.9). Explanation includes a discussion of pain relief options as well as what to avoid and what to do to speed recovery. It is important to help the patient to see that the goal is avoiding debilitating inactivity. This requires an interactive approach that alleviates fears and overcomes past misperceptions.The health care provider (Hep) should show concern as well as empathy for the patient's well-being and safety. Guide­ lines and patient booklets such as "The Back Book" can be used as aids (12). The patient will hear the good news that we can confidently rule out sinister factors, even though we are not very accurate in ident i fying the exact cause or their pain. Their pain can be l i kened to a common cold or the pain from gardening for the first time after a long winter. Performi ng a novel activity such as gardening is expected to give rise to pain, because we realize we are not in shape. This pain is rarely a cause for concern, and L B P can be likened to it. It may also be reassuring that the natural h istory is relatively good. Some improvement begins very rapidly such t hat there is approximately a 50% chance of returning to normal activities within 1 week and a 90% chance within 1 month. Even with sciatica there is a 50% chance of resum i ng normal activi ties within 1 month and a 90% chance wit h in 3 months. However, this does not guarantee that your patient will be in those good outcome groups. We can't promise to have a magic wand, let alone a crystal ball ! Much of t h e early reassurance of acute patients i s so that they don't feel they need an M R I o r aggressive early treatment and vigilant sel f-protection of their back (29,55). Most recent systematic reviews of the l i terature suggest that the traditional back school emphasis on learning how to protect the back actu-

o

o

o

o

o

•

Television commerc ials durin g "prime t i me" dUl-­ i n g t he first 3 mon ths I n ternational & national experts Australian sport i n g and television stal-s w i t h past history o f LBP Lower-key maintenance advertisin g inc l u din g radio and print ads "The Back Book" was w i dely available in 1 6 l a n guages All doctors i n V i ctoria received evidence-based gui deli nes for managi n g LBP Another i n t ensive television campaign for 3 mon ths start i n g in Septem ber 1 999

Study of 4730 individuals i n the general population and 2556 general medical practitioners ( G Ps)

•

The message o f "The Back Book" was delivered in the province of V i ctoria, but not in New South Wales ( NSW)

•

Back pain bel jefs changed in Victoria during the campaign, but not in N SW

•

Among individuals who had back pain in the previous year, fear-avoidance beJiefs about physical activity i mproved considerably in Victoria, but not in N SW

•

GPs in Victoria i mproved their bel i e fs abou t back pain management as com pared to their colleagues i n NSW

•

Previous studies have shown than only one-third of doctors are motivated to change behavior by con t i n u i n g education

•

Outside i n n uences such as a mass media campaign and changed attitudes i n their own pat ients appeared to motivate the doctors

Buchbi nder R, Jolley D, Wya l l M . 200 1 Volvo Award W i n ner in C l i n ical S t u dies: Effects or a media campaign on back pai n bel ids a n d i ts potential inn uence on management or low back pain i n general practice. Spine 200 1 ;26:2535-2542.

84

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Part One: Overview

ally promotes deconditioning through avoidance behavior (20,88,101). It seems back school may be too much of a good t h i ng! Accord i ng to Deyo and Wei nstein (23), the search for a precise anatomi cal d i agnosis is often frust­ rat i ng for physicians and patients. They state that i t is more useful to address the fol lowing three questions: 1.

•

Reactivation advice requires an educational discus­ sion about recovery goals and the means to reach t hose goals. I t starts with reassurance of the safety of gradually resum i ng n ormal act ivi ties such as walk i ng, swi m m i ng, and biking. N ormal activity is necessary to prevent the debi l i ta t i ng effects of i nac­ t i v i ty. It is i mportan t to acknowledge that these aclivites may be uncomfortable, but the patient should be reassured that hurt does not necessari ly equal harm . Most normal activi ties, while possibly uncomfortable, are actually less stressful than pro­ longed sitting. When someone has a flu their back hurts because t hey have been rest i ng. S i m i larly, pain when return i ng to activity i s not usually caused by harmful act iv i ty, rather it is a result of debil i tation. Along with advice to gradually resume normal acti­ vities education about si mple activity modifications to reduce biomechanical strain (i.e., early-morning Oex­ ion, hip h inge, cats, abdominal braci ng, etc.) is impor­ tan t . Basic activity modification advice for severe pain is to l i m i t sitting to 20 m i n u tes and l i m i t un­ assisted l i ft i ng to 20 pounds. Although healthful biomechanics can hopd-ully facilitate recovery and prevent recurrences, it can also have an unant ici­ pated negative effect of deconditioning the patient! Strict avoidance of bending, reachi ng, and Ii fting will certainly decondition. This is like wearing a brace or cast for too long. If we modify activities to reduce harmful bio­ mechanical stress and strain, then we must provide some prescribed therapeutic exercise to mai n tai n conditioni ng of those important muscles. An exam­ ple is if we advise patients to avoid l i fting with their spine i n ful l flexion, especially first thing in the morning or after prolonged s i l t i ng. In such a case it is i m portant to also prescribe cat/camel exercises to maintain mob i l i ty throughout the entire functional range of motion and to teach patients N OT to over-

I s systemic disease causi ng the pain?

2. Is there psychosocial distress present t hat will

am p l i fy or prolong the pain ? 3.

I s there a neurologic compromise present that may require surgical evaluation?

This requires a care[�ul history and examination with imaging not typically being necessary. One-hal f to two-thirds of acute patients have sub­ stan tial worries about the safety of activity, whereas between one-quarter and one-half of subacute pat ients report hav i ng reduced their housework, sexual activity, and walking (65,95). Such unneces­ sary bel iefs are o ften promoted by biomedical action (ordering i m aging tests) or i naction ( proposed bed rest or avoidance of activi ties that hurt ) . Thus, early reassurance is an i ntegral part of the B PS approach. Table 4. 7 illustrates the stark cont rast between a trad itional biomedical report o f findings and a B PS one.

Reactivation Advice (see Chapter 1 4) •

How-an educational discussion about recov­ ery goals and the means to reach those goals

•

What-that normal activities can be resumed (walk, swim , bike, etc . ) and education about simple activity modifications to reduce biomechanical strain ( i . e . , hip h i nge, cats, abdomi nal braci ng)

•

When-day 1

Table

4.7

Biomedical vs Biopsychosocial Approaches (adapted from (12»

Biomedical • • • • • •

Why-dispel the myth that rest is required or that spine i s vulnerable

Emphasize anatomy, i njury & damage " Let pain be your guide" Emphasize further tests Focus on pain rather than activi ty Encourage passivity & dependency Posit ive atti tudes result in a speedier recovery

Biopsychosocial • • •

•

Reassurance-no sign of serious disease L B P is symptom that back is biomechanically unfit Psychologic treatment can help, but long-term results depend on l i festyle Recovery depends on restoring function-the sooner the better

Chapter Four: Putting the Biopsychosocial Model into Practice

protect their backs during otherwise rou t i ne safe activi ties. According to the Occupational Health Guide­ li nes (OHG) (101), the fi rst treatment is generally acknowledged to be advice to remain �ctive. "There is strong evidence that advice to con t i nue ordinary activit ies of daily l iving as normally as possible despite the pai n can give equivalent or faster symp­ tomatic recovery from the acute symptoms, and leads to shorter periods o f work loss, fewer recur­ rences and less work loss over the following year than 'tradi tional' medical treatment (advice to rest and 'let pain be your guide' for return to normal activi ty)."

Rel ief of Pain (see Chapters 21 and 38) •

How-the recommendation of over-the­ counter or prescription medication, or del ivery of skilled manipulation

•

When-within a few days if d iscom fort is present

•

Why-provide greater com fort until recovery begins

Although there are no magic bu llets, pain relief options can take the edge off. If the pain can be soft­ ened, then it will be easier to encourage the patient to resume activi t ies. The main goal i s to avoi d the debil i tation of rest and build activity tolerance through safe conditioning. According to the Danish guidel ines, the following are the recommended, optional, and recommended against acute pain rel ief treatments (20): Recommended •

Acetami nophen, aspirin, ibuprofen

•

Prescri ption NSAIDS

•

Manipulation

•

Surgery-for cauda equina syndrome

Optional •

Modal ities

•

Muscle relaxants

•

McKenzie exercises

•

Acupuncture

•

Epidural-for sciatica

Recommended Against •

Sedatives, hypnotics, steroids

•

Epidural-recommended against for LBP

--

•

Surgery-recommended against for sciatica ( i n the acute phase)

•

Surgery-recommended against for LBP

85

Nicholas has pointed out that if the focus is on pai n rel ief before activation that t h i s can actually rein­ force avoidance behaviors (70). Accord i ng to Main, the adage "let pain be your guide" is responsible for promoting unnecessary fear and functional l i m ita­ tions ( 5 4 ) . Pain is l i kely to run a course and even come and go. The determ ining factors in recovery have to do with how a person copes with their pain. If all the focus on care is on pai n relief, then avoid­ ance behavior will be promoted with t he resul t being that physical and psychological deconditioning will ensue. Patients should be i n formed that light activ­ i ties, w h i l e u ncomfortable, are not harmf-u l . If patients are overly concerned about pain and fearful of activities, then a "stepped-up" approach including exercise and supervised exposure to feared activities is needed ( 6 5 , 9 5 ) .

Re-Eval u ation of Structural , Functional , and Psychosocial Contributors to Continued Pain or Disabil ity •

How-comprehensive bio (structural and h.l nctional) and psychosocial (yellow flags) re-exam i nation (see Chapters 9 and 1 1 )

•

Who-those enteri ng the subacute phase

•

When-in the subacute phase

•

Why-to reassure the patient that there is no serious d isease causi ng their pain or that somethi ng has not been missed that could help them . Also, to identi fy f-u nctional deficits that may be realistic targets for treatment or affect ive or cognitive behaviors that may i mpede recovery

Re-evaluation requires a comprehensive structural, fun c tional , and psychosocial re-exa m in a t i on . For patients not satisfactorily recovering at the 4-week mark, i t is i mport a n t to once aga i n reassure t he patient that there is nothing seriously wrong. At this juncture rather than a m i n i malist approach being recommended, aggressive management strategies are needed to rule out structural pathologies, iden­ ti fy functional deficits, and evaluate for psychosocial "yellow flags." Frequently, only structural i maging is performed, thus boxing the doctor into a corner where he or she is forced to give greater credence to coincidental imaging findings. But if at the same time an MRI is performed on a non-responsive patient, a "yellow flags" questionnaire is adm i nistered and a

86

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Part One: Overview

funclional capaci ty evaluation performed, then the doctor will be able to place i maging findings in con­ text along with coping issues and functional deficits. Reconditioning (see Chapters 2 6 , 2 7 , and 31 ) •

How-skilled assessment and training of pat ient

•

What-McKen z ie, stabilization, progressive strengthening, or cogni tive-behavioral approaches When-in the subacute phase or earli er for those at risk of chronicity

•

•

Why-dispel the myth that more aggressive treatment of sym p toms is requi red; i nstead, focus on function/physiology not structure/pathology

Recon d i t i o n i ng exercise requ i res s k i l led assess­ ment and trai ning of patient. Exercises may i nvolve McKenzie, stabilization, progressive strengthening, or cognitive-behavorial approaches. Patients should be educated that activity and condi t i o n i ng will fac i l i ­ t a t e recovery. Cond ition i ng is more i m portant with increased age because we lose a significant percentage o[ our muscles protection between 20 and 50 years old. The report of findings after re-evaluation should focus on the importance of building activity tolerance. That this requires training or condi tioning should seem reasonable. Treatment with manipulation, med­ ication, injection, or surgery will not condition the muscles needed to enhance performance or stability. A famous Groucho Marx story applies here: "Doctor! After surgery will I be able to play violi n ?

Groucho Marx:

OHG Recommendations for the Active Rehabi l i tation Program ( 1 0 1 )

Table 4.8

Education-directed at managing their pain and overcomi ng disability Reassurance and advice-to stay active Exercise-an active and progressive physical fitness program Pain management-using behavioral principles Work-in an occupational setting and directed strongly towards return to work Rehabilitation-symptomatic relief measures should support and must not interfere with rehabil i tation

•

When-in the acute phase [or laboratory or i maging tests or to specialists if "red flags" are present ; in the subacute phase for rehabili tation especially if "yellow flags" are present

•

Purpose-provide

"best practice" care following protocols based on current care guideli nes

Practitioner Audit (see Chapter 39)

The reflective practice-based model presented here can be faci l i tated by self-audi t of your practice pro­ cedures ( 1 0) . There is no more important player i n t h e transformation o f t h e paradigm for managing spinal condi tions than the H C P. All the key players who need to work together are shown in Figure 4. 1 0. Chart review should reflect that diagnostic triage has been performed; "yellow flags" have been assessed

" I would t h i n k so." "Good ! Cause I could never play it before."

Doctor:

I ndividual F"tom

Groucho Marx:

Backs are l i ke knees. Regardless of cause or treatment (even surgery), the road to recovery is through reacti­ vation and reconditioning. This allows the patient to prevent debilitation and i ncrease the body's com­ pensatory ability for normal age related changes or defici ts. Accord i ng to the OHG, a rehabil i tation specialist will be working with a team that can o ffer the ser­ vices described in Table 4 . 8 ( 1 0 1 ) .

Treatment Provider Factors

� ...

__

�

Compensation and _-+ Health Care System ... ... Facto rs__-. _

_ ,--

____ Workplace and/or Home Environment Factors

,------.

Probability of Long Term Problems

Figure 4. 1 0 Key "players" driv i n g c hronic spi nal prob­

Referral ( see Chapter 7)

Referral requires knowledge of assessment and treat­ ment protocols

lems. From Pincus T, Vlaeyen JWS, Kendall NAS, Von Korff M R , Kalauokalani DA, Reis S. Cogn it ive-behavioral therapy and psychosocial factors in low back pai n: Direc­ t ions for the future. Spine 2002 ;2 7:E 1 33-E 1 38.

Chapter Four: Putting the Biopsychosocial Model into Practice

(questionnaire); pain relief options (i.e., manipulation or medication) orfered; the patient advised to stay active; self-treatment(s) recommended and i nstructed ("active care"); refenal made ir "red flags" of serious pathology, cauda equina, or unresolving neurological condition; and addi tional investigations or treatment arranged if back pain non-responsive wi thin 6 weeks. A number or decision poi n t s have emerged that are crucial to the modern management of the back pain patient. Guidelines allow us to formulate proto­ cols and even algorithms of care incorporating deci­ sion poi n ts or care pathways. As further evidence accumulates these protocols will be "fine-tuned" and standards of care will gradually emerge. Presently the followi ng ] 0 decision poi nts can be identified for management of acute patients with LBP. These are the cri tical attributes of the new benchmark for man­ aging LBP. 1.

Diagnostic triage-pat ient should be triaged on day 1 i n to one of three main overarch i ng cate­ gories. This involves history and exami nation wi thoul special tests. It is best performed by a primary care doctor such as a general practi­ tioner or chiropractor. •

Red flags of possi ble serious d isease

•

Nerve root pai n

•

Mechanical LBP

2. If there are no red flags, the patient should be

reassured that the prognosis is good. 3 . If

there are red flags present, the patient should be referred ror further tests or treatments.

4.

Baseline outcome measurements of symptoms (e.g. , visual analog scale), impairments (e.g., range of motion), and disabil ity (e.g., activity intolerances) should be captured at the i n itial visit and moni tored at regular intervals to moni­ tor patent status and treatment effectiveness.

6.

7.

Bed rest should not be prescribed unless the pat ient is in severe pai n , and then i t should not last more than 2 to 3 days. Ir patient is failing to return to normal activities within 1 or 2 weeks or the patient needs addi­ tional help with pain relief then manipulation by a trained specialist ( i.e., chiropractor) or medica­ lion (prescribed by a physician) is recommended.

87

8.

Evaluation of "yellow flags"-does not need to wai t until 4 or 6 weeks, but can be screened ror on visit 1 .

9.

I f there i s an unresolving condition after 4 to 6 weeks of conservative care the patient should be refelTed for additional investigations. Structural tests such as i maging or laboratory work-up. Functional tests such as a physical performance or hmctional capacity evaluation and psycho­ social evaluation, including a "yellow flags" screen and possibly a referral to a pain psychologist.

1 0.

By week 6 if the pat ient is fai l i ng to resume nor­ mal acti v i t ies, rehab i l i tation should be com­ menced by a rehab i l i tation specialist.

At a recent International Forum on Low Back Pain Research i n Primary Care, the emphasis was on how to dissemi nate and i m plement the new guideli nes ( 7 , 89 ) . The d i fficulties of changing physician behav­ i or and ideas on h ow to accompl ish i t were d i s­ cussed. The recent Australian study shows that physician behavior can change, although it may take changes in patient behavior to stimulate it ( 1 ] ) ! Goldberg found that physician education lowered spine surgery rates ( 3 6 ) . A multi pronged approach was used i n corporati ng surgeon study groups, out­ comes researc h , conferences for prim ary care phy­ sicians with a local physician presen t i ng essen tial components of the model i n what is called "academic detail i ng," and, lastly, a hospital i ntervention led by a health care economi s t ai med at d i scussing cost­ e ffect iveness.

Audit Process

Self-Check of the Chapter's Learning Objectives •

Are you comfortable reassuring patients who have diagnosis such as degenerative arthritis or herniated discs that they can safely reactivate and t hat i n fact

s . The patient should be advised to stay as active

as possible and to gradually increase their phys­ ical activity. They can be encouraged that it i s sare t o d o so, s o long a s pain is n o t peripherali z­ i ng. Explanation should i nclude a discussion men tioni ng t hat hurt does not necessarily equal harm , bUl is just a sign t hat s t i ff areas are being mobi lized.

--

this is the best way to recover? •

Are you able to identify when negative coping s trategies such as fear-avoidance behavior are leading a patient to avoid activity and thus promote deconditioning?

•

What shift in management is necessi tated by the presence of "red flags"?

•

What shift in management i s necessitated by the presence of "yellow flags" ?

•

Is a structural and psychosocial reevaluation sufficient i f a patient is not adequately recovered after 6 weeks?

88

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Part One: Overview

• REFERENCES I . Allan DB, Waddell G . An h i storical perspective on low back pain and d isab i l i ty. Acta Orthop Scand Suppl 1 989;60 : 1 . 2 . Amundsen T, Weber H . Nordal H J , M agnaes B , Abdelnoor M , L i lleas F. Lum bar spinal stenosis: Conservative or surgical management? A prospec­ t ive 1 O-year study. Spi ne 2000;25: 1 424- 1 436. 3 . Bigos, S, Baltie MC. Back disa b i l i ty prevention. Clin Orthop 1 987;22 1 : 1 2 1 . 4 . Boden S D , Davis DO, D i n a TS, et a l . Abnormal magnetic-resonance scans of the l u mbar spine in asymptomatic subjects. J Bone Joint Surg [Am] 1 990a;72 :403. 5 . Boden SD. McCowin PR, Davis Do, D i na TS, M ark AS, Wiesel S. Abnormal magnetic-resonance scans of the cervical spine in asym ptomatic subjects. J Bone Joint Surg J 990b;72A: I J 78- 1 1 84 . 6. Borenstei n DG, O'Mara JW, Boden SD, e t aJ. The value of magnetic resonance i maging of the l umbar spine to predict low-back pain i n asym ptomatic sub­ jects. J Bone and Joi n t Surg 200 1 ;83-A: 1 306- 1 3 1 1 . 7 . Borkan J , Van Tulder M , Reis S, Schoene M L , Croft P, Hermoni D . Advances in the field of low back pa i n in pri mary care: A Report from the Fourth I n ternational Foru m . Spine 2002;27 : E I 2 8-E 1 32 . 8 . Bortz W M . The disuse syndrome. West J Med 1 984; 1 4 1 :69 1 . 9. Brandt-Zawadzki M N , Jensen MC, Obuchowski N , e t a l . I n terobserver and i n t raobserver variabi l i ty in interpretation of l umbar disc abnornlali ties: A com parison of two nomenclatures. Spine 1 995;20: 1 2 5 7- 1 263. 1 0. Breen AC, Langworthy J , Vogel S, e t a l . Prim ary Care Aud it Toolk i t : Acute Back Pai n . Bournemou t h : I nstitute for M u sculoskeletal Research and C l i nical I m plementation. www . i m rc i .ac.uk. 2000. 1 1 . Buchbinder R, Jolley D, Wyau M. 2 00 1 Volvo Award W i n ner in C l i n ical Studies: E ffec ts o f a media campaign on back pain bel iefs and i t s poten­ tial innuence on management o f low back pain in general practice. Spine 200 1 ;26:2535-2542. 1 2 . Burton K, Waddel l G . I nformation and advice to patients w/ back pain can have a pos i tive effect . Spine I 999:24;2484-249 l . 1 3 . Bush K , Cowan N , Katz D E , et al. The natural his­ tory of sciatica associated with disc pathology: A prospective study with c l i n ical and i ndependent rad iologic follow-up. Spine 1 992; 1 7 : 1 20 5 . 1 4. B u s h K, Chaudhuri R , H il l ier S, Penny J . T h e patho­ morphologic changes that accompany the resolu­ tion o f cervical rad icu lopathy. Spine 1 997;22( 2 ) : 1 83- 1 87 . 1 5 . Caragee E , Alamin T, et a l . C a n M R scann i ng i n patients w i t h sciatica predict fai l ure o f open l i m i ted discectomy? Presented at t he annual meeting of the I n ternational Society for the Study of the Lumbar Spine, Edinbu rgh, 200 1 . 1 6. Can-agee EJ , Barcohana B , Alamin T, van den H aak E . Prospective controlled study o f the development of lower back pain i n previously asymptomatic sub­ jects u ndergoing experi mental discography. Spine 2004;29: 1 1 1 2- 1 1 1 7 .

1 7 . Carey T S , M i l l s Garret J , Jackman A M . Beyond t he good prognosis. Spine 2000:2 5 : 1 1 5- 1 20 1 8. C herk i n DC, Deyo RA, Street J H , Barlow W. Pre­ dicting poor outcomes for back pain seen i n pri­ mary care using patients' own criteria. Spine 1 996;2 J : 2900-2907. 1 9. Dabbs VM, Dabbs LG. Correlation between disk height narrowi ng and low-back pai n . Spine 1 990; 1 5 : 1 366. 20. M a n niche C, et a l . Danish Heal th Technology Assessment ( D I H TA). Low back pain : Frequency Management and Prevention from an HAD Perspec­ tive, 1 999. 2 1 . Deyo RA. Low back pain-A primary care chal­ lenge. Spine 1 996;2 1 : 2826-2832. 2 2 . Deyo RA, Diehl AK, Rosent hal M. How many days of bed rest for acute low back pain ? N Engl J Med 1 986;3 1 5 : 1 064. 23. Deyo RA, Weinstein I N . Low back pai n . N Engl J Med 200 1 ;344:363-370. 24. Dworki n SF. Perspectives on psychogenic versus biogen i c factors in orofacial and other pain states. A PS J 1 992;3 : 1 72 . 2 5 . Engel G L . Psychogenic pai n and t h e pain prone patient. Am J Med 1 959;26:899. 26. Fordyce W E , M c Mahon R, Rainwatel- G, et a l . Pain complaint-exercise performance relat ionship in c hron i c pai n . Pain 1 98 1 ; 1 0: 3 1 1 . 2 7 . Fordyce W E , Fowler RS, Lehmann JF, et al. Oper­ ant conditioning in the treatment of chronic pai n . Arch Phys Med Rehabil 1 973 ;54:399. 28. Fordyce WE, Brochway JA, Bergman JA, et al. Acute back pai n : A control-group comparison of behavioral vs. trad itional management methods. J Behav Med 1 986;9: 1 27 . 29. Frank J , Sinclair S, Hogg-Joh nson S, e t aJ. Prevent­ i ng d isab i l i ty from work-related low-back pai n . New evidence gives new hope-if we can just get all the players onside. Can Med Assoc J 1 998; 1 58 : 1 625-J 63 1. 30. Frymoyer JW, Newberg A, Pope M H , et al. Spi ne radiographs in patients with low-back pain : An epi­ demiological study i n men. J Bone Joint Surg [Am] 1 984;66: 1 048. 3 1 . Frymoyer JW. Predicting disabi l i ty fTom low back pai n . C l i n Ol-th 1 992;279: I 03. 3 2 . Fullen love T M , W i l liams AJ : Comparative roentgen fin d ings in symptomatic and asymptomatic backs. JAMA J 957; 1 68:572. 3 3 . G i bson J NA , Grant IC, Waddell G . The Cochrane Review of Surgel-y for Lumbar Disc Prolapse and Degenerative Lum bar Spondylosis. Spi ne 1 999;24( 1 7 ) : 1 820- 1 832. 34. G i bson J NA , Gra n t I C , Waddell G . Surgery for Lumbar Disc Prolapse (Cochrane Review). The Cochrane Library 2004 ; 3 . 3 5 . Gogan W H , Fraser RD. Chymopapa i n : A 1 0-year, double-blind study. Spine 1 992; 1 7 :388-394. 36. Goldberg HI, et al. Can evidence change the rate of back surgery? A randomi zed control led trial of com m u n i ty-based education. E ffective C l i n ical Practice May/June, 200 J :95- 1 04 .

Chapter Four: Putting the Biopsychosocial Model into Practice

37. Hakel ius A. Prognosis in sciatica. Acta Orthop Scand Su ppl .1 970; 1 29: I . 38. Hi tselberger WE, W itten R M . Abnormal myelograms in asymptomatic patients. J Neurosurg 1 968;28:204. 39. I ndahl A, Haldorsen E H , Holm S, Reikeras 0 , Hursin H. Five-year follow-up study of a controlled clin ical trial using light mobi l i zation and an i n for­ mative approach to low back pai n . Spi ne 1 998;23:262 5-2630. 40. I n ternational Association for the Study of Pain . Pain terms: A l i s t w i t h defini tions and notes o n usage. Pain 1 979;6:249. 4 1 . Jarvi k JG, Deyo RA . Imaging of lumbar i nterverte­ bral disc degeneration and aging, excluding disc herniations. Radiology C l i n ics of North America 2000;38: 1 2 55- 1 266. 42. Jarvik J G , Hollingworth W, Heagerty P, Haynor DR, Deyo RA. The longi tudinal assessment of imaging and disab i l i ty of the back ( LAIDBack) study. Spine 200 1 ;26: 1 1 58- 1 1 66. 43. Jensel M C , Brant-Zawadzki MN, Obuchowki N , et a l . Magnetic resonance imaging o [ the l umbar spine in people without back pai n . N E ngl J Med 1 994;2:69. 44. Kendrick D , Fielding K, Bentler E , Kerslake R, M i ller P, Pringle M. Radiography of the l u mbar spine i n primary care patients w i t h low back pain: Randomi zed controlled tri a l . BMJ 200 .1 ;322: 400-405. 45. Klassen AC, Berman ME. Medical care [or headaches. A consumer survey. Cephalgia 1 99 1 ; 1 1 (suppl 1 1 ):85-86. 46. Larequ i-Lauber T, Vader J P , Burnand B, et a l . Appropriateness of i ndications for surgery o f l u m ­ bar disc herni a and spinal stenosis. S p i n e 1 997; 2 2 ( 2 ) : 203-209. 47. LaRocca H, Macnab IA. Value of pre-employment radiographic assessment o[ the lumbar spine. Can Med Assoc J 1 969; 1 0 1 :383. 48. LaRocca H. A taxonomy of chronic pain syndromes. 1 99 1 Presidential Address, Cervical Spine Research Society Annual Meet i ng, December 5 , 1 99 1 . Spine 1 992; 1 0:S344. 49. Li nton SJ. The socioeconomic impact of chronic back pain : Is anyone benefiting? Editorial. Pain 1 998;75: 1 63- 1 68 . 5 0 . Linton SJ . T h e relationship between activity a n d chronic pai n . P a i n 1 985;2 1 :289. 5 1 . Loeser J D , Fordyce WE. C h ronic pai n . I n : Carr JE, Dendgerin k HA, eds. Behavioral Science i n the Practice of Medicine. New York: Elsevier, 1 983. 52. Magora A, Schwartz A. Relation between the low back pain syndrome and x-ray findings. Scand J Rehabil Med 1 976;8: 1 1 5 . 53. M a i n CJ, Watson PJ . Psychological aspects of pai n . M a n Ther 1 999;4:203-2 1 5 . 54. Main CJ. Concepts o[ treatment and prevention i n musculoskeletal disorders. I n : L i n ton SL, ed. New avenues for t he preven t ion o[ chronic musculoskele­ tal pai n and disab i l i ty. Amsterdam: Elsevier 2002 . 55. Malm ivaara A, Hakkinen U , Aro T, et a l . The treat­ ment of acute low back pai n-bed rest, exercises, or ordi nary activity? N E ngl J Med 1 995;332:35 1 -3 5 5 .

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56. McGuirk B , K i n g W, Govind J , Lowry J , Bogduk N . Safety, efficacy a n d cost-effectiveness of evidence­ based guideli nes for t he management of acute low back pain in primary care. Spine 200 1 ;26:2 6 1 5-2622. 57. Melzack R , Wall PD. Pai n mechanisms: A new t heory. Science 1 96 5 ; 1 50:978. 5 8 . Melzack R . In: Gatchel RJ, Turk D C , ed. Psychologi­ cal factors i n pain. Critical pel-spect ives. New York : The G u i l ford Press, 1 999:3- 1 7 . 59. Mel-skey H . The defi ni tion of pain. EUI- J Psychiatry 1 99 1 ;6: 1 53- 1 59. 60. Merskey H. L i m i tations o f pain behavior. APS Jour­ naI 1 992;2: 1 0 1 . 6 1 . Merskey H . The i mportance o f hysteria. B r J Psyc hi­ atry 1 986; 1 49 : 2 3 . 62. Merskey H . Regional p a i n is rarely hysterical . Arch Neurol 1 988;45:9 1 5 . 63. Merskey H , Bogdu k N , eds. Class i fication of c h ronic pai n : Description of c h ron i c pain syndromes and defi n i tions of pain terms, 2nd ed. Seattle, WA: TASP Press, 1 994. 64. M ixter WJ, Barr JS. Rupture of the i n tervertebral disc w i t h i nvolvement of the spinal canal . N Engl J Med 1 934;2 1 1 :2 1 0. 65. Moore J E , Von Korff M , C herk i n D, Saunders K, Lorig K. A randomi zed trial of a cognitive-behavioral program for enhancing back pain sel f-care in a pri­ mary care setting. Pain 2000;8 8 : 1 45- 1 53 . 6 6 . Nachemson A. I ntroduction . I n : Nac hemson A , Jonsson E , eds. Swedish S B U report. Evidence based treatment for back pain. Stockholm/P h i ladelphia: Swedish Cou n c i l on Tec h nology Assessment i n Health Care ( S B U )/Lippi ncott W i l l i ams & W i l k i ns ( Engl ish translation), 2000. 67. Nachemson AL. Newest knowledge of low back pain . C l i n Ot-thop 1 992;279:8. 68. N ac hemson A. Work for a l l , for those w i t h low back pain as well . C l i n Orthop 1 98 3 ; 1 79 : 7 7 . 69. Naliboff B D , Cohen M J , Swanson GA, et al . Com­ prehensive assessment of c h ronic low back pain patients and controls: P hysical abi l i t ies, level of activities , psychological adjustment and pai n per­ ception. Pain 1 98 5 ; 2 3 : 12 1 . 70. N icholas M K. Reducing disab i l i ty i n injured work­ ers: The importance of collaborative management. I n: L i n ton SL, ed. New avenues for the prevention o f c hron i c musculoskeletal pain and disabi l i ty. Amsterdam: E l sevier, 2002. 7 1 . P h i l i ps HC, Jahanshahi M . The componen ts of pain behavior report. Behav Res Ther 1 986;24: 1 1 7 . 7 2 . Pilowsky I . A general classification of abnormal i l l ­ ness behavior. B r J M e d Psychol 1 979;5 1 : 1 3 1 . 73. Rozenberg S, et a l . French mul ticen ter prospective, randomized, open study comparing advice t o stay active and bed rest in acute low back pai n , pre­ sented at t he annual m eeting of the International Society for the Study o[ the Lumbar Spine. Edin­ burgh , 200 1 . 74. Rothman R H , et al. A study of computer-assisted tomography. Spine 1 984;9:548. 7 5 . Saal JA, Saal J S . Nonopel-at ive treatment of hern i­ ated l umbar i n tervertebral disc with rad iculopathy. Spi ne 1 989; 1 4:43 1 .

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76. Schneider PL, Kahanovi tz N . C l i nical testing i n chronic low back pai n . Surg Rounds Orthop 1 990;4: 1 9. 7 7 . Slater E, G l i t hero E . A fol low-up of patients d i ag­ nosed as su fferin g from "hysteria." J Psychosom Res 1 965;9:9. 7 8 . Spl i t hoff CA. Lumbosacral j unction: Roen tograph i c com parison of patients w i t h and w i t h o u t b a c k ache. JAMA 1 95 3 ; 1 52 : 1 6 1 0. 79. Sternbach RA, Timmermans G . Personality changes associated with reduction of pain . Pain 1 975; 1 : 1 77 . 8 0 . Szasz T S . T h e pai n fu l person. Lancet 1 968;88 : 1 8 . 8 1 . Teresi L M , L u fki n RB, Reicher MA, et a l . Asympto­ matic degenerative disk d isease and spondylosis o f the cervical spine: M R I maging. Radiology 1 987; 1 64: 83-88. 82. Torgeson WR, Dotler WE. Comparative roentgeno­ graph ic st udy of the asymptomatic and sympto­ matic l u m bar spi ne. J Bone Joint Surg [Am] 1 976;58:850. 83. Troup J D G . The perception of pain and i ncapaci ty for work: Prevent ion and early treatment. Physio­ therapy 1 988;74:43 5 . 8 4 . Turner JA. Educational a n d behavorial i nterven­ t ions for back pai n in pl-imary care. Spine 1 996;2 1 :285 1 -2859. 8 5 . Vader J P, Forchet F, Larequi-Lauber T, Dubois RW, Burnand B. Appropriateness of surgery for sciatica: Rel iabi l i ty of guideli nes from expert panels. Spine 2000;25( 1 4): 1 83 1 - 1 836. 86. Value H ea l t h Science: I nd ications [or La m i nectomy-Phys i c i a n Expert Pane l . Santa Mon ica, Cal i fornia ( U npublished data), 1 989. 87. van Tulder M W , Assendel ft JJ , Koes BW, Bouter LM. Spinal radiographic fin d ings and nonspeci fi c l o w back p a i n : A systemat i c review of observat ional studies. Spine 1 997;22 :427-434. 88. van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pai n : A systematic review of randomized con­ trolled trials of the most common i n terventions. Spine 1 997;22( 1 8) : 2 1 2 8-2 1 56. 89. van Tulder WE, Croft PR, van Splunteren P , et a l . D issemi nating and i m plementi n g the results of back pain research in pri mary care. Spine 2 002 ; 2 7 : E 1 2 1 -E 1 2 7. 90. Vic torian Workcover Aut hority. C l i nical framework for the del ivery of heal t h services to i nj u red work­ ers. www.workcover.gov.au. 2004. 9 1 . Videman T, Nurminen M, Troup J D G . Lumbar spinal pathology i n cadave.-ic material in relation to h istory o f back pai n , occupation, and physical load­ ing. Spine 1 990; 1 5 : 728. 92. Videman T, Sarna S, Battie MC, et al. The long-term effects of physical load i ng and exercise l i [estyles on back-related symptoms, d isab i li ty and spinal pathology among men. Spine 1 99 5 ;20:699-709.

93. Videman T, Ballie Me. The innuence of occupation on l u m bar degeneration. Spine 1 999;24: 1 1 64- 1 1 68 . 9 4 . Vlaeyen J W S , Crom bex G . Fear of movement! ( re)injury, avoidance and pain disab i l i ty in chronic low back pain patients. Manual Therapy 1 999:4: 1 87- 1 95 . 95. V o n Kor[f M , Moore J E , Lorig K , et a l . A random­ i zed trial of layperson-led sel f-management group i n tervention [or back pain pat ients i n primary care. Spine 1 998;23 : 2608-2 6 1 5 . 96. Vroom en PCAJ, de Krom MCTFM , W i l m i n k JT, Kester ADM, Knollnerus JA. Lack of effect iveness of bed rest for sciat ica. N Engl J Med 1 999;340: 4 1 8-42 3 . 97. Waddell G . A n e w c l i nical model for the treatment of low-back pai n . Spi ne 1 987; 1 2 :634. 98. Waddel l G . A new cli nical model for the treatment of low back pain. I n : Weinstein I N , Wiesel SW, eds. The Lumbar Spine: The I n ternational Society for the Study of the Lu m bar Spine. Phi ladelphia: WB Saunders, 1 990:38-56. 99. Waddell G . The Back Pain Revol ution, 2nd ed . Edinburgh: Churc h i l l Livingstone, 2004. 1 00. Waddell G , Main Cl , Morris EW, et al. Chronic low back pain, psychological distress and i l l ness behav­ ior. Spine 1 984;9:209. 1 0 1 . Waddell G, B urton AK. Occupational health guide­ l i nes [or the management of low back pai n at work-evidence review. Faculty of Occupat ional Medicine. London, 2000. 1 02 . Wadde l l G, Morris EW, D i Paoloa M, e t al . A con­ cept o f i l lness tested as a n i m proved basis [or surgical decisions in l ow back di sorders. Spine 1 986 ; 1 1 : 7 1 2 . 1 03 . Weber H . Lumbar disc herniation : A control led, prospective study with 1 0 years of observation. Spine 1 983;8: 1 3 1 - 1 40. 1 04 . Wiesel SE, Tsourmans N, Feffer H L, e t al. fl_ study of computer-assisted tomography. 1. The i ncidence of pos i tive CAT scans i n an asymptomatic group of patients. Spine 1 984;9:549. 1 05 . Wil tse LL, Rocchio PF. Preoperative psyc hological tests as predictors of success of chemonucleolysis in the t reatment of the low back syndrome. J Bone J o i n t Surg [Am] 1 975;57:478. 1 06. Scotland's Work i ng Backs Partnership 2000. Working Backs Scotland, www.workingbacksscotland.com 1 07 . Yu kawa U , Kato Fu m i h iko, Ma tsu bara Y, Kaj i no G, Nakamura S, N i tta H. Serial magnet ic reso­ nance i maging fol low-up study of l u m bar rusc herniation conservat ively t reated for average 30 months: Relation between reduction of hern i a­ tion and degeneration of disc. J Spinal Disord 1 996;9: 2 5 1 -2 5 6 . 1 08 . Zarkowska E , P h i l i ps He. Recen t onset vs. persis­ tent pai n : Evidence for a distinction. Pain 1 987; 25 :365.

PART

Basic Science

CHAPTER 5

Lumbar Spine Stability: Mechanism of Injury and Restabilization

Stuart M. McGill

Editor's Note The foundation of the reactivation self-care model is grounded in the sciences of biomechanics and

neurophysiology. This section reviews the most

CHAPTER 6

common mechanisms of spine injury as well as the

The Sources of Back Pain

most likely sources of pain. How to improve stabil­

Nikolai Bogduk and Charles Aprill

ity patterns and the exercise science behind that are also key areas of discussion in this section.

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Lumbar Spine Stability: Mechanism of Injury and Restabilization

Stuart M. McGill

Introduction

Learning Objectives

The Injury Process

On completion of this chapter you should be able to:

Summary of Specific Tissue Injury Mechanisms The Injury Process-Motor Changes Instability as a Cause of Injury

•

•

On Stability: The Foundation A Philosophy of Low Back Exercise Prescription What are the Stabilizers of the Lumbar Torso? Training Quadratus Lumborum Training Rectus Abdominis, the Obliques, and Transverse Abdominis

•

Explain stability and the foundation [or clinical instability Understand injury mechanisms to ensure that injury exacerbating maneuvers are not unknow­ ingly involved when prescribing therapeutic exercise Be able to prescribe basic stabilization exercises designed to coordinate muscular contraction to challenge both muscle and the motor system while simultaneously sparing the spine joints

Training the Back Extensors (and Stabilizers) The Beginner's Program for Stabilization Advanced Techniques

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Part Two: Basic Science

Introduction

Trad itional emphasi s on the enhancement of muscle strength and spine range of motion during rehabili­ tation protocols has not reduced back troubles; in fact, some evi dence suggests a link to negative out­ come in signi ficant numbers of people. Scientific efforts to quantify the mechanisms of i njury and of stability suggest that a spine must first be stable to minimize the risk of t issue overload and damage that result fTom either inappropriate muscle activation and/or spine joint position. The concept of stability, together with notions of design and application of stabilization exercise, is briefly synthesized. The objec­ tive is to challenge muscle systems to achieve suffi­ cient functional stability, but to achieve this challenge in a way that spares the spine of excessive exacerbat­ ing load. Lumbar stability, core stability, and low-back sta­ bilizing exercises are popular topics related to opti­ mal athletic/occupational performance and to the rehabilitation of painful backs. The objective of such exercise is to enhance the ['unction of these critical torso muscles in a way that spares the spine from damage. The intention of this chapter is to develop a synthesis of the scientific foundation and formaliza­ tion of the notion of stability as it pertains to the lum­ bar spine, and then to provide specific guidelines [or enhancing stability to advance spine rehabilitation. Although a large book could be written to describe ideal exercise programs for the entire population including those with chroni c low back pain, adoles­ cents to geriatrics through to elite athletes, the focus of the exercises discussed here is more toward the begi nner's program-develop ing the safest exercise for enhancing stability and for acquiring and main­ taining low back health. For the i nterested reader, more extensive references together with tabulated data of specific muscle activation profiles, resultant spine loads, etc., can be found in the authors review chapters and original papers listed at www.ahs. uwaterloo.ca/kin/kinfac/mcgill.html or in my recent textbooks Low Back Disorders: Evidence Based Pre­ vention and Rehabilitation (56) and Ultimate Back Fit­ ness and Performance (58). In most trad itional approaches to designing low back exerci se, an emphasis has been placed on the immediate restoration, or enhancement, of spine range of motion and muscle strength.Generally, this approach has not been sufficiently efficacious in reducing back troubles; in fact, a review of the evi ­ dence suggests only a weak link with improving back symptoms, whereas some studies suggest a link with negative outcome in signi ficant numbers of people (51). It appears that the emphasis on early restora­ tion of spine range of motion continues to be driven

by legislative definitions of low back disability, namely loss of range of motion. Thus, therapeutic success is often judged on motion restored. Most recent work suggest little correlation between ROM and work ver­ satility ratings (64). The underlying theme of this chapter, and in fact book, reflects the developing phi­ losophy based on mechanisms of injury and stability that a spine must first be stable before moments and forces are produced to enhance performance but to do so in a way that spares the spine h-om potentially inju­ rious load. Preliminary field evidence (although not yet definitive) suggests that the approach has promise. The meaning of the words "spi ne stabili ty" depends on the background of the individual; to the biome­ chanist, they pertain to a mechanical structure that can become unstable when a critical point is reached; a surgeon may view abnormal joi nt motion patterns as unstable but correctable by changing the anatomy; the manual medicine practitioner may interpret patterns of muscle coordination and posture and attempt to alter one, or a few, muscle activation pro­ files. Several groups have made contributions to the stability i ssue but only a vel-y few have aLLempted to actually quantify stability and joint moment and force demands. This chapter is biased toward efforts to quanti fy stability and develop cl inical notions based on direct biomechanical evidence of stability indexes, resultant joint and paraspinal tissue loads, and measurements of processed muscle activation and joi nt motion patterns. For this reason, the reader is familiarized with injury mechanisms first to mini­ mize the risk of inadvertently prescribing routines that produce unnecessarily high loads on damaged tissues.

The Injury Process­ Tissues Damage

There is a tendency among those reporti ng or describ­ ing the back injury to identify a single specific event as the cause of the damage, such as lifting a box and twisting. This descri ption of low back injury is com­ mon, particularly among the occupational/medical community who are often required to i dentify a single event when filling out injury reporting forms. How­ ever, relatively few low back injuries occur fTom a sin­ gle event. Rather, the culminat ing injury event was preceded by a history of excessive load ing that grad­ ually, but progressively, reduced the level of tolerance to tissue failure (49). Thus, other scenarios in which subfailure loads can result in injury are probably more important. For example, the ultimate failure of a t issue (i.e., injury) can result from accumulated trauma produced e ither by repeated application of load (and failure from fatigue) or of a sustained load

Chapter Five: Lumbar Spine Stability: Mechanism of Injury and Restabilization

that is applied for long durations or repetitively applied (and failure fl-om deformation and strain). Thus, the injury process may not always be associ­ ated with loads of high magnitude. Finally, it goes without saying that loss of mechanical integrity in any load bearing tissue of the spine 'will result in stiffness losses and an increased risk of unstable behavior. Thus, documenting the injury process is a necessary foundation for understanding, formulat­ ing, and utilizing the concepts of spine instability and stability. Whereas excellent progress has been made in the laboratory documen ti ng specific instabilities in flexion-extension, lateral bend, and axial rotation modes in animal preparations (63), understanding the injury process in humans (the cause of back trou­ bles in real life) has perhaps been hampered by the focus on exposure to a single variable, namely acute, or single maximum exposure to, lumbar compres­ sion. A few studies have suggested higher levels of compression exposure increased the risk of LBD (e.g., 31), although the correlation was low. Further, some studies show that higher rates of LBDs occur when levels of lumbar compression are reasonably low. Are there other mechanical variables that mod­ ulate the risk of LBDs? There are many tissues in the lower back and many different modes of loading that occur when performing work and exercise. Apart fl-om joint com­ pression, joint shear has been shown to be very important as a metric for injury risk in the Norman et al. study (60), particularly cumulative shear over a work day. Shear is an interesting variable because whereas most studies report reaction shear (that is the action of gravity and load in the hands to shear forward the ribcage on the pelvis through the lumbar spine), this is not the form of shear load that is expe­ rienced by the lumbar joints. In a series of work, the Waterloo group (43,66,48) has shown that if the spine maintains a neutral curvature (the torso is flexed for­ ward about the hips, neither flexing nor extending the spine itself), then the dominant low back exten­ sors with their unique force vector direction (specif­ ically longissimus thoracis and iliocostalis lumborum) support the shear reaction forces caused by the action of gravity on the flexed torso, resulting in a lowering of the shear load experienced by the joint. These forces would normally be borne by the disc and facet joints. However, if the individual elects to flex the spine itself when bending forward, suffi­ ciently so to stretch the posterior ligaments with full spinal flexion, then the architecture of the inter­ spinous ligaments cause anterior shear forces (32) to add to the shearing reaction fl-om gravity. Further­ more, ligamentous involvement disables the lumbar muscles (specifically noted) from supporting the

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reaction shear as they reorientate to a line of action more parallel to the compressive axis (54) (Fig. 5.l). With full spine flexion and a modest amount of grav­ itational reaction shear, it is not diff]cult to exceed shear failure loads of the spine, which have been found to be approximately 2,000 to 2,800 Newtons in adult cadavers (20). This paragraph suggests that personal work technique or, more specifically, spine motion can affect the risk of spine damage. Recent work by Yingling et al. (77) on pig spines has shown that load rate is not a major modulator of shear tol­ erance unless the load is very ballistic, such as what might occur during a slip and fall. Summarizing the lumbar sagittal motion and shear issue, evidence from tissue-specific injury studies generally supports the notion of avoiding full lumbar flexion when per­ forming loading tasks to minimize the risk of low back injury. There is no evidence to support conscious effort to perform pelvic tilts (i.e., hyperlordosis or lumbar flexion) during lifting or exertion. Although twisting has been named in several studies as a risk factor for low back injury, the liter­ ature appears confused by not making the distinc­ tion between the kinematic variable of twisting and the kinetic variable of generating twisting torque. Whereas many epidemiological surveillance studies link a higher risk of LBD with twisting, twisting with low twist moment results in relatively low muscle activity and correspondingly low spine load (45,46). Further, passive tissue loading is not substantial until the end of the twist range of motion (22). However, developing twisting moment places very large com­ pressive loads on the spine because of the enormous co-activation of the spine musculature (46) and this can occur when the spine is not twisted, but in a neu­ tral posture in which the ability to tolerate loads is higher. It would appear that either single variable (the kinematic act of twisting, or generating the kinetic variable of twist torque while not twisling) is less dangerous than may be suggested by epidemio­ logical surveys. However, it would appear that ele­ vated risk from very high tissue-loading occurs when the spine is fully twisted at the same time when there is a need to generate high twisting torque (46). There are many personal factors that appear to affect spine tissue tolerance, for example age and gender. Jager et al. (35) compiled the available liter­ ature that passed their inclusion criteria on the tol­ erance of lumbar motion units to bear compressive load. Their results revealed that if males and females are matched for age, females were able to sustain only approximately two-thirds of the compressive loads of males. Furthermore, the data of Jager et al. showed that within a given gender, the 60-year-old spine was able to tolerate only approximately two­ thirds of that tolerated by a 20-year-old. There are

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Figure 5.1 Subjects rotated about the hips while maintaini n g a

neutral l ordosi s to act ivate the longissimus/il iocostal i s complex. Note the oblique angle of the fibers in the u l t rasound image w i t h respect to the compressive a x i s suggesting these muscles produce large shear forces. This angle is lost, together w i t h the protective shear fOITes , when the spine i s flexed.

other personal factors such as motor control system fitness in which it appears a motor control error can lead to a back injury during very benign tasks such as picking up a pencil from the floor. (This is explained in a subsequent section.) Many factors appear to modulate the risk of spe­ cific low back tissues damage other than load mag­ nitude and loading mode. Although disc herniations have been produced under controlled conditions (e.g., 28), Callaghan and McGill (14) have been able to consistently produce disc herniations by mimick­ ing spine motion and load patterns seen in workers

and in replicating the motion and loads of some lumber extension exercise machines. Specifically, it appears that only a very modest amount of spine compression force is required (only 800-1000 N) but the spine specimen must be repeatedly flexed­ mimicking repeated torso-spine flexion from con­ tinual bending to a fully flexed posture. In these experiments, the progressive tracking of disc nucleus material traveling posteriorly through the annulus of the disc was documented with sequestration of the nucleus material approximately 18,000 to 25,000 cycles of flexion (fewer cycles were required for her-

Chapter Five: Lumbar Spine Stability: Mechanism of Injury and Restabilization

niation with higher simultaneous compressive loads). This study included the utilization of a pig degener­ ative trauma model, which on one hand was an ani­ mal model but on the other, control over age, diet, and physical activity provided a uniqu� opportunity. Spines and discs obtained from humans are typically older and have lost sufficient disc hydration to match the hydration levels, and potential for herniation, seen in the age groups of workers at risk for this spe­ cific type of event (typically 30-50-year-olds). But the important point here is that herniation appears to be more strongly linked to repeated flexion motion rather than load. Another modulator for tissue damage appears to be the posture of the joint resulting from the curva­ ture of the spine in vivo. For example, Adams et al. (3) showed that a fully nexed spine is weaker than one that is moderately flexed. In a most recent study, Gunning and McGill (29) have shown that a h.Illy flexed spine (using a controlled porcine spine model) is 20% to 40% weaker than if it were in a neutral posture, and that hydration levels matched to the changes seen in peoples' discs throughout the work day also modulate the tolerance. For example, the spinal discs are more easily damaged first thing in the morning on rising [Tom bed when they are fully hydrated. A fascinating study, reported by Snook and colleagues (70), demonstrated that of 85 patients randomly assigned to a group that controlled the amount of early morning lumbar flexion had signifi­ cant reduction in pain intensity, compared to a con­ trol group. Then, when the control group received the experimental treatment they responded with similar reductions. Collectively, the evidence suggests that the risk of spine tissue damage is a f-unction of load magnitude, directional mode of the applied load, motion repeti­ tion, spine posture, hydration level and time of day, motor control and instantaneous stability, and indi­ vidual age and gender. Injury history and tissue dam­ age is an overlaying modulator. Collectively these data supports the notion of an envelope of motion and loading for optimal tissue health. In addition, it is well known that tissues adapt and remodel with load (e.g., bone, Carter (16); ligament, Woo et al. (76); disc, Porter (65); vertebrae, Brinckrnann et al. (11 », which is at the core of any rehabilitation program. However, biological variability prevents the identifi­ cation of specific levels of loading that either build tis­ sue or initiate breakdown, together with the optimal rest periods and days off that promote healthy tissue adaption for a given individual. Thus, it would appear that the wisest philosophical approach for the opti­ mal design of activity, either during the activities of daily living or during rehabilitation efforts, may be to adopt the notion that too much of any single activ-

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ity is problematic. No rehabilitation program can be fully effective if patients undo the beneficial responses of therapy with inappropriate activities of daily living.

Summary of Specific Tissue Injury Mechanisms A very brief description of tissue damage from exces­ sive load is provided here. All injuries noted are known to be accelerated with repetitive loading. Endplates Schmorls nodes are thought to be healed

end plate fractures (75) that are linked to trauma (5). In fact, traumatic Schmorls node formation has been documented (via MRI) in a patient after forced lum­ bar flexion, which resulted in an injury (40). People apparently are not born with Schmorls nodes and their presence is associated with a more active lifestyle (30). Under excessive compressive loading of spinal units in the laboratory, the endplate appears to be the first structure to be injured (11,14), whereas Gunning and McGill (29) have shown discs hydrated to mimic conditions similar to just rising from bed fail at a much lower load (20%-40%), compared to the strength later in the day (they also observed that failure was reached at lower levels if the spines were fully flexed at the time of loading). Endplate avulsion has been observed under excessive anterior-posterior shear loading. Vertebrae Vertebral cancellous bone is damaged under compressive loading (26) and often accompa­ nies disc herniation and annular delamination (29). Disc Annulus Several types of damage appears to

occur. Classic disc herniation appears to be associ­ ated with repeated flexion motion with only moder­ ate compressive loading required (14) and repeated full flexion with lateral bending and twisting (1,28). Avulsion of the lateral annulus, in particular, has been documented under anterior posterior shear loading (78). Annular damage during twisting has been noted in animal spines (e.g., 61) but the link remains a controversial issue in humans. Farfan et al. (23) concluded that axial twists were the most important factor in the initiation of damage to the annulus, whereas Adams and Hutton (2) suggested that healthy facet joints prevent such an occurrence. Disc Nucleus Although Buckwalter (12) has stated

"no other musculoskeletal soft tissue structure under­ goes more dramatic alterations with age .. . " the relationship between loading, disc nutrition, de­ creasing concentration of viable cells, accumulation of degraded matrix molecules, and fatigue failure of the matrix remain obscure. However, recently Lotz

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Part TlNo: Basic Science

et al. (41) has documented cell death (apoptosis) within the nucleus increases under excessive com­ pressive load. It is interesting that these changes are not delectable or diagnosable in vivo. Neural Arch (Posterior Bony Elements) Spondylitic

fTactures are thought to occur from repeated stress strain reversals associated with cyclic full flexion and extension (30,13). Excessive shear forces have been also documented to fTacture parts of the arch (20,75). Ligaments It appears that ligaments avulse at lower

load rates but will tear in their midsubstance at higher rates of load (61). Landing on the buttocks fi"om a fall has been hypothesized by McGill (49) to rupture the interspinous complex given the docu­ mented forces (52) and joint tolerance. Falling on the behind results in a higher risk for prolonged disabil­ ity (73), which is consistent with the prolonged length of time for ligamentoLis tissue to regain struc­ tural integrity, if ever (76).

Summary

of

Injury Pathways

Avoidance of further tissue damage during rehabili­ tation exercise and activities of daily living is a criti­ cal objective. Evidence suggests that reduction in specific tissue damage could be accomplished by: 1.

Reducing peak (and cumulative) spine compres­ sive loads to reduce the risk of end-plate damage;

2. Reducing repeated spine motion to full flexion to reduce risk of disc herniation; reducing spine flexion in the morning reduces symptoms; 3.

Reducing repeated full range flexion to full range extension to reduce the risk of pars (or neural arch) fracture;

4.

Reducing peak and cumulative shear forces to reduce the risk of facet and neural arch damage;

5. Reducing slips and falls, or ballistic loading, to reduce risk of passive collagenous tissues such as ligaments; 6.

Reducing length of time sitting, particularly exposure to seated vibration to reduce a risk of disc herniation or accelerated degeneration.

making a case for targeting specific muscle groups during rehabilitation. Specifically, their objective is to re-educate fault), motor control patterns after injury. The challenge is to train the stabilizing system during steady-state activities together with stabilizing during rapid voluntary motions and to withstand sudden surprise loads. A wide variety of motor changes have been docu­ mented with particular attention directed to the transverse abdominis and multifidus muscles. For example, during anticipatory movements like sud­ den shoulder flexion movements, the onset of trans­ verse abdominis has been shown to be delayed in some individuals with back troubles (34,67,62), sug­ gesting compromise of the ability to ensure spine sta­ bility. They have developed a rehabilitation protocol specifically intended to re-educate the motor control system for involvement of the transverse abdominis. Changes to the multifidus complex in some indi­ viduals have also been well-documented by a num­ ber of laboratories. For example, Sihvonen et al. (69) documented diminished myoelectric activity around the unstable joints during concentric contractions. Jorgensen and Nicoliasen (37) and Nicoliasen and Jorgensen (59) have associated lower endurance in the spine extensors in general, whereas Roy et al. (68) established faster fatigue rates in the multi­ fidus, in many individuals with low back troubles. Further, there is evidence that the structure of the muscle itself experiences change after injury or pain episodes, and several have documented selective atro­ phy in the type II fibers (24,25,38,42,79), whereas long-term outcome was associated with certain composition characteristics. Specifically, good out­ come was associated with normal fiber appearance, whereas poor outcome was associated with atrophy in the type II fibers and a moth-eaten appearance observed in type I fibers. Further, even after symp­ toms have resolved, Hides et al.(33) have documented a smaller multifidus and suggested impaired reflexes as a mechanism. This theory appears tenable given documented evidence of this at other joints, partic­ ularly at the knee (36,71,72). It is this collection of evidence that supports stabilization exercises that pro­ mote patterns of muscular co-contraction observed with fit spines.

The Injury Process-Motor Changes Those reporting debilitating low back pain conclu­ sively have simultaneous changes in their motor con­ trol systems. Recognizing these changes is important because they effect the stabilizing system and, there­ fore, are a focal point for optimal rehabilitation. Richardson et al. (67) have produced quite a com­ prehensive review of this literature together with

Instability as a Cause of Injury

Although biomechanists have been able to success­ fully explain how strenuous exertions cause specific low back tissue damage, explaining how injury occurs from tasks such as picking up a pencil from the floor has been more challenging.Recent evidence suggests that such injuries are real and result [Tom the spine

Chapter Five: Lumbar Spine Stability: Mechanism of Injury and Restabilization

buckling or exhibiting unstable behavior. But this buckling mechanism can occur during far more challenging exertions as well. A number of years ago we were investigating the mechanics of power-lifter spines while they lifted extremely heavy loads using video fluoroscopy to view their vertebrae in the sagittal plane. During their lifts, even though the lifters outwardly appeared to fully flex their spines, in fact their spines were 2 to 3 degrees per joint fTom full flexion, thus explaining how they could lift magnificent loads without sus­ taining injury-the risk of disc and ligamentous damage is greatly elevated when the spine is fully flexed (which the lifters skillfully avoided). We hap­ pened to capture one injury on the fluoroscopic motion fi1m-the first such observation that we know of. During the injury incident, just as the semi­ squatting lifter had lifted the load approximately 10 cm off the floor, only the L2/L3 joint briefly rotated to the full flexion calibrated angle and exceeded it by one-half a degree, whereas all other lumbar joints maintained their static positions (not fully flexed) (17). The spine buckled! Sophisticated modeling analysis revealed that buckling can occur fTom a motor control error in which a short and tem­ porary reduction in activation to one, or more, of the intersegmental muscles would cause rotation of just a single joint so that passive or other tissues become irritated or possibly injured (18). Adams and Dolan (4) have noted that passive tissues begin to damage with bending moments of 60 Nm-this occurs simply with the weight of the torso when bending over and a temporary loss of muscular support. This scenario is not an excessive task, but it is often reported to clinicians by patients as the event that caused their injury (i.e., picking up a pencil). However, reporting of such an event will not be found in the scientific literature. Medical per­ sonnel would not record this event because in many jurisdictions it would not be deemed a compen­ sable injury-the medical report attributes the cause elsewhere. Other evidence linking poor motor coordination with higher risks for the lumbar spine reaching crit­ ical points of instability exists and is revealing. Cholewicki and McGill (18) have identified through a modeling analysis, the nodal points, or specific spinal joint, where buckling could occur from specific motor control elTors. Such inappropriate muscle sequencing has been observed in men who are chal­ lenged by holding a load in the hands while breathing 10% CO2 to elevate breathing. On one hand, the mus­ cles must co-contract to ensure sufficient spine sta­ bility, but on the other, challenged breathing is often characterized by rhythmic/contraction/relaxation of the abdominal wall (44). Thus, the motor system is

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99

presented with a conflict-should the torso muscles remain active isometrically to maintain spine stabil­ ity or will they rhythmically relax and contract to assist with active expiration (but sacrifice spine sta­ bility). Fit motor systems appear to meet the simul­ taneous breathing and spine support challenge­ unfit ones may not. All of these deficient motor con­ trol mechanisms will heighten biomechanical suscep­ tibility to injury or reinjury (18,19). In vitro, a ligamentous lumbar spine buckles under compressive loading at approximately 90 Newtons (approximately 20 lb) highlighting the critical role of the musculature to stiffen the spine against buck­ ling (with the critical work and analysis of he passive tissues being performed by Crisco and Panjabi (21) . Anatomical arrangement of muscle around the spine, coupled with critically important patterns of activa­ tion, enables the spine to bear a much higher com­ pressive load as it stiffens and becomes more resistant to buckling but in so doing, the spine bears even more load because of the stiffening muscle activity. As noted, aberrant patterns of activation can result in instantaneous spine instability (18) and acute tis­ sue overload. But over the longer-term, several groups including the Queensland group (66) have developed a tissue damage model which suggests chronically poor motor control (and motion patterns) initiates microtrauma in tissues, which accumulates leading to symptomatic injury. Injury leads to further dele­ terious change in motor patterns such that chronic­ ity can only be broken with specific techniques to re-educate the local muscle-motor control system. Both acute and chronic instability tissue models have been proposed. But given the wide range of indi­ viduals and physical demands, questions remain as to what is the optimal balance in terms of stability, motion facilitation, and moment generation-if sta­ bility is achieved through muscular cocontraction, how much is necessary and how is it best achieved?

On Stability: The Foundation

This section shall formalize the notion of stability from a spine perspective. During the 1980s, Profes­ sor Anders Bergmark of Sweden, very elegantly for­ malized stability in a spine model with joint stiffness and 40 muscles (9). In this classic work he was able to formalize mathematically the concepts of energy wells, stiffness, stability, and instability. For the most part, this seminal work went unrecognized largely because the engineers who understood the mechan­ ics did not have the biological-clinical perspective, and the clinicians were hindered in the interpreta­ tion and implications of the engineering mechanics. This pioneering effort, together with its continued

J 00

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Part Two: Basic Science

evolution by several others, is be synthesized here­ the current author has attempted to encapsulate the critical notions without mathematical complexity but directs the mathematically inclined reader to other sources (9,18). The concept of stability begins with potential energy that, for the purposes here, is of two basic forms. In the first form, objects have potential energy by virtue of their height above a datum. PE

=

mass

*

gravity

*

height

Critical to measuring stability are the notions of energy wells and minimum potential energy. If a ball is placed into a bowl it is stable, because if a force was applied to the ball (or a perturbation) the ball will rise up the side of the bowl but then come to rest again in the position of least potential energy at the bottom of the bowl, or the energy well. As noted by Bergmark, a stable equilibrium prevails when the potential energy of the system is at minimum. The system is made more stable by deepening the bowl and/or by increasing the steepness of the sides of the bowl (Fig. 5.2). Thus, the notion of stability requires the specification of the unperturbed energy state of a system followed by study of the system following perturbation-if the joules of work performed by the perturbation is less than the joules of potential energy inherent to the system, then the system will remain stable (i.e., the ball will not roll out of the bowl). The corollary is that the mechanical system will collapse jf the applied load exceeds a critical value (determined by potential energy and stiffness). The previous ball analogy is a two-dimensional example. This would be analogous to a hinged skeletal joint that only has the capacity for flexion/extension. Spinal joints can rotate in three planes and trans­ late along three axes requiring a six-dimensional bowl for each joint-mathematics enables the exam­ ination of a 36-dimensional bowl (6 lumbar joints with 6 degrees of fTeedom) representing the whole lumbar spine. If the height of the bowl were decreased in any one of these 36 dimensions, the ball could roll

A

B

out. In clinical terms, a single muscle having an inappropriate force (and thus stiffness), or a damaged passive tissue, which has lost stiffness, can cause instability that is both predictable and quantifiable. Whereas potential energy by virtue of height is usef"ul for illustrating the concept, potential energy as a function of stiffness and storage of elastic energy is actually used for musculoskeletal application. Elastic potential energy is calculated from stiffness (k) and deformation (x) in the elastic element: PE

=

1/2

*

k '" x'2

In other words, the greater the stiffness (k), the greater the steepness of the sides of the bowl (from the previous analogy), and the more stable the struc­ ture. Thus, stiffness creates stability (Fig. 5.3). Active muscle produces a stiff member and in fact the greater the activation of the muscle, the greater this stiffness-it has long been known that joint stiffness increases rapidly and non-linearly with muscle acti­ vation such that only very modest levels of muscle activity create sufficiently stiff and stable joints. Fur­ thermore, joints possess inherent joint stiffness as the passive capsules and ligaments contribute stiff­ ness particularly at the end range of motion. The motor control system is able to control stability of the joints through coordinated muscle co-activation and to a lesser degree by placing joints in positions that modulate passive stiffness contribution. How­ ever, a faulty motor control system can lead to inap­ propriate magnitudes of muscle force and stiffness, allowing a valley for the ball to roll out or clinically and for a joint to buckle or undergo shear transla­ tion. But mechanical systems, and particularly mus­ culoskeletal linkages, are limited to analysis of local stability since the energy wells are not infinitely deep and the many anatomical components contribute force and stiffness in synchrony to create surfaces of potential energy where there are many local wells. Thus, local minima are located from examination of the derivative of the energy surface (9,18). Spine

c

o

Figure 5.2 The continuum of stability. A is most stable whereas D is least stable. The

ball in the bowl seeks the energy well or position of minimum potential energy ( m"g,·, Deepening the bowl or increasing the steepness o f the sides increases tbe ability to survive perturbatio n . This increases stability.

Chapter Five: Lumbar Spine Stability: Mechanism of Injury and Restabilization

p

Figure 5.3

101

p

�

A

--

�

B

(A) Increasing the sti ffness of the cables (muscles)

i ncreases the stabil i ty (or deepens the bowl) and increases the abil i ty to support larger applied loads p without fal l i ng. (B) Spine stiffness (and stability) i s achieved by a complex interacti o n of stiffening structures along the spine and (C) those forming the torso wall ( right panel).

stability, then, is quantified by forming a matrix in which the total stiffness energy [or each degree of fTee­ dom of joint motion is represented by a number (or Eigen value) and the magnitude of that number rep­ resents its contribution to forming the height of the bowl in that particular dimension. Eigen values less than zero indicate the potential for instability. The eigenvector (different fTom the Eigen value) can then identify the mode in which the instability occurred, whereas sensitivity analysis may reveal the possible contributors allowing unstable behavior. Gardner­ Morse et al. (27) have initiated interesting investiga­ tions into eigenvectors by predicting patterns of spine deformation caused by impaired muscular interseg­ mental control or for clinical relevance-what mus­ cular pattern would have prevented the instability? Activating a group of muscle synergists and antago­ nists in the optimal way now becomes a critical issue. In clinical terms, the full complement of the stabiliz­ ing musculature must work harmoniously to ensure stability together with generation of the required moment and desired joint movement. But only one muscle with inappropriate activation amplitude may produce instability, or at least unstable behavior could result at lower applied loads. How much stability is necessary? Obviously insuf­ ficient stiffness renders the joint unstable but too much stiffness and co-activation imposes massive load penalties on the joints and prevents motion. Sufficient stability is a concept that involves the determination of how much muscular stiffness is necessary for stability together with a modest amount of extra stability to form a margin of safety. Interest­ ingly enough, given the rapid increase in joint stiff­ ness with modest muscle force, large muscular forces are rarely required. In our recent papers, stabilization exercises were quantified and ranked for muscle acti-

vation magnitudes together with the resultant spine load (15,56). Quantification of individual tissue loads in the spine is a complex procedure and an issue out­ side the constraints of this article and is reported else­ where (47) (see Table 26.1).Furthermore, Cholewicki's work (19) has demonstrated that sufficient stability of the lumbar spine is achieved, in an undeviated spine, in most people with modest levels of co-activation of the paraspinal and abdominal wall muscles. This means that people, from patients to athletes, must be able to maintain sufficient stability in all activities with low, but continuous, muscle activation. Thus, maintaining a stability margin of safety when per­ forming tasks, particularly the tasks of daily living, is not compromised by insufficient strength but rather insufficient endurance. We are now beginning to understand the mechanistic pathway of those studies showing the ef-ficacy of endurance training for the muscles that stabilize the spine. Having strong ab­ dominals does not necessarily provide the prophylac­ tic effect that had been hoped for, but several works suggest that endurable muscles reduce the risk of future back troubles (e.g., 10).

A Philosophy of Low Back Exercise Prescription

Many traditional notions that exercise professionals consider to be principles for exercise prescription, particularly when dealing with the low back, may not be as well supported with data as generally thought. A review of the efficacy of traditional exercise versus stabilization programs both identified and motivated a re-examination of conventional thought (51). For example, there is a widely held view that sit-ups should be performed with bent knees, but it is becoming

1 02

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Part Two: Basic Science

apparent that the resultant spinal loading (well more than 3000 N of compression to a [-ully flexed spine) suggests sit-ups are not suitable for most people at all. Other abdominal challenges are more effective and safer. Other examples include, contrary to the belief of many, adopting a posterior pelvic tilt when per­ forming many types of low back exercise actually increases the risk of injury by flexing the lumbar joints and loading passive tissues. Having stronger back and abdominal muscles appears to have no prophylactic value for reducing bad back episodes; however, muscle endurance has been shown to be protective ( 1 0). Greater lumbar mobility leads to more back troubles, not less (10) ! And, in fact, ROM appears to have little correlation with work disability status (64). It is also troubling that replicating the motion and spine loads that occur during the use of many low back extensor machines used for training and therapy produces disc hernia­ tions when applied to spines in our laboratory! It is clear that some cunent clinical wisdom needs to be re-examined in the light of relatively recent scientific evidence (those interested in the literature evidence should consult my review in my textbooks) (56,58). It appears that the safest and mechanically justifi­ able approach to enhancing lumbar stability through exercise entails a philosophical approach consistent with endurance, not strength; that ensures a neutral spine posture when under load, and that encourages abdominal cocontraction and bracing in a functional way. (A neutral posture is defined as one in which the joints and surrounding passive tissues are in elastic equilibrium and thus at an angle of minimal joint load). It is also acknowledged that optimal athletic performance, which demands reaction and prehen­ sion challenges, is not synonymous with health objec­ tives and that additional risk is accepted for extreme ranges of motion and particular motor patterns. The most recent insights provided by Cholewicki suggest that whereas steady-state motor patterns are impor­ tant for daily activity, the health of reflexive motor patterns is critical for maintaining stability during sudden events ( 1 9), achieving a fit and effective motor control system probably requires training in a variety of static and dynamic, expected and unexpected, and stable and labile conditions.

What are the Stabilizers of the Lumbar Torso?

Although many muscles have been regarded as pri­ mary spine stabilizers, confirmation of their role requires two levels of analysis. First, engineering sta­ bility analysis must be conducted on anatomically robust spine models to document the ability of each

component to stiffen and stabilize. Second, electro­ myographic recordings of all muscles (even deep muscles requiring i ntramuscular electrodes) are nec­ essary to confirm the extent that the motor control system involves each muscle to ensure sufficient stability. For some time, our limited intramuscular EMG and modelling studies, and those of others, sug­ gested that virtually all torso muscles play a role in stabilization. (Our most recent quantification break­ throughs appear at the end of this section). How­ ever, whereas multifidus, the other extensors, and the abdominal wall, have been highlighted before, the architecture of quadratus lumborum (QL) suggests that it can be a stabilizer. This notion is further strengthened by some earlier observation that the motor control system involves this muscle together with the abdominal wall when stability is required in the absence of major moment demands. The fibers of QL cross-link the vertebrae. They have a large lateral moment arm via the transverse process attachments and traverse to the rib cage and iliac crests. Thus, the QL could buttress shear instability and could be effec­ tive in all loading modes, by design. Typically, the first mode of buckling is lateral-the QL can play a significant role in local lateral buttressing. Further, activation profiles support the notion of the stabilizing role of quadratus. It is active during a variety of flexion-dominant, extensor-dominant, and lateral bending tasks. Specifically, Andersson et al. (7) found the QL did not relax with the extensors during the flexion-relaxation phenomenon. The flex­ ion- relaxation phenomenon is an interesting task because there is no substantial lateral or twisting torques and the extensor torque appears to be sup­ ported passively, suggesting some stabilizing role for QL. Other very limited data suggest (our laboratory techniques to obtain Q L activation were rather imprecise at the time) that in an experiment in which subjects stood upright, but held buckets in either hand in which load was incrementally added to each bucket, the QL appeared to increase its activation level (together with the obliques) as more stability was required. This task forms a special situation since only compressive loading is applied to the spine in the absence of any bending moments. The three lay­ ers of the abdominal wall are also important for sta­ bility together with muscles which attach directly to vertebra-the multisegmented longissimus and ilio­ costalis and the unisegmental multifidi. Cholewicki (18) has also presented an argument for the role of the small intertransversarii in producing small but critical stabilizing forces. However, psoas activation appears to have little relationship with low back demands-the motor con trol system activates it when hip flexor moment is required (6,39).

Chapter Five: Lumbar Spine Stability: Mechanism of Injury and Restabilization

Most recently we have completed evolution o[ our model to quantify the role of individual muscles to contribute to stability. Once again the conclusion is that all muscles are important and that the most important muscle at any instant or task is a transient ' variable-they continually change their relative con­ tribution. An example fl.-om one individual (Fig. 5.4) shows how the rank order o[ importance among muscles to stabilize changes with each task. In this case we have quantified the contribution to prevent buckling. It is interesting to observe how, in flexion tasks, the pars lumborum (in this example) plays a larger stabilizing role over the rectus abdominis. In contrast, during the extension tasks, the opposite holds true demonstrating the task dependent role reversal between moment generation and stability. In another example, we computed the stability index for a group of eight healthy men performing a vari­ ety of "stabilization" exercises, together with the resultant compression (Fig. 5.5). More stability is

'0 f'!

Tra ining Quadratus Lumborum

Given the architectural and electromyographic evi­ dence for OL as a spine stabilizer, the optimal tech­ nique to maximize activation but minimize the spine load appears to be the side bridge (Fig. 5.6) beginners bridge from the knees, whereas advanced bridges are from the feet. When supported with the feet and elbow the lumbar compression is a modest 2500 N, but the OL closest to the floor appear to be active up to 50% of MVC (the obliques experience similar challenge). Advanced technique to enhance the motor challenge is to roll [Tom one elbow over to the other, with abdominally bracing (Fig. 5.7) rather than repeated hiking the hips off the floor

350

[J RectAbd o ExtObl III lntObl

300

• ParsLum

250

� LongThor ffg) QuadLum I:J LatDors &I Mult rJ Trans

. l lioLum

c 0

� .� t5

I

en Q)

U

(J) ::J

200

:2 -5 .�

1 50

E

x Q) -0 c

.£

:0

1 00

en

Ui .� Q) (J) en Q)

50

U E 0 Abdcurl

1 03

generally associated with more compression. So, which are the wisest ways to challenge and train these identified stabilizers?

� -0

E �

--

Ball Exercise Posture

Figure 5.4 I n an altempt to understand the contributions of each m uscle pai r on spine

stab i l ity, the i ncrease in the stabil i ty i n dex is shown as a function of set t i ng each muscle pai r activation to 1 00% MVC; in this way t heir relative contribut i on could be assessed. This is an example from a single person; others w i l l have d ifferen t patterns. Note that the relative order of muscles t h at i ncrease stabil i ty changes across exercises. Also, in flexion tasks, the pars lumborum (in this example) plays a larger stabili z i ng role over the rectus abdom inis. I n contrast, during the extension tasks the opposite holds true, sug­ ges t i ng a task dependent role reversal between moment generation and stabil i ty. The exercises were: abcurl, curl-up on the stable floor; ball, sitting on a gym ball; and fpn leg/arm , four-poi n t kneeli n g while extending one leg and the opposite a1"111.

1 04 -- Part Two: Basic Science

1 600

3000 CJ Stability -+- Compression

2800

1 400

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Figure 5.5 Stabil i ty versus L4-LS compression for eight d ifferent stabil i7.ation exercises

(averages from a group of eight heal thy men), All exercises were performed with the abdom inal wall active and wel-e as Fol lows: ball , s i lt i ng on a gym ball ; chair, s i l t i ng on a chair; abcurl, curl-up on the noor; fp n leg, Four-poi n t kneeling while extending one leg at the h i p; bridge, back bridge on the noor; side bridge, s i de bridge with the elbow and Feet on the noor; bridge leg, back bridge but extending the knee and holdi ng one leg agai nst gravi ty; and fpn arm/leg, four-poi n t kneeling while extend i ng one leg and the opposite arm, Exercises are rank-ordered based on increasing lumbar spine stab i l i ty.

Figure 5.6 The horizontal i sometric side bridge. Support i ng the lower body w i t h the

knees on the noor reduces the demand further for t h ose who are more concerned w i t h sa fety w h i l e supporti ng t he body with t he feet increases the muscle challenge, b u t also the spine load.

�

Chapter Five: Lumbar Spine Stability: Mechanism of Injury and Restabilization

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1 05

Figure 5.7 Advanced side bridge-following each side bridge hold, one rolls from one

elbow to the other wh ile abdo m i nally braci n g locking the pelvis and the rib cage.

into the bridge position. Higher levels of activation would be reached with the feet on a labile sur­ face (71 ).

Training Rectus Abdominis, the Obliques, and Transverse Abdominis

Given the evidence [or the obliques and transverse abdominis in ensuring suFficient stability, quantita­ tive data have confirmed that there is no single abdominal exercise that challenges all of the abdom­ inal musculature (8,39) requiring the prescr i ption of more than one single exercise. Calibrated intra­ muscular and surface E MG evidence suggests that the various types of curl-ups challenge mainly rectus abdominis because psoas and abdominal wall (inter­ nal and external oblique, transverse abdominis) activity is relatively low. Sit-ups (both straight-leg and bent-knee) are characterized by higher psoas activation and higher low-back compressive loads that exceed NIOSH occupational guidelines, whereas leg raises cause even higher activation and also spine compression (8). It is also interesting that myoelec­ tric evidence suggests that there is no functional distinction between an upper and lower rectus ab­ dominis in most people but, in contrast, the obliques are regionally activated with upper and lower motor point areas together with medial and lateral compo­ nents. Transverse abdominis is selectively activated by dynamically hollowing in the abdominal wall (67), whereas an isometric abdominal brace co-activates transverse abdominis together with the external and internal obliques to ensure stability in virtually all modes of possible instability ( 1 8). Several relevant observations were made regard­ ing abdominal exercises in our investigations. The challenge to psoas is lowest during curl-ups, followed by higher levels during the horizontal side bridge, whereas bent-knee sit-ups were characterized by

larger psoas activation than straight-leg sit-ups, through to the highest psoas activity observed during leg raises and hand-on-knee flexor isometric exertions. It is interesting to note that the often-recommended press-heel sit-up that has been hypothesized to acti­ vate hamstrings and neurally inhibit psoas was actu­ ally confirmed to increase psoas activation (39) ! We note here that some clini cians and coaches who intentionally wish to train psoas and will find these data informative. Once again, the horizontal side support appears to have merit as it challenges the lat­ eral obliques and transverse abdominis without high lumbar compressive loading. Clearly, curl-ups excel at activating the rectus abdominis but produce relatively low oblique activ­ ity. Curl-ups w i th a twisting motion are expensive in terms of lumbar compression because of the additional oblique challenge. A wise choice for abdominal exercises, in the early stages of training or rehabilitation, for simple low back health objectives would consist of several variations of curl-ups for rectus abdominis and the side bridge for the obliques and quadratus, the variation of which is chosen com­ mensurate with patient/athlete status and goals.

Training the Back Extensors (and Stabilizers)

Most traditional extensor exercises are characterized with very high spine loads that result from externally applied compressive and shear forces (either h-om free weights or resistance machines). From our search for methods to activate the extensors (including longis­ simus, iliocostalis, and multifidi) with minimal spine loading, it appears that the single leg extension hold m inimizes the spine load ( <2500 N) and activates one side of the lumbar extensors to approximately 18% of MVC. Simultaneous leg extension with contralateral arm raise (birddog) increases the unilateral extensor muscle challenge (approximately 27% MVC in one

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Part Two: Basic Science

side of the lumbar extensors and 45% MVC in the other side of the thoracic extensors) but also increases lumbar compression to well more than 3000 N. This exercise can be enhanced with abdominal bracing and deliberate mental i maging of activation of each level of the local extensors. The often performed exercise of lying prone on the floor and raising the upper body and legs off the floor is contraindicated for anyone at risk for low back injury or re-injury. In this task the lumbar region pays a high compression penalty to a hyperextended spine (usually much higher than 4000 N), which transfers load to the facets and crushes the interspinous ligament.

Clinical Pearl A

Note on abdominal hollowing and bracing

In this aut hor's opinion, t here appears to be some confu­ sion in the broad i nterpretation of the l iterature regard­ ing the issue of abdom i nal hollowing and bracing. The Queensland group has evaluated hollowing-observing that the drawing i n of the abdomi naJ wall recruits trans­ verse abdo m i n is. G i ven that transverse abdomi n is has been noted to have i mpaired recruitment after injury (34,66), the Queensland group developed a therapy pro­ gram designed to re-educate the motor system to activate t ransverse abdom i n i s in a normal way in L B P patients. Hollowing was developed as a motor re-education exer­ cise and not necessarily as a technique to be recom­ mended to patients who require enhanced stabil i ty for performance of the ADL, which has perhaps been m isintel-preted by some c l i nical prac t i tioners. Rather, abdom i nal bracing that activates the three l ayers of the abdominal wall (external oblique, i n ternal oblique, trans­ verse abdo m i n is ) w i t h no drawing-in is m uch m ore effect i ve at enhancing spine stab i l i ty ( 5 6 ) . Specifically, the l u m bar torso must prepare t o wi t hstand steady­ state load i ng (which may be a complex combination o f nexion-extens i o n , lateral bend, and axial twisting mo­ ments), and w i t hstand sudden unexpected complex loads together w i t h loads t hat develop from anticipated and planned baJlistic motion. The abdominal brace is required to ensure suffici en t stab i l i ty using the oblique cross braci ng alt hough h igh levels of cocontraction are rarely required-probably approxi mately 5% MVC co­ contraction of the abdom i nal wall during performance of A D L and up to 1 0% MVC during rigorous act i vi ty.

The Beginner's Program for Stabilization

Some specific recommended low back exercises have been shown (50). We recommend that the program begin wi th the flexion-extension cycles--cat- camel-

(Fig. 5.8) to reduce spine viscosity and floss the nerve roots as they outlet at each lumbar level, fol­ lowed by hip and knee mobility exercises. Note that the cat-camel is intended as a motion exercise, not a stretch, so the emphasis is on motion rather than pushing at the end ranges of flexion and extension. We have found that five to six cycles are often suffi­ cient to reduce most viscous stresses. This is fol­ lowed by anterior abdominal exercises, in this case the curl-up with the hands under the lumbar spine to preserve a neutral spine posture (Fig. 5.9), and one knee flexed but with the other leg straight to lock the pelvis-lumbar spine and minimi ze the loss of a neutral lumbar posture. Then, lateral muscula­ ture exercises are performed, namely the side bridge, for quadratus lumborum and muscles of the abdom­ inal wall for optimal stability (Fig. 5.6). Advanced variations involve placing the upper leg-foot in front of the lower leg-foot to facili tate longitudinal rolling of the torso to challenge antelior and posterior por­ tions of the wall. The extensor program consists of leg extensions and the birddog (Fig. 5.10) . In general, we recommend that these isometric holds be held no longer than 7 to 8 seconds given recent evi­ dence from near-infrared spectroscopy indicating rapid loss of available oxygen in the torso muscles contracting at these levels; short relaxation of the muscle restores oxygen (55). Motivated by the evidence for the superiority of extensor endurance over strength as a benchmark for good back health, we have recently documented normal ratios of endurance times for the torso flex­ ors relative to the extensors (for example, i t is normal to hold a flexor posture, approximately 0.77 of the maximum time holding a reference extensor pos­ ture) (53,58) and for the lateral musculature relative to the extensors (0.5) to assist clinicians to identify endurance deficits, both absolute values and for one muscle group relative to another. Our most recent evidence suggests that these endurance ratios (both right-to-left side and flexor to extensor) are signifi­ cantly out of balance in those who have had a history of low back troubles with work loss (57). Finally, as patients progress with these isometric stabilization exercises, we recommend conscious simultaneous contraction of the abdominals (i.e., bracing-simply isometrically activating the abdominals for maxi­ mum stability). 0

Advanced Techniq ues

The beginner's program should be sufficient for daily spine health. Athletic performance demands higher challenges of low back training but is achieved with much higher risk of tissue damage from over-

Chapter Five: Lumbar Spine Stability: Mechanism of Injury and Restabilization

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107

Figure 5.8 The nexion-extension (cat-camel ) stretch i s performed b y slowly cycl i n g

through full spine nexion to fu ll extension. S p i n e mobil i ty is emphasized rather t han pressing at t he end range of motion. This exercise fac i l i tates motion for t h e spine with very low loading o f the i n tervertebral join ts, reduces v iscous stJ"esses for subsequent exercise, and nosses the nerve roots t h rough the fora m i na at each spine j o i n t ( hence coord i nation of fu ll cervical. thoracic, and l umbar Oexion-extens i o n ) .

load.Furthermore, specific athletic objectives require specific training techniques (space restrictions do not permit their discussion here). The interested reader is directed to my textbook Ultimate Back Fitn ess and Performance [or athletic progression of back exercise (58). But, [or example, torsional moments are often required athletically but the question must address how to maximize stability and minimize injury during training for trunk tor-

sion. The fact that generating torque about the twist axis imposes approximately 4-times the compres­ sion on the spine than for an equal torque about the flexion extension axis cannot be dismissed. The technique we have found for producing low spine loads while challenging the torsional moment gen­ erators is to raise a hand-held weight while supporting the upper body with the other ann and abdominally bracing (Fig.5.11) to resist the torsional torque with

Figure 5.9 The curl-up, in which the head and shoulders are raised o ff t h e ground

with t he hands under the l umbar region to help stab i l i ze the pelvis and support the neutral spine. Only one leg i s bent to assi s t i n pelvic stabi l ization and preservation of a neutral lumbar curve. Addi tional challenge can be created by raising the elbows from the noor and generating an abdo m i nal brace or co"contraction.

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Part Two: Basic Science

Figure 5. 1 0 Single leg extension holds, while on t he hands and knees, pro­

duces m i l d extensor activity and lower spine com pression ( <2500 N ) . Raising the contralateral arm ( b i rddog) i ncreases extensor muscle act ivity and also spine com press ion to levels more than 3000 N . Su fficien t stab i l i ty is ensured w i t h m i ld abdominal braci ng.

an isometr i cally contracted and neutral spine. Dynam i c challenged twisting is reserved for the most robust or athlete backs. Finally, it is recognized that challenges to the sp ine during daily activity i nclude the maintenance or stability during stable, steady-state posture main-

tenance, and during unexpected loading events together with ballistic movement that is apprehen­ sively planned. This has motivated some clinicians to utilize labile surfaces such as gym balls. Certainly, these labile surfaces challenge the motor system to meet the dynamic tasks or daily living. But is this

Figure 5. 1 1 A chall enge ror the torsional components that produces low spi ne loads

is to support the extensor moment of t he nexed torso w i t h one hand while the other raises a modest weigh t. The lu mbar torso i s braced ( i ncluding al1 layers of the abdo m i ­ n a l wal l ) i n a neu t ral posture resisting the t w i s t i n g moments generated b y the weigh t .

Chapter Five: Lumbar Spine Stability: Mechanism of Injury and Restabilization

type of training of concern for some patients? Our recent quantification of elevated spine loads and muscle co-activation when performing a curl-up on labile surfaces (74) suggests that the rehabilitation program should begin on stable surfaces. Labile sur­ faces should be introduced once the spine load bear­ ing capacity has been sufficiently restored. In summary, progression of a patient through rehab to h.ll1ction follows the three-step procedure: 1.

Establish motion and motor patterns that avoid the injury mechanisms identified earlier in this chapter. Pain motion/motor patterns may have also been identified through provocative testing described in other chapters, which should be avoided at this step (see Chapters 15 and 26).

• ACKNOWLEDGMENTS The author acknowledge the contribu t ions or several col leagues who have contri bu ted to the col lect ion of works reported here: Dan iel J u ker, M D, Craig Axler, MSc, Sylva i n Gren ier, P h D , and Jack Callaghan, P h D a n d i n part icular Professor Jacek Cholewicki , w h o I consider to be t h e prem ier scient ist i n the worl d regardi ng the engi neering analysis of spine stabi l i ty. Also, t h e continual financial support from the Natural Science and Engi neering Research Cou n c i l , Canada h a s made this series o r work possible.

Audit Process

Self-Check of the Chapter's Learning Objectives •

Progress to functional tasks while ensuring suffi­ cient stability and ensuring commensurate toler­ ance to the elevated loads placed on the spine (see Chapters 26 and 29).

•

Rehabilitation endeavors are continuing to embrace techniques that consider notions of lower torso, or core stability. Whereas there is no question that first a system must be stable before presented with a physical challenge, the enhancement of low back health, and the avoidance of troubles have moti­ vated scientific inquiry into the mechanics of sta­ bility. Many groups continue to work to understand the contributions to stability of various components of the anatomy at particular joints and the ideal ways to enhance their contribution; to understand what magnitudes of muscle activation are required to achieve su fficient stability; and to identify the best methods to re-educate faulty motor control systems to both achieve sufficient stability and reduce the risk of inappropriate motor patters occurring in the future. Motor patterns to achieve stability appear to be different depending on whether the activity is steady-state (with or without com­ bined loads) or with dynamic motion, which may involve rapid voluntary motions or unexpected load­ ing requiring reaction. Understanding stability in all of these unique conditions is the global goal. Finally, the efficacy studies to date, although promis­ ing, can only be considered to provide preliminary data. Rigorous efficacy trials are needed on popula­ tions of patients who have been sufficiently exam­ ined to be categorized into pathological groups and on athletes classified by performance goals. Much remains to be done.

W h a t is t h e mechan i sm of i njury [or facet and d i sc t issues?

•

Can exercises that do not place i nj u red t i ssues at risk be prescribed to t ra i n the back?

•

• CONCLUS ION

What is the role of the motor contro l system i n i njury prevent i o n ?

2. Enhance lumbar stability (see Chapter 26). 3.

109

G i ve examples o f basi c sta b i l i zation exercises designed to coord i nate m uscular co-contract i o n to challenge both muscle and the motor system while s i m u l taneously sparing t he spine joints.

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Chapter Five: Lumbar Spine Stability: Mechanism of Injury and Restabilization

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III

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6 3 . Oxland TR, Panjabi M M , Sou thern E P, Duranceau JS. An anatomic basis for spi nal i nstabi l i ty: A porc i ne trauma model . J Orthop Res 1 99 1 ;9:452-462.

4 7 . McG i l l S M . A myoelectrically based dynamic t h ree­ d i lllensional model to predict loads on l u mbar spine tissues during lateral bending. J B iomech 1 99 2 ; 2 5 : 395-4 1 4 . 48. M c G i l l SM , Ki ppers V. Transfer of loads between l u m bar tissues during the flexion-relaxation phenom­ enon. Spine 1 994; 1 9:2 1 90-2 1 96 . 4 9 . M c G i l l S M . ] S B Keynote Lecture-The biomechanics of low back injury: I m pl icat ions on current pract i ce in i ndustry and t he c l i nic. J Biomech 1 997;30:465-475. 50. McG i l l S M . Low back exercises: Prescri ption for t he healthy back and when recovering from i nj u ry. Resource manual [or guideli nes for exerc ise testing and prescri ption, American College of Sports Medi­ cine, 3rd cd. Bal t imore: W i l l iams and W i l k ins, 1 998. 5 1 . M c G i l l S M . Low Back Exercises: Evidence [or i m provi ng exercise regi mens. Physical Ther 1 998;78:754-76 5 . 5 2 . McG i l l S M , Cal l aghan J P. O n t he r i s k of i njury from fal l i ng as a result of an unexpected removal of a chair wh ile sitt ing. Accident Anal Prevent 1 998;3 1 :85-89. 53. McG i l l S M , Chi lds A, L iebenson C . E ndLl l-ance t imes [or stabi l i zat ion exercises: C l i n ical targets for tes t i ng and tra i n i ng from a normal database. Arch Phys Med Rehab 1 999;80:94 1 -944. 54. McG i l l S M , Parks K, H ughson R. Changes i n l u m bar lordosis mod i fy the role of the extensor muscles. C l i n Biomech 2000; 1 5( 1 0 ) : 777-780. 55. McG i l l SM, H ighson R, Parks K . Erector spinae oxy­ genation during prolonged contractions: I mp lications for prolonged work. Ergonom ics 2000;43:486-493.

64. Parks KA, Crichton KS, Goldford RJ, McGill S M . On t h e val idity of rati ngs of i m pa i rment for low back d isorders. Spine 2003 ;28(4):380-384. 65. Porter RW. Is hard work good for the back? The rela­ t ionsh i p between hard work and l ow back pain­ related d isorders. I n t J I nd Ergonom ics 1 992;9: 1 5 7-1 60. 66. Potvin J, McG i l l SM, Norman RW. Tru n k muscle and l umbar l igament con tributions to dynamic l i fts with varying degrees of tru n k flexion. Spine 1 99 1 ; 1 6( 9 ) : 1 099-1 1 07 . 6 7 . Richardson C, J u l l G , Hodges P, H ides J . Therapeu t i c exercise for spinal segmental stabi l i zation i n low back pai n . E d i n burgh : Churc h i l l -Livingston, 1 999. 6 8 . Roy S H , DeLuca C J , Casavant DA. L u m bar muscle fatigue and chronic low back pai n . Spine 1 989; 1 4: 992- 1 00 1 . 69. S ihvonen T, Partanen J , Hanninen 0 , Soi m aka l l i o S. E l ectric behavior of low back m uscles duri ng l u m bar pelvic rhyth m in low back pain patients and hea l t hy controls. Arch Physi Med Rehab i l 1 99 1 ;72: 1 080- 1 08 7 . 7 0 . Snook S H , Webster BS, M cGorry RW, Fogleman MT, McCann K B . The reduction of chronic non­ spec i fic low back pa i n t h rough the con trol o[ early morn i ng l u m bar flexion. Spi ne 1 998;23:260 1 -2607. 7 1 . Stokes M, Young A . The contribution of reflex i n h i bi­ t ion to arthrogenous m uscle weakness. Clin Sci 1 984;67:7- 1 4. 7 2 . Stratford P. E M G of the quadriceps femoris m uscles in subjects w i th normal knees and acutely effused knees. Physical Ther 1 98 1 ;62:279-2 8 3 . 7 3 . Troup J DG , Mart i n JW, L l oyd D C E F. Back p a i n i n i ndustry-A prospect i ve study. S p i n e 1 98 1 ; 6 : 6 5-69.

56. McGi l l SM. Low back disorders: Evidence based pre­ ven t i on and rehabi l i tation . Champaign, I L : H u m an K i netics Publ ishers, 2002.

74. Vel-a Garc i a FJ , Grenier SG, M cG i l l S M . Abdom ina l response during curl-ups on b o t h stable a n d l a b i l e surfaces. P h y s Ther 2000;80(6 ) : 564-569.

5 7 . McGi l l SM , G renier S, Bluhm M , Preuss R, Brown S, Russell C . Previous history of LBP with work loss is related to l i ngering effects in biomechanical , physio­ logical , personal and psychosoci a l characteristics. Ergonomics 2003;46(7):73 1 -746.

7 5 . Vernon- Roberts B, P i rie CJ. Hea l i ng t rabecular m icrofract u res i n the bodies of l u m bar vertebrae. Ann Rheum D i s 1 97 3 ; 3 2 :406-4 1 2 .

58. McG i l l SM. U l t i mate Back Fitness and Performance. Wabuno Publ ishers, 2004. Available at: www. backfitpro.com 59. N i colaisen T, Jorgensen K. Tru n k strength, back muscle end urance and low back trou ble. Scand J Rehabil Med 1 985 ; 1 7 : 1 2 1 - 1 2 7 . 6 0 . Norman R W , Well s R, Neumann P , Frank J , Shan­ non H, Kerr M. A com parison of peak vs. cum u l a tive physical work exposure risk factors [or the reporti n g of l o w back pain i n the automoti ve i ndustry. C l i n Biomech 1 998; 1 3 : 5 6 1 -5 7 3 . 6 1 . Noyes F R , D e Lucas J L, Torvik PJ . B i omechanics of l igament fai l ure: An analysis o f strain-rate sens i tivity and mechanisms of fai l u re i n pri mates. J Bone Joi n t Surg 1 974;56A:236-2 5 3 .

7 6 . Woo S L-Y, Gomez MA, Akeson W H . Mechanical behaviors of soft t i ssues: Measurements, modi fica­ t ions, i nj u ri es, and t reatment. I n : Nahum H M , Melvin J , eds. Biomechanics o f trau ma. N orwa l k , CT: Appleton Century Crofts, 1 98 5 : 1 09- 1 33 . 7 7 . Y i ngl i ng VR, Callaghan J P , McG i l l S M . Dynamic loadi n g affects the mechanical propert ies and fai l u re site of porcine spi nes. C l i n B iomech 1 997; 1 2 : 30 1 -305. 78. Yingling VR, McGill S M . Mechanical propert ies and fai l u re mechanics of the spine under posterior shear load: Observations from a porcine model . J Spinal D i sord 1 999; 1 2( 6 ) : 5 0 1 -508. 79. Zhu XZ, Parnianpou r M, Nord i n M, Kahanovitz N. H i stochemistry and morphology of erector spi nae m uscles in l u m bar d isc herniation. Spine 1 989; 1 4:39 1 -397.

The Sources of Back Pain

Nikolai Bogduk and Charles Aprill

Introduction Tradition Principles Diagnostic Blocks Provocation Discography

Losers

Learning Objectives

After reading this chapter you should be able to: •

•

Winners Future Players

•

•

•

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Evaluate on what grounds you believe that cer­ tain conditions are the cause of back pain. Provided a list of philosophical criteria by which to judge if a condition can be credited as a cause of back pain. Offer a synopsis of conditions that fail to satisfy these criteria. Offer a summary of the evidence for conditions that do satisfy the criteria. Utilize a means by which to evaluate the extent to which past beliefs and future suggestions about the causes of back pain can be credited.

Chapter Six: The Sources of Back Pain

Introduction How do you know what causes back pain? This is a philosophical question that few practitioners would have wreslled with. Few spine scientists have addressed this question in a systematic, and unbi­ ased, manner. The convention has been for practi­ tioners to be taught by senior practitioners and academics what the causes of back pain are. What has not been a tradition is to allow and to encourage students to ask, why do you say it is a cause of back pain; how do you know? This chapter addresses this issue and provides the answer to this question, as far as is currently known.

Tradition In any textbook on back pain, one is likely to en­ counter lists of possible causes of back pain. These lists usually include, as common conditions, entities such as spondylosis, degenerative disease, and disc prolapse, and rare conditions such as metabolic dis­ orders, ankylosing spondylitis, chondrocalcinosis, etc. Some lists might include conditions such as myofascial disorder, trigger points, postural abnor­ malities, or segmental dysfunction. The basis for such lists is largely, if not exclusively, "I say so." The author creates the list from experience and education or copies it fTom other sources. Stu­ dents learn the list and learn to reproduce it for their examinations. Close scrutiny of such lists reveals that few of the entities satisfy contemporary standards of clinical science and critical reasoning. Those who espouse the lists, those who learn them, and those who set the lists as the correct answers to exam questions have not answered the question, how do you know?

Principles ...

.

.. ..

Patients have a strong desire to know what the cause of their pain is. Are most diagnostic labels commonly given to patients based on actual knowledge of the pain's source or are they based on a number of less certain bel iefs and assumptions) I f the l allel-, what can clini­ cians do to i mprove the report find i ngs given to patients?

There are various criteria that, logically, should be satisfied before an entity can be regarded as a cause of back pain. The more an entity satisfies the criteria, the more credible it is as a cause of back pain. Con-

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versely, the less an entity satisfies the criteria, the less credible it is. If certain key criteria are not satisfied, or if the available evidence is contrary to the criteria, the entity cannot be held to be a cause of back pain. Without resorting to jargon terms, such as plausi­ bility, face validity, concept validity, and content valid­ ity, the criteria can be encapsulated by the questions: 1.

Could it be a source of back pain?

2.

Can it be a source of back pain?

3. Is it ever a cause of back pain? 4.

Is it ever a source of back pain?

The first criterion is the easiest to satisfy. In essence, if a structure in the lumbar spine has a nociceptive nerve supply, it is potentially a source of back pain. The strength of this criterion lies not in what could be a source of pain, but in what cannot be a source. For example, it was long held, until approximately 1980, that intervertebral discs could not be a source of back pain because they lacked a nerve supply (2,39,70). Once that nerve supply was demonstrated, however, the discs were promoted to the list of possible sources of back pain. Anatomical studies have shown that the fascia (65), muscles (8), ligaments (8,34,35,56,71,72), vertebrae (3,17,25,32), synovial joints (8,17), and intervertebral discs (4,8,16,32,33,44,55,57,73) of the lumbar spine are all innervated. Any of these struc­ tures, therefore, could be a source of pain, in princi­ ple. Only the nucleus pulposus, in its natural state, lacks a nerve supply. So, it cannot be a source of pain. However, recent studies have shown that damaged discs obtain a neo-innervation (29). It may be that in damaged discs the nucleus becomes sensate. This first criterion has paved the way [or various suggestions, models, theories, and assertions that muscles, ligaments, joints, and fascia could be or are the source of back pain. However, the first criterion only satisfies that the structure could be a source o f pain; it does not satisfy that the structure can b e or ever is a source. The second criterion is, to an extent, technical or ceremonial, for it may be superfluous when subse­ quent criteria are satisfied. However, it is included not only for the sake of completeness and to reinforce other criteria but also to dispel rhetorical cynicism. In other words, it is there as a vaccine to dispel ar­ guments that can be raised by critics. The second criterion requires that it be shown that noxious stim­ ulation of the structure in normal volunteers does, in fact, cause pain. It is the physiological correlate to the anatomical first criterion. Structures believed on the basis of traditional wisdom not to be sources of pain can be elevated into consideration if stimulation of them in normal volunteers produces pain of similar

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Part Two: Basic Science

quality and distribution as that seen in patients. Showing that a structure can be a source of pain does not, of itself, prove that it does cause pain in patients, but it nevertheless enhances the plausibility of that structure being a possible source of pain. The strength of this criterion lies not in it being satisfied but more in when it is not satisfied. An assertion that particular structure can be a source of back pain is somewhat shallow if and when it has not been shown to be painf'ul in normal volunteers. Doubts or reser­ vations in lhis regard are dispelled once the formality of undertaking experiments in normal volunteers has been acquitted. Examples include the lumbar zyga­ pophysial joints and the sacroiliac joint. Traditional wisdom long maintained that these structures could not be sources of back pain until experiments in nor­ mal volunteers showed that they could. Thereafter, subsequent investigations were undertaken to satisfy other, and more compelling, criteria. The third criterion is the most traditional. It re­ quires demonstration of a unique palhology on which the pain can be blamed. It is also lhe most abused crilerion. A habit of lhe past has been to blame back pain on lhe mosl obvious, or any, pathology evident in a patient, usually on medical imaging. As a result, back pain has been blamed on degenerative joint dis­ ease, spondylosis, spondylolysis, spondylolisthesis, spina bifida, transitional vertebrae, etc. This is inlel­ leclually moribund and has caused a great disservice to patienls, the health system, and the medicolegal syslem. For an evident pathology to be regarded, log­ ically and responsibly, as a cause of back pain, an epidemiological requirement must be satisfied. If lhal requiremenl is nol satisfied regarding the pathol­ ogy lo be lhe cause of pain is illogical because it defies lhe data. The condition must be present in patients with pain but not present in patients without pain. This requires population surveys to collect data that com­ plete a contingency table (Fig. 6.1). If the condition

Pathology

Pain

Present

Absent

Present

A

B

Absent

C

D

Figure 6.1 A conti ngency table w i t h data tests whet her a pat hology can be held to be a cause of pai n . The strength of correlation is renected by the magnitude of the A-to-B and O-to-C ,-atios.

really is a cause of pain, the numbers A and D must be large. That means lhat when the condition is pres­ ent so is pain, but pain is absent when the condition is absent. Reciprocally the numbers B and C must be small. That means lhat rarely does lhe condition occur in the absence of pain, and that pain is rarely present when the condition is absent. Slatistically, the ratios of A to B and of D to C must be large and well in excess of values that might arise by chance alone. When subjected to scrutiny in lhis manner, many popular and traditional entilies fail the crilerion. If a condition is equally present in patients with pain and in individuals without pain, it cannot logically be deemed to be a cause of pain. Abuses have arisen in this regard either when aUlhorilies have based lheir beliefs having seen only symptomatic patienls and having never studied asymptomatic individuals (or read the literature), or when they have deliberately defied the evidence and have irresponsibly applied a false diagnosis just because il was convenient to do so. The fourth criterion is the most novel. It is designed to accommodate circumstances when the causal pathology is not evident because il defies available means of detection. Back pain is not a lelhal disorder and so patients rarely to come to poslmortem, at which microscopic or molecular causes of pain might be identified. Contemporary techniques of medical imaging lack resolution for any bUl large abnormalities. Failure to detect pathology is not evi­ dence of absence of pathology, especially if and when the wrong or inadequate techniques of invesligalion are used. Plain x-rays can show fractures or defor­ mities, but they do not show intervertebral discs. Therefore, a normal x-ray does nol exclude an abnor­ mal (and painful) disc. Pain cannot be seen. It is not a structure. It cannol be photographed. Pain is a sensory experience. Con­ sequently, its detection requires a physiological test. The fourth criterion requires demonstration that invesligations that selectively target the struclure either aggravate or relieve the pain lhat it is presumed lo cause. But stringent subsidiary criteria apply. If a test is used to aggravate a patient's pain, il must be shown that the test stresses only the struc­ ture inferred to be the source of pain. If the test hap­ pens, inadvertently, to stress other slructures il lacks specificity. Under these conditions, the test may be positive for reasons other lhan the professed or pre­ ferred reason. All too often tests have been promoted without validation. They may be said to be specific for a given source or cause of pain, bUl when sub­ jected to scientific scrutiny they prove not to be. Yet many tests, particularly clinical examination lests, continue to be taught solely on the basis of assertion that they work when in fact lhey do not. Practition-

Chapter Six: The Sources of Back Pain

ers prefer to believe the myths lhat they were taught or invented, ralher lhan face the evidence and the realily lhat il reveals. IL is beholding on anyone who invenls, professes, or leaches a test to show objec­ tively lhat il has specificity. Insistence and wishful lhinking do nol conslilute evidence in this regard. Similarly, relief o[ pain musl be target-specific. A cheslnut thal arises in lhis regard is trial by treat­ menlo Some people believe that i[ a theory maintains lhal a specific condition is the cause o[ pain, then a cerlain trealmenl is appropriale; and if that treal­ men l works, il constilules evidence that the theory is correct. This is wrong. The fallacy arises when lhe lreatmenl works [or reasons other than those expressed in the lheory. Thus, i[ a theory maintains that the pain slems [yom a subluxated zygapophysial joint, and that manipulalion is indicated, a success­ fLil manipulation is not necessarily evidence that the abnormal joint was the source of pain and was suc­ cessfLdly treated. Relief might have arisen because of simultaneous manipulation of a painful disc, because of fortuitous stretch of the back muscles, or because of non-specific factors, such as attention and expecta­ tion of relief. In[erences drawn fyom trial of treatment require studies that control [or these confounding effects and that show a consistent correlation between diagnosis and outcome of treatment. "It works some­ times" simply does not wash. The most rigorously studied physiological tests thal pertain to back pain are diagnostic blocks and discography. Diagnostic blocks involve anaesthetiz­ ing a larget Sll-ucture or its nerve supply. Discogra­ phy involves provoking a target disc. All of these procedures involve the use of needles under fluoro­ scopic control. The advantages of needles are several. •

•

•

They are target-specific. Fluoroscopy shows that the needle is used to anaesthetize or stimulate selectively the target structure, and no other. Faith is not involved. Radiography shows where the needle is and where it is not. They can be controlled. Controls are critical [or diagnostic procedures. They militate against [alse-positive (and false-negative) results. Thereby they secure correct inferences. The nature o[ the controls that should be used differs according to the test at hand (q.v.). They are less subject to observer bias than manual clinical tests. The drug injected does the work. Special perceptual skills that involve years of training and practice to master are not required. The only skills required are the ability to deliver the needle safely and accurately. Thereafter, the test is performed by the drug injected, and the patient announces the response, not the examiner.

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Diagnostic Blocks Diagnostic blocks are not a treatmen l. They are a means by which to test a diagnostic hypothesis. The investigator raises a suspicion about where the pain might be coming from. He or she then tests that sus­ picion by selectively anaesthetizing the suspected structure or its nerve supply. In this regard, the block does not test the patient or the veracity o[ the symp­ tom. Blocks are a tesl of the investigator's acumen or how well they have guessed the source o[ pain. Inves­ tigators are allowed to be wrong; the test can be negative. But questions can be raised about the investigator's practice if all or most of their blocks are negative. Perhaps they are guessing wrongly too often and should change their perceplions about what are the likely sources of pain in their patients. In the pursuit of low back pain, diagnostic blocks can be performed of the zygapophysial joi nts and the sacroiliac joint (10,15). Other structures mighl also be tested in the same manner, such as muscles or lig­ aments, but few studies of these lal ler struclures have been undertaken to date. Zygapophysial joints can be anaesthetized directly by intra-articular injections or indirectly by anes­ thetizing their nerve supply via the medial branches of the lumbar dorsal rami (10,15). The sacroiliac joint can be anaesthetized only by intra-articular injection (15). "Face validity" means that anatomically the tesl does what it is alleged to do, lhal it affects the targel structure and no other. The [ace validity of intra­ articular injections is secured by performing an arthrogram of the target joint. The arthrogram should show that what is injected goes into the target joint not into any other structure and stays in the joinl. This requires respect for the capacity of the joint, which, in the case of lumbar zygapophysia\ joinls is approximately 1 ml and in the case of the sacroiliac joint is approximately 3 m1. If the injectant spills out of the joint, the target specificity of the test is cor­ rupted and no legitimate in[erence can be drawn from a positive response. The target specificity of lumbar medial branch blocks has been assiduously studied and estab­ lished. When small volumes of injectant are accu­ rately deposited onto the target nerve, they stay lhere and spread to no other structure that mighl confound the effect (22). Blocking medial branches in normal volunteers protecls them [rom zygapo­ physial joint pain (36). Controls are of paramount impOrlance during lhe conduct of diagnostic blocks. Patients may report relief of their pain for reasons other than the action of lhe local anesthetic agent injected. Studies have shown that patients expecting to undergo diagnostic blocks of the zygapophysial joints can repOl-t complete reljef o[

IJ 6

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Part Two: Basic Science

pain after just a subcutaneous injection (63). Such is the power of just simply "doing a procedure." Controls do not perfectly eliminate false-positive responses, but they guard against them and reduce the likeli­ hood of a false-positive inferences being drawn about the source of pain. For research purposes, the optimal control is placebo injections. Under double-blind conditions, the patient is injected with an agent that does not have the intended physiological effect. A positive response refutes the diagnostic hypothesis. The patient has obtained relief for reasons other than the intended effect of the block. Placebo controls, however, are not practical for conventional practice. They require informed consent and at least three procedures (i.e. "challenges") to provide an interpretable pattern of response (10,13). More practicable are comparative blocks (6). On separate occasions, under double-blind conditions, the target joint is anaesthetized using local anesthetic agents with different durations of action. Double­ blind conditions are essential to prevent the investi­ gator cueing the patient as to what to expect, and thereby imposing the investigator's bias, usually for a positive response. A convincing positive response is one in which the patient reports long-lasting relief when a long-acting agent is used and short-lasting relief when a short-acting agent is used. Comparative blocks are not perfect. They have a finite but small false-positive rate (14%) (41). For practical purposes this is more than acceptable. It is far more preferable than relying a single diagnostic blocks, which have a much higher false-positive rate that in context of lumbar zygapophysial joint pain means that for every three positive results two are wrong (58).

Provocation Discography Provocation discography is a more vexatious proce­ dure, for it relies on provoking pain rather than relieving it. Consequently, it cannot be controlled using injections of different agents or placebos. It involves introducing a needle into an intervertebral disc suspected of being the source pain and using the needle to distend the disc from the inside, with an injection of saline or of contrast medium (14). The test is positive if stressing the disc reproduces the patient's pain. But provocation discography is sub­ ject to false-positive responses. Provocation may be positive if the patient has seg­ mental hyperalgesia, i.e., something else, innervated by the same segmental nerves as supply the target disc is actually the source of pain and stressing the disc aggravates the pain from that other source

rather than any pain fTom the disc. There are no expedient measures by which to guard against hyper­ algesia. On assessing the patient, the investigator must be confident that there are no possible, or likely, confounding sources of pain. Diagnostic blocks of the zygapophysial joints or the sacroiliac joint may need to be performed before discography to exclude these other sources of pain. Or discography might be performed while these other structures are anesthetized. The latter combination has not yet been evaluated. Provocation may also be positive for behavioral reasons. The patient may report a positive response to disc provocation because anything and everything hurts in the back. It is for this reason that the Inter­ national Association for the Study of Pain (IASP) has required anatomical controls for provocation discog­ raphy (48). For the diagnosis of discogenic pain, provocation of the target disc must reproduce the patient's pain, but stressing adjacent discs does not. Such a response refutes the competing hypothesis that anything and everything hurts in the patient's back. Several studies have warned of possible false­ positive responses to provocation discography (18,19). Patients with no back pain but with a painful iliac crest can have a positive response to discography (18). Some normal volunteers have a positive response to disc provocation (19). The incidence of false­ positive responses is greater in patients with chronic pain and is even greater in patients with a somatiza­ tion disorder diagnosed (19). However, if the IASP criteria for a positive response are rigorously applied, the putatively alarming published figures are deflated. In normal volunteers and in patients with chronic pain, the false-positive rate is only 10%. In patients with somatization disorder it is 25%. These data warn physicians to be careful with over-inter­ preting response to provocation discography, but they do not impugn the test. Read reciprocally, the data attest to a true positive rate of 90% in most patients and 75% in patients with somatization. Confidence in a diagnosis of discogenic pain is enhanced if pathology can be demonstrated in a disc found to be painful. The cardinal pathology is that of internal disc disruption (IDD). This condition is characterized by radial fissures penetrating to the outer third of the anulus fibrosus but in a disc whose circumference is essentially intact, i.e., there is no herniation (9,11). Such fissures are demonstrated by performing CT of the disc soon after it has been injected with contrast medium. Large studies have shown that radial fissures correlate strongly with the affected disc being painful, but that they are not related to age changes or disc degeneration (49). Fur­ thermore, it has been shown that IDD is associated

Chapter Six: The Sources of Back Pain

with abnormal stress profiles in the nucleus pulposus and the anulus fibrosus of the affected disc (1). and that these abnormal profiles correlate strongly with the affected disc being painful (47).

Losers Of the many sources and causes of back pain pro­ fessed by conventional wisdom, few withstand philo­ sophical scrutiny. They do not satisfy the criteria. Back muscles have been made to hurt in normal volunteers (7,37), but no controlled studies using diagnostic blocks have shown if and how commonly the back muscles cause pain. Nor have any studies shown the pathology responsible. Muscle sprains might be inferred as a cause of acute low back pain, but no pathology of muscle is known to cause chronic low back pain. Doubtless, patients exhibit tender areas in their back muscles, but the notion of trigger points is not sustainable. There is no evidence that trigger points are an explicit pathological entity. Clinically, the diag­ nosis of trigger points in the lumbar spine has been shown to lack reliability (52,53). Ligament sprain is an entity easy to conceive of but difficult to prove. Stimulation of interspinous liga­ ments in normal volunteers does produce back pain and somatic referred pain (7,38), but no controlled studies have demonstrated relief of back pain on anes­ thetizing these ligaments. One uncontrolled study indicates that if interspinous ligaments are a source of back pain, its prevalence is less than 10% in primary care (68). No studies have provided evidence that other ligaments are a source of back pain, such as the ilio­ lumbar ligament. That is not to say that these liga­ ments are never a source of pain; there is simply no evidence, yet, to credit the belief that they are. Spondylosis or degenerative joint diseases are simply age changes. They occur increasingly with age and are not significantly more common in patients with back pain than in individuals with no pain (31,40,42,64,66,69). Egregious has been the habit of ascribing patients' pain to "pre-existing degenera­ tive changes." Being contrary to the available epi­ demiological data, such behavior is heretical to the science of medicine. Similar comments apply to spondylolysis and spondylolisthesis. The prevalence of spondylolysis is 7% in the asymptomatic population (51). Seeing a pars defect on a radiograph does not make it the source of pain. Such defects might be painful, but evi­ dence other than radiographic presence is required. To test if a defect is painful it can be blocked in an attempt to relieve the patient's pain. Spondylolisthe­ sis has a prevalence of 8% in men and 5% in women,

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and may be totally asymptomatic (67). In men with spondylolisthesis, back pain is not significantly more common than in the general population, although women with spondylolisthesis are more likely to have back pain (67). Finding spondylolisthesis does not automatically render it the cause of pain. Radio­ graphic investigation cannot and does not reveal the actual source of pain. It could lie in the disc or the posterior elements of the affected segments, or it might be anywhere else in the lumbar spine and be unrelated to the spondylolisthesis. Simply sighting the abnormality does not discriminate between these possibilities. "Instability" is an abused term (12). It is invoked to convey the sense that something is wrong with the way the lumbar spine works, but no objective crite­ rion for its diagnosis has been validated. The practi­ tioner may believe that the patient's back is unstable, but he or she has no means by which to objectify that belief. Even spondylolisthesis is not unstable (54). High-precision studies have shown that the motion patterns of patients with spondylolisthesis are indis­ tinguishable fTom those with degenerative disc dis­ ease (5). Diagnosis such as segmental dysfunction and lumbar insufficiency are no more than metaphors. They say nothing about the source of pain or its cause. These words mean nothing more than "something must be wrong with the back, about here."

Winners There are absolutely no data on the common causes of acute low back pain. Patients in primary care with acute low back pain have simply not been studied with techniques that might reliably identify a valid source of pain. For red flag conditions, such as tumors and infections, the evidence is that they are rare (<1 %) (20,21). Moreover, red flag conditions usually provide cues that permit recognition, such as history of cancer, systemic disturbances, risk factors, or uncharacteristically severe pain. Back pain without such accompanying features is extremely unlikely to be caused by occult tumor or infection. There are, however, data on the possible sources of chronic low back pain. These data come from studies using controlled diagnostic blocks or provocation discography. These procedures have not been applied to random or general populations. So, the prevalence figures may not be accurate in a true epidemiological sense. However, the figures stem from populations seen in specialist spine centers in Australia and in the US and reflect what is seen in such practices. In normal volunteers, stimulation of the sacroiliac joint produces low back pain (28). In approximately

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Part Two: Basic Science

20% of patients with chronic low back pain the source of pain can be traced to the sacroiliac joints. Two stud­ ies have demonstrated this. The first used anatomi­ cal controls, in that all patients had negative responses to previous zygapophysial joint blocks (61). The sec­ ond study used comparative local anesthetic blocks (43). Previously, belief in sacroiliac joint pain had been based purely on conjecture or wishful thinking. Now there are data that satisfy criteria 1, 2, and 4. The pathology of sacroiliac joint pain remains unknown. [n normal volunteers, stimulation of the lumbar zygapophysial joints produces low back pain and referred pain in the lower limb (30,46,50). Using con­ trolled diagnostic blocks, in younger patients with chronic low back pain after some sort of injury, the prevalence of lumbar zygapophysial joint pain was found to be 15% ± 5% (59). In older patients without a history of injury, the prevalence of lumbar zygapophysial joint pain may be as high as 40% ± 13% (63). In a heterogeneous population it has been found to be 36% (45). The lumbar zygapophysial joints satisfy criteria 1, 2, and 4 as possible sources of back pain. The causative pathology is not known. The single most common cause of chronic low back pain is IDD. A stringent study using IASP crite­ ria found the prevalence of IDD to be 39% ± 10% (59). This prevalence may be an underestimate because the diagnostic criteria were strictly applied. The patients had to have a positive response to provoca­ tion discography at one level and a negative response at least one adjacent level, and had to exhibit at radial fissure on CT discography. The cri­ teria used did not admit IDD at multiple levels, which is one reason why the prevalence estimate might underestimate the true prevalence of IDD in all forms. Conspicuously, these various prevalence figures add up to approximately 70%, which dispels the myth that the source of chronic low back pain can­ not be diagnosed in more than 80% of cases. That myth obtains only if inappropriate diagnostic tests are used. X-rays do not show zygapophysial joint pain, sacroiliac joint pain, orIDD, nor do CT or M RI. Relying on such investigations serves a self-f"ulfilling prophesy: that no cause of back pain will be found. The opposite applies if diagnostic blocks and provo­ cation discography are used. Moreover, studies have shown little overlap be­ tween the cardinal sources of chronic low back pain. When investigated by zygapophysial joint blocks and/or sacroiliac joint blocks and/or provocation discography, few patients are positive to more than one test under controlled conditions (60,61). Despite prevailing wisdom to the contrary, zygapophysial joint pain, sacroiliac joint pain, and discogenic pain

are separate entities and rarely co-exist at the same time in the one patient. Readers who feel that their favorite condition has not been mentioned in this chapter are invited to assess for themselves to what extent there is evidence about that condition that satisfies the four criteria.

Future Players There is room and opportunity for people to produce compelling evidence that muscles, ligaments, or other structures might be sources of acute or chronic low back pain. Individuals intent on promoting a particu­ lar belief need only satisfy the criteria outlined. That, however, has yet to be performed. An intriguing proposition is that of torsion injury to the disc (9,11). In this condition, the nucleus pulposus is intact, and there are no internal radial fissures; it is not IDD. The condition is characterized by circumfer­ ential tears in the outer anulus fibrosus. Metaphori­ cally, this condition may constitute the sprained ankle of the back. It has been produced experimental in cadavers (23,24). It has been described in case reports (26,27) but not in any substantive population studies. Its diagnosis requires the injection of contrast medium accurately into the anulusfibrosus to demonstrate the tear (which is not easy) and subsequently anesthetiz­ ing the tear with a very small volume of local anes­ thetic. The prevalence of this condition is currently being explored in some research centers. If validated, this condition would add to the prevalence of disco­ genic pain.

• CONCLUSION •

•

In the past, proclamations about the causes and sources of back pain have been based on concept validity at best and hearsay at worst. The extent to which a particular entity might be credited as a cause of back pain depends on the extent to which it satisfies the criteria: 1.

Could it be a source of back pain?

2.

Can it be a source of back pain?

3. Is it ever a cause of back pain? 4. •

•

Is it ever a source of back pain?

Conditions that fail to satisfy these criteria and that therefore are no more than conjectures include muscle sprain, myofascial pain, ligament pain, spondylosis, spondylolysis, and spondylolisthesis. Conditions that fulfill at least criteria 1,2, and 4 are zygapophysial joint pain and sacroiliac joint pain (see p. 113). Internal disc disruption satisfies all four criteria.

Chapter Six: The Sources of Back Pain

•

•

Collectively, these condilions account for more lhan 70% of chronic low back pain. Whal has prevented grealer and earlier recognilion of lhese condilions in the past is lhe preoccupation wilh imaging studies and l h e reluclance to use diagnostic blocks and provocation discography in the investigation or back pain.

. ..

.. .

.

. . :

Readers are invited to fol low the approach ou t l i ned i n this chapter on low back pai n , and apply the principles to what they believe and know about neck pain and t ho­ racic spinal pa in. They should find that although there is experi mental evi­ dence fyom normal vol unteers that cervical and t h oracic muscles, synovial j o i n ts, and i n tervertebral discs can

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4 . Ashton I K , Roberts S , Jaffray DC, Polak J M , Eisentstein S M . Neuropeptides i n the human in ter­ vertebral disc. J Orthop Res 1 994; 1 2 : 1 8 6- 1 92 . 5 . Axelsson P , Johnsson R , Stromqvist B . Is there i n creased i n tervertebral mobi l i ty in isth m i c ad u l t spondylolisthesis? A malched compara t i ve study u s i ng roentgen stereophotogra m m etry. Spine 2000;2 5 : 1 70 1 - 1 703. 6.

Barnsley L , Lord S , Bogduk N . Comparative local anaest hetic blocks in the d i agnosis o f cervical zyga pophysial j o i n t s pai n . Pain 1 99 3 ; 5 5 : 99- 1 06.

7.

Bogduk N. L u mbar dorsal ramus syndrome. Med J Aust 1 98 0 ; 2 : 5 37-54 1 .

8.

Bogd u k N . The i n n ervation of the l u mbar spine. Spine 1 9 8 3 ; 8 : 2 86-2 9 3 .

9.

Bogd u k N . T h e l u m bar d i sc and l o w back pai n . Neu­ rosurg C l i n N or t h Am 1 99 1 ; 2 : 79 1 -806.

1 0 . Bogduk N. I n ternational Spinal Injection Society guideli nes for the performance of spinal i njection procedures. Part I : Zygapophys ial joint blocks. Clin J Pain 1 99 7 ; 1 3 : 2 85-302 .

of these Sl 1-uc tures is the source of pain in patients.

1 1 . Bogduk N . C l i n ical Anatomy of the Lu m bar Spine and Sacru m . 3rd ed. E d i n burg h : C h u rc h i l l l i v­ i ngs ton, 1 99 7 : 205-2 1 2 .

Only the prevalence of cervical zygapophysial joint pain

1 2 . Bogd u k N . C l i n ical Anatomy of the L u m ba r Spine

hurt, there is a povel-ty of data on exactly how often any

and Sacrum . 3rd ed. E d i n burg h : C h u rc h i l l liv­

is known. The available evidence refu tes spondylosis as a cause of neck pa in. Conditions such as myofasc ial pai n , cervical instab i l i ty,

119

i ngsto n , 1 99 7 : 2 1 5-2 2 5 . 1 3.

Bogduk N , Lord S M . Cervical zygapophysial joint pai n . Neurosurg Q 1 99 8 ; 8 : 1 07- 1 1 7 .

1 4.

and segmental dyshmction do not satisfy criteria 2, 3, or 4.

Bogduk N , Apri l l C, Derby R. D i scography. I n : White AH, ed. Spine Care, Vol u m e One: D i agnosis and Con­ servat i ve Trea t m e n t . St Lou is: M osby, 1 995 : 2 1 9-2 3 8 .

1 5.

Bogduk N , A pr i l l C , Derby R . Diagnostic blocks of synovial joints. I n : W h i t e A H , ed . Spine Care, Vol u m e

Audit Process Self-Check of the Chapter's Learning Objectives •

1 6 . Bogduk N , Tynan W, Wi lson AS. The nerve su pply to t he h u man l umbar i n tervertebral d i scs. J Anat

What criteria have been presen ted to j udge i f a cond i t ion is the cause of back pai n ?

•

One: D iagnosis and Conserva t i ve Trea t ment. St Lou is: Mosby, 1 99 5 : 2 98-32 1 .

1 98 1 ; 1 3 2 : 39-5 6 . 1 7.

What common diagnostic e n t i ties fai l to m e e t these

end plate in patients w i t h degenerative di sc d i sease.

criteria? •

What d iagnostic e n t i ties succeed in mee t i n g these criteria?

•

J Bone J o i n t Surg 1 99 7 ; 7 9 B : 1 4 7- 1 5 3 . 1 8 . Carragee E J , Tanner C M , Yang B , Bri to J L , TI-uong T. False-posi tive find i ngs on l u mbar di scogra phy. Rel i ab i l i ty of subjective concordance dul"i ng provoca tive d i sc i njec t i o n . S p i n e 1 99 9 ; 2 4 : 2 542-2547.

What cond i t ions that you presently label your patients as h aving are based on "soft" criter i a ?

Brown M F , H ukkanen MVJ , M cCarthy J D , et al. Sen­ sory and sympathetic in nel-vation of the vertebral

1 9 . Can-agee E J , Tanner C M , K h u rana S, et a l . The rates of false-posi tive l u mbar d i scography in select pa tients w i thout low back symptoms. Spine 2000 ; 2 5 : 1 3 7 3 - 1 3 8 1 .

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Deyo RA, R a i n v i l l e J , Ken t D L. W h a t can the histol-y and physical exa mi nation tel l us abou t low back

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West mount: Eden Press, 1 9 8 0 : 2 3-3 2 . 3 . Antonacci M D , Mody D R , Heggeness M H . Innerva­ tion of the human vertebral body: A hi stologic study. J Spinal Dis 1 99 8 ; I I : 5 3 6-53 1 .

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Farfan HF, Cossette JW, Robertson G H , Wel l s RV, Kraus H. The effects of torsion on the l u m bar

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Part Two: Basic Science

i n tervertebral joints: The role of torsion i n the pro­ duct i o n of disc degeneration. J Bone Joint Surg 1 970;52A:468-497. 24. Farfan HF, Huberdeau R M , Dubow H I . Lumbar i n tervertebral d i sc degeneration. The i n fluence of geometrical features o n the pattern of disc degenera­ tion-a post mortem study. J Bone Joi n t Surg 1 97 2 ; 54A:492-5 1 0. 2 5 . Fei n stein B, Langton J N K , Jameson R M , Schi ller F. Experi ments o n pain referred from deep somatic tis­ sues. J Bone Joint Surg 1 95 4 ; 3 5 A:98 1 -987. 26. Finch P M, Khangure M S . Analgesic d i scography and

April 8- 1 0 . Meeting Abstracts p 8. Fortin JD, Dwyer A P , West S, Pier J . Sacro i l i ac joi n t : P a i n referral m a p s upon applying a new i njection/art h rography tech n i que: Part I : Asympto­ matic volunteel-s. Spine 1 994; 1 9 : 1 475- 1 4 8 2 . 2 9 . Freemont A J , Peacock TE, G o u p i l l e P , Hoyland J A , O'Brien J , Jayson MIV. Nerve ingrowth i n to diseased i n tervertebral d i sc in chronic back p a i n . Lancet 1 997 ; 3 5 0 : 1 7 8-1 8 1 . 30. Fukui S , Ohseto K, Shiotani M , Ohno K, Karasawa H, Nagaauma Y. D istribution of referred pain from the lumbar zygapophyseal j o i n t s and dorsal ram i . C l i n J Pa i n 1 99 7 ; 1 3 : 303-3 0 7 . 3 1 . Fullenlove T M , W i l l i a m s A J . Comparative roentgen fi ndi ngs in sym p tomatic and asymptomatic backs. Rad iology 1 95 7 ; 6 8 : 5 72-5 74 . 3 2 . G roen G , Baljet B , Drukker J . T h e nerves and nerve plexuses of the human vertebral col u m n . Am J A n a t 1 990; 1 8 8 : 2 82-296. H i rsch C, I ngelmark BE, M i l ler M. The anatomical basis for l ow back p a i n . Acta Orthop Scandinav 1 96 3 ; 3 3 : 1 - 1 7 . 34. Jackson HC, W i n ke l m a n n RK, B ickel W H . Nerve endings i n t he human lumbar s p i n a l col u m n and related structures. J Bone Joi n t Surg 1 966;48A: 1 2 72- 1 2 8 l . 3 5 . Ji ang H , Russel l G , Raso J , Moreau MJ, H i l l D L , Bag­ n a l l K M . The nature and distributi o n of the i nnerva­

4 5 . M anchikanti L, Pam pati V, Fellows B , Bakh i t CEo The diagnostic val id i ty and therapeutic value of lum­ bar facet j o i n t nerve blocks with or wi thout adjuvant agents. Curr Rev Pain 2000 ; 4 : 3 3 7-344. 46. McCall IW, Park WM, O'Brien J P. I nduced pain referred from posterior lumbar elements i n normal subjects. Spine 1 9 79;4 :44 1 -446. 4 7 . McNa l ly DS, Shackleford 1 M , Goodship A E , Mulhol­ land R C . I n vivo Stress measurement can predict p a i n on discography. Spine 1 996;2 1 : 2 500-2 5 8 7 . 48. Merskey H , B o g d u k N . Cl assification of Chronic Pai n . Descriptions o f Chronic Pain Syndromes and D e fi n i t i ons of P a i n Terms, 2nd ed. Seattle: IASP Press, 1 994. 49. Moneta GB, Videman T, Kaivanto K, et al. Reported pain during lumbar d iscography as a function of annular ruptures and disc degeneration. A re-analysis of 833 d i s kograms. Spine 1 994; 1 7 : 1 968- 1 974. 50. Mooney V, Robertson J . The facet syndrome. C l i n Orthop 1 976 ; 1 1 5 : 1 49- 1 5 6. 5 1 . M oreton RD. Spondylolysis. JAMA 1 996; 1 9 5 : 6 7 1 -674. 52. N ice DA, Riddle DL, Lamb R L , Mayhew TP, Ruckler K. I ntertester rel i ability of judgements of the pres­ ence of trigger points in patients w i t h low back pai n . Arch Phys M e d Rehabi l 1 99 2 ; 7 3 : 893-898. 53. Njoo KH, Van der Does E . The occurrence and i n ter­ rater reliab i l i ty of myofascial trigger points in the quadratus lumborum and gluteus medius: A prospec­ tive study in non-specific low back p a i n pat ients and controls in general practice. Pain 1 994;5 8 : 3 1 7-3 2 3 .

t i on of human supras p i na l and i nters p i n a l l igaments. Spine 1 99 5 ; 2 0 : 869-876.

5 5 . Rabischong P , Louis R , V ignaud J, Massare C . The

Kaplan M , D reyfuss P , H a lbrook B, Bogduk N . The a b i l i ty o f l um bar medial branch blocks t o anes­

i ntervertebral disc. Anat C l i n 1 97 8 ; 1 : 5 5-64.

t he t i ze the zygapophysial joint. S p i n e 1 99 8 ; 2 3 : 1 847- 1 8 5 2 .

56. Rhalmi S, Yahi a L , Newman N, Isler M . Immunoh is­ tochemical study of nerves in lum bal- spine l i ga­ ments. Spine 1 99 3 ; 1 8 : 2 64-2 67.

Kellgren J H . Observations o n referred p a i n arising

5 7 . Roberts S, Eisenstein SM, Menage J , Evans E H , Ash­

3 8 . Kellgren J H . O n the distribution of pain ari s i n g from deep somatic structures with charts of segmental pain areas. C l i n Sci 1 93 9 ; 4 : 3 5-46. Lamb DW. The neurology of spinal pain. Phys Ther 1 97 9 ; 5 9 : 9 7 1 -9 7 3 . 40.

1 996;2 1 : 1 889- 1 892. 44. Mali nsky J. The ontogenetic development of nerve

5 4 . Pearcy M , Shepherd J. Is there instabi l i ty in spondy­ l o l i s thesis? Spine 1 9 8 5 ; 1 0 : 1 75- 1 77.

form muscle. Clin Sci 1 93 8 ; 3 : 1 7 5- 1 90.

39.

Rehabil Med 1 97 6 ; 8 : 1 1 5- 1 2 6 . 43. Maigne JY, Aivalikl is A, P fe fer F. Results of sacroi l iac j o i n t double block and value of sacro i l i ac pain provo­ cat i o n tests i n 54 patients with low-back pain. Spine

termi n ations in the i ntervertebral discs of man. Acta

ing o f t he V I t h World Co ngress on Pain, Perth , 1 990,

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42. Magora A, Schwartz A. Relat ion between the low back p a i n syndrome and x-ray fi n d i ngs. Scand J

Anat 1 95 9 ; 3 8 : 9 6- 1 1 3 .

sion d i agnosis and treatm e n t , O fficial Satel l ite Meet­

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controlled blocks for the diagnosis of cervical zygapophysial joint pain. C l i n J Pain 1 995; 1 1 :208-2 13.

magnetic resonance i m aging ( M RI ) . Pain 1 990;

spinal pai n . Paper presented at "Spinal Pain": Preci­

33.

Lord S M , Barnsley L, Bogduk N . The util ity of com­ parative local anaesthetic blocks versus p lacebo­

Suppl 5 : S 2 8 5 . 2 7 . Fi nch P . Analgesic d iscography i n t h e diagnosis of

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Lawrence JS, Bremner J M , Bier F . Osteo-arthrosi s . Prevalence i n t h e population and rel a t i onsh i p between symptoms a n d x-ray changes. A n n Rheum Dis 1 96 6 ; 2 5 : 1 -24.

ton I K. Mechanoreceptors in i n tervertebral discs: morphology, distri bution, and neuropeptides. S p i ne 1 99 5 ; 2 0 : 2 645-265 1 . 5 8 . Schwarzer AC, April! C N , Derby R , Fortin J , Kine G , Bogduk N . T h e false-pos i tive rate of uncontrolled d i agnostic blocks of the lumbar zyga pophysial joints. Pain 1 994 ; 5 8 : 1 95-200. 59. Schwarzer AC, April! eN, Derby R, Fortin J , Kine G, Bogduk N. Cli nical fea t u res of patients with pain stem m i ng fyom the lumbar zygapophysial joints. Is

Chapter Six: The Sources o f Back Pain

t he l u m bar facet syndrome a c l i n ical e n t i ty ? Spine 1 994; 1 9 : 1 1 3 2 - 1 1 3 7 . 6 0 . Schwarzer AC, Apri l l C N , Derby R, For t i n J , K i n e G , Bogduk N . The relative contributions o f t h e disc and zyga pophyseal j o i n t i n c h ronic low back pain. Spine 1 994; 1 9 : 80 1 -806. 6 1 . Schwarzer AC, Apri l l CN, Bogduk N . The sacro i l iac joi n t i n chron ic low back p ai n . Spine 1 99 5 ; 2 0 : 3 1 -3 7 .

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6 7 . V i l-ta L , R o n n e m aa T . The assoc i a t i o n o f m i l d ­ moderate i s t h m i c l u m ba r spondy l o l i s t hesis a n d l ow back p a i n i n m i d d l e-aged p a t i e n t s is weak a n d it only occurs in women. Spine 1 99 3 ; 1 8 : 1 49 6- 1 5 0 3 . 68. W i l k V . P a i n ari s i ng from t h e i n terspi nous and supraspi nous l igaments. Austral Muscu loskel Med 1 995 ; 1 : 2 1 -3 1 .

62. Schwarzer AC, Apri l l C N , Derby R, Fort i n J , Kine G , Bogduk N . The prevalence a n d c l i n i ca l features o f i n ternal disc disru p t i on i n patien ts w i t h chronic low back pai n . Spine 1 99 5 ; 2 0 : 1 87 8- 1 8 8 3 .

69. W i l t I , Vestergaard A , Rose n k l i n t A. A comparative

63. Schwarzer AC, Wang S, Bogduk N , McNaught PJ,

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analysis of x-ray findings o f the l u m bar spine in patients with and without l u m b al- pa i n . S p i n e 1 984;9: 298-300.

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Ann Rheum Dis 1 99 5 ; 5 4 : 1 00- 1 06 . 6 4 . Splithofr CA. Lumbosacral j u nction : Roentgeno­ graphic comparison of patients with and without backaches. JAMA 1 95 3 ; 1 5 2 : 1 6 1 0- 1 6 1 3 . 65. Stillwell DL. Regional variations in the i n n ervation of deep fasciae and aponeuroses. Anat Rec 1 95 7 ; 1 2 7 : 635-6 5 3 . 6 6 . Torgerson WR, D o t t e r WE. Comparative roentgeno­ graphic study of the asymptomatic and symptomatic l u mbar s p i ne. J Bone Joint Surg 1 9 76;58A:8 50-8 5 3 .

7 1 . Yahia LH, Newman N , Rivard C H . Neuro h i s tology of l u m bar s p i ne l igaments. Acta Orthop Scandinav 1 98 8 ; 5 9 : 5 08-5 1 2 . 7 2 . Y a h i a L H , N ew m a n N A . A l i g h t and electro n m i croscopic study o f s p i n a l l i gamen t i n n erva t i o n . Z m i kroskop a n a t Forsch Leipzig 1 9 8 9 ; 1 0 3 : 664-6 74. 7 3 . Yoshi zawa H , O'Brien J P , Thomas-S m i t h W, Trumper M . The neuropat hology o f i n tervertebral discs removed for low-back pai n . J Pa t h 1 980; 1 3 2 : 95- 1 04.

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PART

Assessment

CHAPTER 7

CHAPTER 11

Diagnostic Triage in Patients with

Quantification of Physical

Spinal Pain

Performance Ability

Neil Craton

Craig Liebenson and Steven Yeomans

CHAPTER S

CHAPTER 12

Outcome Assessment

Physical Performance Tests: An

Steven Yeomans, Craig Liebenson,

Expanded Model of Assessment

Jennifer Bolton, and Howard Vernon

and Outcome

ApPENDIX SA

Forms CHAPTER 9

Assessment of Psychosocial Risk Factors of Chronicity-"Vellow Flags" Craig Liebenson and Steven Yeomans

Maureen J. Simmonds and Ellen Lee CHAPTER 13

Employment Screening and Functional Capacity Evaluation to Determine Safe Return to Work Leonard Matheson and Vert Mooney

ApPENDIX 9A

Yellow Flag Form

Editor's Note

CHAPTER 10

Pain is subjective, and unfortunately it is all we as

Evaluation of Muscular Imbalance

clinicians have as a starting point in the evaluation

Vladimir Janda, Clare Frank,

of patients. Objectification of our patient's symp­

and Craig Liebenson

toms has proven remarkably elusive. This has even

124

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Part Three: Assessment

Editor's Note

(Continued)

led many to conclude that back problems are largely psychosomatic! However, this may point out more about the limitations of the biomedical model than about the source of our patient's pain. The practice of using advanced diagnostic imag­ ing, with its high false-positive rate for coincidental structural pathology, as a screening test on nearly all severe pain patients only conf�uses and frustrates the patient and doctor. The resulting "labeling" of the patient has too high a potential to foster illness

peting in a marathon!). Disability in the sense of actual skills or activities we perform, dys[-unction in the sense of impairments in mobility or strength identified, and distress that patients feel over slow or failed recoveries are all equally important to assess in the modern biopsychosocial paradigm. Naturally, the first role of the clinician is to diag­ nose the patient. Unfortunately, this is only possible with certainty for a minority of spine patients. The next question is, can we at least classify patients into meaningh.ll subgroups who will respond to or

behavior in patients with excessive fear-avoidance

require specific interventions? Recent developments

behavior.

in diagnostic triage, outcomes management, assess­

The World Health Organization has described

ment of "yellow flags" prognostic traits, and func­

how symptoms, disability (activity level), and im­

tional assessment enable clinicians to give patients a

pairment are inter-related. Many people with sub­

better explanation of what is causing their pain,

stantial impairments are participating in high level

what can we do for them, what can they do for them­

activities (e.g., a person with an artificial limb com-

selves, and how long might it take.

Diagnostic Triage in Patients with Spinal Pain

Neil Craton

Diagnostic Triage in Patients with Spinal Pain

Learning Objectives

Arter reading this chapter you should be able to:

The Red Flag The Yellow Flag Sinister Conditions Simple Backache Versus Nerve Root Problems The Patient in Jeopardy Special Populations and Diagnostic Labels

Investigations in the Diagnostic Triage Process

•

•

•

•

Plain Radiography CT Scans

•

MRI Bone Scan

•

Electrophysiologic Testing Invasive Diagnostic Needling Techniques

Clinical Vignettes

•

•

•

•

Define the "red flag" as i t applies to the diagnostic triage of patients with spinal pai n Define the "yellow flag" as it applies to the diag­ nostic triage of patients with spinal pain List five red flags for the presence of cancer in patients with spinal pain List two red flags for the presence of infection in patients with spinal pain Describe the role of plain radiography in the diag­ nostic triage algori thm [or patien ts with spi nal pain List the specific deep tendon reflex, myotome, dermatome, and dural stretch signs associated wi th radiculopathy from C5- T1 and L4-S 1 Describe the "patient i n jeopardy" of chronic spi nal pain associated with work loss and disabil ity List 10 yel low flags For work loss and disability in patients with acu te spinal pai n . Describe t h e l i m i tations associated with t h e clin­ ical identification of a specific tissue label For patients with simple backache Describe the sensitivity and specificity of magnetic resonance imaging in the diagnosis of spinal pain

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Part Three: Assessment

Diagnostic Triage in Patients with Spinal Pain

The diagnosis and treatment of spi nal pain is a con­ lroversial and enigmatic subjecl. M any di fferen t par­ adigms have been developed to explain where back pain comes from and how to treal it. The treatment offered to patients is o ften based on t issue-specific, parad igm-specinc diagnostic labels. Unfortu nately, the same patient may receive disti nctly different diag­ noses from di fferent practitioners to explain the same episode of spinal pain. Despite the use of d iffering diagnoslic labels, clinicians from all paradigms are required lo iden t i fy patients with serious u nderlying condilions responsible for the patient's back pain. This chapler discusses a process o f diagnostic triage lhat can be used to c haracterize pati ents as fal l i ng i n to one of the foll owing categories: 1. Possible serious pathology 2. Benign spi nal problems with no neurologic

dencit (si mple backache) 3. Spi nal causes with neurologic deficit 4. Non-spinal problems

The process of making a tissue-specinc diagnosis for palienls with chronic lumbar pain is also reviewed. Mosl spinal c l i n ic i a n s pride themselves on t h e abililY lo conduct a comprehensi ve physical assess­ menl of a patien t with spinal pai n . The identi fication o f a pain generator, biomechan ical anomalies, and olher c u l prits forms a large part of the d i agnostic process of mosl pract itioners . However, the assess­ menl of patients w i t h acute spi nal pai n does not requ i re the c l i n ician to make a tissue-specific di ag­ nosis. Even lhough a d iagnosis might be made using eleganl c l i n ical assessments or invasive tec h niques, lhis is oflen only of academic i n terest, because many pat ienls will recover regardless of diagnosis or man­ agemenl (4). This, combined with the fact that many common spinal conditions have no rel iable or val i­ daled physical manifestations, l i m i ts the u ti l i ty of a lissue-specinc diagnosis i n the triage of patients wit h spinal pain (6, 1 2, 2 1 ,23,27,36,39). Therefore, the diag­ nostic algori lhm regardi ng palients with spinal pain focuses ini tially on the exclusion of serious pathology (Fig. 7. 1 ). Palients with spinal pain that may be caused by mal ignanl lu mors, i n fections, fTactures, or cauda equina syndrome require emergent lriage to tertiary care insli lulions for defin i tive investigation and man­ agemenl. The diagnostic triage process then must exclude non-spinal pathology such as renal, abdomi­ nal, or gynecological disease. After rul i ng out serious or non-spinal pathology, the clin ician can then con-

duct a musculoskeletal assessment to exclude spinal pathology and should disti nguish a nerve root prob­ lem fTom si mple backache ( 3 3 ) . The diagnostic triage process does not end wilh the simple determination of what is causing a palient's pai n . The biopsychosocial model o[ spine care empha­ sizes that pai n and suffering are di fferent entilies, and thal emotional and social factors can strongly i n fluence whether a person seeks care [or a part ic­ ular spinal problem and the oUlcome of lhat prob­ lem. The pandemic of spi nal pain-related disabililY and work loss clearly poi n ts to the importance of pre­ venting chronicity i n people wilh spine pai n, and psy­ chosocial factors strongly infl uence the prognosis of organ ic spi nal pathology. The process of assessing palients wi th spi nal pai n has been the subject of subslanlial scholarship. Guide­ l i n es have been publi shed lhroughout the world to assist the cli nician i n making evidenced-based cost­ effeclive decisions lo deal wi lh the back and neck pai n populalion ( 1 ,4,24,33 , 4 1 ,44). Multi-discipli nary diag­ nostic algori thms outl i n i ng the consensus opinion o[ researchers have been published wilh recom menda­ tions for the i nves tigation and clin ical lreatmenl of patien ts wi th spinal pain ( 1 ,4,24,33 ,4 1 ,44).

The Red Flag

The red flag can be defined as a cl in ical symptom or sign that may i ndicate sinister palhology as a source of the patient's spinal pain ( 1 ,4). The idenlincation of a red flag should trigger action steps lhat need lo be indi­ vidual ized to each patienl. The red flag may prompt advanced imaging, serological invesligations, patient referral, or expectant observation (see Table 4.6). The key tools used i n delerm ining which patienls may have a serious u nderlying condition presenting as spi n al pain are the patienl hislory and physical exam i n ation . The i den t i fication o f the "red flag" [Tom a delailed history is t h e mosl i mportant parl of the diagnostic triage process. The majori ty of red fl ags are symptoms and can be elici led withoul a physical exami n a l i o n . Si mple hi slorical red flags serve as a sensitive diagnoslic lool for the i dentifi ­ cali on of tumor, i n feclion, a n d fraclure (IJ). The physical exa m ination is typi cal ly less val uable i n delerm i n i n g which patienls have serious problems Ii ke cancer (l ,4). The exisling evidence show thal no particular c l i ni cal consle l lation of physical signs elici ted o n physical examinalion allows a valid or reliable diagnosis to be made in anatom ical or patho­ logical terms (4). The maj ority o f patie nls with spi nal pain will nol have sin ister pathology as the source of their spinal pain ( 1 ,4). Health care pracli lio ners who see a high

Chapter Seven: Diagnostic Triage in Patients with Spinal Pain

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127

History and physical examination. Does the patient manifest any red flags for sinister conditions? Yes

No

Patient should have CT or MRI

Does the patient have any non-spinal symptoms

for suspected cancer, infection

or signs such as fever, chills, urinary complaints,

or cauda equina syndrome. Plain

abdominal pain/tenderness or costo-vertebral

radiograph for fracture. Bone scan

tenderness?

or CT if clinical suspicion of fracture is high and plain films negative.

CBC, ESR, Urinalysis, other serology

No

Yes

as indicated, abdominal imaging as indicated (plain film, flat and upright, ultrasound, CT) genito-urinary imaging as indicated (KUB plain film, IVP).

I

If unilateral and unisegmental, no imaging necessary in first 4 weeks. CT or MRI at 4 weeks to confirm

Does the patient have radicular features?

I

Yes

discopathic cause of radiculopathy. If progressive neurologic loss or

I

No

any features of cauda equina CT/MRI. Simple Backache Does the patient with simple backache have yellow flags for long term disability and work-

Yes

loss?

Psychosocial inventory required, consider psychological or social

No

work referral.

_Yes

Active adolescent-SPECT scan for

I

Does the patient have any characteristics of a special population?

pars stress fracture.

No

Older patient-plain film for osteoporotic compression fracture. Asymmetry-plain radiography for scoliosis. Prior spinal surgery-MRI for discitis, epidural fibrosis.

In the absence of red flags, non-spinal symptoms or signs, month long radiculopathy or the characteristics of a special population, diagnostic testing is not required.

Figure 7.1 Acute spinal pain diagnostic triage algorithm.

volume of spinal pai n patients w i l l generall y see benign mechan ical low back pai n , w h i c h c a n be referred to as simple backache ( 3 3 ) . Still, t he clini­ cian needs to maintain a h igh level of vigilance to avoid m issing sinister pathology among the many patients wi th benign spinal pain .

The Yellow Flag

The yellow flag is a symptom or s ign that should raise the i ndex of suspicion regarding the develop­ ment of chronicity in a patient with spinal pain (24).

Although the red flag can be though t of as a physical problem worse n i ng a patient's prognosi s, the yel low flag can be thought of as a psychosocial factor that worsens prognosis. The yellow flag i s not a h arbi n­ ger of s i ni s ter pathology but should be cons idered a risk factor that the patient is i n "jeopardy" of c h ronic spin a l pain and disabil i ty. Yellow flags are often foun d i n the patients' psychosocial, psycho­ dynamic, or socioeconomic background ( 1 ,24) (see chap ter 10) . The process of diagnostic triage i n patients with spinal pain should attempt to u ncover such yellow flags. There is ample l iterature describing risk factors for t he develop m e n t of chro n i c i ty that

128

Part Three: Assessment

can be elici ted through a patient i n terview ( 1, 24,43). The prevention of c h ronicity should be the founda­ tion of the tri age and m an agement algori t h m for all pa tients w i t h spinal pai n .

Sinister Conditions

The most serious conditions that may cause spinal pain incl ude cancerous lesions, i n fections, unstable vertebral fTactures, in tra-abdomi nal vascular acci­ dents, or a ruptured viscus. The triage process for t hese condi tions should begi n with the patient i nter­ view focusing on symptoms suggestive of s i ni ster pat hology (Table 7. 1 ).

Malignancy

The probabi l i ty o f a patient prese n t i ng to a primary care prac ti tioner w i t h back p a i n h avi ng cancer i s less t han 1 % (4,1 1 ). M o s t o f these patients would be elderly . The m ost common presenting symptom of pat ients w i t h spi nal neoplasia is back pai n ( 13). This is obvi ously of l i ttle use i n the diagnostic triage pro­ cess. The fact that patients with spinal neoplasia will often report an episode of traum a at t h e onset of t heir pain is also a challenge to the cli nician . Symptoms that are suggestive of spi nal malignancy are pain t hat is persistent, progressive, and worse at night. The lack of pai n relief with recu mbency is not typical of benign low back problems (7). Patients wi t h low back pai n and weakness of the lower extrem ities must also be considered to be at i ncreased risk for harboring a spinal tu mor. Up to 40% of people with primary neo­ plasms of the spine present with lower extremity weak­ ness (49), whereas 30% of patients w i t h metastatic lesions will presen t w i t h a neural compression syn­ drome ( 2 8 ) . Deyo and Diehl showed that age older than 50, cancer h istory, u nexplained weight loss, pain lasting more than 1 month, and no i mprovement with initial t herapy were symptoms signi fican tly associated with back pai n attlibuted to cancer ( 1 1 ). Other worri­ some sym ptoms for malignancy include anorexia, fevers, chills, rigors, and n igh t sweats. The presence of these red flags requires the clinician to undertake diag­ nostic tests to rule out a mal ignancy. The m ajori ty of t u mors t h at a ffec t t he l u m bar spi ne are metastatic . Metastatic disease accounts for 40- ti mes as many cases of spinal neoplasi a as all ot her forms o f bone cancer combined ( 13) . T here­ fore, ascertai n ing other risk factors for malignancy can help guide the triage process. In females, the most common tumors to metastasize to the vertebrae are fTom the breast and lung (28). A personal h i story of breast cancer or a personal h i story of smoking

wou ld be considered important risk factors for t hese malignancies. In males, the most common tumors to metastasize to the vertebrae are from the prostate and lung. Advanci ng age and symptoms of prostatism such as urinary h es i tancy, n octuria, and decreasi ng cal i ber of t h e urin ary stream should prompt con­ s i dera t i o n o f prostate disease. A rectal exam i­ n a t i o n i nc l u d i n g assessment of t h e volume and co nsistency of t h e prostate w i l l i n dicate w h i c h patients s h o u l d b e sent to t h e urologist for addi­ tional tes t i ng. Serological i nvestigations including semm calcium, alkaline phosphatase, and acid phos­ phatase should be performed if metastatic prostate cancer is suspected. Prostatic serum ant igen ( PSA ) blood levels can also be a useful screen ing test [or prostatic malignancy. Aside from i magi ng tes ts, simple laboratory tests i ncluding a complete blood count and erythrocyte sedimentation rate can aid the diagnostic process when there is a suspicion of i n fection or tumor being the causes for a patient's spinal pai n (1). The higher the ESR and white blood cell count, the greater the probability of cancer, i n fection, or an inflammatory process being responsible [or the patient's pai n.

Infections of the Spine

The probabil i ty of a patient presenting to a pri mary health care practi tioner with back pain h aving an i n fection as the cause is said to be less than 0. 0 1 % (4, 1 0) . However, i n the past decade, the i ncidence of central nervous system infections has increased largely because of t h e epide m i c of acq u i red immu n ode fi ­ ciency syndrome (AIDS). As a consequence, spinal i n fecti o ns h ave also i n creased (32 ) . Th erefore, the diagnostic triage process must i nclude appropriate questions regarding the risk factors for HIV acquisi­ tion. Intravenous drug use, anal intercourse, multi­ ple sexual partners , and hemoph i l ia are important risk factors for HIV i n fection . The most common symptoms of spinal i n fection include malaise and back pain ( 32 ) . The most sensi­ tive historical factors for the identification of spinal osteomyelitis in a patient with back pai n are a h istory of intravenous drug use, a previous urinary tract infec­ tion, or a skin i nfection (48). Symptoms more spec i fic for a spi n al i n fection or an i n fection that is respon­ si ble for spinal pain m ay also i nclude [evers, c h i l l s , rigors, a n d n i g h t sweats. Individuals w i t h these symp­ toms need to be evaluated for osteomyelitis, disci tis, or an epidural abscess (4). The compromised host, such as diabetic subjects, i n travenous drug users, and the chronically ill are particularly susceptible to spinal i n fections. Previous spinal surgery should also raise the index of suspicion regardi ng an infectious process.

Chapter Seven: Diagnostic Triage in Patients \Nith Spinal Pain

Table 7. 1

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129

Estimated accuracy of medical history i n diagnosis of spine diseases causing low back problems: Diseases to

Medical history

True-positive

True-negative

References

be detected

red flags

rate (sensitivity)

rate (specificity)

Deyo and Diehl

Cancer

Age >50

0.77

0.7 1

Previous cancer h istory

0.31

0.98

U nexplained weight loss

0. 15

0.94

Fai lure to improve with 1 month of therapy

0.31

0.90

Bed rest no relief

>0.90

0.46

Duration of pain >1 month

0.50

0.8 1

Age >50, h istory of cancer or unexplained weight loss or fai lure of conservative Rx

1.00

0.60

Spinal os teo myeli tis

Intravenous dmg use, UTI, or skin i nfection

0.40

NA

Compression fracture

Age >50

0.84

0.6 1

Age >70

0.22

0.96

Trauma

0.30

0.85

Corticosteroid use

0.06

0.995

Waldvogel and Vasey

Deyo

Herniated disc

Sciatica

0.95

0.88

Turner, Ersek, Herron, et al.

Spinal stenosis

Pseudoclaudication

0.60

NA

Age >50

0.90

0.70

Positive responses 4 out of 5

0.23

0.82

Age at onset <40

1.00

0.07

Pain not relieved i n supine position

0.80

0.49

Morni ng back sti ffness

0.64

0.59

Gran

Ankylosing spondylitis

Duration of pain >3 mon ths From Bigos S, Bowyer 0, Braen G . et al. Acute Low Back Problems in Adults. Clinical Practice Guidelines. N o . 14. Rockville MD, Agency for Health Care Policy and Research , 1 994, AHCPR publication 95-064 2 .

Patients who have had previous chemotherapy, radio­ t herapy, or used corticosteroids or other i m mu ne­ suppressant dmgs should be considered at i ncreased risk for spinal i n fection when they present with back pai n. Dysuria, udnary frequency, Ulinary urgency, and pain radiating to t he groin i ncrease the l i ke l i hood of a uri nary tract infection.

There are few c l inical signs that are sensitive and spec i fi c for the identification of a spinal i n fe c t i o n . Fever, vertebral tenderness, a n d very l i m i ted spinal range of motion can suggest the possi bi l ity of a spinal i n fection but may also be present i n other causes of spinal pain ( 1, 32 ) . The urinalysis i s a si mple non­ invasive test that can be used to screen for hematuria

130

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Part Three: Assessment

or pyuria i n the presence of urinary tract pathology. Subsequent m id-stream urine assessment for culture and sensit ivi ty can c o n fi rm t h e presen ce of bacte­ rial pathogens and guide subsequent anti-microbial treatmen t . The eval uation o f a patient suspected o f h aving an infection as the source of their spinal pain should include a complete blood coun t (CBC) and an erythro­ cyte sedimentation rate (ESR). The ESR is a very sen­ si tive tool for i nfection, although it is not specific and may be elevated i n other systemic condi tions l i ke spondyloarthropathies and rheumatic conditions (4). Cul ture of the appropriate body fluids should precede any advanced i maging. The bone scan is the pri mary i nvestigation for suspected spinal i nfection (4).

Spinal Fractures

Signifi can t trauma i s the most i mportant h istorical ractor that would lead the c l i n ician to suspect a frac­ ture in a pat i e n t wi t h acute spinal pain. The age of the patient will i n fluence the magnitude of trauma req uired to cause a spinal fracture and is the second most important factor in t he assessment of t hese prob­ lems. In the general population, significant fractures presenting as back pain occur only in patients with a history of major trauma (4,35). A fall from a significant height or a h igh-velocity motor vehicle accident asso­ ciated with acute low back pain should prompt the cli nician to consider a t least plain radiographic imag­ i ng to detect a fracture. In older i ndividuals or in those wi th other consti tutional difficult ies, simple heavy lift­ ing or a mi nor fall should raise the i ndex of suspicion of a spinal [Tacture (1). I ncreasing age and osteoporo­ sis are defi n i te risk factors for spinal fractures with minimal iden tifiable trauma. A patient with spi nal pain a fter trauma needs to be considered to have an u n s table spinal i nj ury u n t i l prove n o t herwi se. A n y neu rological symp toms o r al tera tion i n the patient's level of consciousness man­ date that t he patient be i m mobilized and emergently triaged for spinal i maging. Hard collar immobiliza­ tion for cervical i njuries and the use of a backboard w i t h pelvic and cervical i m mobi l i zation should be used for more caudal i njuries. Practitioners who cover athletic events with a high risk of spinal trauma such as football and hockey need to rehearse the manage­ men t of an ath lete with a suspected spinal fracture. Any a t h le te who has bony tenderness, d i m i nished range of motion, or even transient neurologic signs needs to be managed w i t h great caution. The t riage of a patient with trauma and back pain should i nclude plain radiography as the i n itial i nves­ t igat ion. Screening for spinal i nj uries i n which i nsta­ bil i ty is a possibility is typically performed with lateral

p l a i n radiographs. The spine must be evaluated for evidence of soft t i ssue swe l l i ng and al ignme n t . The lateral radiograph can be performed while the patient i s i n the appropriate i mmobilizing devices if a sus­ pected unstable spine fracture is being evaluated (18). Focal kyphosis or other local alignment anomalies can be an important sign of injury. The lateral radiograph must i nclude all of the spinal elements t hat may be at risk. I m ag i ng of the lower cervical spine and the cervico-thoracic j unction is a frequent problem be­ cause of the overlapping bony anatomy in that area. The lateral radiograph alone is insu fiicient to rule out fracture and i s the start i ng poin t i n the triage of a patient w i t h a potential spinal fTact ure. If t he lateral film is normal, other views can be obtained. If plain radiographs are normal and i ndex of sus­ picion i s high enough, either bone scan or CT should be performed. In a patient wi th persisting pain after trauma with an i n i ti al normal x-ray, the i nvestigation should be repeated in 10 to 14 days. When a fTacture is identified on plain film, CT can be of particular value i n demonstrating the relation­ ship of the fracture fragments to the spi nal canal (18). CT is also of particular value for imaging the poste­ rior spinal elemen ts.

Other Red Flags

Cauda Equina Syndrome Patients who manifest incontinence of stool or uri ne need to be considered as having cauda equina syndrome until proven o ther­ wise. Associated symptoms i nclude bilateral leg pain, urinary urgency, uri nary retention, and sexual dys­ function. Physical signs that may accompany the h is­ torical red flags could i ncl ude a peri neal sensory dist urbance often referred to as saddle anesthesia and decreased rectal tone. In t hese patients, it is beli eved t ha t emergent surgical decompression of the cauda equ i n a can preven t a n europraxia [Tom pro­ gressing to a more permanent neurologic defi c i t . Therefore, emergent advanced imaging with C T or M R I is necessary i n t h i s popu lation.

Progressive Neurologic Loss The presence of pro­ gressive neurologic l oss is another harbinger of sin­ ister spinal pathology (13). Most spinal clin icians are quite comfortable after patients with u n ilateral and u n i segmental lower motor neuron abnorma l i t ies. These findings are often associated with compressive discopathy or chem ical radicul itis secondary to dis­ copathy. Pubhshed guidelines state that such patients do not requi re advanced spinal imaging or referral i f t hey improve w i t h the i n itial c l i n ical i nterventions and time (1,34). However, when patients have pro­ gressive loss of s trength , sensation, or hyporeflexia, urgent i maging for an expanding space occupying

Chapter Seven: Diagnostic Triage in Patients with Spinal Pain

lesion i s indicated. Magnetic resonance i maging is the most sensi tive lool for the i nvestigation of this group or palients (34). I n di vi duals wilh upper motor neu­ ron findi ngs of hyperreflexia, i ncreas i ng muscle tone, up-go i ng toes, and clonus also require urgen t central nervous system i maging to ru l e o u t com­ pressive myelopathy or other central nervous system anomal ies. Patients mani festi ng these signs need to have a definitive diagnosis reached as soon as possible.

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131

col ic, endomettiosis, pelvic i n fl a m matory disease, ectopic pregnancy, and ovarian cysts can all cause back pai n . M ost of these condi tions wou ld be missed if the c l i n ician fai l s to lay a hand on the patien t's belly or considered gynecological problems in female patients.

Non-Spinal Causes ofBack Pain The most common

Simple Backache Versus Nerve Root Problems

systemic condi t ions that present with spi nal pain are the spondyloarthropath ies. Patients w i t h spondylo­ arthropalhies or other i nflammatory condi tions need to be i denti fied as early as possible i n the diagnostic process, because they often requ i re specific i nvesti ­ gations and pharmacologic therapy i n addition to manual, modal ity, or exercise-based therapy. Psoriatic rashes are a clue to the presence of psoriatic spondy­ loarthropathy. Symptoms of diarrhea or inflammatory bowel disease also should prompt the cli nician to con­ sider Reiter disease and ankylosi ng spondylitis. Ankylosing spo ndy l i t i s is c haracterized by morn­ i ng st iffness, im provement with exerc i se, o nset a t younger t h a n 4 0 years of age , and duration of more than 3 mont hs. Recurring tendi noplasties or en t he­ sitis should also i ncrease the i ndex of suspicion of this class of disorder. I nitial blood work for the evalua­ tion of a patient with a suspected rheumatic condition or spondyloarthropathy should include a complete blood count, an erythrocyte sedi mentation rate, a rheumatoid factor, an anti-nuclear antibody screen, and a uric acid level. Concern regarding ankylosing spondylitis should prompt an HLA B27 h istocompata­ bility screen. Diagnostic triage should disti nguish patients with non-spinal causes of pain felt i n the vertebral area. Pai n emanat i ng from i n t ra-abdo m i nal and ret ro­ peri toneal structures w i l l frequen t l y requi re non­ pri mary care i nvestiga tion and man agement. Various i ntra-abdomi nal condi t ions can present with spinal pai n . The most sinister would be a rup­ tured abdom inal aortic aneurysm. These patients may have no specific features early in their presentation. A h istory of vascular disease or the presence of cardio­ vascular risk factors warrants assessment for this con­ dition. Careful abdomi nal palpation should reveal a pulsalile mass, which may be tender. Any abdominal guarding, rebound tenderness, or vital sign anomaly would prompt emergent refen-al to a tertiary care i nsti­ tution via ambulance. En roule to hospital, large-bore intravenous access wil l be established. At t he hospital, definitive imaging will include CT, M R!, or ultrasound. There are many other intra-abdominal condi t ions that can refer pain to the back. Peptic u lcer disease (wi th or without perforation ) , pancreati tis, b i l iary

The term "simple backache" can be used to describe mechanical back pain that is musculoskeletal in ori­ gi n . Pain receptors are present in bone, z-joints, mus­ cle, connective tissue, periosteu m , the outer th ird of the i n tervertebral disc , and i n perivascu lar tissue. Pai n receptors can be activated by mechan ical strain or dysfunction, metabol i tes, or i n flammation. Sim­ ple backache can be very painfu l and can refer pain to the leg, hip, or t h igh, but generally not below the knee (33). The term simple backache implies that the nerve roots and spinal cord are not compromised, and that there is no evidence of si nister or non-spi nal pathology. This group of pat ients can receive a wide array of diHerent diagnoslic labels depending on the trai n ing of the healt h care practitioner they visil. Pa­ tients with si mple backache and no red flags do nol require any diagnostic i nvestigations in the first month of symptoms. Simple backache can be considered from diFferent perspectives in the process of diagnostic triage. Tra­ di tional medical diagnostic labels have involved struc­ tural changes purported to be pathoanatomic. Such changes have often been based on radiograph ic evi­ dence. However, c hanges such as degenerative discs and oSleophytes on plain radiography and other i mag­ i ng are not sensitive or speci fic for patients with spinal pai n . Clinicians from other discipli nes use diagnostic labels based o n a functional model, often involving manual palpation. D i agnostic labels such as su blux­ ation, fixation, somatic dysfunction, myo fascial lrig­ gel' poi n t , and others are often used lo explain spinal pain episodes. M ost of these labels have had diffi­ cul ties with sci e n t i fic val idity, in ter-rater rel iabi l i ty, and sensitivity and specificity for spi n al pai n . Other models for categori zing sp inal pain patients i nvolve movement patterns and impairments iden tified dur­ i ng physical exami nation associated with the patien t's pai n . The McKenzie protocol is one or the best known of these models. T h i s method has been shown to be a useful way of c lassifyi ng patients i n to groups that respond to a speci fi c t reat men t (29). A l though not havi ng face validi ty for its purported pathoanatomic correlates, it is useful fyom a treatment perspective. Modi fications to the McKenzie melhod have been made and eval uated in a sc ientific fashion (14).

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Part Three: Assessment

Table 7.2

Treatment-based classification system

categories • • • • • • •

1mmobi l i zation Lu mbar mobilization Sacra-iliac mobilization Extension syndrome Flexion syndrome Lateral sh ift Traction

From Fritz, J M , George S. T h e u s e of a classification approach to identify subgroups of pat ients with acute low back pain. Jnterrater reliabil ity and short term outcomes. Spi ne 2000;25( 1 ) : 1 06-1 1 4.

So-called treatmen t-based classification systems, which use i nformation gathered from a physical exam ination, patient self-report of pain (pain dia­ gram and pai n scale), and Oswestry pai n question­ naires, have been used to classify patients with acute spi nal pai n i n to graups for specific treatments. The classifications are not based primarily on a t issue-spe­ ci fic diagnosis or pathoanatomy, but rather the type of treatment indicated for t he particular patient (Table 7.2). This type of classification system has been doc­ umen ted to h ave a moderate degree of i nter-rater rel i abi l i ty but req u i res furth er i nves tigation to establ ish i t s vali d i ty ( 1 4 ) . Some of the premises i n

Table 7.3

t h is classification system do not withstand close sci­ entific scrutiny (see Chapter 6). Nerve root p a i n commonly arises from a single nerve root , and i s assoc iated with u n i l ateral pain radiating down the leg i n a distribution that approx­ imates a dermatome. T he pai n can refer to the foot. Leg pai n i s often more bothersome to the patient t ha n the back pain . The pai n is often associated w i t h numbness or paresthesiae. There are often spe­ c i fi c physical signs of nerve root i rritation such as myotome weakness, diminished deep tendon reflexes, dermatomal sensory loss, and dural stretch signs (Tables 7.3 to 7 . 5 ) . The finding of leg pai n in the con­ tralateral l eg w i t h straigh t l eg rai sing is a very spe­ cific test for neurologic compromise wi th a herniated l umbar disc (1). This abbreviated neurologic exami ­ nation of t h e lower extrem i ties w i l l allow detection of most c l i n i cally sign ificant nerve root comprom ise, w hich makes up more than 90% of all radiculopathy of the lumbar spine. Such screening examination i n the di agnostic triage may miss more cephalad dis­ copathy and radiculopathy (25 ) . I n the cervical spine, an accurate diagnosis regard­ i ng nerve root i nvolvement can be obtained through the patient's h istory 75% of the time (47) . Pai n is often greater i n the upper extremi ty than in the cervical region. The pain is often associated with paresthesiae and weakness. A lancinati ng quality to the pain is often reported. The distribution of the pain depends on the nerve root i nvolved. Cl and C2 rad icul opath ies are

Typical physical findings associated with the most common lumbar radiculopathies

Nerve root involved

Muscular weakness

Sensory loss

Reflex effected

L4

Quadriceps, tibialis anterior

Medial malleolus

Knee jerk

L5

Extensor h al lucis longus

First web space of foot

Medial hamstring

Sl

Gastrocnemius, soleus

Lateral malleolus

Ankle jerk

------- ---- -

Table 7.4

-

-

---

Typi cal physical findings associated with the most common cervical radiculopat hies

Nerve root involved

Muscular weakness

Sensory loss

Reflex effected

C5

Biceps, deltoid

Lateral arm

Biceps

C6

Biceps, wrist extensors

Lateral forearm

Brachioradialis

C7

Triceps, wrist extensors

Triceps

M iddle finger

C8

H and intrinsics

Medial forearm

Tl

Hand i ntrinsics

Medial arm

Chapter Seven: Diagnostic Triage in Patients with Spinal Pain

Table 7.5

--

J 33

Estimated accuracy of physical examination for lumbar disc herniation among patients with

sciatica Physical

True-positive

Examination test

rate (sensitivity)

Ipsilateral SLR

0.80

0.40

Positive result: leg pain a t <60 deg

Crossed SLR

0.25

0.90

Positive result: reproduction of contralateral pain

Ankle dorsiflexion weakness

0.35

0.70

HNP usually at L4-L5 ( 80%)

Great toe extensor weakness

0.50

0.70

HNP usually at L5- S 1 (60%) or L4-L5 (30%)

I mpaired ankJe reflex

0.50

0.60

HNP usually at L5-S 1 : absent reflex increases specificity

Sensory loss

0.50

0.50

Area of loss poor predictor of HNP level

Patellar reflex

0.50

NA

For upper lumbar HNP only

AnkJe plantar flexion reflex

0.06

0.95

-

Quadriceps weakness

<0.0 1

0.99

-

True-negative . rate (specificity)

Comments

From B igos S, Bowyer 0, Braen G, et a l . AcuLe Low Back Problems in Adul ts. C l in i cal Practice Guidelines. No. 1 4. Rockville MD, Agency for HealLh Care Pol icy and Research, 1994, A HCPR publication 95-0642. H NP, hern i aLed nucleus pulposis; SLR, straighL leg raise.

uncommon and can refer pain to the occipital and retro-orbital regions, respectively. The C3 root refers pain to the ear and jaw regions. C4 radiculopath ies refer pain along the base of the neck. C5-T 1 radicu­ lopathies are listed in Table 7 .4. Severe dermatomal loss of sensation is rare in cervical radiculopathies. Loss of manual dexterity, gai t instabi l i ty, generalized weakness, or urinary symptoms are red flags for cer­ vical myelopathy and require emergent i maging with CT or M RI. Aside from routine local musculoskeletal and neu­ rological examination, some provocati ve physical examination tests are advocated for the evaluation of patients with suspected cervical radiculopathy. Spurl­ i ng's neck compression test has a high sensitivity but low specificity. It i nvolves axial compression with cer­ vical extension and rotation provoking upper extrem­ ity or scapular pain. Relief of symptoms w i th cervical traction or glenohumeral abductio n also implies the presence of nerve root pathology. In the patient with suspected nerve root compro­ mise, close clinical atten tion is required to ensure no progressive neurologic loss or cauda equina symp­ toms develop. In the absence of red flags, patients with unilateral, u nisegmen tal nerve root findings do not require imaging or other diagnostic tests in the

fi rst month of symptoms, as long as they i m prove with clinical treatment and time. In patients with refractory nerve root compromise, diagnostic imag­ ing is required to rule out non-disc-related nerve root compression, such as tumor or other space occupy­ ing lesio n . To evaluate for such abnormalities, the c l i n ician can utilize myelography, CT, CT myelogra­ phy, or M R!. Most studies indicate no significan t dif­ ference in the true positive and true negative rates for diagnosing l u mbar disc herniation among CT, CT myelography, and M RI ( 1 ,22). Plain myelography was i n ferior t o t hese t h ree modali ties. Because any myelographic procedure can expose the pati e n t to complications of headache after spinal tap, reaction to contrast media, and men i ngeal infection, the non­ invasive modalities of CT and M RI are l i kely a supe­ rior choice for diagnostic triage of the patient with suspected h erniated nucleus pulpos us with nerve root compression.

The Patient i n Jeopardy

Disabi lity associated with chronic spinal pain syn­ dromes is a significant public healt h problem (40). Chronic low back pain causes more disability than all

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other health care problems combined for people younger than age 45 (40). Chronic cervical spine pain after whiplash is also a common cause of disability (44). There is evidence that the clinician can contribute to this disability in n umerous ways (43). Primary care medical doctors often receive l ittle training in the man­ agement of spinal pain, sllch that diagnosing and treat­ ing these problems is not their area of greatest clinical competency (8). The prescription of prolonged periods of rest, encou raging work absenteeism, the indiscrim­ inate lise of narcotics or sedatives, and facilitating dependence on passive care all can serve to increase the risk of the development of chronicity. U nder­ iden tifying at-risk patients may also result in inadver­ tently reinforcing factors that are disabling (24). For exam ple, failure to u nderstand that patients believe that movement will be harmful may result in t hem unnecessari ly experiencing the negative consequences of withdrawal from social, vocational, and recreational activities. It is also important to note that cognitive and behavioral factors can produce important physiologi­ cal consequences such as muscle wasting and joint sti ffness, prompted by i nactivity. Consistently missing yellow flags can be hat-mful and usually contributes to the development of chronicity (24). To m i n im i ze the risk for c h ro n i c i ty, the t riage process should include an effort to identify lisk factors for the development of chronic spinal pain (see chap­ ter 1 0) ( 24). M ost risk factors are based on h istorical information and can be documented in a t horough patient i n terview. The iden tification of t hese yellow flags should lead to appropriate psychosocial i n ter­ ven tions such as cogni tive and behavioral manage­ ment (24). Such management can i n turn help with the patien t's physical condition. The New Zealand M i nistry o f Heal th commis­ sioned a series of guidel i nes on the assessment o f yel­ low flags for long-term disab i l i ty and work loss (24). That group prepared a template o n how to j udge if a person is at risk for long-term disability or work l oss because of psychosocial factors. They also compiled an extensive list of psychosocial factors that adversely affect t he prognosis for patients with spi nal pai n . They emphasized t h a t the most accurate identifica­ tion of yellow flags required adequate time for evalu­ ation. They also suggested that pain drawings and other pain-speci fic psychometric measures could assist in the triage process. The key question to be kept in mind while conducting the risk assessment in one's diagnostic triage is, "What can be done to help this person experience less distress and disabil i ty?" (24). These [actors need to be considered in each patient presenti ng with spinal pain . There is greater risk to the patient in under-identifying these factors than over-iden tifying t hem. Patients may benefit from early cogn itive and behavioral therapy as opposed to being

referred as a salvage procedure with so-called failed back syndrome (see chapter 1 5 ) . T h e person at t h e greatest risk for chronicity can be described as a "patient in jeopardy" ( 43 ) . The pa­ tient i n jeopardy of chronic pain cannot be identi fied by paradigm-based p hysical exam ination findi ngs. Psychosocial factors are of greater prognostic value than traditional physical findi ngs based on range of motio n assessment, palpation, and alignment factors. However, in 1 980, Gordon Waddell described non­ organic physical signs that identified patients who required more detailed psychological assessment (46). Waddell described his non-organic physical signs as a simple and rapid screen to help ident i fy patients who required more detai led assessment (Table 7.6). The n on-organi c signs documen ted by Waddel l were more common i n patients w i t h out clear-cu t pathology a n d were n o t presen t i n normal patients. The nonorganic signs were equal ly common in medicolegal cases, compensation patients, and tbose who had no such t h i rd party i nvolvement. Waddell suggested that the examination for t h e non-organic signs should form part of a rou t i n e preoperative screen . The signs did not indicate a patient was malin­ gering or that they did not have a treatable lesion, but simply identified those patients who requi red formal psychological assessment prior to surgery. Gi ven the ease o f perform i ng these signs on patients with c h ro n ic l ow back pain, t hey should be part of the diagnostic triage process o[ any patient with chronic spinal pain i n whom surgery is contemplated ( see C hapter 1 0) .

Table 7.6 • •

•

•

•

•

•

•

The Waddell nonorganic signs

Superficial tenderness to light pinch Nonanatomic tenderness, which is not localized and often extends fTom lumbar spine to thorax or pelvis Axial loading pain, when low back pain is reported with vertical loading to the patients head Pain wi th whole body rotation, when shoulders and pelvis are rotated in the same plane D iscrepancy between seated and lyi ng straight leg raise G ive-way or cogwheel weakness that cannot be explained on a localized neurologic basis Sensory disturbances in a stocking rather than a dermatomal distribution Disproportionate verbal ization and facial expres­ sions during examination

From Waddell G , McCul loch M D, Kummel E , Venner R M . Nonorganic physical signs in low back pai n . Spine J 980 ; 5 ( 2 ) : J J 7- 1 25 .

Chapter Seven: Diagnostic Triage in Patients with Spinal Pain

Special Populations and Diagnostic Labels

The Elderly and Osteoporosis

Vertebral osteoporotic com pression frac tures are a common cause of spinal pain in the elderly. The pro­ gressive loss of spinal bone mass renders the verte­ brae at risk for wedge fl-actures with activities of daily living. Clinical suspicion of a vertebral compression fracture should exist in all females older than age 65 and in the presence of risk fac tors in both men and women. H istorical risk factors include smoking, cor­ ticosteroid use, premature or surgical menopause, small stature, and a positive fam i ly history of osteo­ porosis. Physical findings suggestive of vertebral com­ press ion fractures include an i ncreased t horacic kyphosis (dowager h u m p ) , an increased l u mbar lordosis, and a protuberant abdo men. In the t riage of these patients, a plain radiograph is often a l l t hat is necessary to identify t h e osteoporotic com pres­ sion fTacture ( 3 5 ) . Bone scintigraphy can determine whether the identified radiographic abnormali ty is recent ( 3 7 ) . The elderly typically have a lower i ncidence of acute herniated nucleus pulposus with nerve root compres­ sion. Therefore, any acute radiculopathy in the elderly should ra ise the c l i n ical suspicion of a compressive lesion such as a tumor. The other con d i t i o n that is more common in t he elderly is spinal ste nosis. The patient will typical ly report pain that increases with walking with relief with rest . These patients often have difficulty with s tanding and rel ief with sit t ing.

The Active Adolescent: Pars Interarticularis Stress Fractures

The majority of spinal pain i n young athletes is not sin­ ister. However, any evidence of neurological abnor­ mal ity in a young patient should be considered a red nag for mal ignancy. Davids has shown that radicu­ l opathy in the adolescent popu latio n is more com­ monly associated with malignancy than in adults (9). The other condition that needs to be considered in the process of diagnostic triage in the active adoles­ cent is a pars i n terti cularis s tress frac ture or acu te spondylolysis. This condi tion is found in adolescents involved in activi ties characterized by repetitive spinal l oading in flexion and extension. The pain is said to be exacerbated by spinal extension, particularly when performed on one leg (20). These patients can mani­ fest an accen tuated lumbar lordosis, shortened ham­ stri ngs, and a characteristic gait known as the pelvic wadd le ( 2 0 ) . These need to be differe n t i a ted from more generic mechanical spi nal pain , because t he managem ent for t h i s group requ i res t he cessatio n of activities associated wi t h pain . I n addi t i o n , some

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135

authors recommend spi nal bracing with t horaco­ l um bar spinal orthotics (TLSO) ( 1 6,45). In the investigation of a patient with a suspected pars interarti c u l aris stress fTac ture, plain radiogra­ phy is of l im i ted usefulness ( 2 , 3 5 ) . Even with the use of oblique views, up to 50% of patients wi th an acu te stress fTacture will have normal fi lms. The other com­ plicating issue using plain radiographs alone is that an iden tified spondylolysis or spondylolisthesis may not be the patient's pain generator. It may be an old l esion and not currently metabolically active or experiencing bone stress. T herefore, bone scin tigraphy with tec h­ netium 99M has been used as a more sensitive too l . Bone scintigraphy with compu ter enhancement o r so­ cal led single-photon emission computerized tomog­ raphy (SPECT) scanning is even more sensitive for this condition than plain bone sci n tigraphy (3 1 ) .

The Postoperative Lumbar Spine: Discitis, Arachnoiditis, and Epidural Fibrosis

The triage of patients who have had spinal surgery presents several unique chal l enges. This group of pa­ tients may h ave recurren t disc h e rn i a t i o n , epi dural fibrosis, spinal stenosis, arac hnoiditis, or disc i t is. O t h er conditions such as osteomyelitis, nerve root i njury, soft tissue i nfection, i nstrument fail ure, pseud­ arthrosis, and adjacent segment degeneration make this group of patients particularly d i fficult to evalu­ ate clinical ly. The diagnostic process can be further clouded by the potential of psychosocial issues (see previous section) that may be i nvolved in the genesis and perpetuatio n of t h e patients pain syndrome. Plain radiography with weight-bearing vi ews sup­ plemen ted by flexion and extension are usef-ul in the patient who has u ndergone a fusion procedure to eval­ uate i n tegrity of the procedure ( 1 6) . MRI is the imag­ i ng modali ty of choice for all postoperative patients except those with spinal instrumentation. MR pro­ vides the best evaluation of the soft tissue structures. MR is the most usefu l m odality for the differen tia­ tion between recurring disc and fibrosis. Most postoperative in fections are related to the disc space and the adjacent vertebral bodies. These pat i e n ts generally have u nrelen ting back pai n a fter surgery. An e levated ESR is frequently found. In this population, M R I is the imaging modality of choice. M RI is more sens i t ive in this popu lation than tech­ netium bone scan or gal l i u m scan ( 1 6) . Spinal fusion i s a common operation i n certain geographic areas. An increasing array of operative devices and tech niques are being used for these pro­ cedures ( 1 6) . The compl ications o f fL.lsion surgery i nclude hardware malalignmen t , hardware fail ure, pseudarth rosis, adj acent segment disk degeneration,

J 36

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Part Three: Assessment

and infec tion. Plain radiographs can be the first diag­ nostic technique in this patient population. Lucency noted adjacent to pedicle screw hardware implies hardware loosening.

Spondylosis/Disc Degeneration/ Spondyloarthrosis

This d i agnostic label assu mes t hat degenera t ive changes identified on imaging tests are pathoanatomic and related to a patien t's pain. The purported patho­ logic changes include disc space narrowing, facet a rL h rosis, osteophytes, and subchondra l sclerosis. H owever, whereas most patients i mprove with epi­ sodes of spinal pain, degenerative changes obviously do nol. Many people have such changes but do not have spinal pa i n or dys f-unction. These changes are si mply age-related changes. They occur with increas­ i ng frequency wit h age and are not more prevalent i n patients with spinal pain t h a n in i ndividuals with no pai n .

The Old Spine: Spinal Stenosis

In most i nd ividuals, aging leads to a decrease in the spinal canal volume. The person's canal size and shape will determ i ne which individuals are at greater risk for spinal canal compro m ise. Spinal canal com­ promise is referred to as spinal s tenosis. Pati e n ts with spinal stenosis will often have h ad a long history or spi nal pa in. With increasi ng age, they will have leg pain, particularly with wal king. Patients with central canal spinal stenosis typically manifest leg pain with wal king variable distances, called neurogenic claudi­ cat i o n . This differs from vascul ar claudi cation in that pa tients with vascular claudication tend to stop walking to al leviate the pain in the legs. Patients with neu rogen i c claudication tend t o h ave to sit down or stoop forward to relieve t h e pain . Walking u p hi l l i s be tter for t hose w i t h spinal stenosi s, because it i nvolves forward spinal flexio n , w hereas dow n h ill wal king with its relative spinal extension makes the problem worse. Lateral canal spinal stenosis typically manifests itself as in tense radicular pain rather than with neu­ rogenic claudication . This pain may not be posture­ related and may persist nocturnally during sleep. Physical examination may be u nremarkable. Patients can be differentiated from radiculopathy associated with disc herniation because they will often have a lack of dural tension signs. Diagnosis of spinal s tenosis i nvolves a careful h is­ tory and physical exa m i nat io n and can be confirmed by CT, CT myelography, and M R I . Electromyogra­ phy may be necessary to demonstra te denervation.

The Arching Spine: Scheuermann Kyphosis

Scheuermann kyphosis is a common condition affect­ i ng up to 8% of the population. The condition usually affects adolescents beginn ing at age 1 2 or 1 3 . It gener­ ally affects the lower thoracic and upper lumbar vertebrae. I t tends to presen t with pain and a thora­ columbar kyphosis. Other postural anomalies may be presen t , such as an i ncreased lumbar lordosis and rounding of t he shoulders. This condition is associated with an increased risk of pars interarticularis stress fractures and spondylolysis. The diagnosis is suggested by t he appropriate h istory and physical findings com­ b ined with plain radiographic features. The x-ray find­ i ngs i nclude irregular vertebral end plates, anterior wedging of t he i nvolved vertebrae, and Schmorl nodes. Schmorl nodes are thought to represent vertebral end­ plate bulging into the vertebral body.

The Curving Spine: Scoliosis

Scoliosis re fers to lateral deviation of the vertebral colu m n in t h e coronal plane. The deviation in the coronal plane is often accompanied by rotation of the vertebral bodies. Often compensatory curves develop with the convexity i n an opposite direct ion to the pri­ mary curve. The diagnosis of scoliosis is most impor­ tant before the growt h phase of adolescence, when t h e curves and subsequent deform ity can i nc rease in magni tude. The diagnosis of scoliosis can be made with a t horough h i story and physical examination . Careful attention for biomechanical factors that could be contri b u t i ng to the scol iosis is necessary. Most scoliosis is idiopath ic . Plain radiographs confirm the diagnosis.

Investigations in the Diagnostic Triage Process

The investigative process needs to be i ndividual ized ' for each pati e n t with l ow back pai n. Most patients can be managed without invest igations as long as they do not manifest red f lags and i mprove wi th treatment and time (I). The clinician's index of suspicion, the patient's demographics, and spec i fic symptoms will influence the nature of the i nvestigations performed. Although there are guideli nes throughout the world to assist t he clinician in the consideration of which tests are requi red in various situations, they cannot replace t h e i n t u i t i on of t h e caregiver ( 1 ,4 1 ) . I nvestigations general l y include diagnostic imaging and serological tests. Neurophysiologic studies such as electromyog­ raphy (EMG) and nerve conduction studies (NCS) are also of value i n the triage of patients with spinal pain associated with potential neurological anomalies.

Chapter Seven: Diagnostic Triage in Patients with Spinal Pain

Plain Radiography

In patients presenting with acute spinal pain, radio­ graphic, or other spinal imaging is generally u nnec­ essary in the first several weeks ( 1 ,34,35 , 4 1 ) . P lain radiographs have traditionally been ordered as the initial step in the diagnostic imaging of lumbar spinal pain. The purpose of plain x-rays is to identify bony and structural pathology that may be associated with back pain (Table 7 . 7 ) . Unfortunately, spinal radio­ graphs have limited useful ness in the triage process of patients with low back pain. Scavone showed that nearly 75% of plain x-rays provided no useful clinical information (35). They are of use to rule out spinal fracture after trauma but provide less soft tissue detail than computed tomography and magnetic res­ onance imaging. Conventional radiography may be valuable in the initial evaluation of suspected spine infection ( 3 2 ) . H owever, bone scint igraphy is likely the best imaging modality in this patient population, because plain x-ray cannot rule out the presence of a spinal infection ( 1 ,32). Flexion-extension radiographs are a usef'ul modality to ru le out ligamentous insta­ bility aher trauma ( 1 8 ) . In the neck, translatio n of one segment on another more than 3 millimeters should be considered evidence of l igamentous dis­ ruption, and the patient should be managed as hav­ ing an unstable cervical spine. There are many plain radiographic findings that t raditionally have been considered to be indicative of pathology and t herefore associated with the presen­ tation of acute back pain. An example of such a find­ ing is an altered l umbar or cervical lordosis t hought to be indicative of muscular hypertonicity associated with acute back pain. However, Hansson has shown that t here is no difference in l umbar lordosis on x-ray among patients with acute low back pain, chronic low back pain, and asymptomatic subjects ( 1 7) . Degenerative changes of the spine have been con­ sidered to represen t pathology by some clinicians. The presence of degenerative disc narrowing and osteophytes correlates poorly with the presence of low back pain. These fi ndings are more likely related

Table 7.7 •

•

•

•

I ndications for plain radiography

To rule out a fracture in a well patient with signif­ icant trauma To rule out a h-acture in a compromised patient with minor trauma To rule out spinal instability with flexion-extension views in the post-traumatic patient The evaluation of a patient for hardware failure in a post-fusion patient

Table 7.8 •

•

•

•

•

•

•

--

137

I ndications for CT scanning

To rule out tumor or other space occupying lesion in a patient with refractory radiculopathy (no improvement with 4-6 weeks o r treatmen t ) T o rule out cauda equina syndrome i n a patient with u rinary anomalies, incontinence of stool or u rine, bilateral leg symptoms, saddle anest hesia, or decreased rectal tone To confirm a m atch between disc herniation at a particular segment with nerve root compression at a particular segment in a case of radiculopa­ thy when surgery is contemplated To evaluate for spinal fracture in cases where c l inical suspicion of fTacture remains high despite normal plain radiographs ( head injury or altered level of consciousness) To evaluate spinal cord anatomy in a patient with neurologic symptoms or signs after trauma To evaluate a patient with suspected spinal stenosis To obtain the best image of bony lesions in patients with red flags or abnormal bone scans

to aging ( 1 , 3 3 ) . M ost patie n ts wit h low back pain improve whether the plain radiograph reveals degen­ erative c hanges. T herefore, the finding of degenera­ tive changes on plain films is not a decision point in the diagnostic triage algorithm. The diagnostic significance of many other findings of plain radiographs remains u nknown. Bigos et al showed that spondylolysis, transi tional vertebrae, spina bifida occulta, l umbar lordosis, moderate scoli­ osis, and degenerative joint disease were not predic­ tive factors for acute low back pain or chronicity ( 2 ) . P lain lumbar radiography i s of l imited useful ness in the diagnostic triage process. I t can identify many structural anomalies that are not related to the cause of the patient's low back pain ( 2 ) . It is also of insuffi­ cient sensitivity t o rul e out tumor or in Ject ion in the patient presenting with red flags ( 1 ) . Most clinicians have seen patie n ts who h ave become overly con­ cerned with the presence of degenerat ive changes or o ther abnormalities on t heir x-rays. It is often diffi­ cult to convince the patient that t hese findings are or little import .

CT Scans

The objective of using a CT scan in a patien t with spinal pain would be to ide nt ify anatomical pathol­ ogy that is responsible fo r the patient's problem (Table 7 . 8 ) . U nfortu nately, the abnormalities most

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Part Three: Assessment

frequently documented in CT scans are common in asymptomatic individuals (50). Disc herniations, facet hypertrophy, and, to a l esser extent, spinal stenosis were all fou nd in patients with no back or leg pain . As a result, CT scans are not part of the diagnostic triage process for patients w i th spinal pain alone, unless red nags are eviden t. CT scans can be used to confirm the presence of disc hern i ation in patients presen ting with radiculopathy. This group of patients is relatively easy to separate from the patient with spinal pain alone. CT scans are not useful as a screen­ ing tool ( 4 ) . CT scann ing can be used to rul e o u t tumor when red fl ags are present ( 1 ) . T h e C T may be the opt imal imaging modality for bone problems and in some geographical regions may be easier to access ror some prac titioners. Figure 7.2 M R I abnorm a l i t ies on an asymptomatic

MRI

individual

T h e pu rpose behind using M RI i n t h e d i agnos t i c triage o f patients with spinal p a i n i s t o iden t i fy the anatomical or physiological pathology responsible for the pat ient's spinal pain syndrome (Table 7.9). As wi th other imaging tests, the MRI may reveal anatom­ ical abnormali t i es in individuals who do not have spinal pain. Disc hern iation, disc bulgi ng, spinal steno­ sis, and disc degeneration are all commonly found in asym ptomatic i nd i viduals ( 3 ) (Fig. 7 . 2 ) . These find­ ings occur with increasing frequency with age. Disc degeneration is virtually ubiquitous at age o lder than 60 on MRI (4). As a resu l t , the M RI is not part of the diagnostic triage process for patients with spinal pain alone, un l ess red flags are evident. Some have stated that M R I is not justified for t h e investigation

Table 7.9 •

•

•

•

• •

I ndications for M R I

To ru le out tumor o r other space occupying lesion in a patient with refractory radicul opathy (no im provement with 4-6 weeks of treatment) To ru l e out cauda equina syndrome i n a patient with u rinary anomalies, incontinence of stool or urine, bi lateral l eg symptoms, saddle anesthesia or decreased rectal tone To confirm a match between disc herniation at a part icular segment with nerve root compression at a particular segment in a case of radiculopa­ thy when su rgery is contemplated To evaluate for post-operative compl ications such as discitis or perineural fibrosis To evaluate a patient for potential spinal infection To evaluate spinal cord compression in patients with equivocal findi ngs on CT

of acute low back pain, even to screen [or red flag con­ d i tions, because of cost and the relative paucity of red flag condi tions rendered evident by this modality (4). MRI is the recom mended i maging modality for pa­ tients who have had previous spinal surgery ( 1 ) . M R I with contrast i s t he i maging test o f choice t o distin­ guish disc herniation from peri neural fibrosis asso­ c iated with previous surgery. M R I is the best modal i ty for imaging neural tissues and bone mar­ row and for diagnosing tumor or infection.

Bone Scan

The purpose of using a bone scan in the evaluation of patients wi th spinal pai n is to iden tify lesions man­ ifest i ng hyperemia and increased metabolic activi ty (Table 7 . 1 0 ) . The bone scan is an excel lent tool to evaluate the metabolic activity in bone. Bone scintig-

Table 7. 1 0 • •

•

•

•

Indications for bone scan

To evaluate for poten tial spinal infection To evaluate for spinal stress fractures, especially pars in terarticularis stress fract ures (consider SPECT scan with high index of suspicion because of greater sensitivity) To evaluate for spinal fracture in cases where clin ical suspicion of fracture remains h igh despite normal plain radiographs To identify areas of skeletal metastases in patients with known cancer To identify sacro i l i i t is

Chapter Seven: Diagnostic Triage in Patients with Spinal Pain

raphy with 99M-radiolabeled technetium is an excel­ lent screening test for potential spinal i n fection (48 ) . Osteoblastic activity i s i ncreased i n osteomyeli t i s , disci tis, a n d ot her spinal i nfections. I n t h e patien t with a suspected spinal i n fect i o n , bone scans rarely provide false-negative results. Bone scann i ng has also been recommended to evaluate patients with poten­ tial spinal tumor or occult fract ure. The procedure is moderately sensitive in the detection of t hese condi­ tions, but it cannot specify the diagnosis. The bone scan can help in the dati ng of an identified fracture on plain film, such as a compression fracture. Bone scan­ ning is a useful screening tool in patients wi t h known non-spinal malignancy who presen t with spinal pain (22). The use of bone scan is also recommended i n the evaluation o[ patients with suspected pars i n terartic­ u laris stress lesions or other stress fractures of the lumbar spi ne and pelvic regio n . The bone scan can also be used i n the assessment of patients with poten­ t ial i n flammatory sacroi l iitis. It is of note that the bone scan is often not a useful test i n the presence of mul tiple myeloma, the most common primary tumor of spi nal bone. Electrophysiologic Testing

The electrodiagnostic medical consultation can play and important role in the diagnosis and management of patients with spinal pain and neurological prob­ lems. Electromyography (EMG) has the h ighest diag­ nostic yield i n lumbosacral radiculopathy (Table 7 . 1 1 )

Table 7. 1 1 •

•

• •

•

•

•

I ndications for E M G

To show t h e nature, location, d istribution and severity of the nerve lesion; because not all extremity pain is based o n nerve root i njuries, this can be helpful in the diagnostic triage when nerve root signs are normal or equivocal To h ighligh t pathologic processes such as peripheral neuropathy To localize a nerve lesion A properly t imed EMG can differentiate a neuro­ praxic injury from active axonal degeneration; i t can also determ i ne t h e acu i ty o f the problem To confirm whether identi fied pathoanatomy on imagi ng is causing any nerve root pathology; t h i s can be valuable when surgical t herapies are being considered To assist in the determination of whether a radiculopathy with myotome weakness will have a good prognosis for the return of muscle strength To determine whether the patient's problem i s i mprovi ng on a physiologic basis

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139

( 1 5 ) . The E M G provides i n formation regarding neu­ rophysiologic abnormalities as opposed to the struc­ tural anomalies identified on m ost i maging studies. All nerve l esions are not caused by nerve roo t com­ pression and can i nvolve the root , the plexus, t h e peripheral nerve, o r generalized neurologic function. EMG can provide data that correlate more closely w i t h patient symptoms t h a n i m aging studies do. However, the EMG provides data only regarding the motor root and i n the cervical spine where there more spatial diversity between motor and sensory roots may not ident i fy a purely sensory anomaly (IS). E M G is not recom mended in the di agnostic triage of spinal pain alone or s i mple backache. I n summary, the use of electrodiagnostic studies is of value in the patient with radiculopathic fi ndi ngs where m ore specific i n fo rmat i o n about t h e exac t neurophysiology is required. Objective a nomalies o n E M G c a n also b e useful i n the patient w i t h third party i nvolvement.

Invasive Diagnostic Needling Techniques

The Tissue-Specific Diagnosis

The ident i fication of t h e specific pain generator for patients with spinal problems was previously con­ sidered i mpossible i n up to 85% of cases (30). M ore recent publications have stated that by usi ng invasive diagnostic needling t ec h n iques, the c l i nician can determine the pain generator much m ore commonly (see C hapter 6). Because this is not pract ical , cost­ effective, or even necessary, such procedures are not a key component of the diagnostic triage process in the acute spinal pain patient. They may play a greater role in the triage of chronic pain patients with disabi l i ty.

Internal Disc Disruption and Discography

D i s cography i s a n i n vasive d i agnost i c procedu re designed to determ i ne whether a disc is i n trinsically pai n [u l (5) ( Fig. 7 . 3 ) . D iscography i nvolves the i njec­ tion of contrast material or saline i nto the nucleus pul­ posus of the i nter-vertebral disc. Information can t hen be documented regard i n g the amou n t o f con t rast accepted, the pressure necessary to i nject the mate­ rial, the morphology the contrast assumes, and the reproduct i o n of the patient's pai n . Postdiscography computed tomography can be used to highlight the features of i nternal disc disruption, which is the most common known cause of d iscogenic pain in pat ien ts with chronic spinal problems ( 5 ) . The diagnostic goal of discography is t o determine the structural anatomy of the disc, to characterize t he pain response prompted by the i njection of the disc,

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Part Three: Assessment

Figure 7.3 Pain provocation with d iscography

for a patient with c hronic spinal pain and establ ishes t hat a patient's pain is not imaginary ( 5 ) . This can be of particular i mportance when t h i rd parties or liti­ gation is i nvolved, and when i magi ng studies such as CT or M R have been non-con tribu tory. The i ntervertebral disc can be a source of pain in the cervical spine also (36). Attempts to identify a char­ acteristic marker of cervical discogenic pain with M RI have been largely unsuccessful. In cases of chron ic cervical spine pain in which conservative treatment has not been effective and in which surgical proce­ dures are being contemplated, the importance of cer­ vical d iscography should be stressed (32a). Patients will often h ave their pai n provoked by di scography at morphologically i nconspicuous discs, o ften a fter failed surgery on the morphologically more aberrant discs (36). Patients can have discogenic pain with nor­ mal CT and M R fi ndi ngs, and can also have annular tears that are asymptomatic.

The Sacroiliac Joint

and to compare that to the patient's typical pain ( 1 ). To reduce the number of false-positive discograms, the diagnosis of discogenic pain requires that a pa­ tien t must report reproduction of pain on stimulation o[ the target disc but no pai n when an adj acent disc, and preferably two discs, are stimulated ( 5 ) . Single­ level discography is not clinically meaningful, because the lack of a control level prevents the i nvestigator from concluding t hat a positive response is specific to d isc disrupt ion as opposed to other factors. In a simi lar fashion, triple-level positive disc stimulation should not be considered a tme positive ( 5 ) . Holt h as reported that di scography is painfu l i n normal volun teers ( 1 9) . However, this position has been refu ted in subsequent publications ( 5 ,42). It is bel ieved that discogenic pain as manifest on discog­ raphy correlates with substantial dismption in the annulus ri brosis ( Fi g . 7 . 4 ) . D i scogenic pain does not correlate with disc degeneration ( 5 ) . The use of discography with t hi s type of rigorous standard has shown that spinal pain caused by i n ternal disc dis­ ruption is presen t in more than 39% of patients with chronic low back pain ( 3 8 ) . Given i t s i nvasive nature, poten tial compl ica­ tions, cost, and lack of avai labil i ty i n some regions, discography is not part of the diagnostic triage process [or acute spinal pain. There is no red flag that would pro m p t discography. D i scography is not recom­ mended as a part of the diagnostic triage process for patients with suspected disc herniation ( 1 ). Discog­ raphy can identify a particular d isc as a pain genera­ tor and may al low better result in spinal surgery, which is planned on the basis of positive discography. This procedu re can provide an anatomic diagnosis

It is generally accepted that the sacroiliac joint can be a source of spinal pain ( 1 2,26). Sacroil iac i njections can prompt pai n over the region of the joint which can radiate to the buttock and thigh. The sacroiliac joint can be i nvolved in the spondyloarthropathies, fTac­ tures of the pelvis, childbirt h , and pregnancy and in crystal-i nduced or pyogenic arthropathy ( 1 2 ). The

Figure 7.4 Depiction of d iscogram revea l i ng substantial

annular tear. This woul d appeal" normal on CT and on some M R I images.

Chapter Seven: Diagnostic Triage in Patients with Spinal Pain

paradigmatic constructs o f sacroil iac joint dysfu nc­ tion, fixat i o n , or subluxation are more c o n trover­ sial. These terms are used to explain p a i n from a sacroiliac j o i n t that i s morp hologically normal but that i s presumed to have a biomechanical d isorder that causes the pai n ( 1 2 ) . Some c l i nicians assert that they can ide n t i fy the biomechani cal anomali es on c l i n ical exam i nation alone ( 2 6 ) . The vali d i ty of most o f these physical exami nation tec h n i ques has not been establ ished. I ntra-art icular sacroil iac diagnostic i njections can now be performed. The joint can be cannulated under fluoroscopic guidance, and contrast can be i njected to perform arthrography. If a patient has pain ema­ nating from the sacroiliac joint, tradi tional logic would indicate that this pai n should be ablated with the i njec­ tion of local anaesthetic ( 1 2). Using this as the criterion standard, 1 2 common physical fi ndings h ave been evaluated for external vali d i ty ( 1 2 ) . The diagnostic tests eval uated i nc luded joint play, sacral sulcus tenderness, t h igh thrust, the G illet test, Patrick test, Gaenslen test, a midline sacral thrust, and pain draw­ i ngs over areas traditionally assoc iated with sacro i l ­ iac pai n referral. Trad i t ional physical exa m ination tests such as t h e G i l l e t test, the Patrick test, and Gaenslen test were demonstrated to be unrel iable in the diagnostic triage of patients with potential sacroil­ iac pai n ( 2 ) . The G i l let test has also been demon­ strated to have poor in ter-rater reliability (6, 1 2 ) . With respect to medical h istory, no aggravating or alleviat­ ing fac tor is of value ror diagnosi ng the presence of sacroil iac joint pai n .

are used i n a chro n i c l u m bar spinal pai n popula­ t i o n , 1 5% of pat i e n t s appear t o have the z-j o i n t as the key pain generator. In this group, there are no c l i n i cal features that could d i s t i ngu ish the z-j o i n t patient from t hose who did not respond to blocks (2 1 ,39). The z-j o i n t is a n i mportant p a i n generator in t h e cervical spine after wh iplas h ( 2 7 ) . Pat i e n ts w i t h z-j o i n t-mediated pain often have n o sign i ficant fi n d i ngs o n physical e xami n a t i o n . These pat i e n ts also have no consistent abnormal i ties on x-ray, CT, or MRI ( 2 3 ) . Therefore, the diagnostic process requi res t he use of stri nge n t met hods i n volving fl uoroscop­ i cally guided, placebo-con trolled medial branch blocks if a d i agnosis o f z-j o i n t pain is to be con­ firmed. Using such i nvasive tec h n i ques, it can be s hown t hat t h e prevalence of z-j o i n t pain after w hiplash i s u p t o 64% ( Fig. 7 . 5 ) ( 2 7 ) . The upper cer­ vical z-joints often provoke head pain and the lower cervical z-joints often provoke shoulder girdle pai n . Such tes t i ng h as only been performed on pa tients with chronic neck pain after whiplash , and the rele­ vance to the acute situation has yet to be determi ned. T herefore, given that the maj ority of patien ts with whipl as h w i l l return t o usual activities w i t h i n the first 2 months of i njury, z-joint diagnostic blocks are

The Zygapophyseal Joint

Many c l i n icians bel ieve that the zygapophyseal joint (z-j o i n t ) is an i m portant source of spi nal pai n in both the cervical and lumbar regions ( 2 7 , 3 9 ) . The primary pathology was t hought to be that of osteo­ arthri t i s , chondromalacia, or occu l t fractures. M echan i cal anomalies are also c i ted as poten t i a l factors involved i n pai n generation according to the fi xation, subluxation , or somatic dysfunction mod­ els. I n the process of diagnostic triage, the iden t i fi ­ cation o r z-joint pain i s d i ffi cult on c l i n i cal grounds alone ( 2 1 ,39). There are no cl i ni cal features that are pathognomonic of z-joi n t pain ( 3 9 ) . Fu ndamental to the diagnosis o r lumbar z-j o i n t pai n i s t he use of diagnostic blocks. Rad iologically controlled blocks of the joints performed under fl uoroscopic guid­ ance consti tute the only gold standard for the d iag­ nosis or z-j o i n t pain ( 3 9 ) . M u l t iple b l ocks w i t h either extra-art icular or variable-length l ocal anes­ thetic controls are requ i red to decrease t h e false­ posi tive rate of z-joint blocks. When m u l t iple blocks

141

Figure 7.S D i agram matic representation of cervical

medial branch block.

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Part Three: Assessment

not part of the diagnostic triage process for acute whiplash i njury (44). They are typically reserved for the evaluation and treatment of c hronic pain and can be of particular uses i n cases complicated by third party and l i tigation issues.

Clinical Vignettes

A 1 7-year-old eli te athlete had been out all day moun­ tai n b i k i ng. He returned home and ret i red for the nigh t . H e awoke from sleep to urinate. He collapsed and struck his head and neck on the side of h i s bath­ tub and was rendered u nconscious. He was taken by ambulance to a local emergency room. I n emergency, he underwent rou tine cervical spine x-rays and was discharged, because the x-rays were i n terpreted as normal ( Fig. 7 . 6 ) . The next day, h i s m o t h er call ed my office and described the situation. I saw h i m that afternoon, when h e m a n i fested no cervical spi ne motion in any plane and substantial paraspinal mus­ cular hypertonicity. H e was placed in a P h i ladelphia hard collar and sent for emergent CT scan. The CT revealed an u nstable C 2-3 fracture ( Fig. 7.7). He was treated by a neurosurgeon for 1 2 weeks in a cervi­ cothoraci c orthotic. H e was left with a 3- to 4-m m slip at C2-3 but has no neurological findi ngs and has returned to cycli ng. An M RI was performed by the neurosurgeon to evaluate for disc desiccation at C2-3

Figure 7.7 CT showing rTactu re

( Fig. 7 . 8 ) . Significant disc desiccation would have i ncreased the stre ngt h of the recom m endation for spinal fusion.

Clinical Pearl The trauma in this case was "significant" and should have merited more t han plain radiographs in the diagnostic triage. Flexion-extension views, CT, or MRI should have been performed w h i le t he patient was in the emergency roo m . He had two red flags, significant t rauma, and loss of consciousness. This case demonstrates t hat plain radiography alone i s not sensit ive enough ror all cases o[ traum a , particularly when red flags are present. I t demonstrates t hat C T i s a sensitive modality [or fracture identification. I t shows t hat M R can have u t i l ity in plan­ n i ng fol low-up care.

Figure 7.6 Original plain cervical radiographs.

An 1 8-yeapold woman presented on referral from her family doctor. She had "scoliosis" that was wors­ eni ng. She was getting pai n with exercise. She had been receiving adj ust ive therapy from her chiroprac­ tor with no benefit. She had no other symptoms and no red or yellow n ags. Her family doctor had won-

Chapter Seven: Diagnostic Triage in Patients with Spinal Pain

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1 43

Figure 7.8 M R I showing small spondylo li s t hesis at C2-3.

dered whether a trigger poi nt i njection m ight help her problem. Cli nical exam i nation revealed asym­ metry i n t he musculature of her spine, but no true scoliosis. On pal pation, the area presumed to be muscular hypertonicity in the paraspinal area was soft . An emergent M R I revealed an extensive arterio­ venous malformation that had extended i n t o h er vertebrae and spinal canal , as wel l as the subcuta­ neous areas (Fig. 7 . 9 ) . She was referred to several neurosurgeons, and at this time has h ad no defini tive th erapy. She is 24, and doing wel l , but she h as a guarded prognosis.

Clinical Pearl This patient "new beneath t he radar" based on her h is­ tory alone. She had no true red nags. The only factor was her chronic pain. This emphasizes that whereas guide­ lines and algori thms can assist us in our management of

Figure 7.9 M R l showing extensive subcutaneous and

patients with spinal pai n, they are not a replacement for

intra-spi nal arteriovenous malformation.

clinical evaluation and i n t u i t ion.

• CON CLUS I O N

The c l i nical management of patien ts with spinal pain i nvolves both the art and science of health care. There is much art and tradition surroun d i ng many of the paradigms that diagnose and t reat spinal disor­ ders. As with art, these diagnostic and t herapeu tic techniques often bri ng the joy of rel i e f from suffer­ ing to the patron. H owever, it is apparent that i n the evidence-based, con t rolled care environment of the

new m i llennium, art alone will not su ffice. H owever, as we stri ve to allow science to e nhance t he valid i ty and rel i abi l i ty of our art, we must remember our patrons with spi nal pai n . We must do everyt h i ng in our power to survive the tension between therapeu­ tic n i h i l ism and overly i n vasive or poorly validated t reatments. Through t h i s tension , it is comforting to know that the most i m portant i n formation we can glean from our patients with spinal pain is that obtained t h rough si mple conversation.

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Part Three: Assessment

Audit Process Self-Check of the Chapter's Learning Objectives •

Are you i n qu i ri ng about red !lags for cancer and i n fection i n your review of systems i n patients who present with spinal pain ?

•

Are you fac i l i tating disab i l i ty a n d work loss t h rough emphasizing passive care or ignoring yelJow flags?

•

Are you relying on plain radiographs to make a t issue-specific diagnosis such as degenerative disc disease or facet arthrosis in your patients?

•

Do you use M Rl as a primary d i agnosti c or screeni ng tool in your patients with spinal pain ?

•

D o you rout i nely exami ne for deep tendon reflex abnormalities, weakness, sensory change, or dural irri tability in patient with leg pain ( l eg begins at i l iac crest ) ?

•

Are you referring patients t o mental health professionals when you think someone has a risk for chronicity because o f psychosocial factors, or do you only do this as a last resort?

•

Do you always make a tissue-specific d i agnosis for your patients with low back pain based on your c l i nical assessment?

•

Do you tel l your patients that you know what is wrong with them after viewing their x-ray or MRl?

•

Do you know which o f your patients are at the greatest risk for chronic pain and disab i l i ty after taking a history?

• REFERE N C E S I.

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2 . B igos SJ, H ansson T , Cas t i l l o RN, Beecher PJ, Wort l ey M D . The val ue o f preemployment roentgenographs for pred i c t i ng acute back i njury c l a i m s and ch ron i c back pai n and d isabi li ty. C l i n Orthop ReI Res 1 99 2 ; 2 8 3 : 1 24- 1 29 . 3 . Boden S O , Davis D O , D i n a T S , Patro n as N J , Wisesel SW. Abnormal magnetic resonance scans o f t h e lu mbar spine i n asymptomatic subjects. J Bone Joint Surg J 990;72A: 403-408. 4 . Bogduk N . Evidence-based c l i nical guideli nes for the management of acute l ow back pain. Draft. Submit ted for endorsement by the N H & M RC , November 1 999. 5 . Bogd u k N . The argu ment for discography. Neuro­ surg Q 1 996;6( 2 ) : 1 52- 1 53 .

6 . Carmichael J P . Inter-and intra-tester rel iabil i ty of palpation for sacro-i liac joint dysfunction. J Man ipu­ lative Physiol Ther 1 98 7 ; 1 0: 1 64- 1 7 1 . 7. Cherkin DC, Deyo RA, Street J H , Barlow W. Predict­ i ng poor outcomes for back pain seen in pri mary care using patient's own criteria. Spine 1 996;2 1 : 2900-2907. 8. Craton N , M atheson GO. Tra i n i ng and cli nical com­ petency in musculoskeletal medicine: I dent i fying the problem. Sports Med 1 993; 1 5( 5 ) : 328-33 7 . 9 . Davids J R , F u l p T. Tumors and tumorlike conditions of the cervical spine and neck in chi ldren. Spine: State o f the art reviews. 1 996; 1 O( 1 ): 1 44- 1 66 . 1 0. Deyo R A , Rainvil l e J , Kent D L . W h a t can t h e history and physical exam i nation tell us about low back pai n? JAMA 1 992;268(6):760-76 5 . 1 1 . Deyo RA , D i e h l AK. Cancer as a cause of back pain : Frequency, clinical presentation, a n d d i agnostic strategies. J Gen I n tern Med 1 98 8 ; 3 ( 3 ) : 230-23 8 . 1 2 . Dreyfuss P , M ichaelsen M , Pauza K, M c Larty J , Bogduk N . The value o f medical hi story and physi­ cal examination in d i agnos i ng sacroil iac joint pain. Spine 1 996;2 1 ( 2 2 ) : 2594-2602 . 1 3 . Frank CJ, Brantigan JW, McGuire M H . Evaluation of patients with spinal column t umors. Spine: State of the art reviews. 1 996; 1 O( 1 ) : 1 3-23 . 1 4. Fri tz, J M , George S . T h e use o f a classification approach to identify subgroups of patients with acute low back pai n. Interrater reliabilit y and short-term outcomes. Spine 2000;25( 1 ): 1 06- 1 1 4. 1 5 . Grant PA. Electrodiagnostic medical consu ltation in l umbar spine problems. Occup Med: State of the art reviews 1 998; 1 3 ( 1 ):97- 1 20. 1 6. Gundry CR, Heithof f K B , Pollei SR. I maging of t he postoperative l umbar spine. Spine: State of the art reviews 1 995;9 ( 1 ) : 2 1 1 -244. 1 7 . Hansson T, B i gos S , Beecher P, Wortley M. The l u m bar l ordosis i n acute and chronic low back pai n . Spine 1 98 5 ; 1 0( 2 ) : 1 54- 1 5 5 . 1 8 . H art B L , Orrison W W , Benzel EC. I maging spinal trauma Spine: State of the art review 1 995;9( 1 ):93- 1 1 8. 1 9. H o l t E P . The question of lu mbar diskography. J Bone Joint Surg 1 968;50A:720-725 . 20. Jackson OW, W i l tse L L , D ingeman R D . Stress reac­ tions i nvolving the pars in terart icu laris in young athletes. Am J Sports Med 1 98 1 ;9: 304-3 1 2 . 2 1 . Jackson R P . The facet syndrome myt h or reality? C l i n Orthop ReI Res 1 992;279: 1 1 0- 1 20. 22. Jackson R P , Cain JE, Jacobs RR, Cooper BR, M c M anus GE. The neuroradiograph ic d i agnosis of l u mbar herniated nucleus pul posus: II. A compari ­ son of computed tomography, (CT), myelography, CT-myelography, and magnetic resonance i m aging. Spine 1 98 9 ; J 4 ( 1 2 ) : 1 362- 1 367. 2 3 . Kel ro ser D B . W hiplash, chronic neck pain and zygapophyseal joi n t disorders. A selective review. M i nnesota Med 2000;83 : 5 1 -54. 24. Kendall N AS, Linton SJ , Main CJ . Guide to assessi ng psychosocial yellow flags in acute low back pain: Risk factors for l ong-term d i sab i l i ty and work loss. Acc i dent Rehab i l i tation and Compensation Insur­ ance Corporation of New Zealand and the National Health Committee. Wel l i ngton N Z .

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2 5 . Kortelainen P, Puranen, J , Koivisto E , Lahde S. Symptoms and signs o f sciatica and their I-elation to the local i zation of the lumbar disc herniation. Spine 1 985; 1 0( 1 ) : 88-9 2 .

3 8 . Schwarzer AC, April l CN, Derby R, Fortin J , Kine G, Bogduk N. The relative contributions of the d isc and zygoapophyseal j o i n t i n chronic low back pai n . Spine 1 994; 1 9 :80 1 -806.

26. Laslett M, W i l l iams M. The rel iabi l i ty of selected pain provocation tests for sacroiliac joint pathology. Spi ne 1 994; 1 9( 1 1 ): 1 243- 1 249.

39. Schwarzer AC, April ! CN, Del-by R, Fon i n J , Kine G, Bogduk N. C l i n ical features o f patients with pain stem m i n g fyom the l u m bar zygapophyseal joints: I s t h e l umbar facet syndrome a c l i n ical e n t i ty. Spine 1 994; 1 9( 1 0) : 1 1 3 2- 1 1 3 7 .

27. Lord SM, Barnsley L , Wal l is BJ, Bogduk N. C hron ic cervical zygapophyseal j o i n t pain after w h i plash . A placebo-controlled prevalence study. Spine 1 996; 2 1 ( 1 5 ) : 1 737- 1 745. 2 8 . Mardjetko S M . , DeWald CJ. M a nagemen t of metastatic spinal d isease. Spine: State of the art reviews 1 996; 1 O( 1 ) : 89- 1 05. 29. McKenzie RA. The l u m bar spine. Mechanical d i agnosis and therapy. Wai kanae, New Zealand: Spinal Publ ications L i m i ted, 1 989.

40. Shelerud R. Epidemiology of occupational low back pai n . Occupational Medicine: State of the art reviews. 1 998; 1 3 : 1 -2 2 . 4 1 . S i m mons J W , Apri l l C N , Dwyer A P , B rodsky A E . A reassessment of Holt's data on "the question of lum­ bar discography." Clin Orthop 1 98 8 ; 2 3 7 : 1 20- 1 24.

30. Nachemson A L . Low back pain. Its etiology and treatment. Clin Med 1 97 1 ;78: 1 8-22

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3 1 . Read MT. Single photon em ission computed tomography (SPECT) scan n i ng for adolescent back pai n . A s i n e qua n o n ? B r J Sports M e d 1 994;28( 1 ) : 5 6-57.

43. Sommer H M . T h e patient i n jeopardy: h o w t h e low back pain pat ient becomes d i sabled. Occup Med: State of t h e art reviews. 1 99 8 ; 1 3 :2 3-3 1 .

32. Reddy S, Lei te CC, J i nkins J R . Imagi ng of i n fectious disease of the spine. Spine: State of the art reviews 1 99:;9( 1 ): 1 1 9- 1 40 .

44. S p i t zer WO, Skovron M L , Sal m i L R , et a l . Scien­ t i fic monograph of t h e Quebec Task Force on W h i plash-Assoc iated D i s o rders: Redefi n i ng "whiplash" and i t s manage m e n t . Spine 1 99 5 ; 2 0 ( 8 Suppl ) : I S-7 3 S .

3 2 a . Rogers C , Joshi J, D reyfuss P. Cervical i n t ri ns ic d isc pain and radiculopathy. Spine: State of the art reviews 1 998; 1 2( 2 ) : 32 3-356. 33. Rosen M . Chair. Back Pai n . Report of a C l i n ical Standards Advisory Group on Back Pai n . M ay 1 994.

45. Steiner M E , M ichel i LJ . Treatment of symptomatic spondylolysis and spondylo listhesis with the mod i­ fied Boston BI-ace. Spine 1 98 5 ; 1 0:937-94 3 .

34. Russo R, Cook P. D iagnosis o f low back pai n : Role of imaging studies. Occup Med: State of the art reviews 1 998; 1 3( t ) : P83-P96.

46. Waddell G , M cCulloch M D , Kummel E , Venner R M . N o norganic physical signs i n low back pa i n . Spine 1 980 ; 5 ( 2 ) : 1 1 7- 1 2 5 .

3 5 . Scavone JC, Latshaw R F , Rohral- GV. U s e o f l um bar spine fil ms: Statistical evaluation at a univers i ty teaching hospi tal . JAMA 1 98 1 ;246: 1 1 05-1 1 08.

4 7 . Wainnel- RS, G i l l H . D i agnosis and nonoperative management o f cervical radiculopathy. J. Orthop Sports Phys Ther 2000;30( 1 2 ) : 72 8-744 .

36. Sche l l has K P , S m i th MD, Gundry CR, Pollei SR. Cervical discogenic pai n . Prospect ive correlation o f magnetic resonance i maging a n d d i scography i n asymptomat ic subjects a n d pain su fferers. Spin e 1 996;2 1 ( 3 ):300-3 1 1 .

48. Waldvogel FA, Vasesy H . Osteomye l i t i s : The pase decade. N Engl J Med 1 980;303 ( 7 ) :360-370.

37. SchUlte H E , Park W M . The d i agnostic value of bone sci nt igraphy in patients w i t h low back pain. Skeletal Rad ioI 1 983; 1 0( l ) : 1 -4 .

49. Wei nstein IN, McLain RF. Pri mary tumors of the spine. Spine 1 987; 1 2 : 843-8 5 1 . 50. W i esel SW, Tsourmas N , Feffer H L , C i t ri n C M , Patronas N . A study o f computer assisted tomography. I . The i ncidence of positive CAT scans in an asympto­ matic group of patients. Spine 1 984;9:549-55 1 .

Outcome Assessment

Steven Yeomans, Craig Liebenson, Jennifer Bolton, and Howard Vernon

Introduction What Outcomes? Criteria Regarding Outcomes Assessment Validity

Learning Objectives

After reading this chapter you should be able to understand: •

Reliability Responsiveness Ceiling and Floor Effects

•

Practicality

Domains Pain General Health Region-Specific Functional Disability Outcomes Patient-Specific Functional Disability Outcome Work Status Patient Satisfaction Outcomes Assessment Tools Psychological Distress

146

•

How to evaluate if outcome tools meet the mini­ mum criteria for effective measurement instru­ ments by possessing good validity, reliability, responsiveness, and practicality How to choose which outcomes to measure based on the needs of your practice How to administer and score simple queslion­ naires for many of the major domains of outcome assessment

Chapter Eight: Outcome Assessment

Introduction Outcomes assessment (OA) is essential in modern health care to assure quality and contain costs.1L typ­ ically starts on the first visit with the establishment of baselines,and thus is an aid in goal settjng. OA tools should be simple to administer and inexpensive, as well as being reliable, valid, and responsive. By uti­ lizing them, health care providers (HCPs) can docu­ ment patient status and progress over time, and thus enhance the quality of their decision-making by hav­ ing the most accurate information regarding health status readily available. OA is a component in promoting quality without sacrificing cost. Frymoyer defined value as the ratio of quality to cost (53). Cost containment has been a major focus of managed health care, but without qual­ ity assurance it may lead to dissatisfaction of health care consumers. In a patient-centered paradigm, the primary goals of care are pain reduction, functional restoration (i.e., prevention of disability), and avoid­ ance of psychosocial distress. How are these goals achieved? First, by keeping the focus of care on reducing disability or activity limitations/intolerances such as in walking, sitting, standing, etc. (79). Second, by addressing "yellow flags" barriers to recovery (26,44,72,123). And third, by utilizing quantifiable OA tools to establish baselines, document progress, assist in goal setting, and motivate patients. OA allows the value of the health care en­ counter to be audited. OA benefits all the players in the health care system-the patient, HCP, employer/ government, and payer. At the present time, it appears that health care has shifted to a customer-driven market (185). Health care "customers" now include patients, employers, unions, government, managed care organizations, and insur­ ance companies (45,63). These customers want choice, value, and data to help them in their decisions (45, 104). Future competencies of HCPs likely will depend on their ability to work with these new information systems. Hansen explains, "The methods of outcomes assessment, even in their cUITently evolving form may help provide tools clinicians can use to learn to focus on important attributes of care that not only meet accountability demands, but enhances efficiency, qual­ ity and patient satisfaction" (64).

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pain, distress, and perception of functional abilities (i.e., disability) also be utilized (1 1 ,12,17, 8 6). In the spine care field in which patient dissatisfac­ tion with care runs high, measuring outcomes that matter to the patients themselves is of paramount importance (1 1 ). Patient-centered outcomes include pain severity, distress, and ability to perform common activities of daily living (disability). Interestingly, the "objective" tests such as imaging, laboratory tests,and physical impairments (muscle strength and range of motion) correlate poorly with self-reported symp­ toms and functional status (i.e., disability) (1,106,171). Thus, patient-centered outcomes derived from self­ administered questionnaires have achieved a surpris­ ingly high level of significance (73,103,135,158). Because of the multidimensionality of the biopsy­ chosocial model, a broad spectrum of outcomes can be potentially measured. Deyo et al and Bombardier have listed the following domains as most relevant to a patient's clinical status-pain, disability, well-being, work status, and satisfaction (23,43). Psychosocial status, especially fear-avoidance beliefs, is another relevant area to document (92,101,102,123).

Criteria Regarding Outcomes Assessment An effective outcome measure should be valid, reli­ able, responsive to clinical change, and practical (18-20,60,93). Ironically, the so-called subjective mea­ sures have been shown to be more psychometrically valid than the so-called objective measures. Many of the latter, such as muscle strength and mobility, are vulnerable to submaximal effort and impairment exaggeration (50,51, 1 31) (see Chapters II and 12).

About Statistical Measures

Pearson's Correlation Coefficient: This is the degree to which two di fferent tests are correlated. It is designated as a Pearson r val ue. The range is

+

1 . 0 (perfect positive

or d i rect correlation) to - 1 .0 ( perfect negative or inverse correlat i o n ) . Values between 0 . 5 and -0.5 are consid­ ered o f questionable rel iabil i ty. Intra-Class Correlation Coefficient (ICC): The I C C is used t o study the consistency and agreement between

What Outcomes? Traditional medical care has emphasized "objective" measures such as imaging and laboratory modali ties. However, multifactorial conditions such as lower back pain are best explained by a biopsychosocial model of illness rather than a biomedical one of dis­ ease. This necessitates that "subjective" measures of

two or more exami ners or rat i ngs. It is calculated with repeated measures o f analysis o f variance (AN OVA) . ICCs range from a t o I , w i t h 1 represen t i ng t h e h ighest agreemen t . Scores more t han 0.75 are considered good to excellent and those less than 0.50 al"e generally considered poor.

(continued)

1 48

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Part Three: Assessment

About Statistical Measures (Continued)

Cronbach's Alpha: T h i s measure is used to determi ne the degree of correlati o n between d i fferent i tems i n a quest ionnaire. I t is a measure of i n ternal consistency. If al l of the i tems of a part ic u l ar questionnai re corre­ l ate very h i g h ly , t h e n any one of t h e m predicts the results o f t h e others and, t herefore, some o f t he i tems may be redundan t . Researchers l i ke t o see the resul ts of Cronbach alpha of at least 0 . 5 . A value of 0 . 8 is con­ sidered good and a value of 0.9 is excellent. The higher the coefficient, the greater the l ikelihood that all the questions in the calculation are related to each other and t herefore are measuring a s i m ilar underlying concept.

correlated. In other words, the scores of the two measures will increase (or decrease) together; and (ii) divergent or discriminative: this is tested when two or more variables that measure some­ thing totally unrelated are studied. Good dis­ criminative validity is shown if two unrelated measures do not correlate with one another. For example, if anxiety is independent of intelli­ gence, then we should not find a strong correla­ tion between the two (15l). Predictive validity: The ability or a test to pre­ dict a future event/state (i.e., readmission rates to a hospital).

]l. value: This is a standard measure of the probability

thal t he resul t s of a statistical test are caused by chance. Typical p values of 0.05 or 0.0 1 mean t hat t he results of the statistical test have a 95% or 99% probab i l i ty, respectively, o f not having occurred by chance. Thus, the smaller the p value, the less l i kely the effect i s a chance event, and the more l i kely i t is an actual effect . Confidence intervals (CIs): Confidence i n t ervals are normally given as either the 90% CIs or the 95% CIs. The 90% CIs of A to B means that there is a 90% proba­ b i l i ty that the actual mean value ( for example) l ies between the values of A and B. A 95% confidence i n ter­ val means that the act ua l value of the test l ies wi t h i n t hat interval 1 9 t imes out of 20.

Validity

Validity refers to the ability of an outcome measure­ ment (OM) to accurately quantify what it purports to measure. Face validity: The extent to which a test appears to measure a purported construct. Content validity: The extent to which the O M incorporates all relevant features o f the domain in question. Criterion validity: Generally refers to a compari­ son of a measure against some sort of "gold stan­ dard," or criterion measure. There are no gold standards for health status measures because health is a latent (or non-observable) trait, so one can never quantify it with certainty. In such a case, validity is established by testing a construct. Construct validity: The extent to which the mea­ surement corresponds to theoretical concepts (constructs) concerning how the phenomenon under study is expected to react (151). Concurrent validity: The comparison of two measures completed at the same time. There are two subtypes: (i) convergent: the expectation that the scores between two related variables will be

Reliability

Reliability is the amount of error associated with a measurement. It is defined as "the degree of stability exhibited when a measurement is repeated under identical conditions" (99). Thus, if a reliable measure is used, any change that occurs over time is caused by an actual change in patient status. Test-retest reliability: demonstrated when repeated test scores on an individual whose health status is unchanged gives the same result. This is a measure of an instrument's standard error of measurement (SEM) (6 1 ). Interobserver reliability: reflects the consis­ tency of measurement application when different observers measure the same phenomenon. Intraobserver reliability: a specific type of test­ retest reliability in which the degree of consis­ tency within the same examiner is evaluated.

Responsiveness

Responsiveness is defined as "the accurate detection of change when it has occurred" (37). If a tool is responsive to change, the score on a questionnaire should improve as a person's health status improves. This is clinically significant change that is not caused by a random occurrence. Responsiveness is essential when an OA tool is used by an Hep to show clini­ cal improvement in health status as a result or care over time. Validity Validity: The extent to which a measure is a true estimate of the underlying property. Longitudinal validity: The capacity of a measure to detect true change over ti me.

Chapter Eight: Outcome Assessment

Minimal clinically important difference: The change score that maximizes the accurate classi­ fication of those patients who change (improved) an imporLant amount from those who do not.

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149

sures on stable patients (expressed in the same units as a measure). For a change to be significant, it must be equal to or greater than the MDC.

Ceiling and Floor Effects How Is the Minimal Clinically Important Change in an Outcome Determined?

A key di mension of responsiveness is t he m i n i mal cl i n­ ically imporlant change in an outcome in a spec ific patient population (48,8 1 ). This is the small est change in the OA score that the patient perceives as beneficial. A patient's own global i m pression of change ( PGIC) ( i mprovement/deterioration ) is the most commonly used external cri terion to compare the outcome against (48,6 1 ) (see appendix form I). PGIC scores are calculated on the basis or the patients own percept ion or change with care. A PGIC may ask i f

A ceiling effect occurs when a respondent begins at a high level of function and therefore if they improve, the instrument cannot accurately detect this improve­ ment. An example would be an athlete. A floor effect occurs when a respondent begins at a low level of function and further deterioration in function cannot be detected by the measure. An example is a fTail or postoperative person. Ceiling or floor effects are caused by the inability of the instrument to discrimi­ nate at the higher or lower end of the dimension being measured. The impact of ceiling and floor effects is that clinically important change will not be measured or detected.

the patient i s very much improved, much improved, slightly improved, unchanged, or worse with care (48,6 1 ) . The P G I C ror improvement has been defined b y subtract­ ing the mean OA score or "unchanged" from "much im proved" or "very much i mproved" (48,6 1 ). The PGIC ror deterioration has been defined by the subtracting the mean OA score or "unchanged" from "worse" (6 1 ).

Another common way responsiveness is determined is by the effect size. This is the size of an effect from a treatment intel-vention ( 1 56). It is determined fTom a comparison of different instruments measuring the same thing. The larger the effect size, the greater the treatment eFfect (signal) as related to the variability (noise) in the sample. An effect size of 0.2 is small, 0.5 is moderate, and 0.8 or more is large. Different methods are used to calculate effect size. They each use a ratio with the same numerator of the mean pretreatment score minus post-treatment score across the study population. The denominator is usualJy the range of scores or standard deviation of the entire group. In individuals who classify themselves as having improved greatly, a responsive instrument should have a large effect size. Whereas in individuals who classify themselves as not improving, the effect size should be small. Thus, it would be expected that in chronic patients (who are less likely to show improve­ ment) an instruments effect size would be much smaller than in acute patients (who are more likely to show improvement). Another way of determining when meaningful change in an outcome instrument has occurred is fTom the minimal detectable change (MDC). This is the amount of error associated with a multiple mea-

Practicality

An outcome tool should be simple to administer and understand, time-efficient, and easy to score and interpret. Disability questionnaires should have word­ ing that is simple and unambiguous so that patients will easily be able to complete the entire form. Scor­ ing should be possible with a simple computer pro­ gram that shows a percent improvement over time. "Yes" and "no" responses are ideal for research ques­ tionnaires because they are easier to administer with telephonic follow-up. However, HCPs may prefer forms with 0-to-l0 visual analog scales that give patients more options for their answers. A practical tool is time- and cost-efficient as well as valid, reliable, and responsive.

Domains There are two broad categories into which OA tools can be assigned, subjective and objective ( 1 84). Subjective OA tools are patient-driven, whereas objective mea­ sures are driven by the HCP. This chapter discusses the subjective OA tools and the objective tools are dis­ cussed in chapters 1 1 to 1 3 . There are several outcomes assessment tools included in the appendix to this chap­ ter. When available, the MDC score is reported. There have been several classifications of the var­ ious domains or groups of OA tools ( 1 84). Bom­ bardier describes a core set of measures that should be considered when managing patients with spinal disorders-pain, generic health status, disability or functional status, work status, and patient satisfac­ tion (Table 8 . 1 ) (23). Psychological distress is a sixth domain that should also be addressed.

1 50

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Part Three: Assessment

-

Table 8.1

-- -----

An Example of Recommended Outcomes Assessment Tools for Low Back Pain Patients

Domain

Instrument

Number of items

Score (best to worst)

Time to complete

Pain

NRS

1 item

0-10; clinically meaningful change 30%

< 1 minute

=

Generic health status (including well-being)

Single self-rated health question

1

0-10

< 1 minute

Function! disability

PSFS or Oswestry

3

0-30

1 minute

1 0 (6 levels)

0- 1 00

3-5 minutes

Work status

Time off work

1

Number of days

< 1 minute

Satisfaction

Satisfaction with care

10

1 -5

2-3 minutes

Pain

In the assessment of pain, there are several measures to consider, including the pain severity, pain affect, pain location, and pain persistence (chronicity). The severity of pain is related to how much a person hurts, whereas pain affect measures the mental or emotional component of pain. When assessing pain severity for chronic and recurrent pain conditions, assessing the pain severity during a specified time period such as I week, 1 month, 6 months, etc., may be more impor­ tant than reporting the pain status at a particular point of time (1 69). Von Korff describes key parame­ ters of pain status based on a retrospective report to include: (a) the number of days pain is experienced during a specified time [Tame; (b) the average or usual pain intensity when in pain; (c) average interference with activities; and (d) the cumulative number of activity limitation days caused by pain (1 68).

pain level may be the best choice when limiting the number of questions asked regarding pain intensity to one. The report of average pain intensity has been found to correlate with a 3-month daily pain diary in a number of studies (82,84, 1 4 1 ). These validity stud­ ies support using measures of average or usual pain intensity for up to a 3-month recall period with acceptable discrimination. An example of a simple 0to-IO NRS for pain intensity using the "usual," "typ­ ical," or "average" is depicted in Figure 8.1.

What is the Minimum Amount of Change in Pain Severity/Intensity that Is C l inically Significant?

Farra and colleagues demonstrated in patients with scores of at least 4 out of 1 0 that an i mprovement of 2 poi nts or 30% was shown be a clinically meaningful i mprovement (48). This equates to the patient's own

Pain Severity/Intensity

Measuring pain intensity can be accomplished using verbal rating scales, visual analog scales (VAS), and! or numerical rating scales (NRS). Von Korff con­ cludes that " ... 0- 1 0 NRSs have many advantages over the alternatives [or clinical use and for research in clinical populations in which a simple and robust measurement method is needed" ( 1 69). Hence, a 0-to-l0 NRS anchored by "no pain" at the "0" end and "extreme pain" at the " 1 0" end (or vice versa) is a commonly used and practical approach. A VAS of current pain has been shown to be less responsive than a rating of pain over the past 24 hours, week, or 2 weeks (20,54,85, 1 3 9) . Therefore, when asking a patient to rate pain, the usual or average

global i mpression of change (PG IC) of "much i mproved." A 50% i mprovement was shown to correspond to a PGIC of "very much improved." I n those with scores less than 4 out of J 0, an i mprovement of only 0.5 points indicated c l i nically meaningful improvement. Therefore, using percent i m p rovement rather than numerical or "raw" scores is recommended. If the pain severity score at base­ l ine has wide valiabi l i ty, such as i ncluding subjects with scol-es less than 4 out of 1 0, the raw change will not cor­ relate with the PGIC , but the percent change will! Clinically Meaningful Change in VAS o r NRS •

30% i m provement

=

P GI C of "much i mproved"

•

50% i m provement

=

PG I C of "very much i mproved"

Chapter Eight: Outcome Assessment

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15 1

What is your TYPICAL or AVERAGE pain?

o

2

3

4

5

7

6

8

9

10

no

Worst

pain

pain possible

Figure 8.1 The numerical rating scale ( N RS) using the pain i ntensity

at usual , typical . or average.

Hagg and colleagues found a change of 1 8 to 1 9 out of 1 00 in the VAS of chronic low back pain patients to be clinically significant (6 1 ). Turner studied the COlTelation of pain with disability (160). If the initial VAS was 5 or more, a change of at least 2 points was needed to influence disability scores significantly. If the initial VAS score was less than 5, then a VAS change of at least 1 point would have a clinically rel­ evant ef{ect on hmctioning.

•

Sensory discrimination

•

Affective

•

Evaluative

•

Miscellaneous

A detailed description for scoring this instrumenl is described elsewhere ( 1 84).

Pain Diagrams Pain Affect

Pain intensity may be defined as the amount a per­ son hurts, whereas pain affect can be defined as the emotional arousal and disruption created by the pain experience (49,56, 1 1 7, 1 2 7, 1 69). The McGill Pain Questionnaire (MPQ) ( 1 1 3,114) includes 20 category scales of verbal pain descriptors categorized in order of severity and clustered into four subscales:

PAIN DIAGRAM

PAIN DIAGRAM

INSTRUCTIONS

INSTRUCTIONS

On the following diagrams, indicates all areas of : pain stiffness numbness other (specify)

A

The pain diagram or drawing is perhaps the besl way to obtain the patient's perception of the location of their symptom (94, 1 2 8, 1 84). Improvement or exac­ erbation can quickJy be determined by comparing current to previously completed pain diagrams. Pain diagrams enhance the HCP's ability to differentiate between a mechanical low back, nerve root, and psy­ chogenic problem (Fig. 8.2).

-

XXXX

-

////

-

0000

On the following diagrams, indicates all areas of : pain stiffness numbness other (specify)

-

-

-

XXXX

//// 0000

B

Figure 8.2 Pain diagram. (A) Example of a well-delineated, anatomically correct

depiction. (B) Example or a poorly delineated, anatomically i ncorrect, exaggerated depiction.

1 52

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Part Three: Assessment

Abnormal illness behavior or somatization is sug­ gested i[ the pain diagram shows multiple types of pain qualities (achy, stabbing, burning, numbness, pins and needles, etc.) in all four extremities and the trunk, and/or if markings outside of the body such as lightening bolts are presenl . This can then be corre­ lated with other subjective information such as psy­ chometric "yellow flags" that include poor coping strategies, depression, and anxiety, as well as objec­ tive tools such as the Waddell Non-Organic Low Back Pain signs (see Chapter 9). Though the pain drawing is usually used qualita­ tively, there are several validated methods for scor­ ing pain drawings ( 1 1 9,1 20,1 5 5,1 6 1 ). The scoring procedure is usually accomplished by overlapping the patient's pain drawing with a transparency that includes the same drawing but with grid lines and addingup points based on the number of body regions/ extremities marked and quantity of pain quality markings used. Summary

The NRS and pain diagram have the greatest utility [or the typical practitioner. General Health

Patient-based general health outcome measures can be classifled into two general categories: generic and

Table 8.2

disease or condition-specific measures (95,98). Gene­ ric measures include global ratings of health status and multidimensional measures of health-related quality of life, which include the Sickness Impact Pro­ file (SIP) (9, 1 0), SF-36 Health Survey ( 1 72), Nolling­ ham Health Profile (NHP) (78), Dartmouth COOP Health Charts ( 1 1 8), and others. The strength of generic measures of general health is that these are not speciflc to any one condition or disease and, there­ fore, are applicable across populations regardless of their health status. However, this is also a weakness because they are not as responsive to change over time compared to condition-specific tools ( 1 84). An exam­ ple of a highly responsive condilion-speciflc version of the SIP general health questionnaire is the Roland­ Morris questionnaire. The SF-3 6 is a popular generic outcome tool that has been used in outcomes-based research has been translated into more than 40 languages as part of the International Quality o[ Life Assessment (IQOLA), and it is often utilized in clinical settings (2 5,1 76). The strength of the SF-36 lies in the fact that norma­ tive data exist for healthy and non-healthy popula­ tions (69, 70). Both versions 1 .0 and 2 . 0 are divided into eight scales representing different aspects of general health ( 1 72- 1 74). Utilizing the eight individ­ ual scales, version 2 . 0 yields two composite scores, which include mental health and physical health. Table 8 . 2 lists the eight scale titles, the number of items or questions that are used to compute the

The SF-36 Subscales

Scale (SF-36 scale titles in parentheses when different) Health perception (general healthY Physical functioning;'

N of Items 5 10

Scale Items

Minimum N of Items Needed to Compute a Score

1 , 33, 34,35,36

3

3, 4,5,6, 7, 8, 9, 1 0, 1 1 , 1 2

5

Role limitations caused by physical health;'

4

1 3, 1 4, 1 5, 1 6

2

Role limitations caused by emotional problems'·';'

3

1 7, 1 8, 1 9

2

Social functioning;d

2

20, 32

1

Mental health'"'"

5

24, 25, 26, 28,30

3

Bodily pain;'

2

2 1 , 22

1

Energy/fatigue (vitality)'-';'

4

23, 27,29, 3 1

2

"Four scales used to calculate the physical component. ''''Four scales used to calculate the mental component. M odified from Yeomans. The C l i n ical Application of Outcomes Assessment. M cGraw- Hili, 2000.

Chapter Eight: Outcome Assessment

score, the specific scale items, and the minimum number of items needed to compute a score. The physical component summary (PCS) is made up of the following four scales: Physical Function, Role Physical, Bodily Pain, and General Health. The Mental Health component (M HC) is made up of Mental Health, Role Emotional, Social Function, and Vitality. The advantage of grouping all 3 6 questions into two rather than eight scales results in an improvement in the reliability. The mean score for a healthy adult population regarding both scales is 50 ± 1 0 points, which carries a reliability level of 0.92 and 0.88 for the PCS and the MHC, respectively. The SF-3 6 has generally been shown to be a res­ ponsive instrument for measuring clinically mean­ ingf-ul change in low back pain and sciatica individuals in certain studies ( 1 2 1 ,156), whereas in others it has not ( 1 38). Even in the Taylor et al study in which it was found to be responsive, it was not as good as the Oswestry Disability Index ( 1 56). The scales with the greatest responsiveness were Physical Function, Bodily Pain, and Social Function ( 1 56). In fact, the Physical Function scale was more sensitive to change than the Oswestry Disability Index (156). The SF- 1 2 is an abbreviated version derived fTom the SF-36 that was designed to improve the practical­ ity and utility of the longer 36-item version introduced (17 5). The SF-36 can also be utilized to form two dis­ tinct scales, the physical function and mental health scales. The advantage of the SF- 1 2 over the SF-36 is the length of time needed to complete the form is only 2 to 5 minutes. Standard and acute versions of the SF- 1 2 and 36 are available in multiple languages ( 1 76).

Summary

If the clinician is planning to assess other outcome domains, it may be more practical to use the SF-12 instead of the SF-36 for measuring general health status. If time is still deemed excessive, a single ques­ tion about self-perceived health can be utilized as has been used in "yellow flags" questionnaires ( 1 57) (see Chapter 9).

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1 53

correlate very well with functional limitations (i.e., dis­ ability) or participation. Whereas clinical decisions are fTequently guided by tests of specific dysf-unction or impairments, it is important to realize that patient's goals are oriented toward general dysfunctions, func­ tional limitations, or disability.

Low Back Pai n Oswestry Disability Index The Oswestry Disability

Index (ODI) was developed fTom studying low back pain (LBP) patients attending hospital outpatient departments. Since Fairbank presented the original version in 1 980, various revisions have been pub­ lished, including the original author's updated ver­ sion, version 2 .0, as well as others (47,52, 1 33). One of these, the Revised OD!, published by Hudson-Cook et al. (77), was an attempt to enhance the sensitivity of the ODI for patients with less dis­ abling LBP than those receiving hospital treatment (in other words, lower the floor of the instrument). A sim­ ilar goal was sought by Fritz et al. in their revised ODI (52). Test-retest reliability, responsiveness, and con­ struct validity were obtained and found superior when compared to the Quebec Back Pain Disability Scale. The utility of the ODI is enhanced by the fact that it has been translated into a number of languages (47, 1 33). It has been shown to be responsive to clin­ ically meaningful change ( 1 1 ,8 8, 1 05, 1 1 0, 1 3 3 , 1 5 6). The mean baseline scores for this instrument in dif­ ferent populations are shown in Table 8 . 3 .

What I s the Minimum Amount o f Change i n the Revised 001 that Is Clinically Significant? •

8% ( 110)

•

1 0% (6 1 )

•

1 2% ( 5 2 )

•

1 6.3% ( 1 56)

How to Score the Revised 001

Region-Specific Functional Disability Outcomes

Disability is defined as the ability of a person to per­ form common activities of daily living (ADL) (13). Thus, disability is an outcome of paramount impor­ tance in charting the progress of a patient undergo­ ing treatment. The International Classification of Disabilities and Health has contrasted disability with impairment (79, 1 82). Impairments such as range of motion or strength, although objective, do not always

It consists of 1 0 sections, each covering a difTel-ent activ­ ity of daily l iving ( for example, personal care, l i fting, walk­ i ng, and social l i fe) and a 6-point rating scale for each section ( from 0 to 5), which the patient uses to rate his or her ability to [unction (see appendix form 2). The disabil­ ity score is obtained by adding the scores of each of the sections ( maximum score 50), wh ich is usually converted to a percentage. I f one section is missed or not appl icable, the score is calculated as a percentage fTom the remain­ ing total possi ble score (e.g., 45) (see appendix form 2).

154

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Part Three: Assessment

Table 8.3 How Does the Mean Baseline ODI Score Vary in Different Patient and Asymptomatic Groups ( 1 9,46,47,77) Asymptomatic individuals- 1 0% (SD ± 2- 1 2) Hospital outpatient patients-22% Chiropractic patients-27% (revised ODI 3600/ -4 Mixed L B P-27% (SD ± 6-24) Chronic LBP-43% (SD ± 1 0-2 1 ) Sciatica-45% (SD ± 1 0-30) Orthopedic surgical patients-47%

• • •

• • • •

Roland-Morris Disability Questionnaire The Roland­

Morris Disability Questionnaire (RDQ) is a modifica­ tion of the SIP with 24 items most relevant to LBP patients. Each of the 24 questions refers to the per­ ceived effect of back pain on a particular daily activity and requires a simple yes or no answer. As with the ODI, the RDQ has been subjected to considerable psy­ chometric testing over the years and shown to be reli­ able and valid (39, 1 3 3). Shortened versions of the RDQ containing 1 8 and 1 1 items, respectively, have been shown to have good reliability and validity crite­ ria (145, 1 52). Responsiveness was compared to the SI P's physical subscales and were found to be similar (40,83) and others have also reported data on respon­ siveness ( 1 2,96,12 1 , 1 30,144, 1 46, 1 49, 1 53).

What Is the M i n i m u m Amount of Change in the RDQ that Is Clinica l ly Significant? •

2 . 5 to 5 poi nts ( 1 2 )

•

2 to 4 points (24. 1 2 1 . 1 33 )

•

1 t o 2 points in those w i t h l ittle disab i l i ty ( 1 1 4)

•

7 to 8 points in t hose with high levels of disab i l i ty ( 1 46)

•

5 points in a m ixed population ( 1 46 )

•

4 to 5 poi n ts i n acute and subacute L B P patients i n an outpatient setting ( 1 44)

How t o Score the ROO

The score is a s i m p l e addition of the n u m ber of a ffir­ mat ive replies (maximum score 24). If a quest ion is not answered. then only those responses answered are used to determ i ne the percent (see append i x form 3).

Comparison o f the Oswestry Disability Index and the Roland-Morris Disability Questionnaire The

ODI has been directly compared with the RDQ in a

number of studies (5,75, 1 00, 1 33, 1 42). It has generally been found that the ODI tends to score higher than the RDQ. For this reason, the ODI may be better in detecting change in more severely disabled pa­ tients, whereas the RDQ is more sensitive in detecting change in less disabled patients. However, the Revised ODI was found to be more sensitive than the original om (75,77). The questionnaires do address different aspects of daily functions, with the Revised om covering only approximately half of the f'unctional categories of the RDQ. An interesting and unexpected finding from the study by Stratford et a!. ( 1 42) was the frequency of blank and multiple response items associated with the OD!. This may be because of the fact that ODI uses a multiple choice format, whereas the RDQ has a more direct yes/no format. Other factors that may influence a decision to using one over the other include transla­ tion availability (either tool), telephonic administra­ tion necessary for long-term follow-up needed in research (favors the RDQ), ceiling effects (favors the ODI), whereas floor effects favor the RDQ. Fairbank and Roland suggest using the ODI in patients with persistent severe disability and the RDQ in those 'v'lith relatively little disability ( 1 3 3). Studies regarding test-retest reliability and internal consistency show high correlation between the two (5,33,96). The layout of the ODI more clearly depicts each activity of daily living in 10 clear-cut sections and therefore can be utilized as a goal-setting tool by the health care provider easier than the RDQ. When comparing patients who had reached their treatment goals versus those who did not, a corresponding sig­ nificant change (improvement) versus lack o[ change in the ODI and RDQ score was noted, respectively, as noted in Table 8.4 ( 1 2, 1 00, 1 42). Although the RDQ and ODI (or Revised Om) are considered "gold standards" for [u ' nctional ment in LBP patients there are other validated tools available, as noted in Table 8 . 5 . Spinal Function Sort The Performance Assessment

and Capacity Testing Spinal Function Sort (SFS), authored and developed by Leonard N. Matheson, PhD, and Mary L. Matheson, MS (199 1 ), measures a patient's perception of his or her capacity to perform 50 different activities of daily living shown in picture form ( 1 08, 1 1 6). These represent the positions or activities defined in the Dictionary of Occupational Titles (DOT). A total score referred to as the rating of perceived capacity (RPC) is calculated and reliability checks are made to determine internal consistency and effort. The score is compared to a chart listing the physical demand characteristics of work devel­ oped by the United Stated Department of Labor. Tasks that are utilized at work are identified and work-related lift/carry capacities are determined.

Chapter Eight: Outcome Assessment

Table 8.4

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1 55

The Mean Scores of the ODI and RDQ in Different Patient Populations

Study

RDQ

ODI

Patients recruited to trial,less than 3 out of 1 0 pain, no radiculopathy ( 1 00) (mean, range, and standard deviation)

1 0. 9, 0-22, 4.7

3 3 .0, 4-70, 1 4. 7

EMG evidence of radiculopathy ( 1 00) (Canada) (mean, range, and standard deviation)

1 4. 2, 0-24, 5.2

49. 1 , 6-86, 1 7 . t

Patients referred to a physical therapist ( 1 42)

Pre-PT 1 1 .8 ± 6 . 2 4 weeks: 7 . 1 ± 5 . 7

Pre-PT 40.5 ± 1 7 . 8 4 weeks: 24.4 ± t 5 . 5

Patients with nonspecific LBP for >6 weeks ( 1 2)

Baseline: 1 2 .1 5 weeks: 7.5 improved 1 2 . 1 -4 . 3 unimproved: 1 1 . 8- 1 0.6

Baseline: 2 7 . 6 5 weeks: 2 1 . 9 improved 26.2- 1 4 . 3 unimproved: 29. 1 -2 9 . 5

Modified from Table 3 of Roland M and Fairbank J. Roland-Morris D isabil i ty Questionnaire a n d Osweslry Disabilily Questionnaire. Spine 2000;25 : 3 1 1 5-3 J 24.

current job). This comparison allows the HCP to determine if the patient is capable of returning to their "normal" duty or current job versus to a more limiting PDC work level.

Several important items are derived from this evalu­ ation. These include: • •

• •

•

•

A score of RPC The RPC score categorizes the patient into one of the five physical demand charac­ teristics (PDC) work levels (sedentary to heavy) A perceived maximum lift/carry Internal reliability is checked when the scores or similar tasks are compared The RPC score is compared to normative data collected on working and disabled/unemployed males and females The physical demand characteristics level that the RPC score places the patient is then compared to a Job Demands Questionnaire (which describes the demands of their

Table 8.5

•

Work-related duties are circled so that tolerance to specific work activities can be appreciated and separated from non­ occupational duties. This can also be used to institute work-specific exercise protocols or work simulation in a rehabilitation setting.

The practicality and utility of the SFS is excellent because it takes only 5 to 7 minutes for the patient to complete and approximately 5 to 1 0 minutes to cal­ culate the score, interpret the results of maximum lift/carry, and compare it to their current work demands (Job Demands Questionnaire) and to the normative data. Though the intention or the SFS is

Other Validated Lumbar Spine Assessment Tools

Quebec Back Pain Disability Scale (QBPDS) (96,97)

Spinal Stenosis Questionnaire (SSQ) ( 1 53, 1 54)

North American Spine Society Lumbar Spine Questionnaire (NASS-LSQ) (36)

Million Visual Analogue Scale (MVAS) ( 1 1 5)

Curtin Back Screening Questionnaire (CBSQ) (65)

Waddell Disability Index (WDI) ( 1 70)

Activities Discomfort Scale (ADS) ( 1 59)

Resumption of Activities of Daily Living Scale (RADL) ( 1 8 1)

Low-Back Outcome Score (LBOS) (58)

Clinical Back Pain Questionnaire (CBPQ) (138)

J 56

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Part Three: Assessment

not to function as an OA tool, the RPC scores improve (increase) as the patient's disability decreases.

After analysis, a 5-point change was reported as clin­ ically important change with an internal consistency of 0 . 8 7 and test-retest reliability or 0.94. The SEM was estimated at 2 . 7 NDI points (95% confidence interval 2 . 7 x 95% ± 4. 5points) (see appendix form 3). A typical range for patient scores on the NDI are reported to be between 35% and 39% (1 47, 1 62). =

Neck Pain Neck Disability Index The Neck Disability Index (ND!)

(1 62) was designed using the ODI as a template. This instrument was initially studied using a sample of 1 7 consecutive whiplash-injured patients and showed good statistical significance (Pearson r 0.89, p $ 0.05). The alpha coefficients were calculated [yom a pool of questionnaires completed by 52 patients resulting in all items having individual alpha scores more than 0.75 and a totaJ index alpha of 0.80. Con­ current validity was reported with moderate correla­ tions when assessed in two different ways (0.60 and 0. 69-0. 70). It has been studied in individuals with work-related neck pain as well ( 1 64). More recently, Hains et al. (62) studied seven modified versions of the NDI against the original N DI and confirmed the validity of the original NDI items. The item presentation revealed a strong cor­ relation with internal consistency reported at 0 . 92 (Cronbach alpha). The NDI was utilized in monitoring the outcome of patien ts with whiplash-associated disorders (WAD) ( 1 65). The ND! favorably compared to other neck pain and disability self-report tools in a group or WA D patients ( 1 66, 1 67). In this study, the NDI, Neck Pain Questionnaire, and the Copenhagen Neck Functional Disability Index were compared for assess­ ing pain, impairment, and disability. The results of the study revealed numerous similarities i n content and format and equally good basic psychometric effi­ cacy. The NDI was found to be more extensively studied and, therefore, was the recommended tool for use in research settings. Vernon et a1. ( 1 63) compared WAD patients with three or more Waddell non-organic signs (NOS) ver­ sus those without and found that the mean scores of the NDI was over double for the high NOS group (1 7 . 6 ± 9 . 1 verses 36 ± 3 . 7). Additionally, it was found that strength was lower in the high NOS group. Stratford et al. ( 1 47) evaluated the use of the NDI when evaluating individual patients. They reported on 49 initial and 48 follow-up patients using the stan­ dard error of measurement (SEM) and also applied tbis to 1 5 stable patients. Three primary questions were asked: =

1 ) What is the variability for an obtained score value? 2 ) What is the minimal detectable change (MDC)? 3) What is a clinically important change?

=

What Is the Minimum Amount of Change in the NOI that Is Clinically Significant? •

1 0% or 5 points out of 50 (1 1 5, 1 29)

How to Score the NDI

Like the ODl it consists of 1 0 sections, each covering a d i fferent acti v i ty of d a i ly l iving ( [or example, driving, and s i t t i ng), and a 6-point rating scale [or each section ( from 0 to 5), which the patient uses to rate his or her abi l i ty to [un c tions. The disabil ity score is obtained by adding the scores of each o[ the sections ( maximum score 50), which is usually converted to a percentage (see append i x form 4 ) .

Other Forms The Copenhagen Neck Functional Dis­

ability Scale has been found to have very good relia­ bility, responsiveness, validity, and practicality (90). The Cronbach alpha coefficient for internal consis­ tency was 0.9 for the entire scale, and the coefficients for individual items were all more than 0.88. Disabil­ ity scale scores correlated strongly to pain scores as well as to doctor and patient global assessments, indi­ cating good construct validity. Relative changes in dis­ ability scores demonstrated a moderately strong correlation to changes i n pain scores after treatment. Another validated form is the Neck Pain and Disabil­ ity Scale ( 1 79). A Whiplash-Specific Disability Measure has re­ cently been published ( 1 24). It was shown to have no significant floor or ceiling effects and high internal consistency (Cronbach alpha 0.96). It covers items relevant to whiplash patients that are absent in the NDI such as emotional health, social activity, and fatigue (see appendix form 4). =

Upper Extremity The Shoulder

The Croft Index This questionnaire has good con­ struct vaJidity in that it is able to discriminate between those with shoulder pain of severity sufficient to make them seek health care versus those who did not (35). It has also been shown to discriminate between those with disabling shoulder pain and those with no dis-

Chapter Eight: Outcome Assessment

ability ( 1 25). It has good concurrent validity because of its moderate con"elation with the SPADI instru­ ment (r 0.79) (57). I ts test-retest reliability is high (ICC 0.95) (57). A clinically significant change would require a change of 3 points to represent a change greater than the en"or associated with the instrument 95% of the time (57). It also has a high level of inter­ nal consistency (approximately 0.9 1 ) (57). However, the responsiveness of the tool is not yet assessed. =

Shoulder Pain and Disability Index The Shoulder Pain and Disability Index (SPAD!) covers the follow­ ing domains: pain, mobility, and self-care. Test-retest reliability of the SPADI is very good in a surgical pop­ ulation (ICC 0.9 1 ) and marginal in a primary care setting ( ICC 65,95% confidence interval) ( 1 32, 1 80). The internal consistency of the entire scale is very good (Cronbach alpha 0.9 1 ), with the disability scale higher than pain scale ( 1 80). Its construct valid­ ity has been established in a variety of ways, includ­ ing cOlTelating it with the S IP (74) and SF-36 (7). The SPADI's responsiveness has also been established (74). The minimum amount of change that is clini­ cally significant is 1 0% (57,74, 1 80). Neither the SPADI nor Croft form correlates well with ROM (r 0.24 to 0. 56) (57). Another popular questionnaire for use in this region is the Shoulder Evaluation Form (SEF). The SEF involves a ] 5-item activity of daily living ques­ tionnaire developed by the American Shoulder and Elbow Surgeons (6,1 3 6). The SEF was studied as a stand-alone instrument in the non-operative treat­ ment of rotator cuff tears (68). It is not as well-studied as the other forms described.

--

157

administered questionnaire used t o measure the functional loss of upper extremity disorders (UEDs), including shoulder or elbow tendonitis or carpal tun­ nel syndrome (CTS) ( 1 26). This instrument was tested in two groups of patients in a prospective follow-up study using 1 08 patients with work-related UEDs and 1 65 patients with carpal tunnel syndrome (CTS). Good internal consistency (Cronbach alpha > 0.8 3), relative absence of floor effects, and excellent conver­ gent and discriminant validity, compared with mea­ sures of symptom severity and clinical findings was reported. The UEFS was more responsive in the CTS group when compared to clinical measures such as grip and pinch strength.

=

=

=

=

The Wrist The Carpal TUnl1el SyndrOlne Questionnaire The Car­ pal Tunnel Syndrome Questionnaire (CTSQ) is a valid, reliable, self-administered outcome tool used with patients with carpal tunnel syndrome (4). The validity was tested against the SF36 and reliability (test-retest) was tested at 1 and 3 weeks. A strong internal consistency score of 0 . 8 to 0.95 (Cronbach alpha) was reported and the responsiveness ranged between 0.94 and 1 .7 .

Hand Function Sort The Hand Function Sort (HFS) is a patient self-report of their ability to perform 62 tasks involving a broad range of physical demands, including ADLs. The HFS has demonstrated construct validity by virtue of the HFS scores corresponding to impairment when the dominant hand was involved in the disability, but not if it was the non-dominant hand ( 1 07).

What Is the M i n i m u m Amount of Change i n the U E FS that Is Clinically Significant? •

More than 1 5% (96)

How to Score the UEFS

Scoring of the questionnaire is sim ply the calculat ion o r t h e sum o f a l l responses. Not answel"ing one response i s allowed and i s i nterpolated a s t h e average or t h e ot her responses (see append i x form 5 ) .

The Upper Extremity Functional Index (UEFl) The UEFI was designed as a single, all-purpose upper extremity functional outcome to cover patients with shoulder, elbow, wrist, or hand symptoms ( 1 50). It has good test-retest reliability (0.94). The standard error of measurement is 3 .9 . When compared to the UEFS, this form was found to have similar test-retest reliability and cross-sectional validity but better lon­ gitudinal validity. Longitudinal validity was deter­ mined by comparison with independent clinician impression of patient improvement.

What Is the M i n i m u m Amount of Change i n the UEFI that Is Clinically Significant? •

Nine scale points

How To Score The UEFI

Subjects check wh ich answer best describes their a b i l ­ i ties. There are 2 0 questions and SCOI"es range rrom 0 to 4 for each quest i o n , w i t h the h i gher the score the less the dysfu n c t i o n . The scori ng range for the ent ire questionnaire is from 0 to 80, w i t h 0 being the most

General Upper Quarter Function

Upper Extremity Function Scale The Upper Extrem­ ity Function Scale (UEFS) is an eight-item, self-

dysfunction and 80 the least dysfu nc t i on (see append i x form 6).

J 58

--

Part Three: Assessment

The Lower Extremity The Hip There are a number of hip outcome tools

available for use (66, 89, 9 1 , 1 8 3, 1 84). Some are de­ signed with the objective of assessing pre- versus post­ surgical hip arthroplasty function ( 1 84). A commonly used hip-related outcome tool in the United States is the Harris Hip Score (66). Many young active patients with activity-limiting hip pain require a modified out­ come tool such as the Nonarthritic Hip Score (3 2). This form takes only approximately 5 minutes to com­ plete. Its reproducibility, internal consistency, and validity have all been demonstrated (32). This is a modification of a general arthritis form called the Western Ontario and McMaster Universities Osteo­ arthritis I ndex (8). The Knee

Functional Index Questionnaire (FIQ) A review of five methods of evaluating patellofemoral pain syndrome (PFPS) was conducted to investigate the psychomet­ ric properties of each tool (67). The five methods included the Functional I ndex Questionnaire (FIQ) (31); visual analogue scales for pain at worst, least, and usual; the Patellofemoral Function Scale (PFS) ( 1 29); a step test; and a subjective report of functional limitations. A sample of 56 patients with PFPS partic­ ipated in a randomized clinical trial before treatment and 1 month after treatment. The Functional Index Questionnaire compared very favorably to the other measures and was concluded to be a practical easy-to­ score tool with high utility for tracking the care of the knee-injured patient (67). The F IQ was shown to have modest test-retest reliability and to have very good internal consistency of 0 . 8 5 before treatment and 0 . 8 8 after treatment (Cronbach alpha) (3 1 ). The FIQ was also found to be a good discriminator for measuring clinical change.

Other Questionnaires The Noyes and Lysholm Knee scoring questionnaires are commonly used in assess­ ing the outcome of knee surgery in athletes (38). These questionnaires consist of activities of daily living con­ sistent with knee function. The Lysholm Knee Rating Scale was also used along with the SF-36 in a study of 426 patients with knee impairment who were treated conservatively (87). The outcome after physical ther­ apy revealed simultaneous improvements in the results obtained from both tools. The International Knee Documentation Committee Subjective Knee Form is a relatively new but psycho­ metrically robust outcome measure for health-related quality of life in knee patients (80). It has been shown to have very good test-retest reliability, internal con­ sistency, convergent and discriminative validity, and responsiveness. However, it is a slightly longer form to complete than the F IQ .

Ankle A simple-to-administer 1 2-question form, The

Ankle Joint Functional Assessment Tool (AJFAT), has been validated for assessing disability in ankle sprain patients ( 1 37). This is based on various vali­ dated knee outcome assessment tools (3 8,87). Ankle sprain patients' disability scores improve concur­ rently with impairment score improvements in bal­ ance ability ( 1 3 7). General Lower Quarter Function

The Functional Assessment Scale (FAS) The FAS has been developed for assessing functional levels in the elderly with osteoarthritis o[ the knee(s) (1 77). It was devised from the mobility and physical activity compo­ nents of the Arthritis Impact Measurement Scale ( 1 1 1 ), which has been shown to be reliable and valid ( 1 1 2). The FAS has demonstrated internal consistency by being able to discriminate between an elderly group with osteoarthritis and one without it (Cron­ bach coefficient alpha 0 . 8 3) ( 1 77). Arthritis su[fer­ ers' mean score was 1 3 . 0 (S D 2 . 68), whereas a control groups mean score was 6.4 (SD 1 . 35) out of maximum score of 2 5 . The age range for the sample was 54 to 79 years. Age was not associated with func­ tional score. This form could also have utility for measuring functional status in any lower-quarter patient with marked functional limitations relating to standing, walking, stair-climbing, or those requiring aids such as a cane or crutches. =

=

=

How to Score the FAS

Subjects c ircle the answer that best describes their abi l ­ i t i es. There are five question a n d scores range [Tom 5 to 25 ( for each scale, a

=

1,b

=

2,

.

.

. [ = 6). H igher scores

i n dicate greater dysfu nction (see append i x [orm 7).

The Lower Extremity Functional Scale (LEFS) The LEFS was designed as a single all-purpose lower extremity functional outcome to cover patients with joint replacement, patellofemoral disorders, arthritis, ankle sprain, joint instability, etc. ( 1 6). It has superior sensitivity to change in lower extremity patients than a general measure such as the SF-36 ( 1 6). The 90% confidence interval, or error, ror a specific score is 6 scale points ( 1 6). Ninety percent o[ stable patients have an inherent variation of less than 9 scale points when tested on different occasions ( 1 6) . Thus, the Minimal Detectable Change or Minimal Clinically I mportant Difference is 9 scale points ( 1 6). I t is effi­ cient to administer and score. An initial follow-up study validated this questionnaire on patients with lower functional levels-these were patients recover­ ing from total hip or knee arthroplasties ( 1 49). A sec-

Chapter Eight: Outcome Assessment

ond rollow-up study demonstrated the test-retest reliability, cross-sectional, and longitudinal validity of the LEFS on a more athletic population who had sustained an ankle sprain within the past 1 4 days (2). Because the LEFS was valid in highly disabled and high-performing individuals, this demonstrates both a strong "floor" and "ceiling" effect for this OA tool.

•

PSFS effect size

•

Numerical pain scale effects size

•

RDO effect size

•

=

=

--

159

1 .6 =

1.3

0.8

Impairment evaluation (ROM) effect size to 0.6

=

0.1

What I s t h e Minimum Amount o f Change i n the PSFS that Is Clinica l ly Significant? What Is the Minimum Amount of Change

•

3 scale points ( 1 78)

in the LEFS that Is Clinically Significant? •

9 scale points ( 1 6)

How to Score the PSFS

Subjects choose t hree activities that are giving them the How to Score the LEFS

Subjects check which answer best describes their abil i ­ ties. There are 2 0 quest ions a n d scores range fTom 0 to 4 for each question, with the h igher the score the less

most trouble. They then score them on a scale of 0 to 1 0 , w i t h 0 mean i ng "unable to perform activi ty" and J 0 mea n i ng "able to perform activi ty at pre-inj ury level" (see appendix form 9 ) .

the dysfu nction. The scori ng range for the en tire ques­ tion naire is from 0 to 80, w i t h 0 being the most dys­ function and 80 the least dysfu nct ion (see appendix form 8).

Summary

A wide variety or region specific functional question­ naires are available that measure a patient's activity intolerances related to his or her chief symptom. Table 8 . 6 summarizes the author's recommenda­ tions for which rorms to choose for which regions of the body.

Patient-Specific Functional Disability Outcome Patient-Specific Functional Scale (PSFS)

The PSFS is an innovative OA tool that allows the patient to choose three activities they either are unable to perform or are having the most difficulty with as a result of their pain (2 7,1 43, 1 48 , 1 78). The PSFS has been shown to be more responsive than other outcome tools or impairment tests ( 1 22).

Table 8.6

Recommended Outcome Forms

Any region-PSFS Low back-Revised ODI, R DO or Back BO Neck-ND I or Neck BO Upper Extremity-UEFI Lower Extremity-LEFS

The PSFS was designed to be administered weekly. It is to measure progress (make ongoing clinical decisions) and outcome. It could be administered less often if slower change is expected. The MDC of three is validated per item, rather than the average of all three items. Activities mentioned by patients are all of different levels of dirficulty and averaging could mask potential improvement on one while others may change slower. As an example, if a breast cancer patient has shoul­ der dysfunction, number one on her PSFS might be playing volleyball (not on most functional scales!), and combing her hair and washing floors are numbers two and three. Obviously, two and three will change faster and when number one increases to nine or 1 0 on the scale, it will likely mean that she is ready for discharge. The clinician should set short-term goals around the "easier" items with an "increased ability to play volleyball to more than eight out of 1 0" as a mea­ surable long-term goal.

Summary

The PSFS is an excellent complement to the more well­ known region specific functional disability scales.

Work Status

Many reasons exist for measuring work outcomes (7 1 ,109). Five that stand out include (3): •

To assess productivity loss in clinical trials

•

To evaluate the effectiveness or health services

1 60

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Part Three: Assessment

Table 8.7

Psychometrics of WL-26 Scales

Scales

Number of Items

Con bach Alpha

Scaling Success'�

6 8 4 3 5

0.88 0.88 0.92 0.08 0.90

1 00% 91% 94% 92% 95%

Work scheduling Physical demands Mental demands Social demands Output demands

" Scaling success is the extent that an i tem correlates with the scale it i s hypothesized to correlate with as opposed to another scale. A success rate greater than 90% is considered successf-u l . Repri nted with permission from A m i c k B e , et a l . S p i n e 2000;25(24 ) : 3 1 5 2-3 1 60.

•

•

•

To target injury and re-injury prevention programs To evaluate the effectiveness of work reorganization projects such as ergonomic changes To improve provider-worker and provider-safety engineer interaction

The Work Loss-26

The WL-26 is an example of a generic role-specific measure. Originally, it was designed for use in occu­ pational illness and injury populations but has since been used in the clinical setting, especially those managing a variety of musculoskeletal disorders (Table 8 . 7). The WL-26 scales can discriminate between work­ ers with low or high hand-wrist symptom severity or upper extremity functioning. Also, construct valida­ tion is supported by emerging data on the relationship between work limitations and productivity. In general, when a worker's capacity to work is limited because of a condition, work performance is compromised. Amick et a!. described a 20-point change in work lim­ itations for Massachusetts workers with upper extrem­ ity musculoskeletal disorders as being associated with an additional 2.7 weeks of lost productivity (3).

Summary

The simplest measure by far of work status is the actual time off work. For most practitioners this may be the most practical outcome to obtain.

Patient Satisfaction Outcomes Assessment Tools

The fifth domain described by Deyo et al and Bom­ bardier is patient satisfaction (23,43). This is an impor-

tant domain when assessing quality assurance issues (4 1 ) . Table 8 . 8 represents a partial list of some of the patient satisfaction questionnaires available ( 1 5, 29,34). B y identifying the patient who is dissatisfied with care early on, realistic advice can be given to the patient, and frustration, disappointment, and even anger in patients who do not respond can be avoided (30). Deyo reported that most people treated for hypertension, cancer, and other serious medical dis­ eases are satisfied with their care. However, 20% to 25% of patients presenting with back and neck pain for medical care are dissatisfied (42).

Symptom Satisfaction

Cherkin et al. (30) asked a novel question to a sam­ ple of 2 1 9 patients, "If you had to spend the rest of

Table 8.8 Examples of Various Patient Satisfaction Questionnaires Test

Conditions Tested

1 . Client Experience Survey

Patient satisfaction

2. Client Satisfaction Questionnaire

Patient satisfaction

3. Patient Experience Survey (PES)

Patient satisfaction

4. Chiropractic Satisfaction Questionnaire (34)

Patient satisfaction

5. Work APGAR ( 1 5)

Job satisfaction

6. Patient Satisfaction Subscales (29)

Patient satisfaction

Chapter Eight: Outcome Assessment

your life with your condition as it is right now, how would you feel about it?". He found that at 1 week one-third were satisfied; at 3 weeks one-half were satisfied; at 7 weeks two-thirds were satisfied; and at 1 year 85% were satisfied. In this sample, 82% of patients presented for their first visit of a recurrent low back pain episode in less than 3 weeks [Tom the episode's onset.

Symptom Satisfaction Is a Novel and Highly Predictive Measure of Recovery

--

161

The Patient Satisfaction Subscales (PSS)

The Patient Satisfaction Subscales (PSS) was de­ signed for patients with lumbar spine problems (2 8 , 2 9, 7 6). The PSS consists of 1 7 items, of which 1 0 are used that reflect three distinct dimensions of care: information (3 items), caring (4 items), and effectiveness (3 items). Table 8 . 9 includes the mean, standard deviation, and Cronbach alpha for each subscale. This tool was specifically recommended to be used in outpatient settings and because of its practicality of being short ( 1 0 items) and easy to score (76).

Cherkin showed that a patient's sat isfaction with his o r her cu rrent symptom status was a s predictive of func­ t ional and symptomat ic recovery as self-rated healt h , sciat ica, and a h istory of frequent episodes of LBP ( 3 0 ) .

How to Score the Patient Satisfaction

T h i s can b e determ i ned with a s i ngle question-

Subscales

" If you had to spend the rest of your l i fe w i t h your

condi tion as it is right now, how would you feel about it?" o

2

Each of the t h ree subscales are scored by calculating the mean o f the i tems in each subscale. An overall total scale score is then obtained by adding the numerical

3

4

5

6

7

Delighted

8

9

10

value of the 1 0 subscale items (maximum score possible

Terrible

is 5 x 1 0 or, 50) (see appendi x form 1 0) .

Job Satisfaction

Psychological Distress

Bigos and colleagues used the work APGAR in a lon­ gitudinal, prospective study of 3020 aircraft employ­ ees to identify risk factors for reporting acute back pain at work ( 1 5). At a 4-year follow-up point, 279 subjects reported back problems. Subjects who stated they "hardly ever" enjoyed their job tasks were 2 . 5-times more likely to report a back injury (P 0.000 1 ) compared to subjects who "almost always" enjoyed their job tasks. The authors conclude that " . . . a broader approach to the multifaceted problem of back complaints in industry helps explain why past prevention efforts focusing on purely physical factors have been unsuccessful." The modified work APGAR is a seven-item tool derived initially from a family APGAR-a six-item family function questionnaire (5 5,1 40). Further mod­ ifications came based on findings from the retrospec­ tive analysis of the Boeing company work force ( 1 4), and two additional questions were added for this study (1 5), making the total number of questions to seven. A simple scoring method is based on the for­ mula: Patient Score / Total Possible x 1 00 % risk. Responses include "almost always," "some of the time," and "hardly ever" with points of 0, 1 and 2, respectively. A score of "0" represents no risk, whereas a maximum score of 1 4 (7 x 2 1 4) divided by the highest possible score of 1 4 equals 1 , multiplied by 100 equals 1 00%, which represents the highest risk possible. =

=

=

Different questionnaires for evaluating psychosocial aspects of illness in back pain patients have been developed (92, 1 0 1 , 1 02). Although there are numer­ ous condition-specific questionnaires that measure pain and disability, most do not address affective or cognitive aspects of the pain experience (see also Chapter 9). It has been shown that utilizing a ques-

Table 8.9 Using a 305-Patient Sample, the Three Subscales of the PSS, and the Associated Mean, Standard Deviation and Chronbach Alpha Are Reported Mean ± Standard Deviation

Cronbach alpha

Information

2 . 72 ± 0.92

0.75

Caring

2 .09 ± 0.67

0 . 84

Effectiveness

2.59 ± 0.76

0.7 1

Overall score

NA

0.87

PSS Subscales

Reprinted with permission from C herkin D , Deyo RA , Berg A O . Evaluation o f a physician education interven­ tion to i mprove primary care for low-back pain: I I . I m pact o n patients. Spine 1 99 1 ; 1 6: 1 1 73- 1 1 78. NA, not ava ilable.

1 62

--

Part Three: Assessment

tionnaire for identifying psychosocial stress is more reliable than first impressions from a history (59). The Back Bournemouth Questionnaire The Back

Bournemouth Questionnaire (BQ) is a hybrid measur­ ing instrument that consists of seven scales covering pain intensity, disability in activities of daily living and social life,anxiety, depression, fear-avoidance behav­ ior, and locus of control (2 1 ). The back BQ has been shown to be valid, reliable,and responsive. The inter­ nal consistency (Cronbach alpha 0.9) and test-retest reliability (ICC 0.95) are very good (2 1 ). This is on the basis of two administrations in stable patients (n 61), indicating strong agreement between total scores in these patients. The back BQ has shown good construct validity because of its strong comparison to other outcome measures, especially the Revised aDI questionnaire (Pearson r 0. 78) (2 1 ). The back BQ is responsive to clinically significant change, as demonstrated by its high effect size. This was 1.29 for LBP, which was comparable to other established measures in the same study population such as the Revised aDI (1 .07) (2 1 ). The effect size for the neck is 1 .43 (22).

responsiveness (22). The effect size of the Neck BQ is considerably greater than [or the NDI or Copenhagen scale (22). Scoring of the Neck BQ is identical to the Back BQ (see appendix form 12).

• CONCLUSION Clin ical Utility of OA Tools

=

=

=

=

OA tools can be used to establish mutual ly agreeable goal s of care. I f the N D I reveals that neck d iscomfort is greatest with driving, then i mproving this activity intol­ erance can be established as a pri mary goal of care. Uti­ l i zi ng OA tools hel ps to rocus patients on funct ional goals such as reduction or activi ty intolerances so that symptom reduction is not the sole outcome of interest. OA tools can be used on a weekly or monthly basis to review pat ient progress towards mean ingr-ul goals. If the OD! shows a prominent sitting or walking intolerance, then progress in these fu nctional parameters can be moni tored, discussed , and problem-solved on an ongo­ i n g basis. Such functional , outcome-based dialogues with the patient are an i ntegral part or pat ient care. They allow cli nician and patient to discuss if the patient has

What Is the Minimum Amount of Change

reached a key "decision point" in care such that a di ffer­

i n the Back BQ that Is C l i nically Significant?

ent treatment modal i ty, d iagnostic assessment, or refer­

Stable subjects were found to exh i b i t changes o f between 2 . 6 a n d 4 . 5 poi n ts (or 3 . 7% to 6.4%) over time.

ral is indicated. Such discussions are often necessary to avoid patient d i ssatisfaction with care that can arise when i nappropriate expectations exist.

Thererore, change scores more than 4 . 5 ( 6 .4%) are i n ­ d i cative of real change beyond the variab i l i ty i n change

Outcome-based dialogues offer an opportunity to

scores in stable subjects who used this scale. The mean

review m u tually agreed on goals as well as the patient's

score before treatment in LBP subjects was 50.3 ±

prognosis and expected cou rse of recovel-y. Funct ional

1 8 .8% ( 2 l ) .

outcomes a l low for a d i scussion centered on expecta­ tions and ach ievements ( 6 1 ).

How to Score the Back BO

OA reports are i nval uable for quant ifiably demonstrat­

The ind ividual items are sum med to produce a total

i ng a patient's c l i n ical status. i m provemen t . or lack

overall score. Because the seven d im ensions each have a

t hereof. This is i m portant for med-legal report i ng.

maximum score of 1 0, it is best to express the total score

i nsurance review progress reports, or referral let ters to

or the back BO as a percentage (see appendix rorm 1 1 ) .

other health care providers. The integrity of case man­ agement is preser·ved by u t i l i zing rel iable. val id, and responsive outcomes to measUl-e a patient's progress

The Neck Bournemouth Questionnaire The same seven core items used in the Back BQ are used in the Neck BQ. Some minor changes were made such as replacing activities like "walking," "climbing stairs," and "gelling in/out of bed/chair" in the back BQ by activities "liFting," "reading," and "driving." The instrument demonstrated high internal consistency on 3 administrations (Cronbach alpha 0 . 87, 0.9 1 , 0.92) (2 2). The form demonstrated good reliability in test-retest administrations in stable subjects (ICC 0.65) (2 2). The treatment effect size was found to be very good ( 1 .43-1 . 67), contributing to its good =

=

over time.

All outcome, or evaluative, measures must be valid (measure what they purport to), reliable (repro­ ducible in stable conditions), and responsive (able to detect clinically significant change in the status of the patient). Many outcome tools, although initially considered a burden by health care providers, are surprisingly simple to administer. They enhance doctor-patient communication and improve goal setting and decision-making.

Chapter Eight: Outcome Assessment

Outcome measurements are essential to unmask ineffective treatments believed to be effective. If an outcome represents a mutually agreed on goal between provider and patient, then improvement in the outcome should demonstrate if treatment is suc­ cessful. Regular re-evaluation with outcome mea­ surements is thus important so that treatment that does not improve outcomes can be re-directed. Sim­ ilarly, treatment that is effective but for which a provider is having difficulty justifying to a third party payer can now more easily be defended.

Audit Process Self-Check of the Chapter's Learning Objectives •

What is the m i n i m u m amount of change that i s clinically significant i n the fol lowing O M tools­ ODI, VAS or N RS, N DI, UEFS, LEFS, PSFS, and backJneck BQ?

•

Do you know the mean scores in specific clinical populations for the OM questionnaires that you plan to use i n your practice?

•

How can measurement of activity i n tolerances such as with the 001 help establ ish realistic goals of care for a patient?

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1 1 4. M elzack R. The M c G i l l Pain Questionnaire. M ajor properties and scoring methods. Pain 1 97 5 ; 1 : 2 77-299.

1 3 l . Rissanen A, Alarant H , Sain i o P, H arkonen H . Isoki­ netic and non-dynametric tests i n l ow back pain patients related to pain and d isab i l i ty i ndex. Spine 1 994; 1 9: 1 963- 1 967.

1 1 5 . M i l l ion R, H a l l W , N il sen K H , Baker RD, Jayson M J V. Assessment of the progress of the back pain pat ien t . Spine 1 98 2 ; 7: 204-2 1 2 .

1 32 . Roach KE, Budiman-Mak E , Songsirdej N, Ler­ tratanakul Y. Development of a shoulder pain and disabil ity i ndex. Arth ri t i s Care Res 1 99 1 ;4: 1 43- 1 49.

Chapter Eight: Outcome Assessment

1 33. Roland M , Fairbank 1 . The Roland-Morris D isabil i ty Questionnaire and the Oswestry Disab i l i ty Ques­ tionnaire. Spine 2000;2 5:3 1 1 5-3 1 24 . 1 34. Roland M , Morris R. A study of t h e natural h i s tory of back pai n : Part I : Development of a rel i able and sensit ive measure of disabi l i ty in low back pain . Spine 1 983;8: 1 4 1 - 1 44. 1 35 . Rosenfeld RM. Meaningful outcomes research. I n : I senberg S F , e d . Managed Care: Outcomes and Qual i ty. A practical guide. New York: Thieme, 1 998:99- 1 1 5 . 1 36. Rowe CR. Evaluation of the shoulder. I n : Rowe CR, ed. The Shoulder. New York, NY: Churc h i l l Livingstone, 1 987:633. 1 37 . Rozzi SL, Lephart SM, Sterner R, Kuligowski L . Balance tra i n i ng for persons with hmctionally unstable ankles. I Orthop Sp Phys Ther 1 999;29: 478-486. 1 3 8. Ruta DA, Garratl AM, Wardlaw D, Russell IT. Devel­ oping a val id and rel iable measure of health out­ come for patients with low back pai n . Spine 1 994; 1 9: 1 887- 1 896. 1 39. Scrimshaw SV, Maher C . Responsiveness o f visual analog and McG i l l pain scale measures. J Manipula­ tive Physiol Ther 200 I ;24:50 1 -504. 1 40. Smilkstein G . The fam i ly APGAR: A proposal for fam i ly function test and i ts use by physicians. I Fam Pract I 978;6: 1 2 3 1 - 1 2 3 5 .

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167

l S I . Streiner D L , Norman G R . Health measurement scales: A prac t ical guide to their development and use, 2nd ed. New York: Oxford U n i versity Press, 1 995. 1 52 . Stroud MW, McKnight PE, Jensen M P . Assessment o f sel f-reported physical act ivity in patients with chronic pai n : Development of an abbreviated Roland-Morris D isabi l i ty Scale. J Pain 2004 ; 5 : 2 5 7-263. 1 53 . Stucki G , Lian M , Fossel A, et al. Relative respon­ siveness of condition-speci fic and generic health status measures in degenerative l um bar spine stenosis. J Clin Epidemiol 1 995;48: 1 369- 1 378. 1 54 . Stucki G, Daltroy L, Liang M H , Lipson Sl, Fossel AH, Katz I N . Measurement properties of a sel f­ administered outcome measure in l u m bar spi nal stenosis. Spine 1 996; 2 1 :796-803. 1 5 5 . Tait RC, Chibnall IT, Margol is RE. Pain exten t : Relations w i t h psychological state, p a i n severity, pain h istory and disabil i ty. Pai n 1 990;4 1 : 295-30 1 . 1 56. Taylor SJ , Taylor AE, Foy MA, Fogg AJ B . Respon­ siveness of common outcome measures (or patients with l ow back pain . Spine 1 999;24: 1 805-1 8 1 2 . 1 57 . Thomas E , S i lman AJ, Croft PR, Papageorgiou AC, layson MIV, Macfarlane GJ . PI-edicting who devel­ ops chronic low back pain in primary care: A prospective study. B MJ 1 999;3 1 8 : 1 662- 1 667. 1 58 . Turk DC. E d itoria l : Here we go agai n : Outcomes, outcomes, outcomes. C l i n I Pain 1 999; 1 5 :24 1 -243.

1 4 1 . Stewart W F , Li pton R B , Simon D, et a!. Val i d i ty of an i l l ness severity measure for headache i n a popu lation sample of m igraine su fferers. Pain 1 999;79:29 1 -30 1 . 1 42 . Stratford PW , B i n kley I , Solomon P, G i l l C, Finch E. Assessing change over time i n patients with low back pai n . Physical Ther 1 994;74: 5 2 8-533.

1 59. Turner lA, Robi nson J , McCreary CPo Chronic low back pai n : Predicting response to non-surgical treatment. Arch Phys Med Rehabil 1 983 ;64: 560-563. 1 60. Turner lA, Frank l i n G, Haegerty PJ , et al. The asso­ ciation between pain and disabi lity. Pai n 2004; 1 1 2 : 307-3 1 4.

1 43. Stratford P, Gill C , Westaway M and Bi nkley J. Assessing disabi l i ty and change on i nd ividual pat ients: A report o f a patient specific measure. Physiother Can 1 995;47:258-263.

1 6 1 . Uden A, Astrom M, Bergenudd R . Pain drawings in chronic low back pai n . Spine 1 988; 1 3 :389-392.

1 44. Stratford PW, B i n kley I, Solomon P, et a!. Defining the m i nimum level of detectable change for the Roland-Morris questionnaire. Phys Ther 1 996;76:359-365. 1 45 . Stratford PW, B i nkley J . Measurement properties of the RM 1 8 : A modified version o f the Roland-Morris disabi l i ty scale. Spine 1 997;22 :24 1 6-242 1 . 1 46. Stratford PW, B i n kely J M , Riddle DL, Guyatl G H . Sensitivity t o change o f t h e Roland-Morris Back Pain Quest ionnaire: Part I . Phys Ther 1 998;78: 1 1 86- 1 1 96. 1 47. Stratford PW, Riddle DL, B i n kely JM, Spadoni G , Westaway MD, Padfield B. Using t h e Neck Disabil­ i ty I ndex to make decisions concerning i ndividual pat ients. Physiother Can 1 999;50: 1 07- 1 1 9. 1 48. Stratford PW, Bi nkley J . Applying the resul t s of sel f­ report measures to i ndividual patients: An example using the Roland-Morris Questionnaire. 1 0rthop Sports Phys Ther 1 999;29:232-239. 1 49. SU-at ford PW, B i nkley JM, Watson J , Heath-Jones T. Val idation of the LEFS on pat ients with total joint arthroplasty. Physiother Can 2000;52 :97- 1 05 . 1 50. Strat ford PW, B i nkley 1 M , StratfOl-d D M . Develop­ ment and ini tial validation of the upper extremity fu nctional index. Physiother Can 200 1 ; 5 3 : 259-266.

1 62 . Vernon HT, Mior S. The Neck Disabi l i ty I ndex: A study of reli ab i l i ty and val i d i ty. J Manipula Physiol Ther 1 99 1 ; 1 4:409-4 1 5 . 1 63 . Vernon HT, Aker P, Aramenko M , Batters h i l l D , Alepin A, Penner T. Evaluation of neck muscle strength with a modified sphygmomanometer dynamometer: Rel i a bi l i ty and val id i ty. I M a n i pula Physiol Ther 1 992; 1 5 :343-349. 1 64 . Vernon HT, Piccin i n n i I, Kopansky-Gi les D , R agino C, Fuligni S. Chiropractic rehabilitation of spinal pain patients: Principles, practices and ou tcome data. J Can C h i ropr Assoc 1 99 5 ; 39 : 1 47- 1 53 . 1 65 . Vernon H . The N e c k Disab i l i ty I ndex: Pat ient assessment and ou tcome monitoring i n whiplash. In: Allen M E, ed. M usculoskeletal Pai n Emanati ng from the Head and Neck: Current Concepts in Diag­ nosis, Management and Cost Containment. B i ng­ hamton, N Y : The Haworth Med ical Press, an i m pri n t of The Haworth Press, I nc, 1 996:905- 1 04 . 1 66. Vernon H . Correlations among rati ngs of p a i n , dis­ abi l i ty and i m pairment in chronic whi plash­ associated d isorder. Pain Res Manage 1 997;4: 207-2 1 3 . 1 67 . Vernon H . Assessment o f self-rated disab i l i ty, i mpairment, and sincerity o f effort i n whiplash­ associated d isorder. I MusculoskeI Pain 2000 ; 8 : 1 55- 1 67 .

J 68

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Part Three: Assessment

1 68 . Von Korff M , Ormel J, Keefe F, et al. Grading the severity o f chronic pain. Pain 1 992;50: 1 33-1 49. 1 69. Von Korff M, Jensen M P , Karoly P . Assessing global pain severity by self-report in clinical and healt h services researc h . Spine 2000;2 5 : 3 1 40-3 1 5 1 . .1 70 . Waddell G , M ain CJ. Assessment of severity i n low back disorders. Spine 1 984;9:204-208. .1 7 1 . Wadde l l G, Somerville D , H enderson I , Newton M . Objective clinical evaluation o f p hysical i mpair­ ment i n chronic low back pai n . Spine 1 992; 1 7: 6 1 7-62 8 . 1 72 . Ware J E , Sherbourne CD. The M O S 36-item Short Form Health Survey (SF-36). Med Care 1 992;30: 473-483 . 1 73 . Ware J r. J E , Snow K, Kosinski M , et al. SF36 physi­ cal and mental health summary scales: A user's manual. Boston , M A : The Healt h Institute, New England Medical Center, 1 993a. 1 74 . Ware JE. SF-36 Health Survey: M a nual and Inter­ pretation Guide. Boston, MA: The Health Institute, New England Medical Center, 1 993b.

1 77 . Wegener L , J(jsner C, N ichols D. Static and dynamic balance responses in persons with bilateral knee osteo­ arthritis. J Orthop Sports Phys Ther 1 997;25: 1 3- 1 8. 1 78 . Westaway M , Stratford PW, B i nkley J. The Patient Specific Functional Scale: Validation of its use in persons with neck dysfu nction. J Orthop Sports Phys Ther 1 998;27:3 3 1 -338. 1 79. Wheeler A H , Gool kasian P , Baird AC, Darden BV . Development of the neck pain and disability scale. Spine 1 999;24: 1 290- 1 294. 1 80. Williams J W Jr, Holleman DR Jr, Si mel DL. Mea­ suring shoulder function with the Shoulder Pai n and D isability Index. J Rheumatol 1 995;22 :727-732. 1 8 1 . Williams RM, Myers A M . A new approach to mea­ suring recovery i n injured workers with acute low back pain: Resumption of activities of daily living scale. Phys Ther 1 998;78 : 6 1 3-623. 1 82 . World Health Organization. I n ternational Classifi­ cation of Human Functioning, Disabil i ty and Heal t h : ICF. Geneva: WHO, 200 1 . 1 83 . Wright JG, Young N L . The patient-specific i ndex: Asking patients what they wan t . J Bone Joint Surg (Am) 1 997;79:974-983.

1 75 . Ware J r. J E , Kosinski M, Keller SD. SF- 1 2 : How to Score t he SF- 1 2 Physical the Mental Health Sum­ mary Scales. second ed. Boston, MA: The Health I nstitute, New England Medical Center, 1 995.

1 84 . Yeomans SG. The Clinical Application of Ou tcomes Assessment. Stamford, CT: Appleton & Lange, 2000.

1 76. Ware Jr. J E . SF-36 Health survey update. Spine 2000;2 3 : 3 1 30-3 1 39.

1 85 . Yeomans SG. C h i ropractic and M anaged Care. ACA/FYI, June/July 1 992:29-3 1 .

Appendix SA

GLOBAL IMPRESSION OF CHANGE Since the start of my care,my overall status is: 1 . D Very Much I mproved 2. D Much Improved 3. D Minimally I mproved 4. D No Change 5. D Minimally Worse 6. D Much Worse 7. D Very Much Worse Farra J T , Young JP, LaMoureauz L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an I I -point numerical pain rating scale. Pain 200 1 ;94: 1 49-1 5 8 . Hagg 0 , Fritzell P , Nordwall A. The clinical importance o f changes i n outcome scores after treatment for chronic low back pain. Eur Spine J 2003 ; 1 2 : 1 2-20.

Name Date

______

Signature

_ _ _ _ _ _ _ _ _ _

_ _ _ _

Form 1 (48,6 1 ) Global Impression of Change.

169

1 70

Part Three: Assessment

REVISED OSWESTRY DISABILITY QUESTIONNAIRE Name Date This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in every day life. Please answer by checking one box in each section [or the statement that best applies to you. We realize you may consider that two or more statements in any one section apply, but please just shade the spot that indicates the statement that most clearly describes your problem. _ _ _ _ _ _ _ _ _ _ _

Section 1 : Pain Intensity A. I have no pain at the moment B. The pain is very mild at the moment C. The pain is moderate at the moment D . The pain i s fairly severe a t the moment E. The pain is very severe at the moment F. The pain is the worst imaginable at the moment

Section 5: Sitting A. I can sit in any chair as long as I like B. I can only sit in my favorite chair as long as I like C. Pain prevents me silting more than one hour D. Pain prevents me [rom sitting more than 30 minutes E. Pain prevents me from silting more than 1 0 minutes F. Pain prevents me [rom sitting at all

Section 2: Personal Care (Washing, Dressing, etc.) A. I can look after myself normally without causing extra pain B. I can look after myself normally but it causes extra pain C. I t is pain[lll to look after myself and I am slow and careful D. J need some help but can manage most of my personal care E. I need help every day in most aspects of self care F. do not get dressed, wash with difficulty and stay in bed

Section 6: Standing A. I can stand as long as I want without extra pain B . I can stand as long as I want but it gives me extra pain C. Pain prevents me from standing for more than 1 hour D . Pain prevents m e from standing [or more than 30 minutes E . Pain prevents m e from standing [or more than 1 0 minutes F. Pain prevents me [Tom standing at all

Section 3: Lifting A. I can lift heavy weights without extra pain B. I can lift heavy weights but it gives me extra pain C. Pain prevents me lifting heavy weights off the noor but I can manage if they are conveniently placed, e.g., on a table D. Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positioned E. I can only li[t very light weights F. I cannot lift or carry anything

Section 7: Sleeping A. My sleep is never disturbed by pain B. My sleep is occasionally disturbed by pain C. Because of pain I have less than 6 hours sleep D . Because of pain I have less than 4 hours sleep E. Because of pain I have less than 2 hours sleep F. Pain prevents me from sleeping at all

Section 4: Walking A. Pain does not prevent me walking any distance B. Pain prevents me fTom walking more than 2 kilometers C. Pain prevents me [rom walking more than 1 kilometer D. Pain prevents me [Tom walking more than 500 meters E. 1 can only walk using a stick or crutches F. I am in bed most of the time

Section 8: Social Life A. My social life is normal and gives me no extra pain B. My social life is normal but increases the degree of pain C. Pain has no significant effect on my social life apart [Tom limiting my more energetic interests, e.g., sport D . Pain has restricted m y social li[e and I do not go out as often E . Pain has restricted my social life t o m y home F. I have no social life because o[ pain

Chapter Eight: Outcome Assessment

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1 71

REVISED OSWESTRY DISABILITY QUESTIONNAIRE (Continued) Section 9: Traveling

Section 1 0: Employment/Homemaking

A. I can l ravel anywhere wi thout pain

A. My normal homemaking/j o b activit ies do not

B . I can lravel anywhere but it gives me extra pain C. Pai n is bad but I manage journeys more t han 2 hours D. Pain restricts m e to journeys of less than 1 hour E. Pain reslricls me to short necessary journeys less lhan 30 m i nutes F. Pain preve n ts me from travel i ng except to receive treat m e n t

cause p a in . B . M y normal homemaki ng/job activi ties i ncrease my pain , b u t I can still perform all t hat i s required of me.

C. I can perform most o f my homemaki ng/job activ i t i es, b u t pain preven ts me [Tom perform­ i ng more physica l ly stressful activi t ies ( e . g . , l i ft­ i ng, vacuuming). D. P a i n prevents m e from doing any t h i ng but l ig h t duties

E. Pain prevents me [Torn d o i ng even l ig h t d u ti es F. P a i n prevents me from performing any job or homemaki ng c hores

M i n i m u m Detectable Change (90% confidence): 1 5 points M i nimum Cli nically I m portant D i fference (90% confidence ) : 6 points

Form 2 (52) Oswesll-:, Low Back Pai n D i sab i l i ty I ndex. Form reproduced with permission from Fritz 1M, I rrgang J J . A comparison o f a modified Oswesl ry Low Back Pain D isab i l i ty Questionnaire a n d t h e Quebec Back Pain D isab i l i lY Scale. P hysical Ther 2001;8 ] : 776-788.

1 72

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Part Three: Assessment

ROLAND-MORRIS LOW BACK PAIN AND DISABILITY QUESTIONNAIRE When your back h urts, you may fi n d i f d i fficult to do some of t h e t h i ngs you normally do. M ark only the sen­ tences t ha t describe you today.

1.

0

2.

0 I c h a nge posi t i o n fTequently to try and get m y back comfortable.

3.

0 I walk more slowly t han usual because o f m y back.

4.

0 Because o f my back,

I a m n o t doing any jobs t ha t

5.

0 Because o f m y back,

I use a handrail t o get upstairs.

6.

0 Because o f my b a c k , I l i e d o w n t o rest more often .

7.

0 Because of my back , I h ave to hold on to some t h i ng to get out of an easy chair.

8.

0 Because of my back, I try to get other people to do t h i ngs for me.

9.

0 I get dressed more slowly than usual because of my back.

I s tay at horne most of t h e t i me because of m y back.

I usually do around the house.

1 0 . 0 I stand up only for short periods o f time because of m y back. I I . 0 Because of my back, I try n o t to bend or kneel down. 1 2 . 0 I find it d i ffi c u l t to get o u t of a chair because of my back. 1 3 . 0 M y back i s p a i n fu l almost all of the t i m e . 1 4 . 0 I fin d i t d i fficult to t u r n over i n b e d because of my back. 1 5 . 0 My appet i te i s not very good because of my back pain . 1 6. 0 I h ave trouble p u t t i ng o n m y socks (or stock ings) because o f p a i n i n my back. 1 7 . 0 I walk o n ly s h ort d i stances because of my back pain. 1 8 . 0 I sleep l ess well because of my back. 1 9 . 0 Because of back pain, I get dressed with help from someone else. 20. 0 I sit down for most of the day because of my back. 2 1 . 0 I avo i d heavy jobs around the house because of my back. 22. 0 Because of back pain, I am more irritable and bad tempered w i t h people than usual. 23. 0 B ecause o f my back , I go upstairs more slowly than usual . 24. 0 I stay i n bed most of t h e time because of my back. Patien t name

______

Patient signature

______

Date

Form 3 ( 1 34) Roland- Morris Low B ac k P a in and D isab i l i ty Form reprinted with permission from Roland M, Morris R . A study of the natural h i s tory of back p a i n : Part I: Development of a rel iable and sensitive measure of disabil­ i ty in low-back pai n . S p i ne 1 98 3 ; 8 : 1 4 1 - 1 44 .

Chapter Eight: Outcome Assessment

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1 73

NECK PAIN DISABILITY INDEX QUESTIONNAIRE

PLEASE READ: This questionnaire is designed to enable us to understand

how much your neck pain has affected

your abi l i ty to manage your every day activi ties. Please answer each section by c i rc l i ng the ONE C HOICE that most applies to you . We realize that you may feel that more than one statement may relate to you, but PLEASE JUST CIRCLE THE ONE CHOICE THAT MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW.

SECTION I-Pain Intensity

SECTION 5-Headaches

A I have no pain at the moment.

A I h ave no headaches at a l l .

B T h e pai n is very mild a t t h e mome n t . C The pain is moderate at the moment.

B I have slight headaches w h i c h come i n frequent ly. C I have m oderate h eadaches w h i ch come

D The pain is fairly severe at t h e moment.

E The pain is very severe at the moment. F The pain is the worst i maginable at the

i n frequen tly. D I have moderate headaches w h i c h come frequently.

E I have severe headaches which come fTequently.

moment.

F I have headaches almost all t h e t i m e .

SECTION 2-Persol1al Care (Washing, Dressing, etc.)

SECTION 6-Concentration

A I can look after myse l f normally w i thou t caus-

A I c a n concentrate ful l y when I wan t to w i t h no

d ifficul ty.

ing extra pai n .

B I can look after myse l f normally, but it causes

s l i g h t d i fficulty.

extra pai n .

C I t is pai n ful to look a fter myself and

I am slow

and caref-u l . D 1 need some help, but manage most of my per-

C I have a fai r degree of d i fficulty i n concentrating when I w a n t t o . D I have a lot of d i ffi c u l ty in conce n trat i ng when I want to.

sonal care. E I need help every day in most aspects of self care.

F I do not get dressed,

B I can concentrate ful l y w hen I want to w i t h

I wash w i t h d i fficul ty, and

I stay i n bed .

E I have a great deal of d i fficulty in concen trati ng when I want t o . F I cannot concentrate at a l l .

SECTION 3-Liftil1g

SECTION 7-Work

A I can l i ft heavy weights w i t hout extra pain .

A I can do as m u c h work as I want to.

B I can l i ft heavy weights, but i t gives extra pain . C Pain prevents me fTom l i fting h eavy weights off

B I can o n ly do my usual work, b u t no more . C I can do most of my usual work, b u t no more.

the floor, but I can manage if they are conveniently positioned, for example, on a table. D Pain prevents me from l i ft i ng heavy weights,

D I cannot do my usual work.

E I can hardly do any work at a l l . F I cannot do any work at all .

but I can manage ligh t to medium weights i f they are conveniently positioned .

E I can l i ft very light weights. F I cannot l i ft or carry anything at a l l .

SECTION 4-Reading

SECTION 8-Driving

A I can read as muc h as I want to with no pain i n

A I can drive m y car w i t hout any neck pai n .

my neck.

B I can read as m uc h as I want to w i th slight pai n i n m y neck.

C

I can read as much as I want to with moderate

pain in my nec k . D I cannot read as much as I want because o f moderate pain in my neck.

E I cannot read as much as I want because of severe pai n i n my neck.

F I cannot read at a l l .

B I can drive my car as long as I want w i t h slight pain in my neck .

C I can drive my car as l o ng as I want with moderate pai n i n my neck. D I can not drive my car as long as I want because o f moderate pai n i n my neck.

E I can hardly drive at a l l because o f severe pain i n my nec k . F I cannot drive my car at a l l .

1 74

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Part Three: Assessment

NECK PAIN DISABILITY INDEX QUESTIONNAIRE (Continued)

SECTION 9-SZeeping

SECTION j O-Recreation

A I have no trouble sleeping. B My sleep is slightly disturbed ( less than 1 hour

A I am able t o engage i n all of my recreational

sleepless) .

activit i es with no neck pai n at all .

B I am able to engage in all of my recreational

e M y sleep i s m i l d l y disturbed ( 1 -2 hours sleep­

activities w i t h some pain in my neck.

e I a m able to engage in most, but not all o f my

l ess). D My sleep is moderately disturbed (2-3 hours

recreational activities because of pain in my

sleepless) .

E My sleep i s greatly d i s turbed (3-5 hours

neck. D I a m able t o engage i n a few of my recreational

sleepless) .

F M y sleep i s completely disturbed (5-7 hours )

activi ties because o f pain i n my neck.

E I c a n hardly do any recreational activities because of pain i n my neck.

F I cannot do any recreational activit ies at all. Patient name

______

Patie n t signature

______

Date

Fonn 4 ( 1 62 ) N e c k D isabi l i ty Index repri n ted w i t h permission from Vern o n H, M ior S . T h e Neck Disabi l i ty I ndex: A study o f rel iabil i ty and val i d i ty. J Manipulative P hysiol Ther 1 99 1 ; 1 4:409-4 1 5.

Chapter Eight: Outcome Assessment

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1 75

UPPER EXTREMITY FUNCTION SCALE QUESTIONNAIRE Please indicate w h i c h of the fol lowing t h i ngs you have d i fficulty in doing because of your symptoms. Circle the number that i nd icates how much d i fficulty you have with each activity.

MAJOR PROB LEM (Cannot do it at all)

NO PROBLEM J . Sleep i ng

0

1

2

3

4

5

6

7

8

9

10

2. Writing

0

1

2

3

4

5

6

7

8

9

10

3. Ope n i ng jars

0

1

2

3

4

5

6

7

8

9

10

4. Picking up small objects w i t h fi ngers

0

1

2

3

4

5

6

7

8

9

10

5 . Driving a car more than 3 0 m inutes

0

1

2

3

4

5

6

7

8

9

10

6. Opening a door

0

1

2

3

4

5

6

7

8

9

10

7 . Carry i ng m i l k j u g from t he refrigerator

0

1

2

3

4

5

6

7

8

9

10

8. Wash i ng dishes

0

1

2

3

4

5

6

7

8

9

10

COMM ENTS

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Patient name

______

Pat i e n t signature

______

Date

Form 5 ( 1 26) U pper Extremity Function Scal e reprinted with permission from Pransky G, Feuerste i n M , H i m me l s tein J , Katz I N , Vickers-Laht i M . Measuring functional outcomes i n work-related upper extre m i ty d isorders: Development and validation of the Upper E xtre m i ty Function Scal e s . J Occup E nvi ron M ed 1 997;39:

1 1 95- 1 202.

UPPER EXTREMITY FUNCTIONAL INDEX We are i n teres ted i n knowi ng wheth e r you are having any d i fficul ty at all w i t h t h e act i v i t i es l isted below because of you r upper l i mb problem for w h i c h you are currently seek i ng attention. Please c heck (.I ) an answer for each activi ty.

Today do you or would you have any difficulty at all with,

Extreme Difficulty Or Unable to Perform Activity

Activities

Quite a Bit of Difficulty

Moderate Difficulty

A Little Bit of Difficulty

No Difficulty

Any o f your usual work, household, or sc hool activities Your usual hobbies, recreat ional or sport i ng activi ties L i ft i ng a bag o f groceries to waist level Li ft i ng a bag of groceries above your head Groom i ng your h a i r Pus h i ng up on your hands ( e . g . , from bat htub or c h a i r) Preparing food (e.g. , peeli ng, c u t t i ng) D riving Vacu u m i ng, sweeping, or raking D ress i ng Doing up buttons U s i ng tools or appli ances O pe n i ng doors Cleaning Tying or lacing shoes Sleeping Launderi ng clothes (e.g., wash i ng, i ro n i ng, fol d i ng) Open i ng a jar T h rowing a ball Carrying a small sui tcase with your a ffected l i m b) P a t i e n l name: Score

_______

,/80

_______

Signature:

_______

MDC ( m i n im u m detectable c hange)

=

9 points

Date:

_ _ _ _ _ _ _

Error +/- 5 scale points

Form 6 ( 1 6) Upper E x t rem i ty Funclional Index repri n ted with permi ssion from Stratford PW, B i nkley J M , Strat ford D M . Development and i n i tial val i dation of t h e u pper extremi ty functional i ndex. Physiother Can

200 1 ; 5 3 : 2 59-2 66.

1 76

Chapter Eight: Outcome Assessment

rL

FUNCTIONAL ASSESSMENT SCALE (FAS)

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1 77

--------'

_ _ _ _ _ _ _ _ _ _ _ ---_ ---,_

Please respond to the fol lowing ques t i ons, circ li n g only one answer that best describes your abi l i ties.

1.

PAIN: How much pain do you have?

a.

No pain duri ng walking

b.

Occasional ache, does n o t s t o p y o u from walk i ng

c.

M i l d p a i n after walking a long t i me, may take aspirin

d.

Moderate pain wi t h normal walk i n g . May take medication stronger than asp i ri n or Tylenol® a fter excessive activities that cause considerable pai n .

e.

Severe pai n , but able t o walk . M ay need regular medication s t ronger t h a n aspiri n .

r.

Totally disabled w i t h pai n , unable to wal k

2.

WALKING DISTANCE: How far can you walk?

a.

U n l i m i ted d istance

b.

6 blocks 2 or 3 blocks

c. d.

I ndoors, around t h e house only

e.

Bed to c h a i r, unable to walk

3.

WALKING AIDS: How much support do you need to walk?

a.

Ko support needed to walk com fortably

b.

One cane needed for long walks

c.

O n e crutch needed m o s t o f t h e t i m e

d.

Two canes needed m o s t o f t h e t i me

e.

Two crutc hes o r walker needed m o s t of t h e t i m e

4.

STANDING: How long can you stand?

a.

Com fortable standing w i t hout support for 45 m i nutes

b.

Com fortable standing w i t hout support for 30 m i n u tes

c.

Com fortable standing w i t hout support for 1 5 m i n u tes

d.

N o t able t o stand w i t hout support for 1 5 m i nutes

5.

STAIRS: How do you climb steps?

a.

Foot over foot wi thout a banister

b.

Foot over foot with a ban i ster

c.

Using stairs w i t h banister and outside support (example: cane)

d.

Unable to c l i m b stairs

Patient name

______

Patient signatu re

______

Date

Fonn 7 ( 1 77 ) Functional Assessment Score repri n ted w i t h perm ission from Wegener L , K i s ner C , N ichols D . Static and dynam ic balance responses in persons wi t h b i l a teral knee osteoart h r i t i s . J Orthop Sports P hys Ther

1 997 ;25: 1 3- 1 8 .

LOWER EXTREMITY FUNCTIONAL SCALE We are i n terested in know i n g whether you are h aving any d i fficulty at a l l w i t h t h e ac tivit ies l isted below because or your lower l i m b problem for w h i c h you are curren tly seeking attention. Please check (.I) an answer for each activity .

Today, do you or would you have any difficulty at all withExtreme Difficulty Or Unable to Perform Activity

Activities

Quite a Bit of Difficulty

Moderate Difficulty

A Little Bit of Difficu l ty

No

Difficul ty

Any of your usual work, household, or school activities Your usual hobbies, recreational or sporti ng activi t i es G e t t i n g i n to or out o f t he bath Wal k i n g between rooms P u t t i n g on your s h oes or socks Squa t t i ng L i ft i ng an object, l i ke a bag of groceries fro m t he Aoor Perform i ng l ight act ivi t ies around your home Perform ing heavy activit i es around your h o m e Getti ng i n to or out o f a car Wal k i ng 2 blocks Wal king a m i l e Going up or down 1 0 stai rs ( approx i mately 1 R i g h t o r s tairs) Stand i ng ror 1 hour Sitting [or 1 hour R u n n i ng on even ground Run n i ng on u neven ground M a k i ng sharp turns while run n i ng fast H opping Rol l i ng over i n bed Patient name Score

______

_______

/80

Pat i e n t signature

M DC ( m i n i m um detectable change)

=

______

9 poi n ts

Date

Error +/- 5 scale points

Form 8 ( 1 6) Lower Ex tre m i ty Functional Scale repri n ted w i t h perm i ssion from B in kley J M , Stra t ford POW, L o t t SA, Riddle D L. The lower extre m i ty fun c t i onal scale ( LEFS ) : Scale developmen t , measurement propert ies, and clin ical appl icat i o n . Phys Ther 1 999;79: 37 1 -3 8 3 . 1 78

Chapter Eight: Outcome Assessment

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1 79

PATIENT SPECIFIC FUNCTIONAL AND PAIN SCALES ( PSFS) Name

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Date

_ _ _ _ _ _

Clinician: Complete a fter the h i story and before t h e physical exami nation Initial Assessment: In you r visits here we want to know what 3 activit ies i n your l i fe you are u nable to do or are having t h e m ost d i fficu l ty w i t h as a resulL o f your c h i e f prob l e m . Please l ist and score a t least 3 activi t i es you are u nable to per­ form or havi ng t he most d i fficulLy w i t h because of your c h i e f prob l e m .

Follow-up Assessment: When you were assessed on

, you told us that you had d i fficulty w i t h t h e following activities.

Please score the activities you told us previously you were unable to perform or having t h e m ost d i ffic u l ty with because or your c h i e f problem .

Patient Specific Activity Scoring scheme (Point t o one number): o 1 2 3 4 5 6 7 8 9 10 Unable to perform activity

Able to perform activity at same level as before i nj u ry or probl e m

Date and Score Activity 1. 2. 3. 4. 5. Total score = sum of activity scores divided by number of activities average score = 2 points MDC for single activity = 3 points MDC for

Fonn 9 Patient Speci fic Functional Scale repri n ted w i t h permission from Stratford P, G i l l C, Westaway M , B i nkley J . Assessing disab i l ity and change on individual patients: A report o f a patient spec i fi c measure. Physiother Can 1 995;47:258-2 63.

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Part Three: Assessment

PATIENT SATISFACTION SCALE Here are some ques t i on s about t h e t reatment you h ave been receiving. In terms of your sali sfac tion, how would you rate each of t h e fol l owing? C hoose one response on each l i ne.

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

1 . The doctor gave me enough i n form a t i o n a b o u l t h e cause o f my b a c k pain .

2. T h e doctor d i d NOT give me a c lear explanation o f t he cause of my p a i n .

3 . T h e doctor told m e w h a l t o do to prevent future back problems.

4. The doctor seemed to beli eve that m y p a i n was real .

5 . T h e doctor d i d N O T understand the concerns I had about m y back probl e m . 6 . The doctor d i d NOT seem com fortable dea l i ng with my back pai n .

7 . The doctor was NOT concerned about what happened wi t h m y pain after I l e ft the office.

8. The trea t m e n t the doctor prescribed for my back pain was effect ive.

9. The doctor seemed confident that t h e treatment she/he recom m ended would work.

1 0 . The doctor gave me a clear idea of how long it m i g h t take for my back to get better.

Patient name

_______

Patient signature

_______

Date

Form 1 0 (29) Pati e n t Satisfaction Scale reprin ted w i t h permission from Cherkin D , Deyo RA , Berg AO . Evaluation of a physician education i n t erve n t i o n to i m prove primary care for low-back pai n : II. I mpact on patients. Spine

1 99 1 ; 1 6 : 1 1 73-1 1 7 8 .

Chapter Eight: Outcome Assessment

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181

THE BACK BOURNEMOUTH QUESTIONNAIRE The fol l ow i ng scales have been designed to find out about your back pain and h o w it is affecting you. P l ease answer ALL the scales by circ li ng ONE number o n EACH scale that best describes how you feel :

1.

Over the past week, on average, how would you rate your back pai n ? Worst pain possible

No pain

o 2.

2

3

4

5

6

7

8

9

10

Over t h e past week, h o w m u c h has your back p a i n i nterfered w i t h your daily activHies ( housework, washjng, dressing, wal ki ng, c l imbing stairs, getting in/out of bed/c h air) ? U nable to perform activi ty

No i nterference

0 3.

1

2

3

4

5

6

7

8

9

10

Over t he past week, h o w much h a s your back pain i nterfered with your abi l i ty to take part i n recre­ a t ional , soc ial , and fam i l y activi ties? U nable to perform acti vi ty

No i nterference

0 4.

1

2

3

4

5

6

7

8

9

10

Over the past week, how anxious ( tense, u ptight , i rri table, d i fficulty i n concentrating/relaxing) have your been fee l i ng? Extremely anxious

Not at all anxious

0 5.

1

2

3

4

5

6

7

8

9

10

Over the past week, how depressed (down-in-the-dumps, sad, i n low spirits, pessim istic, u n h appy) have you been fee l i ng? Extremely depressed

Not at all depressed

o 6.

1

2

3

4

5

6

7

8

9

10

Over the past week, how have you felt your work (both i nside and outside the home) has affected ( or would affect) your back pai n ? Have made i t m uc h worse

Have made i t no worse

0 7.

1

2

3

4

5

6

7

8

9

10

Over t h e past week, h o w m u c h have you been able t o control (reduce/help) your back p a i n o n your own? Completely control it

o

1

Patient name

2

No control whatsoever

3

4

5

______

6

7

Patient signature

8

9

10

_______

Date

Form 1 1 (2 1 ) Bournemout h Back Questionnaire reprinted w i t h perm issi o n from Bolton J E , Breen A C . The Bournemouth Questionnaire : A short-form comprehensive outcome measure. I. Psychometric properties in back pain patients. J Manipula Physiol Ther 1 999;22: 503-5 1 0.

1 82

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Part Three: Assessment

THE NECK BOURNEMOUTH QUESTIONNAIRE The rol l ow i ng scales have been designed to find out about your back pain and how it is affect i ng you . Please answer A L L t h e scales by c i rcl i ng O NE n u m ber on EACH scale that best describes how you feel :

1.

Over the past week, on average, how would you rate your neck pai n ? No pain

Worst pain possible

o 2.

2

3

4

5

6

7

8

9

10

Over t h e pas t week, how m u c h has your neck pain i n terfered w i t h your daily activi ties ( housework, was h i ng, dress i ng, l i fting, rea d i ng, driving) ? N o i n terference

o 3.

Unable to perform activity

2

]

3

4

5

6

7

8

9

10

Over t h e past week, h o w m u c h h as your neck pain interfered w i t h your a b i l i ty t o take part i n recre­ a t i o n a l , soc i a l , and fami l y activi t i es ? N o i n terference

o 4.

1

U nable to perform activi ty

2

3

4

5

6

7

8

9

10

Over t h e past week, how anxious ( tense, u p t i g h t , irri table, d i fficulty i n concentrati ng/relaxing) have you been feel i ng? Not at all anxious

0 5.

1

2

Extremely anxious

3

4

5

6

7

8

9

]0

Over t h e past week , h o w depressed ( down-in-t he-dumps, sad, i n l o w spirits, pess i m istic, unhappy) have you been feel i ng? N o t at a l l depressed

o 6.

]

2

Extremely depressed

3

4

5

6

7

8

9

10

Over t h e past week, how have you felt your work ( b o t h i nside and outside the h o m e ) h a s a ffected ( o r would affect ) your n e c k pai n ? H ave made i t n o worse

0 7.

1

2

H ave made it much worse

3

4

5

6

8

7

9

10

Over the past week, h o w much have you been a b l e to control ( reduce/help) your neck pa in on your own? Compl etely contro l i t

o

]

Patient name

2

N o control whatsoever

3

4

5

______

6

7

P a t i e n t signature

8

9

10

_______

Date

Form 12 (22) Bournemouth Neck Quest i o n n a i re repri n ted w i t h permi ssion from Bol ton JE, H u m p h reys BK. The Bou rnemouth Quest i o n n a i re : A short-form comprehensive outcome measure. II. Psychometric propert ies i n neck pain patients. J Manipula Physiol Ther 2002;25 : 1 4 1 - 1 48 .

Assessment of Psychosocial Risk Factors of Chronicity-"Yellow Flags"

Craig Liebenson and Steven Yeomans

Introduction Risk Factors of Chronicity Phase of Care Psycho-Social and Other Factors

Learning Objectives

After reading this chapter you should be able to understand: •

Fear-Avoidance Beliefs Cervical and Upper Quarter Risk Factors

•

Assessment The Waddell Nonorganic Low Back Pain Signs Introduction The Prognostic Value of the Waddell Signs Evaluation Nonorganic Neck Pain Signs

•

•

The prognosis for acute low back pain becoming chronic What prognostic factors have been identified to predict the risk of acute back or neck pain becoming chronic How to capture a "yellow flags" score reliably and efficiently Which prognostic risk factors are amenable to intervention and what type of intervention is appropriate

Treatment for Patients with High "Yellow Flags" Scores

183

184

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Part Three: Assessment

Introduction ..

: ..

.. .

.

.. ..

I s i t possi ble to i n crease the qual ity and efficiency of care by stratirying acute or subacute pat ients i n to groups that are ei t her more or less likely to recover, and thus match them to more or less aggressive management?

It is a commonly held belief that acute low back pain (LBP) resolves within 4 to 6 weeks for most indi­ viduals (750/0-90%) (45,107). This is primarily based on insurance surveillance data concerning disability. Such an optimistic picture has led to false confidence in a passive management philosophy involving symp­ tomatic approaches (bed rest and medication) or a non-management approach of leaving it alone to let "nature run its course." However, there are two prob­ lems with this perspective. First, the view that most acute episodes resolve quickly and completely is dis­ puted by a number of studies of primary care patients (13,22,117). Second, there is a growing body of evi­ dence that it is more cost-effective to prevent chronic­ ity in those at risk for it rather than waiting to treat only those in whom it becomes fully apparent. Von Korff et al demonstrated in a non-occupa­ tional setting that after 1 month only 30% of neck and low back pain patients had achieved pain-free status, and after 1 year 50% still reported recurrent or persistent pain (117). Most recent studies show that the majority of acute episodes tend to improve rapidly, although not completely, and then run an intermittent chronic course with less severe "flare­ ups." The original episode frequently lasts for as long as 3 months-not 4 to 6 weeks-before it can even be said to have remitted (13,22). The "flare-ups," which are predictable in the majority of cases 1 year later, are mild to moderately activity-limiting and painful and lead to general dissatisfaction with the symptoms (13,2 1,22, 1 17). Thus, back problems typically run recurrent or chronic remitting courses with occasional acute self-limiting episodes. Even though only a small percentage (7%) of indi­ viduals with acute LBP have chronic unremitting pain and disability, this group accounts for the majority of the costs (11,107). More specifically, 7.4% of patients account for approximately 75% of all the costs and 85% of the disability days (50,107). Thus, identifying potential risk factors for acute pain becoming chronic has become a "holy grail" of LBP research (1). Risk Factors of Chronicity

Assessment of spine patients has traditionally focused on finding the physical cause of the pain. Imaging techniques have figured prominently in this endeavor.

Unfortunately, this has been an inefficient use of resources because of the poor specificity of this expen­ sive screening approach (4,5,7,54,57,58,64,1 1 1, 1 24). Clinical scientists have summarized that the follow­ ing measurable outcomes are representative criteria of patient recovery: pain, function (disability), well­ being, work status, and satisfaction (6,25). According to Pinchus et aI, the risk of long-term LBP-related activity limitations (disability) and work loss (partici­ pation) arises from four main sources that interact with each other (Table 9. 1 ) (94). Individual factors have been referred to as psychosocial "yellow flags" (63). "Yellow flags" are analogous to the concept of "red flags" in that they both influence the manage­ ment and prognosis of the patient. Whereas "red flags" are indications for biomedical laboratory or imaging investigations and possibly specialist referral, "yellow flags" are indications for investigating the cognitive, affective, and behavioral aspects of LBP. Most yel low flags pertain to individual or work related factors, yet the effect the treatment provider has on outcome is also important (23,99). Reis et al evaluated both the patients ' and clinicians' percep­ tions of worry, coping, limitations, expectation of pain relief, and pain interference. When evaluated individ­ ually, both patients' and clinicians' perceptions were found to predict outcome at 2, 4, 8, and 12 months. Because many patient characteristics are stable and thus non-responsive to change (such as premorbidity, high levels of depression, and catastrophizing), other risk factors that may be amenable to change such as patients' or clinicians' perceptions and expectations should receive greater attention. The influence of perception on outcom� is high­ lighted by Kalauokalani et al.'s study of 135 patients with chronic LBP who were allocated randomly to receive either massage or acupuncture (6 1 ). Patient expectations regarding the potential helpfulness of each treatment correlated more than other variables with subsequent functional outcomes as assessed at 1 0 weeks using the modified Roland Score.

Phase of Care

Because the majority of acute patients have a very good prognosis overly aggressive early management

Table 9.1 Four Main Factors that Influence Chronic Disability [from Pinchus et al (94)] • • • •

Individual Treatment provider Compensation or health care system Workplace or home environment

Chapter Nine: Assessment of Psychosocial Risk Factors of Chronicity-"Vellow Flags"

is an inefficient use of limited health care resources. However, the same cannot be said for patients who are still symptomatic in the subacute phase. Thus, the subacute phase, beginning at the end of the first month, has now been recognized as a critical period when more aggressive management strategies can potentially have a large impact on preventing chronic pain and disability and thus reducing costs (32). Frank has presented the concept of the "number needed to treat" to determine the cutoff for when it would be more efficient and cost-effective to substi­ tute more aggressive treatment for less aggressive approach. He states that it is possible to show that "the number (of individuals) needed to treat" to pre­ vent a single case fTom passing into chronicity at 6 months off work declines swiftly over the first month and then remains rather stable" (32). According to Frank, there are three distinct stages in terms of risk of an acute episode becoming chronic (Fig. 9.1)(32). In the acute stage (first 4 weeks), the risk of chronicity is low. In the subacute stage (weeks 4-12), the risk is high "ipso facto" and the survival curve suggests aggressive treatment will be cost-effective here. In the chronic stage (after 12 weeks) recovery halts. This is borne out by a recent study of worker's com­ pensation claimants, in which it was found that the most robust predictors of future status (recurrence likelihood) were preadmission health care visits and more previous back-related claims (43).

Psycho-Social and Other Factors

Do Structural or Psychologic Factors Predict Future Disabling LBP? A prospective, longi t u d i nal study of 100 subjects with mild persistent low back pai n and a predispos i t ion to disc degenerat ive disease was performed. The development of d isabling LBP over a 5-year period was strongly predicted by base l i n e psychosoci al variables (p<0 . 0001-0 . 004). S t ructural variables on both M R I and d i scography test­ ing at baseline had only weak associ at ion with back pain episodes and no association with d i s ab i l i t y or future medical care. O[ the structural fi n d i ngs measured only moderate or severe Mod i c changes o f the vertebral e n d p l a t e were weakly associated w i t h an adverse outcome. The pri m ary outcome measures at testing duri ng each 6- month in terval: •

E pisodes of serious back pain (vi sual analogue scale score o[ 6)

•

Ep isodes o f occupational d i sab i l i t y less t h an 1 week

•

E p i sodes o[ occu pational d isabi l i t y [or 1 week

100% (J)

80%

ell

S.Y ell

�

��

60%

0::::

Ql O 0>_

�� e(fJ Ql ()

Q; Cl.

40% 20%

II

III

O%""+O""rnho"""""rn�"""rn�",,,,� 15 50 35 20 40 30 25 45 o 12 weeks Time (Weeks) Since Pain Onset 3 to 4 weeks

Figure 9.1

Three-phase model of low back pain natural history ( 3 2 ) .

From Frank J W , Kerr M S , Brooker AS, et al . D isab i l i t y resul t i ng [yom occupational low back pai n . Part 2: W h at do we know about secondary prevention? Spine 1996;2 1 :2 9 18-2 929.

J 85

reported disability (Roland-Morris scale) (87). Six separate review papers of varying methodologic rigor all agreed that psychological characteristics such as coping strategies, self-efficacy beliefs, fear-avoidance behavior, and distress are examples of relevant fac­ tors than can be identified (31,55,73,76,94,114). Thus, the presence of psychosocial "yellow nags" indica­ tive of a decreased likelihood of recovery has been proposed as a technique for early identification and matched appropriate management of those with a poorer prognosis (63,77,79,81,100,118).

Psychological variables have been demonstrated to account for 26% of self-reported pain and 36% of self-

C

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(conlinued)

J 86

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Part Three: Assessment

•

Do Structural or Psychologic Factors Predict Future Disabling LBP? (Continued) • •

E p isodes of aJl back pain symptoms at least 6 months Medical visits primarily for LBP evaluation and U-eatment

CalTagee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI and psychosocial detel-minants of low back pain disability and remission: A prospective study in subjects with benign per­ sistent back pain. Spine 2005;5:24-35.

Gatchel et al. generated a statistical algorithm to iden­ tify acute patients at risk for chronic painidisability (40). By including factors such as gender, self-reported pain, and disability scores, scores on Scale 3 (hysteria) of the Minnesota Multiphasic Personality Inventory (MMPI), and workers' compensation and personal injury status, 90.7% of cases could be correctly classi­ fied as high or low risk for chronic pain/disability. The hysteria subscale of the MMPI had an odds ratio of 1.5 for predicting return to work. Thus, individuals with hjgh hysteria scores on the MMPI are 1.S-times more likely to have chronic LBP than those without such scores. The large Boeing prospective trial also found this scale was predictive of future work-related injury (3). However, this is considered to be of minimal util­ ity because it reflects personality, which is considered a trait measure that is not sensitive to change (94). Further validation of this model showed that a number of other factors also correlate with high risk (98). A less positive temperament identified with the Schedule for Nonadaptive and Adaptive Person­ ality (SNAP), high workaholism (SNAP), an avoidant coping style, and an axis I (psychiatric) disorder were found to predict with 80.8% accuracy (80% sensitivity and 81.5% specificity) whether a person was at high or low risk for chronic LBP (98). Fransen et al. also showed that early identification of risk factors can predict time off work because of back pain (33). This theoretically should lead to tar­ geted interventions to those individuals at greatest risk for future disability. It was found if workers, at the time they make their initial claim for workman's com­ pensation, report any of the following that the odds that they will still be receiving compensation 3 months laler will be significantly increased: • •

• •

a workplace unable to provide light duties on return to work

The authors concluded, "Importantly, these deter­ minants each retained significant associations with chronic occupational back pain, even when statisti­ cal adjustments were made for age, gender, and the other significant individual, psychosocial, or work­ place risk factors" (33). Schultz et al. found lhal cognitive factors were the most predictive of time off work for low back pain over a 3-month period (102). Cognitive beliefs relating to perceptions of current health, physical status, and expectations of recovery were most relevant. Another very important predictor was sciatica. The overall correct prediction rate was 77.6%. Thomas and colleagues performed a prospective study that followed 5000 asymptomatic individuals for 18 months and correlated pre-morbid and clini­ cal factors with development of chronic LBP (112). Ten percent of these individuals had LBP, with 34% of these reporting persistent, disabling LBP at 1 week, 3 months, and 12 months after onset. The premor­ bid features which correlated with persistent, dis­ abling LBP were: sex (female), age (increasing), high psychosocial distress, below average self-rated health, low level of physical activity, history of LBP, and job dissatisfaction. Each of these had a 2- to S-fold effect on the odds of being associated with persistent symptoms.

Psychological Characteristics of Acute LBP Individuals Predicts Future Distress, Pain and Impairment

Subjects:

76 acute LBP i ndividuals

Methods:

Pain Anxiety Symptoms Scale was admi nis­

tered

Results: •

The cognitive d i mension of the scale predicted future affective distress, locus of control, and pain severity

•

The escape and avoidance d imension pred i cted i m pa i rment i n activi t i es of daily l iving

Vowles KE, Zvokensky MJ, Gross RT, Sperry lA. Pain-related anxiety in the prediction or chronic low-back pain distress. J Behav Dis 2004;27:77-89.

severe radiating lower limb pain at least moderate physical disability (Oswestry) psychological distress the need to lift for at least three-fourths of the day

The episode specific factors that correlated with the development of persistent disabling LBP were the presence of widespread pain, long duration of symp­ toms before consultation, leg pain, and significant restrictions in spinal movement. Widespread pain was

Chapter Nine: Assessment of Psychosocial Risk Factors of Chronicity-uYellow Flags"

the most highly correlating item with an odds ratio of 6.4. The other factors were associated with a 2- to 5-fold increased chance of poor outcome. Only 6% of patients with a poor outcome were missed if a mini­ mum of three factors were used to identify risk!!! Shaw et aJ. showed that low back disability was related to the following problem-solving approaches: problem avoidance, lack of positive problem-solving orientation, and impulsive decision-making (104).

Fear-Avoidance Beliefs

One of the major goals of care is to reduce activity intolerances associated with pain (2,81). Thus, the cognitive association of activity with pain or anticipa­ tion of pain is an important psychological construct (14,24,95,101). In fact, the belief that an activity will be painful has been shown to be more predictive of physical performance than purely nociceptive fac­ tors (68,69). Anxious patients predict pain sooner during the performance of physical tasks such as range of motion (ROM) or straight leg raise tests (14,15,24). Council et aJ. documented substantial cor­ relations between pain expectancies and self-rated physical disability with the performance of simple motor tasks (22). It is important to distinguish those factors that are associated with chronic pain from those that predict it. For instance, Ciccione showed that depression, soma­ tization, and current pain ratings combined to explain 34% of the variance in work disability in a chronic group (15). However, these factors explained only 8% of the variance in an acute sample! More significant is the finding that pain expectancies accounted for 33% of the variance in acute subjects (P < 0.001) (15). Fritz et al. has also confirmed that initial fear-avoidance beliefs were significant predictors of subacute status at 4 weeks independent of pain intensity, physical impairment, disability, or therapy received (34,35). Thus, fear-avoidance beliefs such as pain expectancies begin in acute pain and precede other psychosocial problems that develop as acute pain becomes chronic. Linton and colleagues found that fear-avoidance beliefs were even prospectively related to the devel­ opment of acute pain and dysfunction in asympto­ matic individuals (75). Those with scores above the median had twice the risk for acute LBP (odds ratio 2.4). Catastrophizing was also evaluated, but its predictive power was more limited (odds ratio 1.5). Although numerous studies demonstrate the effec­ tiveness of cognitive-behavioral strategies (30,36,65, 74,80,95) simpler re-activation approaches may be all that is needed. Mannion reported that three differ­ ent active care approaches, none of which consisted of psychological or cognitive-behavioral approaches,

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J 87

all improved psychological variables related to self­ report of pain and disability (87). Abnormal illness behavior contributes to a slower or inadequate recovery (92,97). Patients who equate hurt with harm develop a disabling form of thinking. They develop fear-avoidance behavior that promotes deconditioning (Fig. 1.9) (8 1 ,116). It is important to identify the patient who is fearful and avoid encourag­ ing them to take on a "sick role." According to Troup (113), "If fear of pain persists, unless it is specifically recognized and treated, it leads inexorably to pain­ avoidance and thence to disuse."

Cervical and Upper Quarter Risk Factors

Tenenbaum et al. has shown that whiplash-associated disorders classification II patients with neuropsycho­ logic problems have a worse prognosis over a 3-year follow-up period (110). Confidence in 'one 's ability to work after 2 years is correlated with 3-year outcome (P < 0.0001) for neck pain caused by whiplash (91). Carroll et al. have demonstrated that high levels of pas­ sive coping are associated with disabling cervical or lumbar spine pain (10). These patients have difficulty functioning with pain, are less likely to take responsi­ bility for care, and have lower self-rated health. Macfarlane et al. performed a prospective study aimed at determining the relative contributions of psychological and work-related factors in the onset of forearm pain (82); 1953 individuals were followed­ up for 1 year and 105 (8.3%) developed forearm pain. Increased risks for forearm pain were associated with a number of factors. Psychological distress had a relative risk (RR) of 2.4 (95% confidence interval 1.5-3.8). Multiple areas of pain had a RR of 1.7 (95% confidence interval 0.95-3.0). Repetitive movements of the arm had a R R of 4.1 (95% confidence interval 1.7-10), whereas that of the wrist was 3.4 (95% con­ fidence interval 1.3-8.7). Dissatisfaction with a col­ league or supervisor support had a RR of 4.7 (95% confidence interval 2.2-10). Hill et al. recently reported that the most impor­ tant factors related to persistent neck pain were age (51-68), concomitant LBP, and regular cycling (53). Age was by far the most significant factor. Both age older than 40 and concomitant LBP were also found to be accurate predictors by Hoving et al. (56). Other authors have has reported that concomitant LBP was a significant prognostic factor for chronic neck pain (20,72,86,93). Feuerstein (29) followed acute «6 weeks from onset) cervical and upper quarter pain patients for up to 1 year to ascertain what factors were predictive of I -month, 3-month, and 12-month outcomes. The findings are summarized in Tables 9.2 and 9.3.

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Table 9.2 Risk Factors for Prolonged Cervical and Upper Quarter Pain (29) 1 month • Upper extremity co-morbidity (RR 1.58) • Pain severity (RR 1.45) • Ergonomic risk factor (RR 1.07) • Low job support (RR 1.03) • Catastrophizing pain coping style (RR 1 .54) 3 months • Pain severity (RR 10.46) • Job stress (RR 1.20) • Catastrophizing pain coping style (RR 1.98) 12 months • Number of pain treatment episodes (RR 1 .77) • Past recommendations for surgery (RR 6.43) • Catastrophizing pain coping style (RR 1.87)

Assessment

Linton reviewed psychological risk factors in back and neck pain with the objective to summarize cur­ rent knowledge concerning the role psychological factors play in the cause and development of back and neck pain (76). In doing so, 913 potentially rele­ vant articles were located and 37 studies consisting of only those with prospective designs to ensure qual­ ity. The review procedure resulted in the reporting of the main predictor variables and the outcome crite­ ria. If a statistically significant relation was deter­ mined, a plus (+) or minus (-) was used to indicate a positive or negative association, respectively. If no sta­ tistical significant relationship was found, a zero (0) was used. The conclusions include a grading system similar to that used for meta-analysis review and guidelines preparation (78). These grades include the following:

Level C: Inconclusive data exist Level D: No studies were found to meet the crite­ ria utilized Table 9.4 offers a summary of the conclusions drawn from this review of prospective studies. What follows is a list of those specific risk factors­ called "yellow flags"-for acute LBP pain becoming chronic. These have been identified primarily from an assortment of prospective longitudinal studies. Few cross-sectional studies were used as sources for the "yellow flags." They are divided into those related to symptoms, examination, psychosocial, functional, and work-related factors (Table 9.5). "Yellow flags" are primarily subjective and have a significant psycho­ social predominance. Whereas "red flags" such as cauda equina syndrome, cancer, fracture, and infec­ tion require urgent attention, further testing, and possibly specialist referral, "yellow flags" only require a shift in the focus of care. These risk factors have been reported to predict Couture chronic pain or dis­ ability in the United States (13,51,83,84), New Zealand (63,77,79), and in England (8). Subjective psychologic screening through the his­ tory taking has low sensitivity and predictive value for identifying distressed or disabled patients, thus for­ mal screening of some sort such as with a question­ naire is recommended (42,46). A 2-item screening test for depression taken [Tom the Primary Care Evalua­ tion of Mental Disorders Procedure (PRIME-MD) was found to be more accurate in screening for depressive symptoms than a physical therapist 's own subjec­ tive ratings, even for individuals with severe depres­ sion (46). Many of these factors can be captured with a simple easy-to-administer form (see appendix). Linton has suggested the ideal cutoff for consid­ ering one definitely at risk is a score of 50% or more ' or 65 or more points out of 130 points (77,79,81). •

Level A: Evidence is supported [Tom two or more good-quali ty prospective studies Level B: Evidence is supported from at least one good-quality prospective study •

Table 9.3 The Sensitivity and Specificity of Cervical and Upper Quarter Pain Predictors (29) Duration

Sensitivity

Specificity

1 month 3 months 12 months

77.4% 80.6% 80.6%

71.8% 82.4% 83.3%

•

•

At this level, the specificity is 75% (people with lower scores who are correctly predicted not to develop chronic disability) and sensitivity is 86% to 88% (people with higher scores who are correctly predicted to develop chronic disability). If the cutoff is higher, specificity may increase, even up to 88%, but sensitivity can be com­ promised down to 34%. If the cutoff is lower, sensitivity may increase to more than 90%, but specificity can be compromised down to less than 50%. Therefore, the utility of the YF screen depends on the need to know the patients who are at risk versus the need to avoid mislabeling people at risk.

Chapter Nine: Assessment of Psychosocial Risk Factors of Chronicity-"Yellow Flags"

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189

Table 9.4 Grading System for Evaluating Prospective Psychological Risk Factors of Neck and Low Back Pain Chronicity Evidence Level

Risk Factor 1. Psychosocial variables are clearly linked to the transition from acute to chronic pain disability.

Level A

2. Psychological factors are associated with reported onset of back and neck pain

Level A

3. Psychosocial variables generally have more impact than biomedical or biomechanical factors on back pain disability

Level A

4. No evidence exists to support the idea of a "pain-prone" personality link

Level D

5. Results are mixed with regard to whether personality and traits are risk factors

Level C

6. Cognitive factors (attitudes, cognitive style, fear-avoidance beliefs) are related to the development of pain and disability a. Passive coping is related to pain and disability b. Pain cognitions (e.g., catastrophizing) are related to pain and disability c. Fear-avoidance beliefs are related to pain and disability

Level A

7. Depression, anxiety, distress, and related emotions are related to pain and disability

Level A

8. Sexual ancIJor physical abuse may be related to chronic pain and disability

Level D

9. Self-perceived poor health is related to chronic pain and disability

Level A

10. Psychosocial factors may be used as predictors of the risk for developing long-term pain and disability

Level A

Reproduced wIth permIssIon fyom Lmton SJ . A revIew o f psychologIcal nsk factors m back and neck pam. Spme 2000, 9:1148-1 1 56 .

Clinical Pearl It is recommended that a screen of "yel low flags" be performed on the first visit for all spine pai n pat ien t s .

would be suitable for a more cognitive-behaviorally oriented treatment program coupled with functional rehabilitation aimed at reducing activi ty intolerances and physiologic impairments.

The Waddell Nonorganic Low

If the "yellow flags" screen is delayed, then it cer­ tainly should be performed as part of the biopsy­ chosocial re-evaluation of a patient who is not recovering satisfactorily at the 4- to 6-week mark. Many of the variables are also worthwhile outcomes of care and can be reassessed at regular intervals (every 4-6 weeks) in the same way as other outcome measurement tools such as the Oswestry or Neck Disability Index questionnaires are utilized. Two simple questionnaires, the Tampa Scale for kinesiophobia (17 items) and the fear-avoidance beliefs ( 1 6 items), were shown to have good internal consistency, test-retest reliability, and concurrent validity for assessing pain-related fear in acute LBP patients(108). All patients had LBP for no more than 4 weeks. This study demonstrates that patients can be classified early as having a psychosocial component to their pain. The implication is that such patients

Back Pain Signs

Introduction

The Waddell non-organic signs are used as objective measures for evaluating abnormal psychosocial issues in patients with low back pain (118). Contrary to the premise behind provocative orthopedic tests in which pain reproduction to identify the specific pain generator is the goal, the objective when perform­ ing the non-organic tests is to purposely not try to provoke pain. It can sometimes be difficult to dis­ criminate between patients with a physiological or organic explanation for the test response; therefore, repeating the test a few times to assure evaluator reliability is recommended. Hence, these tests must be performed and interpreted carefully, because apply­ ing the test too vigorously can result in a false-positive result.

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Table 9.S

Yellow Flags Risk Factors for Acute LBP Becoming Chronic

History and Symptoms • Duration of symptoms 4-12 weeks (112) • Sciatica (8,13,33,70,90,103,112) • History of previous episodes of back pain requiring treatment (8,13) • Severe pain intensity at 3 weeks (8); at 4 weeks (26); at 6 weeks (41); and at 8 weeks (28) • Delaying treatment at least 7 days (90,115) • Widespread pain (112) Examination • Positive straight leg raise test (8,19,66,71) • Positive neurological examination (motor, sensory, reflex) (47,66,52) • Positive range of motion (ROM) or orthopedic findings (47,52,68,109,112) • Lack of centralization of peripheral symptoms with repetitive ROM testing (123) Psychosocial • 3 or more Waddell signs of illness behavior (70,90,122); no (33) • Self-rated health as poor (10,112) [(26) at 4 weeks] • Symptom satisfaction (13) • Fear-avoidance beliefs (3 questions) [(26) at 4 weeks] (34,49,66,77-79) o belief that physical activity makes pain worse belief that if person has pain with activity they should cease the activity o belief that person with pain should not perform normal activities with pain • Anxiety (14,79,80,94) • Coping (praying, hoping, catastrophizing) (8,70) [large effect sizes (94)] • Distress/depression (22,27,77,108) [odds ratio approximately 3 and medium magnitude effect size (94)] • Poor locus of control (yes: 47,70,77-79) (no: 8,88) • Low expectation of recovery (51,77-79) • Blaming others (90) Negative family or workplace social situation (90) • • Increased number of children being cared for (47) • Anticipation of future disability or ability to return to work (51,77,78) o

Work-Related • Receiving compensation (90) • Litigation (90) • Physically demanding job (or perception of) (47,51,33) • Job dissatisfaction (3,12,13,19,112,125) (no: 77-79) • Subjective work-related ability (47) • Prior disability in the prior 12 months (77-79) • A workplace unable to provide light duties on return to work (33) • Low job control or low supervisor support (60) Functional • Light work tolerance (77-79) • Sleep (77-79,90) • At least moderate physical disability (score of 201100 or higher with the Oswestry) (33)

The Prognostic Value of the Waddell Signs

The Waddell signs for low back pain have been widely utilized because they have been reported to help iden­ tify patients with underlying significant psychologi-

cal distress (118,122). Many studies have identified non-organic behavior using the Waddell signs as pre­ dictors of suboptimal surgical and rehabilitation outcomes (16-18,27,62, 1 18, 1 19). Gaines and Heg­ mann (39) reported in LBP subjects that the presence of even only one sign delayed the median time to

Chapter Nine: Assessment of Psychosocial Risk Factors of Chronicity-"Yellow Flags"

return to work by almost four times (58.5 vs. 15 days) and was associated with an increased use of physical therapy and CT scanning. Fritz and colleagues used the non-organic signs as a screening tool to determine when it was safe to · return acute low back pain patients to work (34). The best cutoff values were two or more signs (neg­ ative likelihood ratio 0.75), three or more symp­ toms (0.62), and an index score of three or more (0.59). The authors reported that even with optimal cutoff values, none of the nonorganic tests served as effective screening tools for early identification of acute LBP patients at increased risk for delay in returning to work. Similarly, Polatin and col­ leagues reported no significant associations be­ tween Waddell total positive score or changes in score and therapeutic success as measured by any of the behavioral outcomes such as return to work in a cohort of patients with chronic, long-term low back pain (96). The relationship of Waddell signs and the Min­ nesota Multiphasic Personality Inventory (MMPI) has also been reported (89). Waddell's original article re­ ported that a low but consistent con-elation existed between non-organic physical signs and the first three MMPI scales (hypochondriasis, Hs; depression, D; hys­ teria, Hy) (118). Maruta et al. found that among male patients, MMPI scales 1 (Hs), 3 (Hy), and 8 (schizo­ phrenia, Sc) and high Waddell signs (3-5 signs) were found to correlate with statistically significance, but among the female patients, none of the first three scales con-elated, only MMPI scale 8. In a work-disabled population, non-organic signs were compared to the centralization phenomenon of McKenzie as predictors of the return to work rate (62). The authors reported that the Waddell score was more predictive of the work return outcome compared to the centralization of symptoms. In 1998, Main and Waddell (85) published a "reap­ praisal" of the way the non-organic signs should be interpreted. They stressed that isolated signs should not be over-interpreted and that multiple signs sug­ gest that the patient does not have a straightforward physical problem. Psychological factors that coexist with physical conditions may require both physical management of the structural pathology and a psy­ chosocial and behavioral management of their illness. They also stress that the signs are not by themselves, a test of credibility or faking. =

Evaluation

There are five signs that are evaluated. The presence of three out of five of these signs is significantly cor­ related with disability (l18). The signs are:

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19 1

1) Superficial or nonanatomic tenderness-wide­ spread sensitivity to light touch in the lumbar region and pain referred to other areas such as thoracic, sacrum, or pelvis. 2) Simulation-axial loading (light pressure to the skull should not significantly increase low back pain. Passive rotation of the shoulders and pelvis together in a standing patient should not repro­ duce low back pain. 3) Distractions-difference of 40 to 45 degrees between the supine and seated straight leg rais­ ing tests. 4) Regional disturbances-sensory or motor distur­ bance ("giving way") that is not neurologically correlated. 5) Overreaction-inappropriate overreaction such as guarding, limping, rubbing the affected area, bracing oneself, grimacing, or sighing are all signs of illness behavior. Because three of the five signs include two separate tests, there are a total of eight tests that make up the five Waddell signs. For those signs that include two tests, if either of the two tests is positive, a positive sign is reported. In other words, it is not necessary for both tests to be positive to result in a positive sign, but rather only one of the two tests. The final score is doc­ umented as the total number of positive signs over five (e.g., 2/5). Non-organic LBP must be considered and the psychosocial issues clinically addressed when three or more of the five signs are positive. Wernecke et al. found that these behavioral signs could be improved by a physical rehabilitation program ( 1 22). Waddell's signs were shown to be an integral com­ ponent of a broader assessment of risk for non­ return to work in chronic LBP individuals (67). The full assessment also included measurement of pain intensity, a step test, and a pseudo-strength test. If two of the four tests were positive, correct prediction of risk occurred with a positive predictive value of 0.97 and sensitivity of 0.45. Pain intensity was posi­ tive if the Numeric Rating Scale (0-10) score was 9 or 10. The step test was performed for 3 minutes and was positive if the patient stopped it prematurely (see Chapter 1 2). The pseudo-strength test involved the patient holding two 3-kg weight with straight arms against gravity for 2 minutes. The test was pos­ itive if the test was stopped prematurely. According to Waddell this examination should not be performed on acute patients (118).

1) Tenderness a) Superficial: Superficial tenderness is defined as widespread sensitivity to light touch of the skin over the lumbar spine. This is evaluated by applying light touch over the lumbar skin

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Part Three: Assessment

Figure 9.2

Waddell s ign-superfi c i al tenderness.

floor (Fig. 9.3). A modification of applying the pressure to the shoulders is suggested to avoid cervical spine symptoms.

in a manner that should NOT normally pro­ voke pain (Fig. 9.2).

b) Non-anatomic: Non-anatomic is defined as bone tenderness over a wide area, often extend­ ing to the thoracic spine, sacrum, or pelvis. This is characterized by a non-anatomical, wide area of pain, not localized to one struc­ ture or anatomical region. 2) Simulation

b) Trunk rotation: do not turn the shoulders more than the pelvis when trunk rotation is applied (Fig. 9.4). 3) Distraction: Sitting Versus Supine Straight Leg Raise (SLR) •

a) Axial compression: apply light downward pressure on the head in the direction of the

Figure 9.3

Sitting distracted SLR (simultaneous testing of the plantar reflex) and supine undistracted SLR (Figs. 9.5A and B)

Waddell sign-s i mu l aLion, axial compression.

Chapter Nine: Assessment of Psychosocial Risk Factors of Chronicity-"Yellow Flags"

Figure 9.4 (A)

and

(B) Waddell

4) Regional Disturbance a) Motor (Fig. 9.6A)

b) Sensory (Fig. 9.6B)

193

sign-si mulation, tnll1k rotation.

More lhan a 40-degree difference was defined as significant This is somelimes referred lo as a positive "flip" sign as lhe palient is "flipped" from supine to sit­ ting (or vise versa). •

--

Positive test: non-analomical neurological loss and/or inconsislency on repeated testing • Findings may include (bul are nol limiled to): breakaway weakness, multiple weakness in an extremity (n.de oUl pain­ induced vs. fear-induced weakness), global or patchy altered sensory findings 5) Exaggeration/overreaction

Figure 9.5 (A)

•

and

(B) Waddell

versus supine straight leg raise.

sign-d i strac t i on: s i l t i ng

194

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Part Three: Assessment

Figure 9.6 (A) Waddell sign-regional d i sturbance, m otor. (B) Waddell sign-regional d isturbance, sensory.

This sign includes an inappropriate response at any time during the entire physical examination when exaggeration, overreaction, or a disproportionate response such as a tremor, outcry, or collapse occurs (Fig. 9.7). A list of descriplors includes the following: • • •

•

•

Assisted movemenl (cane, walker, furniture) Rigid or slow movement Bracing: both limbs supporting weight while seated Rubbing the affected area for more than 3 seconds Clutching, grasping affected area for more lhan 3 seconds

•

Grimacing

•

Sighing with shoulders rising and falling

Nonorganic Neck Pain Signs

Sobel and colleagues developed and assessed the reli­ abililY of a group of non-organic signs applicable to neck pain palients (l06). Twenty-six consecutive patients wilh neck pain histories of more than 4 months were evaluated by two health care providers for the presence of cervical nonorganic signs. As pat­ lerned after the low back pain signs of Waddell, the five signs consist of seven tests as follows:

Figure 9.7

Waddell sign-exaggeration/over-reaction .

Chapter Nine: Assessment of Psychosocial Risk Factors of Chronicity-"Vellow Flags"

1.

Tenderness a.

Superficial: patient reports pain with light touch or pinching

h. Non-anatomical: widespread tenderness out­ side of the cervical/upper thoracic .region to deep palpation

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195

Weaver et al. reported that Waddell signs are an efficient way to identify chronic LBP patients that may be either depressed or anxious (121). The study also suggested that the presence of even just two signs is correlated with more depressive and anxiety symptoms.

2. Simulation Rotation of the head/shoulders/trunklpelvis while standing

3. Range of motion Patient rotates neck right and left as far as possi­ ble (positive if >50% deficit in either direction)

4. Regional disturbance a.

Sensory loss: light touch or pinprick decrease that is non-anatomical

h. Motor loss: manual muscle testing with non­ anatomical weakness with "giveway weak­ ness" or observed normal strength but weakness when formal tests are performed 5. Overreaction At any time during the examination, any of the following are observed: •

•

•

Moderate to extremely stiff, rigid, or slow movements Rubbing the affected area for more than 3 seconds Clutching, grasping, or squeezing the area for more than 3 seconds

•

Grimacing because of pain

•

Sighing

•

Disproportionate verbalization

•

Muscle tension

The percent of agreement between the two raters ranged between 68% and 1 00% with simulation (seated test) being the lowest (68%) and regional sen­ sory disturbance being the highest ( 1 00%). The aver­ age agreement was 84.6% and the kappa coefficients ranged from 1.00 to 0.16. As the number of positive signs increased, so did the percentage of agreement. This ranged from 77% agreement with a kappa of 0.44 for one sign to 92% agreement (kappa 0.76 for five signs). The test is considered positive if three of five signs are present (106). Similar to Waddell in his description of the low back pain tests, the authors discussed the importance of care being taken when assessing for over-reaction. This is because over-reaction is very subjective given the cultural variations in response to painful maneu­ vers as well as the evaluator's own emotional feelings about the patient.

Treatment for Patients with High "Yellow Flags" Scores

The results of the "yellow flags" scoring instrument should be used for three purposes: first, to make an informed comment on prognosis; second, to steer care toward the most appropriate interventions; and third, to document patient progress with reli­ able outcomes. A patient with a high "yellow flags" score is either experiencing abnormal illness behavior or is at risk for this. Management should be oriented toward reducing dependency on medication and other pas­ sive forms of treatment and encourage the develop­ ment of self-treatment skills. Such a patient is at increased risk for treatment failure with medica­ tion, manipulation, exercise, and surgery unless a biobehavorial approach is used. In certain cases, spe­ cialist referral for behavorial medicine counseling regarding affective and cognitive issues is required. It is important to realize that "yellow flags" are not the patient's fault, but they suggest management strategies need to be altered to maximize the likeli­ hood of recovery (see Chapters 14 and 31). Treatments incorporating cognitive-behavioral strategies have been shown to be effective for acute, subacute, and chronic patients (see Chapter 1) (44, 81). Chronically disabled workers have been shown to respond to a light multidisciplinary program that incorporated exercise, activity modification, and fear-avoidance beliefs advice (37,38,48,105). Work­ ers with poor prognoses because of the presence of substantial psychosocial "yellow flags" have responded to extensive multidisciplinary programs that incorporate a structured cognitive-behavioral approach (48,105). A mainstay of these approaches was that return to activity was quota-based, rather than being contingent on absence of symptoms. Such graded activity or "graded exposures" is per­ formed for a specific duration or frequency inde­ pendent of symptoms. Another aspect of successful programs is the emphasis on reduction of back-related worry. Re­ activation advice included reassurance regarding the safety of gradually resuming activities. These approaches de-emphasize labels suggesting a purely biomedical diagnosis such as herniated disc, arthri­ tis, or injury as the sole cause of pain.

J 96

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Part Three: Assessment

Patient Beliefs About the Nature and Treatment of Their Pain can Change with Cognitive-Behavioral Therapy

Audit Process

Self-Check of the Chapter's Learning Objectives •

Patients w i t h c hronic L B P who bel ieved their pain was caused by structural pathology had more d i sabil i ty at basel i ne and demonstrated greater reductions in dis­

What is the prognosis for acute low back pain becoming chronic?

•

What prognostic factors can be used to predi c t t h e r i s k o f acute back or n e c k pain becoming c h ronic?

abi l i lY after a cognitive-behavioral i ntervention. In a l l palients, a s biomedical/pathology beliefs were reduced, reported d i sab i l i ty also decreased. Walsh DA, Radcli ffe Je. Pain beliefs and perceived physical disability of patients with chronic low back pain. Pain 2002;

o

Symptom factors

o

Physical exa m ination factors

o

Psychosocial factors

o

Work-related factors

o

Functional factors

97:23-3 1 .

• CONCLUSION The acute phase of patient care is best served by a minimalist approach. Either excessive diagnostic testing or treatment can be iatrogenic (32). But waiting for pain to become chronic before institut­ ing more aggressive measures is also ineffectual because it is easier to prevent than to treat chronic pain. The key time frame for more focused aggres­ sive management is between 4 and 12 weeks. In particular, those with "yellow flags" should be more aggressively managed as early as possible. The I -month mark may appear to be a reasonable "deci­ sion point" for such evaluation (if it has not already occurred). The "yellow flags" screen is the ideal re-evaluation tool for a patient not recovering as well as hoped for. It adds little if anything to the cost of the re-evaluation modality of choice-advanced imaging (magnetic res­ onance imaging)-and is much more likely to reveal clinically useful information that can guide care (9). A positive "yellow flags" screen does not necessitate cognitive-behavioral therapy (87). But at a minimum, care must shift from primarily passive to active ap­ proaches. When these fail, then psychosocial coun­ seling, specifically cognitive-behavioral therapy, is indicated not necessarily because these issues caused acute pain, but because they are interfering with the normal recovery process (78). Framing patient care in this manner takes away the stigma associated with the determination that psychological factors are clin­ ically relevant. Pain is always a "mind-body" problem. Although physical factors may be involved in the condition's cause, once pain becomes persistent, frustration and even anger are normal reactions. Evaluating "yellow flags" is part of the biopsychosocial approach to man­ aging activity limiting disorders of the spine. It is easy to incorporate into management pathways and will allow customization of appropriate care to each indi­ vidual patient.

•

Have a few p at i ents fill out the "ye llow flags" questionnaire and score it.

•

o

Was i t a n administrative challenge?

o

Do certain items o n the questionnaire stand out?

Wou l d your "report of findings" be d i fferent for a patient w i t h a high level of fear-avoidance beliefs t ha n someone without these?

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B igos SJ, Battie M C , Spengler D M, et al. A prospec­ tive study of work perceptions: Psychosocial factors affect i ng the report of back i njury. Spine 1991; 1 6: 1-6.

4.

Boden S D , Davis DO, D ina TS, et a l . Abnormal mag­ netic-resonance scans of the lumbar spine i n asymptomatic subjects. J B o n e Joi nt Surg [Am] 1990; 72:403.

5 . Boden S D , McCowin PR, Davis Do, Dina TS, Mark AS, Wiesel S . Abnormal magnetic-resonance scans of the cervical spine in asymptomat ic subjects. J Bone Joint Surg 1990; 7 2 A : 1178-1184. 6 . Bombardier C . Outcome assessments i n the evalua­ t i o n o f treatment o f spi n a l d isorders: Sum mary and general recom mendations. Spine 2000; 2 5 : 3 100-3103. 7.

Brandt-Zawadzki MN, Jensen MC, Obuchowski N, et al . I nterobserver and i ntraobserver variabil ity i n i nterpretation of l umbar disc abnormalities: A com­ parison Q f two nomenclatures. Spine 1995;20: 12 57- 1 2 6 3 .

8 . B u r t o n AK., T i llotson K , M a i n C , Hollis M . Psycho­ soc i a l predictors o f outcome in acute and sub-acute low back trouble. Spine 1995 ; 2 0 : 7 2 2-72 8 . 9 . Carragee EJ , A l a m i n TF, M i l ler J L , Carragee J M . D i scograp h i c , M R I a n d psychosoci a l determi nants

Chapter Nine: Assessment of Psychosocial Risk Factors of Chronicity-"Yellow Flags"

o r low back pain disab i l i ty a n d rem i ssion: A prospective study in subjects with benign persistent back pai n . Spine J 200 5 ; 5 :24-3 5 . 10. Carroll L , M ercado A C , Cassi dy J D , Cote P . A population-based study of factors associ ated w i t h combi nations o f active a n d passive coping w i t h neck a n d l ow back pa i n . J R e h a b i l M ed 2002 ; 3 4 : 67-7 2 . 1 1. Cats-Baril WL, Frymoyer J W . Demographic factors associated w i t h the prevalence of disabi l i ty in t h e general popu lation: Analysis of the N HA N ES I data­ base. Spine 1 99 1 ; 1 6:67 1 -674.

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25 . Deyo RA, Battie M, Beurskens AJ, et al. Outcome measures for low back pain researc h . Spine 1998;23:2003-20 1 3 . 26. Dionne C E , Koepsell TD, Von Korff M et a ! . Pred ict­ i ng long-term functional l i m i tations amount back pain pat ients in primary care set t ings. J C l i n Epi­ demioI 1 997 ; 3 0:31-43. 27.

Dzioba RE, Doxey N C . A prospective i nvestigation i n t o t he orthopedic a n d psyc hologic pl-ed ictors o r outcome of fi r s t l u m ba r surgery following i ndustrial i nj ury. Spine 1 984; 9:6 1 4-623 .

1 2. Cats-Baril WL, Frymoyer JW. I d e n t i fying pat i e n ts a t risk of becom i ng disabled because of low-back pai n . T h e Vermont Rehab i l i tation E ngi neering Center predictive mode l . Spi ne 1 99 1 ; 16:605-607.

28. Epping-Jordan J E , WahJgren D R , W i l l iams RA, et a l . Tran s i t i o n t o c h ronic p a i n i n men w i t h low-back pain : Pred ictive rel a t i o ns h i ps among pain i n tensity, d i sabi l i ty, and depressive symptoms. H ea l t h Psy­ chol 1998 ; 1 7 :42 1 -4 2 7 .

13. Cherkin D C , Deyo RA , Street JH, Barlow W . Pre­ d i c t i ng poor outcomes for back pain seen i n pri­ mary care using patien ts' own criteria. Spine 1 996 ; 21:2900-2907.

29. Feuerstein M , H u a n g G D , M i l ler J , H a u f l e r AJ. Devel­ opment of a screen for predi c t i ng c l i n i cal outcomes i n patients w i t h work-related upper extremity dis­ orders. J Occup Environ Med 2000;42:749-76 1 .

14. Ciccione DS, Just N. Pain expectancy and work dis­ ability in paLients with acute and chronic pain: A test or the fear avoidance hypothesis. J Pain 2001;2: 18 1 - 1 94.

3 0 . Fordyce W E , Brochway JA, Bergman J A , et a l . Acute back pain : A control-group com parison of behavioral vs. traditional management met hods. J Behav Med 1 98 6 ; 9: 1 27 .

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3 1 . Frank J , Si nclair S, Hogg-Johnson S, e t a l . Prevent­ i n g disabi l i ty from work-related low-back pai n . New evidence gives new hope-if w e can just get a l l the p layers onside . Can Med Assoc J 1 998 ; 158: 1625- 1 63 1.

1 6 . Connally G H , Sanders S H . Pred i c t i n g low back pain patients' response to l u m bar sympathetic nerve blocks and i n terdisc i p l i nary rehabi l itation: The role of pretreatment overt pain behavior and cogn i tive coping strategies. Pain 1991 ;44: 1 39- 1 46 . 1 7 . Cooke C , Menard M R, Beach G N , Locke SR, H irsch G H . Serial l u m bar dynamometry i n low back pai n . Spine 1 992; 17:653-662. 18 . Cooke C , Dusik LA, Menard M R , Fairburn S M , Feach G N . Relations h i p of performance on t h e E RGOS work s i m ulator t o i l l ness behavior i n a workers' compensation popu lation w i t h low back versus l i m b i njury. J Occup Med 1994 ; 3 6 :7 5 7-762. 19. Coste J , Delecoeu i l lerie G , Cohen D E , Lara A , Le Parc J M , Paolaggi J. C l i n ical course and prognostic ractors i n acute low back pai n : An i nception cohort study i n primary care practice. BMJ 1994 ; 3 0 8 : 577-580.

32. Frank JW, Kerr M S, Brooker AS, et a l . D isabi l i ty resu l t i ng from occupational low back pain. Part 2: What do we know about secondary p revention? Spine 1996 ; 2 1 :29 1 8-2929. 3 3 . Fransen M, Woodward M , N o rton R, Coggan C , Dawe M , Sheridan N . Risk factors associated with the tran s i t i o n from acute t o c h ronic occupational back pai n . Spine 2002;27:92-98. 3 4 . Fritz J M , Wainner RS, H i cks G E . The use of non­ organic signs a n d symptoms as a screen i n g tool ror return-to-work in patients w i t h acute low back pa i n . Spine 2000; 25 : 1 925-193 1 . 3 5 . Fri tz J M , George SZ, D e l i t to A . The role of fear­ avoi dance bel iefs in acute low back pain: Relat ion­ sh ips with curre n t and futUl-e disabi l i ty and work status. P a i n 200 1 ; 94:7- 1 5 .

20. Cote P , Cassidy JD, Carroll L . The factors associated with neck pain and its related disab i l i ty in the Saskatchewan popu l a t i o n . Spine 2000;25: 1109-1117 .

36. Frost H , Lamb S E , Shackleton C H . A fu nctional restoration program for chronic low back p ai n : A prospective outcome study. Physiot her 2000 ; 86 : 285-293.

2 1 . Cou ncil JR, Ahern D K , Fol l ick MJ, K l i n e C L . Expectancies and fu nctional i m pairment i n chronic low back pai n . Pain 198 8 ; 3 3 :323-3 3 1 .

37. Frost H , Lamb S, Klaber M o ffet t JA, Faribank J CT, Moser JS. A fi tness program for pat ients with chro n i c low back pain: Two-year follow-up o f a ran­ dom i zed controlled trial . Pain 1998 ; 7 5 :273-279.

22. Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E , Silman AJ . Outcome of low back pain in general pracLice: A prospective study. BMJ 1 998 ; 3 1 6 : 1 3 56- 1 359. 23. Croft PR, Papageorgiou AC, Feny S, et al. Psycho­ logic distress and low back pai n . Evidence from a prospect ive study i n t he general popul a t i o n . Spine 1 995 ;20:27 3 1-273 7 . 24. Crombez G , Vlaeyen J W , Heuts P H , e t al . Pain­ related fear is more disabli ng than pain i tself: Evi­ dence on the role of pain-related fear i n chronic back pai n disabil i ty. Pain 1999;80:3 29-3 39.

3 8 . Frost H , Klaber M o ffett JA, M oser JS, Fari bank J CT . Randomized controlled trial for evaluation or fitness programmed for p at i e n ts w i t h c h ro n i c low back pai n . Br Med J 1 995 ; 3 1 0:151- 1 54 . 3 9 . G a ines WG, Hegmann KT. E ffec t iveness o f Wad­ dell's nonorganic signs in pred i c t i n g a delayed return to regular work in patients experie n c i ng acute occupational low back pai n . Spine 1999;24: 3 96-40 1 . 40. Gatchel R J , Polatin P B , M ayer TG. The dom inant role of psychosocial risk factors i n the development

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of c h ro n i c low back pain d i sabi l i ty. Spine 1995;20: 2702-2709. 4 1 . Gatchel R. Pol a t i n PB, K i n ney RK. Pred i c t i n g out­ come of c h ronic bac k pain u s i ng c l i n i ca l predictors of psychopathology: A prospective analysis. Health Psychol 1 995 ; 14 :415-420. 42. G I'evitt M, Pande K , O'Dowd J, Webb J . D o fi l'st i m pressions cou n t ? A com parison of subject i ve and psychologic assessment o f spi nal patients. Eur Spine J 1998;7:218-223 . 4 3 . G ross D P, B a t t i e M e . Pred i c t i n g t i mely recovery and recun'ence fol l ow i n g m u l t i d i s c i p l inary rehab i l i ­ tation in patients with c o m pensated low back pai n . Spine 2005 ; 3 0 :23 5-240. 44. Guzman J , E s m a i l R, Karjalai nen K, M a l m i vaara A, I rvin E , Bom bard ie r e. M u l t i d i sc i p l i nary bio, psycho,soc ial rehabil it a t i o n for c h ro n i c low back pain ( Cochrane Review). In: Cochrane L i brary, Issue 2. Oxford: U pdate Software, 200 3 . 4 5 . Hadle l' N M . Regional b a c k pai n . N Engl J M ed 1986 ; 3 1 5 :1090-1092. 46. Haggman S, Maher CG, Refshauge K M . Scree n i n g for symptoms o[ depression by physical t h erapists manag i ng low back pai n . Phys Ther 2004 ; 8 4 : 1 1 57-1166. 47.

Haldorsen E M H , I n h a l h l A, U rs i n H. Pat ients w i t h low-back pain n o t returning t o work. A 1 2-month fo l l ow,up s tudy. Spine 1998 ;23: 1 202- 1 20 8 .

4 8 . Haldorsen E M H , Grasada A L , Skouen JS, e t a l . I s t here a r i g h t treatment for a particular patient group? Com parison o f ord i na ry t rea t m e n t , l i g h t m u l t i d i sc i p l i nary trea t m e n t , and extensive m u l t i ­ d i s c i p l i nary treatment For l o ng,ternl s i ck-l isted e m ployees w i t h m usculoskeletal p a i n . P a i n 2002:95:49-63 . 49.

Hasenbring M, M arienfeld G, Kuhlendahl D, Soyka D. Risk Factors of c hron i c i ty in l u m ba r d i sc patients: A prospective i nvestigation of b i ologi c , psyc hologi c , a n d social predictors of therapy out­ come. Spine 1994; 1 9:2759-2765.

5 0 . Hashemi L, Webster B S , C lancy EA, Vol i n n E. Length o f d i sab i l i ty and cost of workers' compensa, tion l ow back pain c l a i m s . J Occup E nviron Med 1998 ;40:26 1 -269. 51.

52.

Hazard RG, Haugh L D , Reid S, Preble J B , MacDon, aid L . Early pred iction of c h ronic disab i l i ty after occupational low back i nj u ry. S p i ne 1996 ;2 1 : 945-951. H e l l s i ng AL, Linton SJ , Kalvemark M. A prospective study of patients w i t h acute bac k and neck pain in Swede n . Phys Ther 1 994;74:116- 1 28 .

5 3 . H i l l J , Lewis M , Papageorgiou AC, D ziedzic K, Croft P . Pred icting persistent neck pai n . Spi ne 2004;29: 1 648- 1 65 4 . 54. H i tsel berger W E , W i tten R M . Abnormal myelo, grams i n asym ptomatic patients. J Neurosurg 1 96 8 ; 28:204. 55.

Hoogendoorn WE, van Poppel M N , Bongers P M , e t a l . Systematic review o f psychosocial [actors a t work a n d private l i fe a s risk factors for bac k pai n . S p i n e 2000 ;25:2 1 14-2125.

56. Hoving J L, de Vet HCW, Twisk JWR, et a l . Prognos, tic factors for neck pain in general practice. Pain 2004; 110:639-64 5 .

5 7 . Jarv i k JG, Deyo R A . I magi ng o[ l u m bar i n telverte­ bral d isc degeneration and aging, exclu d i ng d i sc herniations. Radiol C l i n North Am 2000; 3 8 : 1 255-1266. 58. Jensel MC, Brant-Zawadzki M N, Obuchowki N, e t al. M agnetic resonance i m agi ng of the l u m bar sp i ne i n people wi thout back pa i n . N Engl J Med 1994 ;2:69. 59. Junge A, Dvorak J, Ahern S . Pred i ctors o[ bad and good outcomes o f l u m bar d i sc surgery: A prospec­ tive c l i n i ca l study wi t h recommendations for screen i n g to avoid bad outcomes. Spine 1 995 ;20: 4600-4608. 60. Kai l a-Kangas L, Kivi maki M, R i i h i m aki H, Luukko­ nen R , K i rjonen J , Leino-Arjas P. Psychosocial fac­ tors at work as predictors of hospital ization for back d isorders. A 28-year fo l lovHlp of industrial e m p l oyees. Spine 2004;29: 1823-1830. 61. Kalauokalani D , Cherk i n DC, Sherman KJ, et a l . Patient expec tations a n d treatment e ffects: Lessons [Tom a trial o f acupuncture and massage for low back pai n . Spine 2001;26: 1 4 18-1424. 62. Karas R , M cIntosh G, H a l l H, Wi lson L, Melles T. The relationsh i p between nonorganic signs and cen­ trali zation o f sym ptoms in t he prediction o f return to work [or patients w i t h low back pai n . Phys Ther 1 997;77:3 54-368. 63. Kendall , NAS, L i nton, SJ, M ai n, CJ . Guide to assess­ ing psychosocial yel low flags i n acute low back pai n: Risk factors [or long-term d i sab i l i ty and work loss. Wel l i ngton, NZ: Accident Rehabi l i tation & Compensat i o n I nsurance Corporation of New Zealand and the N at i onal Heal t h Co m m i t tee, 1 997: 1 -22. 64. Kendrick D , Fielding K, Ben t l er E , Kerslake R , M i l ­ l Ier P, Pringle M . Radiography of t h e l u m bar spine in prim ary care patients with low back pain: Ran­ d o m i zed controlled trial. BMJ 2001;3 22:400-405. 6 5 . KJaber M o ffet J , Torgerson D , Bell-Syer S, et a l . A rando m i zed tl"ial of exercise for pl"imary care back pain patients: C l i n ical outcomes, costs, and prefer, ences. Br Med J 1 999;3 1 9:279-28 3 . 66. KJenerman L, Slade P, Stan ley I , et a l . T h e predic­ t i o n o f c h ro n i c i ty in pat ients w i t h an acute at tack of low back pain in a general practice setti ng. Spine 1 995 ;20:4 78-484. 67. Kook JP, Oesch PR, De Bie RA. P red ict ive tests for non-return to work in patients w i t h c h ronic low back pai n . Eur Spine J 2002; 1 1 :258-266. 6 8 . Lackner J M , Carose l l a A M . The relative i n O uence of perceived pain contro l , anxiety, and functional sel f, efficacy on spinal fu nction among patients w i t h c h ro n i c l o w back pai n . S p i n e 1999;24:2254-2261. 69. Lackner J M , Carose l l a AM, Feuerstein M. Pain expectancies, p a i n, and f·u n c t ional sel f,efficacy expectancies as determ i nants o f d i sab i l i ty i n pat ients w i t h c h ronic low back d i sorders. J Consu l t C l i n Psych 1 996 ;64:212-220. 70.

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7 1 . Lan ier D C , Stockton P. C l i n i cal p l'ed ictors of out, come o f acute epi sodes of low-back pai n . J Fam Pract 1 988;27 : 4 8 3-489.

Chapter Nine: Assessment of Psychosocial Risk Factors of Chronicity-"Yellow Flags"

72. Lei n o P, Magni G. Depressive and d i s tress symp­ toms as pred ict ors of low back p a i n , neck-shoulder pai n , and ot her musculoskeletal morbidi ty: A 1O-year fol low-up of metal i n d ustry employees. Pain 1 993 ; 5 3 : 89-94. 73. Liebenson CS, Yeomans SG. Yellow Fh;lgs: Early iden t i ficat ion of risk factors of c h ron icity in acute patients. J Rehabil Ou tcomes Meas 2000;4:31-40. 74.

Lindstrom A, Ohlund C, Eek C , et al. Activation of subacute low back pat ients. Phys Ther 1992;4: 279-293.

7 5 . Linton SJ , Buer N , Vlaeyen J , Hel l s i ng AL. Are fear­ avoidance be l i efs related to a new episode of back pa i n ? A prospective study. Psychol Heal t h 2000; 1 4: 1051- 1 059. 76. L i n ton SJ. A review o f psyc hological risk factors i n back and neck pai n . Spine 2000;9: I 1 48- 1 1 5 6 . 7 7 . L i n ton SJ, Hal lden B H . C a n w e screen for problem­ atic back pa i n ? A scree n i ng quest i o n n a i re for pre­ d i c t i n g outcome in acute and subacute back pai n . C l i n J Pai n 1998 ; 14: 1 -7 . 7 8 . L i n ton S J , An dersson T. Can chronic d i sab i l i ty be preven ted? A random i zed trial o f a cogn i t ive­ behavioral i n tervention for spi nal pain patien ts. Spi ne 2000 ;25:2825-283 1 . 79. L i n ton SJ, H a l l den K. Risk factors and t h e natura l course of acute and recurren t musculoskeletal pai n : Devel oping a scree n i ng i nstrument. I n : Jensen TS, Turner JA, Wiesenfe ld-H a l l i n Z, eds. Proceed i ngs of the 8th World Congress on Pai n , P rogress i n P a i n Research and Managemen t , Vol 8. Seattle: I A S P Press, 1 997 .

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80. L i n ton SL, H e l l s i n g AL, Andersson D. A con trolled study of the effects of an early act ive i ntervention on acute musculoskeletal pain problems. Pain 1993 ;54:3 53-359.

96. Pol a t i n P B , Cox B , Gatchel R J , Mayer T G . A prospective study of Waddell Signs in patien ts with c h ro ni c low back pai n : When t hey may not be pre­ dict ive. Spine 1997 ; 22 : 16 1 8-16 2 1 .

81. L i n ton SL. New avenues for the preve n t ion of chronic musculoskeletal pain and disabi l i ty. Amsterdam: Elsevier, 2002.

97. Poller R , Jones J M . The evol u t i o n of chro n i c pain among patients with muscul oskeletal problems: A p i l low s tudy i n p r i m ary care. Br J Gen Pract 1 992;42:462-464.

82. Mac farl ane GJ, H u n t 1 M , S i l m a n AJ . Role of mechan ical and psyc hosocial factors i n the onset of forearm pai n : prospect ive populat ion based study. B M J 2000;321:676-679. 83.

Magni G , M oreschi C , Rigat t i - L uc h i n i S, Merskey H. Prospect i ve study on the relationship between depressive sym ptoms and c h ron i c musculoskeletal pai n . Pain 1994 ; 5 6 :289-297 .

84. Magni G, Marc h i l l i M , Moresc h i C, Mers key H , Luch i n i SR. C h ron ic m usculoskeletal p a i n and depressive sym ptoms i n the National Hea l t h and Nutrition Exam i n a t i o n : 1 . Epidemiolog ical follow­ u p study. Pain 1 993 ; 5 3 : 16 1 - 1 68 . 8 5 . Mai n C J , Waddell G . Behavioral responses to exam­ i nation: a reappraisal of the i nterpretation of "nonorgan i c signs." Spine 1 998 ;23:2367-23 7 1 . 86. Makela M , H e l i ovaara M , Sievers K, I m pivaara 0, Knekt P, Aromaa A . Prevalence, determ i n a n ts, and consequences of c h ron ic neck pain in Fi n l a n d . Am J Epidem iol 1991; 1 34: 13 5 6-1367. 87. Mannion AF, J unge A , Taimela S, M u n tener M, Lorenzo K, Dvorak J. Active t herapy for chro n i c low back pai n . Part 3 . Factors i n n uencing self-rated d i s­ abi l i ty and i ts change fol l owing therapy. Spine 2001;26:920-929.

98 . P u l l i a m CB, Gatchel RJ , Gardea M A . Psychosocial d i fferences i n h igh risk versus low risk ac u te low­ back p a i n patients. J Occu pat Rehab 200 I ; 1 1:43-52. 99. Reis S, Herm o n i D , Borkan J, et al. The RAM BAM-Israel i Senti nel Prac t i ce Network The LBP Pat ien t Pel-cept i o n Scale. A new pred ictor o f c h ro n i c i ty and o t h e r episode outco mes among pri­ mal-y care pat i e n t s . (In Preparation ) . 1 00. Royal Col lege o f Ge neral Prac t i t i o n e rs ( R C G P ) . T h e deve l o p m e n t a n d i m p l e m e n t a t i o n o f c l i n ical g u i del i n es. Report o f the C l i n i cal G u i del i n es WOI-k i ng G ro u p . London: Royal C o l l ege of General P I-ac t i t i o n ers , 1995 : 1 -3 1. 10 1 . Royal Col lege of General Prac t i t i oners ( RC G P ) . C l i n ical G u i de l i nes for t h e M a nage m e n t o f Acute Low Back P a i n . London , Royal C o l l ege o f General Prac t i t i o n el-s (www . rcgp.org . u k ) , 1999. 102. Schultz IZ, Crook J M , Berkow i t z J, et a l . B iopsycho­ soc i a l m u l t i varia te model o f occupat ional low back disab i l i ty . Spine 2002;27:2720-2725. 1 03 . Sel i m AJ, X i nhua SR, Graeme F, e t a l . The i m por­ tance of rad i a t i n g leg p a i n i n assessi ng heal t h out­ comes a m o ng patien ts w i t h l ow back pa i n . Spine 1998 ;23:4 70-474.

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Part Three: Assessment

1 04 . S h aw WS, Feuers t e i n M , H au n e r A J , Berkowi t z S M , Lopez M S . Work i n g w i t h l o w back pai n : Probl em-solving orientation a n d fu n c t i o n . P a i n 200 1 ; 9 3 : 1 29- 1 3 7 . 1 05 . Skouen J S , Grasdal A L , H aldorsen E M H , et a l . Rela­ t ive cost-effec t i veness o f extensive and l ig h t m u l t i ­ d i s c i p l i nary treatment programs versus treat ment as usual for pat ients w i t h c h ronic low back pain o n long-term sick leave. Spine 2002 ; 2 7 : 90 1 -9 1 0. 1 06 . Sobel J B , Sol lenberger P, Robinson R, Pola t i n P B , Gatchel RJ . Cervical nonorganic signs: A new c l i n i ­ cal tool to assess abnormal i l l ness behavior i n neck pai n patients: A plot study. Arch Phys Med Rehabi l 2000; 8 1 : 1 70- 1 7 5 . 1 07 . Spi tzer WO, L e B l a n c FE, D u p u i s M , et a l . Sci en t i fic approach to the assessment and management o f act ivi ty-related spi nal d i sorders: A m o nograph for c l i n i c ians. Report of t h e Quebec Task Force on Spinal D isorders. Spine 1 98 7 ; 1 2 ( suppl 7 ) : S l -S59. 1 08 . Swi n kels-Meewisse EJC M , Swi n kesl RAH M , Verbeek A L M , Vlaeyen JWS, Oostendorp RAB. Psychometric properties o f t he Tampa Scale for k i nesiophobia and the fear-avoidance bel iefs questionnaire for acute low back pai n . Man Ther 2003 ; 8 : 29-36. 1 09 . Takala EP, Vi kari -Juntura E. D o functional tests pre­ dict low back pai n . Spine 2000 ; 2 5 ( 1 6 ) : 2 1 26-2 1 32 . 1 1 0. Tenenbaum A, Rivano-Fischer M , Tjell C , Edblom M, Sunnerhagen KS. The Quebec Classification and a new Swed ish classification for whiplash-associated d i sorders i n relation to l i fe satisfaction i n patients at high risk o f c h ronic functional i m p a i rment and dis­ abi l i ty. J Reh a b i l Med 2002 ;34: 1 1 4- 1 1 8 . 1 1 1 . Teresi L M , Lufkin R B , Reicher MA, et a l . Asympto­ matic degenerative d isk d isease and spondylosis o f t h e cervical s p i ne : M R I m aging. Rad ioI 1 98 7 ; 1 64: 83-8 8 . 1 1 2 . Thomas E , S i l m an A J , C ro[1 P R , Papageorgiou AC, J ayson M IV, M acfarl ane G J . Predi c t i ng who devel­ ops c h ronic low back pain in pri m ary care: A prospect ive study. BMJ 1 999;3 1 8 : 1 662- 1 66 7 . 1 1 3 . Troup J D G . The perception o f pain and i ncapac i ty for work: Prevention and early treatment. Physio­ t her I 988;74:4 3 5 .

1 1 4 . Truchon M , F i l l ion L . Biopsychosocial determi­ nants of c h ro n i c d isab i l i ty and low-back pain: A review. J Occup Rehabil 2000; 1 0: 1 1 7- 1 42 . 1 1 5 . van den H oogen H J M , Koes BW, Devi l l e W , van E ij k J T M , Bouter L M . The prognosis of low back pain in general practice. Spine 1 99 7 ; 2 2 : 1 5 1 5- 1 5 2 t . 1 1 6 . Vlaeyen JWS, L i n ton S. Fear-avoidance and its con­ sequences in c h ronic m usculoskeletal pai n . A state o f the art . Pain 2000; 85 : 3 1 7-3 3 2 . 1 1 7 . V o n Korff M , Deyo R A , Cherkin D , Barlow W. Back pain in pri mary care: Outcomes at I year. Spine 1 99 3 ; 1 8 : 8 5 5-8 6 2 . 11 8 . Waddell G , McCul loch JA, K i m m e l E , Venner R M . Nonorganic p hysical s igns i n l o w back pa i n . Spine 1 980; 5 : 1 1 7- 1 2 5 . 1 1 9 . Waddell G , M o rris E W , D i Paola M P , B i c her M , F i n layson D A . Concept o f i l l ness tested a s an i m p roved bas i s for surgical dec i s i o n s in low back d i sorders. S p i ne 1 9 86; I I : 7 1 2-7 1 9 . 1 20 . Walsh D A , Radcli ffe J C . Pain bel i e fs and perceived physical d isab i l i ty of patients with chronic low back pai n . P a i n 2002 ; 9 7 : 2 3-3 1 . 1 2 1 . Weaver CS, Kvaal SA, McCracken L. Waddell signs as behavioral i n d icators o f depression and anxiety in c h ronic pai n . J Back M usculoskel Rehabil 2003/2004; 1 7 : 2 1 -2 6 . 1 2 2 . Wemeke MW, H arris EX, Di Paloa M P , Bicher M , F i n l ayson D. C l i n ical effec tiveness o f behavioral signs for scree n i n g chronic low-back pain pat ients i n a work-odented physical rehabil itation program. Spi ne 1 99 3 ; 1 8 : 2 4 1 2-24 1 8 . 1 2 3 . Werneke M , H art D L . Centra l i zation phenomenon as a prognostic factor for c h ronic low back pain and d i sab i l i ty. Spine 2 0 0 ] ; 2 6 : 758-765. 1 24 . Wiesel S E , Tsourmans N, Feffer H L, et a!. A study o f compu ter-assisted tomography. I . The i ncidence o f posi tive CAT scans in an asym ptomatic group of patients. Spine 1 984;9:549. 1 2 5 . Williams DA, Feuerstein M, Durbin D , Pezzulo J. Healt hcare and i ndem n i ty costs across the natural h istory o f disabi l i ty in occupat ional low back pai n . S p i ne 1 99 8 ; 2 3 : 2 3 2 9-2336.

I

I

Appendix 9A

YELLOW FLAG FORM

Name 1.

____

Primary complaint-

Please indicate your usual level of pain during the past week No pain o 1 2 3 4 5 6 7 8

_ _ _ _ _ _ _ _ _ _ _ _ _ _

9

Worst pain possible 10

2.

Does pain, numbness, tingling or weakness extend into your leg (from the low back) &/or arm (fTom the neck)? All of the time None of the time o 1 2 3 4 5 6 7 8 9 10

3.

How would you rate your general health? Poor o 1 2 3 4 5

( t o-x) 6

7

8

9

Excellent 10

4.

If you had to spend the rest of your life with your condition as it is right now, how would you feel about it? Delighted Terrible o 1 2 3 4 5 6 7 8 9 10

5.

How anxious (eg. tense, uptight, irritable, fearful, difficulty in concentrating / relaxing) you have been feeling during the past week: Not at all Extremely anxious o 1 2 3 4 5 6 7 8 9 10

6.

How much you have been able to control (i.e., reduce/help) your pain/complaint on your own during the past week: I can't reduce it at all I can reduce it o 1 2 3 4 5 6 7 8 9 10

7.

Please indicate how depressed (eg. Down-in-the-dumps, sad, downhearted, in low spirits, pessimistic, feelings of hopelessness) you have been feeling in the past week: Extremely depressed Not depressed at all o 1 2 3 4 5 6 7 8 9 10

8.

On a scale of 0 to 10, how certain are you that you will b e doing normal activities or working in six months? Very certain Not certain at all 3 4 0 1 2 8 10 5 7 9 6

9.

I can do light work for a n hour? Completely agree 4 0 1 2 3

5

6

7

8

9

Completely disagree 10

201

202

10.

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Part Three: Assessment

I can sleep at night Completely agree 2 o 1

3

4

5

8

7

6

] 1.

An increase in pain is an indication that I should stop what Completely disagree o 1 2 3 4 5 6 7

12.

Physical activity makes my pain worse? Completely disagree 3 4 5 1 2 o

13.

9

I should not do my normal activities including work with my present pain. Completely disagree o 1 2 3 4 5 6 7 8 9

Please sign your name

_______

SCORING

&

Completely disagree 10

am doing until the pain decreases. Completely agree 8 9 10

8

7

6

I

9

Date

Completely agree 10

Completely agree 10

_ _ _ _ _ _ _ _ _ _ _ _ _

RISK:

Low risk of chronic disability - under 55 points Moderate risk of chronic disability 55 to 65 points High risk of chronic pain and disability - over 65 points -

Evaluation of Muscular Imbalance

Vladimir Janda, Clare Frank, and Craig Liebenson

Introduction Evaluation of Tight Muscles Evaluation of Inhibited Muscles Analysis of Muscular Imbalance in Standing Gait Assessment Hypermobility

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Learning Objectives

After reading this chapter you should be able to understand: • • •

•

•

The etiology of muscle imbalance How to evaluate muscles for tightness or inhibition The interplay of different synergist and antagonist muscles during basic movement patterns How to evaluate posture for signs of muscle imbalance The basic elements of gait analysis

This chapter is dedicated to the memory of Pro Vladimir Janda (1928-2002) who passed away on November 25, 2002.

" ••• t) ••• 203

204

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Part Three: Assessment

Introduction

The primary basis of the functional approach to mus­ culoskeletal pain syndromes is the interdependence of all structures fTom both the central nervous and musculoskeletal system in the production and con­ trol of motion. Movement of non-contractile and con­ tractile elements is produced and controlled by muscle activity. Ultimately, it is the central nervous system in response to various stimuli that controls the activity of muscles and consequently, the pattern of motion in an individual's musculoskeletal system. The mus­ cular system lies at a functional crossroad because it is influenced by stimuli from both the central nervous system and musculoskeletal system. Dysfunction in any component of these systems is ultimately reflected in the muscular system in the form of altered muscle tone, muscle contraction, muscle balance, coordina­ tion, and performance. Therefore, a strictly localized lesion does not exist. Muscle imbalance is a systemic change in the quality of muscle dysfunction that results in altered joint mechanics leading to pain, dys­ f-unction, and eventually degeneration. Muscle imbal­ ance is the altered relationship and balance between muscles that are prone to inhibition or weakness and those that prone to tightness or shortness. Moderately tight muscles are usually stronger than normal. How­ ever, in the presence of pronounced tightness, some decrease of muscle strength occurs. This weakness is called "tightness weakness" (1) to express the closed association between muscle weakness and altered vis­ coelasticity of the muscle. Therefore, when diagnosing muscle weakness, careful differential diagnoses have to be made. The treatment of tightness weakness is not in strengthening, which would increase tightness and possibly result in a more pronounced weakness, but in stretching, oriented toward influencing the visco­ elastic property of the muscle, i.e., the noncontractile but retractile connective tissue. Stretching of tight muscles also results in improved strength of inhib­ ited antagonistic muscles, probably mediated via Sherrington's law of reciprocal innervation. The etiology and terminology of muscle tone is full of controversies, partly because various authors' def­ initions of muscle tone differ. Therefore, a detailed differential diagnosis has to be made among others because each condition requires a different type of treatment (2). Unfortunately, a precise and adequate analysis is often neglected. An imprecise diagnosis results in disappointing therapeutic results. Unfor­ tunately, the detailed physiology of muscle tone is unknown and studies of muscle tone changes caused by altered or impaired function have not been studied sufficiently in the laboratory or in the clinic. In principle it is necessary to differentiate whether the main changes occur in the connective tissue of the muscle (viscoelastic properties) or in over-activation

of the contractile components of the muscle (con­ tractile properties). According to Mense and Simons, "Muscle tension depends physiologically on 2 factors: the basic viscoelastic properties of the soft tissues associated with the muscle, and/or the degree of acti­ vation the contractile apparatus of the muscle" (9). In the former, we speak about muscle tightness, stiff­ ness, loss of flexibility, or extensibility (length), and in the latter, it is a real increase of muscle contractile activity such as in spasmodic torticollis or trismus. In principle, with respect to viscoelastic changes, the muscle gets shorter at rest (decreased extensibility), either because of shortening of contractile muscle fibers or because of retraction of the connective tis­ sue within the muscle and the adjacent fascia. With respect to contractile changes, the increased muscle tone may involve the majority of muscle fibers of the muscles or only a limited number as found as "taut bands" in trigger points. Clinically, resting muscle tone presents a combi­ nation of both situations (contractile and viscoelastic properties), and it is the role of the clinician to estab­ lish an appropriate diagnosis (9). However, measur­ ing muscle tone objectively presents a dilemma. Tests of viscoelasticity involve measurements of the veloc­ ity of motion, viscosity, thixotropy, and resonant fre­ quency when load is gradually applied (9). Tests of contractile activity are simpler in that EMG can be used; however, this is not without inherent difficul­ ties, as in trigger points where only small loci in the muscle show increased electrical activity (9). A detailed differential diagnosis of muscle tone is necessary for the proper treatment approach, and this can be accomplished by a combination of inspection and palpation (Table 10.1). Layer palpation of the skin, subcutaneous tissue, fascia, fat, and any other struc­ ture in the area concerned, although purely subjective is a practical clinical tool and with much practice and experience, detecting the type of muscle tone pre­ sent in the concerned area can be skillfully achieved. Inspection of posture, movement patterns, and gait also yields invaluable clinical information about the underlying source of increased muscle tension. Muscle imbalance should be considered a systemic reaction of the striated muscles. It is therefore a gen­ eral reaction of the whole muscle system and not just an isolated response of an individual muscle (4). This view is strongly supported by the recent findings of neurodevelopmental kinesiology, which show devel­ opmental movement patterns corresponding to the muscle imbalance found in children when their motor system is fully myelinized (at the age of 6 to 7 years) or in adults (7,8,12). The basis from a neurodevelop­ mental viewpoint is that neonatal and early infant posture is maintained by a "tonic" muscle system. Subsequent neurodevelopment of the upright pos-

Chapter Ten: Evaluation of Muscular Imbalance

Table 10.1

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205

Functional Types of Muscular Hypertonicity (from Janda) (2)

Types

Limbic Segmental Reflex "spasm"

Anatomically

Spontaneously

Distributed1'

Painful1d'

Other Signs

no yes not always

no yes yes i E.M.G. at rest part of active TP-yes muscle latent TP-no

stress i.e., tension headache antagonist weak, pain[-ul to stretch :Defense Musculare" i.e. wry neck

Trigger Points (partial "muscle spasm") yes

Muscle Tightness

no

parts of muscle hyperilTitable, neighboring muscle fibers inhibited i irritability, J- extensibility

*Anatomically distributed hypertonicity is present in specific anatomically defined muscles and not in parts of different muscles in the same area. *" Spontaneously painful a muscle is a source of pain at rest and not merely painful on palpation. Reproduced with permission from Liebenson CS. Active Muscular Relaxation Techniques, Part One: Basic Principles and Methods. J Manipulative Physiol Ther 1 989; 12:6 (Table 2). =

=

ture occurs with the co-activation of a "phasic" mus­ cle system with the "tonic" muscle system. Failure of this co-activation between the tonic and phasic mus­ cle system results in a muscle imbalance and is clearly evident in children with cerebral palsy in which the "tonic" muscle system prevails. In addition, the typi­ cal muscle responses seen in chronic low back pa­ tients are observed to be identical or very similar to those that are seen in some structural lesions of the central nervous system. For example, in spasticity seen in a cerebrovascular accident or cerebral palsy, muscles that develop spasticity or even spastic con­ tractures are those that commonly respond by tight­ ness in musculoskeletal conditions. It is proposed that these typical muscle responses observed in the typical hemiplegic posture may be an extreme expres­ sion of the imbalance between the muscular chains that exist to some extent under normal physiologic conditions. Thus, the tendency for some muscles to develop weakness or tightness does not occur ran­ domly but rather in typical "muscle imbalance pat­ terns" (3). Furthermore, the development of these patterns can be predicted clinically and preventative measures should be taken because muscle imbalance does not remain limited to a certain part of the body, but gradually involves the whole striated muscular sys­ tem (6). A thorough evaluation is necessary to intro­ duce preventive measures because muscle imbalance usually precedes the appearance of pain syndromes. Muscle imbalance develops mainly between pre­ dominantly "tonic" muscles, that is, muscles that are prone to develop tightness and predominantly "pha­ sic" muscles, that is, muscles that are prone to develop inhibition (Table 10.2). Muscle imbalance involves

muscles of the whole body; however, if the imbalance is more evident or starts to develop gradually and pre­ dictably in the pelvic region, we speak about the pelvic or distal crossed syndrome, and i fit is more evident or starts in the shoulder girdle/neck region, we term it as a proximal or shoulder girdle crossed syndrome (5). The proximal ( upper, shoulder-neck) crossed syn­ drome is characterized by the development of tight­ ness in the upper trapezius, levator scapulae, and pectoralis major, and inhibition in the deep neck flexors and lower stabilizers of the scapula. Topo­ graphically, when the inhibited and tight muscles are connected, they form a cross (Fig. 10.1). This pattern of muscle imbalance produces typical changes in pos­ ture and motion. In standing, elevation and protrac­ tion of the shoulders are evident, as are also rotation and abduction of the scapula, a variable degree of winging, and a push-forward head position. This altered posture is likely to stress the cervicocranial and the cervicothoracic junctions. In addition, the stability of the shoulder blades is decreased, because of the altered angle of the glenoid fossa, and, as a con­ sequence, all movement patterns of the upper extrem­ ity are altered. The distal (lower, hip-pelvic) crossed syndrome is characterized by tightness of the hip flexors and spinal erectors and inhibition and weakness of the gluteal and abdominal muscles. As in the upper crossed syn­ drome, a line connecting the tight and inhibited mus­ cles forms a cross (Fig. 10.2). This imbalance results in an anterior tilt of the pelvis, increased flexion of the hips, and a compensatory hyperlordosis in the lum­ bar spine. This imbalance tends to over-stress both hip joints as well as the lower back.

206

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Part Three: Assessment

Table 10.2

Muscle 1mbalances

Muscle that have a tendency to develop: Tightness/Shortness

WeaknesslInhibition

Gastrocsoleus Hip flexors Rectus femori Iliopsoas Tensor fascia lata Adductors Hamstrings Erector spinae Quadratus lumborum Piriformis Upper trapezius/levator scapulae Pectorals Sternocleidomastoid Shorl deep cervical extensors Upper extremity flexors

Tibialis anterior Vasti (in particular, the vastus medialis obliquus) Gluteus maximus Gluteus medius and minimus Abdominal wall Lower and middle trapezius Serratus anterior Deep neck flexors (longus colli and capitis) Scalenes Upper extremity extensors

A combination of these two syndromes is expressed in a layer (stratification) syndrome (Fig. 10.3). When a layer syndrome is observed in a patient, it is a sign of a poorer prognosis in terms of rehabilitation because of the fixed muscle imbalance patterns at the central nervous system level. Examination of joints must precede muscle eval­ uation of muscles to exclude any anatomical batTier. In clinical practice, it is advisable to begin muscle

Erector Spinae

�

, I , , , , I ,

Gluteus Maximus

Iliopsoas

Tight Weak Deep Neck Flexors

Abdominals

Weak

Of

Inhibited

Tight Upper Trapezius and Levator Scapula

Weak or Inhibited

Tight Pectorals

Weak Lower Trapezius and Serratus Anterior

Figure

10.1 Upper crossed syndro me.

Figure 10.2 Lower crossed syndrome.

Tight

Chapter Ten: Evaluation of Muscular Imbalance

Muscle Hypotrophy

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207

Muscle Hypertrophy

Cervical Erector Spinae Upper Trapezius Levator Scapulae Lower Stabilizers of the Scapula Thoracolumbar Erector Spinae Lumbosacral Erector Spinae Gluteus Maximus

Hamstrings

Quadratus Plantae

Figure

10.3 Layer (stratincation) syndrome.

evaluation by analyzing erect standing posture and gait. This analysis requires experience and keen obser­ vational skill. In addition, it serves as a screening tool by providing quick and reliable information to direct the clinician the necessary tests that need to be per­ rormed in detail and those that can be omitted. The c1inician is given an overall view of the patient's mus­ cle function through posture and gait analysis and is challenged to look comprehensively at the patient's entire motor system and not to limit attention to the local level of the lesion. Evaluation of muscle imbalance in a patient with an acute pain syndrome, however, is unreliable and must be undertaken with precaution. A precise evaluation of tight muscles and movement patterns can be performed only if the pa­ tient is pain-free or almost pain-free. Its usefulness is greatest in the chronic phase or in patients with recur­ rent pain after the acute episode has subsided.

Figure

10.4 Upper trapezius.

when the movement is restricted, the barrier has an abrupt firm to hard end-reel. Levator scapulae (Fig. 10.5) is examined in a sim­ ilar manner, except that the head is also rotated to the contralateral side. Pectoralis major (Fig. 10.6) is tested with the pa­ tient supine. The trunk must be stabilized before the arm is placed into abduction because a possible twist of the trunk might mimic the normal range of move­ ment. The arm should reach the horizontal level. To estimate the clavicular portion, the arm is allowed to hang down loosely and the examiner applies a poste­ rior glide to the shoulder. Normally, only a slight soft barrier is felt. Deep posterior neck muscles can be tested only by thorough palpation. Evaluation of the sternocleido­ mastoid is not reliable because it crosses too many segments (Fig. 10.7).

Evaluation Of Tight Muscles

Upper trapezius (Fig. lOA) is tested with the patient supine, with the head passively flexed and side-bent to the contralateral side. Once the slack is taken up, the shoulder girdle is pushed distally. Normally, a sort barrier is felt at the end of the push; however,

Figure 10.5 Levator scapulae.

208

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Part Three: Assessment

Figure

10.6 Pectoralis major.

Hip flexors ( iliopsoas [Fig. 10.8] and rectus femoris [Fig. ] 0.9]) are lested wilh the patient in a modified Thomas position. The presented modification also allows for a screening examination of the short lhigh adductors and the tensor fascia lalae. The patienl is supine wilh the torso on the plinth and the lested leg loosely hanging. The non-lesled leg is maximally flexed lo stabilize the pelvis and flat­ len the lumbar spine. A flexed posilion of the hip joint indicates lightness of the iliopsoas, whereas the oblique posilion of the lower leg indicales tighlness of the rectus. The inability to achieve passive hyperex­ tension in the hip joint and passive full flexion of lhe

knee ( 135 degrees) confirms the tightness of the iliop­ soas and the rectus, respeclively. Limitation of passive hip adduction to 15 degrees or less indicates the tight­ ness of the tensor fascia lala ( Fig. 10. 10); abduction less than 25 degrees indicates shortness of the one­ joint thigh adductors. This lest can be influenced by lhe stretch of the joinl capsule and lhus more specific test should be performed to confirm the lightness of the adductors ( Fig. 10.11). Confirmation of tightness is clear when excessive soft tissue resistance and decreased range of motion are encountered on applicalion of pressure in the fol­ lowing direclions:

Figure 10.7 Screening test fOI- sternocleidomastoid tightness.

Chapter Ten: Evaluation of Muscular Imbalance

Figure

•

•

•

--

209

10.8 Iliopsoas.

Hip extension less than 10 to 15 degrees­ iliopsoas. A simultaneous extension of the knee joint points to the shortening of the rectus femoris. Knee nexion less than 100 to 105 degrees­ rectus femoris. Compensatory hip flexion may occur during the test. H ip adduction less than 15 to 20 degrees­ tensor fascia lata and the iliotibial band. An

Figure

10.9 Rectus femoris.

associated deepening of the groove on the outside of the thigh is also noted In the presence of tightness. •

Hip abduction less than 15 to 20 degrees­ short hip adductors. The tendency toward compensatory hip flexion should be controlled during the test.

Hamstrings ( Fig. 10. 1 2) tightness is evaluated by the straight leg raise test. To avoid the influence of

2J a

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Part Three: Assessment

Figure

10.10 A screening lesl for lensor fascia

lala lightness.

tight iliopsoas on the position of the pelvis and consequently on the range of hip flexion, the non­ tested leg should be in placed in flexion. Under these circumstances, the normal range of motion is 90 degrees. Thigh adductors are tested with the patient lying supine at the edge of the plinth (Fig. 10.13). The passive abduction in the hip joint should be at least 45 degrees. Tight hamstrings may contribute to the range limitation. If this situ ation occurs, bending the knee should increase the range or movement.

The piriformis muscle is tested with the patient in a supine position. The tested leg is placed with the hip joint in flexion not more than 60 degrees and in maximal adduction. The pelvis is stabilized by apply­ ing a force on the hip through the long axis of the femur (Fig. 10.14). Then, the adduction and internal rotation of the hip is performed. Normally, a soft, gradually increasing resistance is noted at the end of the range of motion. If the muscle is tight, the end feel is hard and may be associated with pain deep in the buttocks.

Figure

10. 1 1 Screening lest for the short hip

adduclors.

Chapter Ten: Evaluation of Muscular Imbalance

Figure 10.12 Hamstrings.

Figure 10.13 Thigh adductors (A); test if ham­ strings are tight (B).

--

211

Quadratus lumborum is difficult to examine be­ cause this muscle spans m any spinal segments. In principle, passive trunk side bending is lested while the patient assumes a side-lying position (Fig. 10. 15). The reference point is the level of the inferior angle of the scapula, which should be raised approximalely 2 inches from the floor. A simpler screening lesl entails observation of the spinal curve during active lateral flexion of the trunk. Spinal erectors are also difficult to examine for lhe same reason as the quadratus lumborum. As a screen­ ing test, forward bending in a short sit allows obser­ vation of the gradual curvature of the spine ( Fig. 10. 16). A more reliable test, however, is the dual inclinometer test for lumbar flexion mobility shown in Chapter 1 2. Triceps surae are tested by performing passive dorsiflexion of the foot. Normally, the therapist should

212

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Part Three: Assessment

Figure 10.14 Screening test for piriformis tight­ ness (A); palpation test for piriformis tension or irritability (B).

be able to achieve passive dorsiflexion to 90 degrees (Figs. 10.17 and 10. ] 8). More detailed description of the tests is available elsewhere (3).

Evaluation Of Inhibited Muscles

Classic muscle strength testing involves resistance or a m ovement in the direction characteristic for the specific muscle or muscle groups being tested. The production of a m ovement is in actuality, a series of muscles acting as prime m overs, synergists, or stabilizers that combine together to produce a m ovement (3). Therefore, classic m uscle strength testing does not provide su fficient nor reliable infor-

m ation. The quality of performance of the m ove­ m ent is of greater importance than the test for strength. This type of evaluation is less focused on the strength of the particular movement, but more focused on the sequencing and degree of activation of the prime m overs and their synergists. In this respect, the initiation of the movement is more important than the end of the m ovement. Poor qual­ ity and control of movement can produce and/or perpetuate adverse stresses on joints and muscle m echanics. Although m ovement patterns are indi­ vidualized, the typical normal and abnormal pat­ terns can be recognized. In principle, six basic movement patterns provide overall information about the movement quality of the particular subject: hip (hyper)extension, hip

Chapter Ten: Evaluation of Muscular Imbalance

Figure 10.15 Screening test for quadratus lumborum tightness.

Figure

10.16 Screening test for erector spinae

tightness.

Figure 10.17 Gastrocnemius.

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213

2J4

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Part Three: Assessment

Figure 10.18 Soleus.

abduction, curl up, push up, neck flexion, and shoul­ der abduction. During movement pattern testing, minimal verbal cues should be used which test an individual's habitual way of performing a movemenl. If the cues are too "leading," then the test will be of the subject's ability to learn how to perform the move­ ment correctly, rather than how the subject is habit­ ually performing it. The hip (hyper)extension movement test (Fig. 10.19) is examined to analyze one of the most important phases of the gait cycle-i.e., hyperextension of the hip at the terminal stance phase of gait (10,11). This test is performed with the patient lying prone. During straight leg lifting into extension, the sequencing and degree or activation of the h amstrings, gluteus maximus, spinal extensors, and shoulder girdle mus­ cles are observed. The first sign of altered pattern is when the hamstrings and erector spinae are readily activated during the movement, whereas contraction of the gluteus maximus is delayed, decreased, or absent. The poorest pattern occurs when the erector spinae on the ipsilateral side or even the shoulder gir­ dle muscles initiate the movement and activation of the gluteus maximus is weak and substantially delayed. In this situation, the entire motor perfor­ mance is ch anged. Little if any extension in the hip

Figure 10.19 Hip extension.

joint is noted and the leg lift is achieved through pelvic anterior tilt resulting in hyperlordosis of the lumbar spine, which undoubtedly over-stresses this region. Knee flexion should be noted because it indi­ cates the hamstrings are predominating over the glu­ teus maximus. Hip abduction (Fig. 10.20) gives information about the quality of the lateral muscular pelvic brace and thus indirectly about the stabilization of the pelvis in walking. It is tested with the patient in the side-lying position. The gluteus medius and minimus together with the tensor fascia lata act as prime movers while the quadratus lumborum acts as a pelvic stabilizer. The first sign of an altered abduction pattern is a ten­ sor mechanism of hip abduction, when compensatory hip flexion is observed instead of pure abduction The poorest pattern of hip abduction occurs when the quadratus lumborum, in addition to stabilizing the pelvis, initiates the movement through elevation of the pelvis. This altered pattern can cause excessive stress to the lumbar and lumbosacral segments dur­ ing walking. Trunk curl-up (Fig. 10.21) is tested to estimate the interplay between the usually strong iliopsoas and the abdominal muscles. Initially, the examiner observes the patient's spontaneous pattern of sitting

Chapter Ten: Evaluation of Muscular Imbalance

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215

Figure 10.20 Hip abduction.

Figure 10.21 Trunk curl-up.

up. In the presence of weak abdominals and strong dominant iliopsoas, the curling movement of the trunk is minimal and the movement will be per­ formed with an almost straight back and anterior tilting of the pelvis. The movement is thus per­ formed mostly in the hip joint rather than by kypho­ sis of the trunk. Another way to detect if the iliopsoas is the dominant mover during the curl-up is [or the

clinician to place his hands under the patient's heels. The iliopsoas is predominant over the abdominals when the pressure o[ the patient's heels on the clin­ ician's hands is lost. Push-up (Fig. 10.22) [Tom the prone position pro­ vides information about the quality of the stabilization of the scapula. During the push-up, and particularly in the beginning phase of lowering the body from

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Figure 10.22 Push-up.

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maximum push-up, excessive scapular rotation, ele­ vation, adduction, or abduction are noted. The type of motion depends on what muscles are dominant. If lev­ ator scapulae are dominant, then one might see an elevation and downward rotation of the scapulae. If the serratus anterior is not functioning adequately, winging of the scapula will be observed. Head Oexion (Fig. 10.23) provides information about the interplay between the sternocleidomas­ toideus and the deep neck flexors. This information is essential in estimating the dynamics of the cervi­ cal spine and is tested with the patient supine. The subject is asked to raise the head slowly in the habit­ ual way. When the deep neck flexors are inhibited and the sternocleidomastoideus is overactive, the jaw juts forward at the beginning of the movement with hyperextension in the cervicocranial junction. If the pattern is u nclear, slight resistance of approxi­ mately one to two finger weights against the forehead may be applied. This slight resistance may exaggerate the hyperextension even more, indicating a weakness of the deep neck flexors. Shoulder abduction (Fig. 10.24) provides infor­ mation about the coordination of muscles of the shoulder girdle. It is tested while the patient is sitting, with the elbow flexed to control u ndesired rotation.

Clinical Pearl

o

Figure 10.23 Head flexion "correct"

(A) and "incorrect" (B).

Stretch Before Strengthening

If a movement pattern is faulty, the general rule of

thumb is to initiate rehabilitation by treating tight mus­ cles related to the faulty pattern. Once tight muscles are addressed then facilitation and training of the "weak link" can proceed. The reason for this is if muscle tight­ ness is present, then strength training will typically re­ inforce "trick" movements, thus perpetuating the muscle incoordination. For instance, if the trunk curl-up test is positive, then treatment com mences with releasing the iliopsoas first and then com mencing an abdominal training program. With the tight hip flexors relaxed and lengthened, abdominal training will proceed with less joint stress and easier isolation of the target muscles. The exception to this general rule of stretching tight mus­ cles before strengthening "weak" muscles is if length test­ ing shows that the iliopsoas is not actually tight. In this case, facilitation of the inhibited muscle can begin right away. However, because the movement pattern is faulty, a training position and range must be found that allow isolation of the agonist muscle without excessive substi­ tution of synergist or antagonist muscles.

Shoulder abduction is a result of three components: abduction in the glenohumeral joint, rotation of the scapula, and elevation of the shoulder girdle. Move­ ment is stopped at the point at which shoulder girdle elevation commences. This usually occurs at approx­ imately 60 degrees of abduction at the glenohumeral joint. In an individual with shoulder dysfunction, shoulder girdle elevation starts earlier or may even initiate the movement.

Analysis Of Muscular Imbalance in Standing

In an analysis of standing, an attempt is made to differentiate between possible provocative causes, including structural variations, age, altered joint mechanics, and residual effects of pathologic pro­ cesses. In this chapter, only muscular changes are described, although all biomechanical deviations, such as scoliosis, leg length difference, and all other

Chapter Ten: Evaluation of Muscular Imbalance

Figure 10.24 Shoulder abduction "correct"

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217

(A) and "incorrect" (B).

orthopedic deviations are taken into consideration. In muscular analysis, the main concern is with size, shape, and tone of the superficial muscles known to react by hyperactivity and tightness or by weakness and inhibition. The role of deeper muscles may need to be confirmed or negated in subsequent muscle length tests. The patient is first observed [Tom behind and an overall impression of posture is determined. Atten­ tion is then directed toward the position of the pelvis, because abnormalities of other structures such as the lumbar spine, sacroiliac joints, and lower limbs are, as a rule, reflected in the pelvis. An increase or decrease in sagittal tilt (posterior or anterior pelvic tilt), a lateral shift, an oblique position (pelvic un-leveling), rotation (transverse plane), and torsion (multiplanar distor­ tion) should be noted. The pelvic crossed syndrome may be responsible for the increased anterior tilt of the pelvis. This condition is usually associated with increased lumbar lordosis. The pelvic rotation is usu­ ally associated with shortness of the piriformis and/or iliopsoas; an oblique position of the pelvis is associ­ ated mostly with leg length asymmetry. Tightness of thigh adductors, quadratus lumborum, and iliopsoas tend to shorten the leg, whereas tightness of the pir­ iformis tends to lengthen the leg. Next, the shape, size, and tone of the buttock are observed. Observation of the gluteus maximus is

directed to the upper half of the muscle where con­ tour and tone is noted. The general appearance of the gluteus, whether one is bulkier or sagging, gives the clinician a clue on the motor [unction of the muscle. Usually, the gluteus is hypotonic and inhibited on the side where the sacroiliac joint is blocked. The ham­ strings are usually well developed, but it is important to look at their bulk relative to that of the glutei, because when the latter is inhibited, the hamstrings often become predominant. This change is readily evident if the impairment is unilateral. The shape of the line of the medial aspect of the thigh gives important information about the thigh adductors. In individuals with adductor tightness, the one-joint adductors form a distinct bulk in the upper one third of the thigh. The one-joint adductors are, as a rule, short and tender on palpation in patients with pain­ ful hip joint afflictions. On the calf, differentiation must be made between the gastrocnemius and the soleus. If the whole triceps surae is short, the Achilles tendon seems broader, and if the soleus is tight, in addition, the lower leg becomes cylindrical (Fig. 10.25). Careful examination of the back muscles is war­ ranted. The bulk of the erector spinae should be com­ pared from side to side, as well as [Tom the lumbar to the thoracolumbar region. There should be no evident difference between sides and regions. Prevalence or

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hypertrophy of the thoracolumbar spinal erectors may be indicative of poor muscle stabilization in the lumbosacral region (Fig. 10.26). The interscapular space and the position of the shoulder blades give information about the quality of the lower stabilizers of the scapula. If these muscles are weak and/or inhibited, slight abduc­ tion, elevation, and winging of the shoulder blade are observed (Fig. 10.27). Tightness of the upper trapezius and levator scapulae (Fig. 10.28) can be seen on the neck shoulder line. In areas of tightness, the contour straightens. If tightness of the levator predominates, the contour of the neckline appears as a double wave in the area of insertion of the muscle on the scapula. This straightening of the neck shoul­ der line is sometimes described as a "Gothic shoul­ der" in that it is reminiscent of the form of Gothic church windows. Viewing the patient from the front, the quality of the abdominals is observed first. Ideally, the abdom­ inal wall is flat. A sagging and protruded abdomen may reflect generalized weakness of the abdominals. When the obliques are dominant, a distinct groove is apparent on the lateral side of the recti. This finding indicates a possible decrease in the stabilizing func-

Figure 10.25 Soleus lightness on the right.

Figure 10.26 Right t horacolumbar erector spinae

hypenrophy.

tion of the abdominal wall in the anteroposterior direction, an important factor for stabilization of the spine (Fig. 10.29). The two anterior thigh muscles that can influence the lumbopelvic posture are the tensor fasciae lata and the rectus femoris. Normally, the bulk of the tensor is not distinct. Its visibility, coupled with the appearance of a groove on the lateral side of the thigh, usually indicates that this muscle is overused and short. When the rectus femoris is tight, the position of the patella shifts slightly upward and also later­ ally in the case of concurrent lightness of the ili­ otibial tract. Tightness of the pectoralis major is characterized by a more prominent muscle belly and thickness of the anterior axillary fold. Typical imbalance will lead to rounded and protracted shoulders. Much information can be obtained from observation of the anterior aspect of the neck and throat. Normally, the sternocleido­ mastoid muscle is just slightly visible. Prominence of the insertion of the muscle, particularly its clavicular (proximal) portion, is a sign of tightness. A groove along this muscle is an early sign of weakness of the deep neck flexors. Straightening of the throat line (this is the angle made between the chin and throat line-

Chapter Ten: Evaluation of Muscular Imbalance

Figure 10.27 Abduction and winging of the right scapula.

Figure 10.28 Tightness of the levator scapulae.

Figure 10.29 Oblique abdominal dominance.

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normal is usually approximately 90 degrees) is usually a sign of increased tone of the suprahyoid muscles, which may be the underlying cause of a temporo­ mandibular joint dysfunction. Palpation of the supra­ hyoids often reveals trigger points. Additionally, head posture should be observed. From a muscular point of view, a forward head posture is linked to weakness of the deep neck flexors and dominance or even tight­ ness of the sternocleidomastoid. From this brief description, it is evident that neg­ lecting the analysis of the muscular system in standing leads to a loss of a substantial amount of informa­ tion. Only the main changes or most frequent find­ ings are mentioned in this chapter; however, other less common or subtle signs will provide additional valuable information. Gait Assessment

Gait is the most automatized movement. The basic gait reflexes are regulated on a spinal cord level; however, the more complex reflexes are regulated on the subcortical or even cortical level. The variety of the gait patterns is remarkable. In fact, there are no two people on the world who would have the same gait. This fact has lead to a proposal to use the gait pattern to identify individuals in criminology. The gait pattern is so deeply fixed that it can be changed only with greatest difficulties, if at all. Thus the individual subject maintains his/her gait pattern during the whole adult lifetime. Only a severe injury that requires adaptation of the whole motor system results into changes of the gait pattern, although even in this case some basic qualities will remain unchanged. For these reasons it is very difficult, if not impos­ sible, to estimate norms. Therefore, statistical data regarding gait are of a very limited value in the clin­ ics and for an individual patient. Despite all these dif­ ficulties and diagnostic limitations, the visual gait analysis is of a paramount importance as it provides important information about possible over-stresses of critical segments of the human body in the indi­ vidual patient. In addition, skilled observation of gait helps the clinician toward a more detailed diagnosis and rational of treatment. In principle, two general types of gait can be recog­ nized:

The proximal type: The body is propelled forward mainly by pronounced hip and knee flexion, followed by hip extension beyond the midline. The center of gravity remains relatively level with minimal stress on the ankle joints and possibly greater over-stress on the hip joint.

Figure 10.30 One-leg standing test. (A) Normal one-leg stance, pelvis and shoulders level, minimum of lateral pelvic shift. (B) Positive Trendelenburg sign. Lateral shift and oblique position of the pelvis, contralateral shoulders elevated.

Chapter Ten: Evaluation of Muscular Imbalance

In the distal type, the body is propelled forward virtually by plantar flexion of the feet with minimal motion at the hip and knee j oint. The center of gravity is elevated with each step. This type of gait i s seen as "bouncy" or sim ilar to gait <;>bserved i n children with muscular dystrophy who walk on their toes. After estimating the type of gait, length, and sym­ metry of the length of the step, the m ovem ents of the pelvis are observed. There are five basic move­ ments that we should look at: 1.) anterior and 2.) pos­ terior pelvic tilt in the sagittal plane, 3.) lateral and oblique shift, 4.) pelvic rotation, and 5.) the "butter­ fly " movement of the pelvis, which is an "openin�" and "closing" of the pelvis as a result of m ovement m the sacroiliac joint. Anterior pelvic tilt has to be correlated with the lumbar lordosis and thus stability of the whole torso. The easiest way to estimate this clinically is to compare the position of the pelvis with the position of the shoulders. If the trunk stability is good, the whole body-particularly in two critical areas, the pelvis and shoulders-will m ove forward in one line. If trunk stability is i nsufficient, the shoulder move­ ments will lag behind. Pelvic movements are associ­ ated with the range of hip extension and lateral muscular pelvic brace, which is important during one leg stance. It has to be noted that approximately 85% of gait cycle involves standing on one leg A quick test to check on the lateral brace is to have the patient perform a single leg stance with his eyes open ( Fig. 10.30). The clinician observes for the amount of pre-shift to the stance leg and un-leveling of the pelvis and/or shoulders. The normal pre-shift to the stance leg should not be m ore than 1 inch and the patient should be able to perform the single leg stance [or approximately 15 seconds without any com pensatory m ovements. Arm movements during gait are another source of valuable information. Sym m etry of arm m ove­ ments is observed, with particular attenti on to whether the movement is predominantly initiated by movement in the shoulders ( which is ideal), or by a pronounced elbow flexion. The third type of arm m ovement observed is m ovement initiated predom inantly by rotation of the trunk. The latter is often the result of increased stresses on the whole spine.

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Clinical Pearl Differentiating Muscle Weakness from Inhibition for the Gluteus Maximus

M uscle strengthening programs are often time-consu m­ ing. In many instances of supposed muscle weakness, detailed analysis reveals that the muscle is not actually weak, but only inhibited. In such cases the correct man­ agement is facilitation, not strength training. Identifying the specific nature of the muscle dysfunction is a "time­ saver" in the clinic. H i p Extension/G luteus Maximus

The b crluteus maximus is an important hyper-extensor of the hip. The hip (hyper)extension test is a simple screen showing the interplay of gluteus maximus, hamstrings, erector spinae, and hip flexor muscles. The i mportance of this movement is that it is an essential phase of the gait cycle. Neither faulty gait during "toe off" nor a faulty hip extension movement pallern tells us if the gluteus max­ imus is weak or inhibited. However, a simple test involv­ ing backward walking will make this differentiation. During backward walking, the gluteus maximus is nor­ mally facilitated. Thus, incoordinated backward walking as evidenced by increased lumbar lordosis or an anterior pelvic tilt indicates that the gluteus maximus is twly weak and not merely inhibited. This is particularly stri king i f the dysfunc tion i s unilateral. This suggests that longer­ term training will be required to improve function. In contrast, an improved lumbo-pelvic posture during back­ ward walking in comparison to standing posture, forward walking, or during the prone hip (hyper)extension test suggests that the gluteus maximus is only inhibited and probably can be trained easily. If inhibition is present, treat ment may involve post­ isometric relaxation ( PI R ), facilitation ( PNF diagonals, Sister Kenny methods), or joint man ipulation. I f weak­ ness is present, then progl-essive resistance training (e.g., bridges, squats, lunges, and single leg reaches) will also be required. A goal-oriented continuum of care might look like this:

Continuum of Care •

Inhibit-hip flexors

•

Facilitate-gluteus maximus

•

Mobilize-lower quarter and lumbo-pelvic joints

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Clinical Pearl Differentiating Muscle Weakness from Inhibition for the Gluteus Medius

The gl uteus medius is the most important lateral stabi­ lizer of the hip and pelvis. During gait an insufficiency of the lateral brace on the stance leg will lead to pelvic un-leveling (i.e., Trendelenburg) and difllculty achieving clearance of the toes from the ground on the contralateral swing leg. The person may not trip, but an uneconom ical gait wil l result. The hip abduction test is a simple screen showing the interplay of gluteus medius, tensor fascia lata, quadratus lumborum, and hip adductors. Unfortu­ nately, neither pelvic un-leveling du.-ing gait nor a faulty hip abduction movement pattern w i ll tel l us if the glu­ teus medius is weak or only inhibited. However, a sim­ ple test involving walking while holding a light object in the hands overhead w i l l make this differentiation. During this test the gluteus medius is normally facili­ tated. Thus, incoordination as evidenced by increased lateral sway 01- pelvic un-leveling indicates muscle weak­ ness not inhibition is involved. This is most notable if the dysfunction is unilateral. In contrast, an improvement in lateral pelvic stability or pelvic obliquity when compared to normal walking or standing posture suggests gluteus medius inhibition not weakness is present. If weakness is present, then progressive resistance train­ ing (clam shell, single leg bridge, wall ball , and single leg reaches) will also be requil-ed. A goal-oriented continuum of care m ight look like this:

Continuum of Care •

Constitutional h ypermobility involves the entire body, although all areas may not be affected to the same extent and slight asymmetry can be observed. This syndrome is noted more frequently in women and it typically involves the upper part of the body. With aging, h ypermobility decreases . Patients with constitutional hypermobility may develop muscle tightness as well, although it is never so evident. Mostly, this tightness is considered a compensatory mechanism to stabilize, in particular, the weight­ bearing joints. Therefore, stretc hing, if necessary, should be performed gently and only in key muscles that are supposed to be decisive in a particular syn­ drome. Because the muscles generally are weak, they may be easily overused and, therefore, trigger points in muscles and ligaments develop easily. There is no effective treatment of the syndrome of consti­ tutional hypermobility. However, reasonably pro­ longed strengthening and sensorimotor programs are usually helpful. Assessment of hypermobility is in principle based on estimation of muscle tone by palpation and range of motion of the joints. In clinical practice, orien­ tation tests usually are sufficient. I n the upper part of the body, the most usef-ul tests are head rotation high arm cross (Fig. 1 0.3 1 ), touching the hand� behind the n eck (Fig. 10.32), extension of the el bows ( Fig. 10.33), and h yperextension of the thumb (Fig. 10.34). In the lower part of the body, the best choices are the forward bending test (Fig. 10.35), lateral flex­ ion test, leg raising test, and dorsiflexion of the foot (Fig. 10.36).

Inhibit-adductors, Piriformis, TFL, quadratus lumborum, psoas

•

Facilitate-g luteus medi us

•

Mobilize-lower quarter and lumbo-pelvic joints

Hypermobility

M uscles can be involved in many other afflictions. One of the most common situations is constitutional hypermobility. This vague non-progressive clinical syndrome of unknown origin is not really a disease. It is ch aracterized by a general laxity of connective tis­ sues, muscles, and, in particular, ligaments. Muscle strength in affected individuals usually is low, and even a vigorous strengthening exercise does not lead to evident hypertrophy. The muscle tone is decreased when assessed by palpation and the range of move­ ment in joints is comparatively increased. Despite joint instability, it h as not been confirmed that "hyper­ mobile" subjects are more prone to musculoskeletal pain syndromes.

Figure 10.31 High arm cross.

Chapter Ten: Evaluation of Muscular Imbalance

Figure 10.32 Touching the hands behind the neck.

Figure 10.34 Hyperextension of the thumb.

Figure 10.33 Extension of the elbows.

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Figure 10.35 The fon.vard bending lest.

Figure 10.36 Dorsiflexion of the foot.

Chapter Ten: Evaluation of Muscular Imbalance

• CONCLUSION

Muscle imbalance is an essential component of dys­ function syndromes of the musculoskeletal system. Important approaches in the overall therapeutic pro­ gram lie in the recognition of factors that perpetuate the dys['unction and normalization. This fact is true regardless of whether muscle imbalance is considered to cause the join t dysfun ction or to occur parallel to it.

Audit Process Self-Check of the Chapter's Learning Objectives •

Can you evaluate the length of each of the muscles which have a tendency to become tight?

•

Can you perform and interpret the six basic movement patterns described in this chapter?

•

Can you identify signs of muscle imbalance from postural or gait analysis?

• REFERENCES I . Janda V. Muscle strength in relation to muscle

length, pain and muscle imbalance. In: Harms­ Rindahl K, ed. Muscle Strength. New York: Churchill Livingstone, 1 993.

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2. Janda V. Muscle spasm-a proposed procedure for differential diagnosis. J Manual Med 1 99 1 ;6 : 1 36. 3. Janda V. M uscle Function Testing. London: Butterworths, 1 983. 4. Janda V . On the concept of postural muscles and posture. Austl- J Physiother 1 983;29: S83-S84. 5. Janda V . Die M uskularen Hauptsyndrome bei verle­ bragenen Beschwerden . I n : Neumann H D, Wolff H D, eds. TheOl-etische FOI-tschritte und praktische Erfahrungen der Manuellen Medizin. Konkordia, BiihI 1 978:6 1 -65. 6. Janda V. M uscles, central nervous regulation and back problems. In: Korr I, ed. Neurobiologic mecha­ nisms in Manipulative Therapy. New York: Plenum Press, 1 978:27-4 1 . 7. Kolar P . Systematization of muscle imbalances fTom the viewpoint of developmental kinesiology. Rehabil­ i lace Fys Uk 200 1 ;8: 1 52- 1 64. 8. Kolal' P. The sensomotor nature of postural Func­ l ions. Its fundamental role in rehabilitation. J Orthop Med 1 999;2 1 :40-45. 9. Mense S, Simons DG. Muscle pain: U ndel-­ standing its nature, diagnosis, and l reatment. Pain associated with increased muscle tension. Baltimore: Lippincott Williams & Wilkins, 200 1 : 99- 1 3 0 . 1 0. Vogt L , Banzer W. Dynamic testing o f t he motorial stereotype in prone hip extension from the neutral position. Gin Biomechan 1 997; 1 2 : 1 22- 1 27 . 1 1 . Vogt L, Pfeifer K, Banzer W. Neuromuscular con trol of walking with chronic low-back pain. Man Ther 2003 ;8:2 1 -2 8. 1 2. Vojta V, Peters A. Das Vojta-Prinzip. Berlin: Springer Verlag, 1 992.

Quantification of Physical Performance Ability

Craig Liebenson and Steven Yeomans

Introduction

Learning Objectives

Rationale-Why

After reading this chapter you should be able to

Indications-When

understand:

Physical Performance Ability Test Methods-What

Flexibility/Mobility Strength/Endurance Balance/Motor Control Aerobic Fitness Implementation-How

226

•

•

How to evaluate physical performance tests based on their reliability, validity, and practicality. How to administer quantifiable tests of physical impairment that relate to spinal disorders.

Chapter Eleven: Qualification of Physical Performance Ability

Introduction

Functional capacity and physical performance evalu­ ations have become an i mportant part of the physical examination of work-injured and chronic pain patients (96, 1 00). This unique evaluation is needed because traditional examination methods such as orthopedic, neurologic, and i maging tests are able to accurately diagnose the cause of pain in only approximately 1 0% of patients ( 1 48). When advanced i m aging modali t ies are used, an excessive amount of coincidental findings (high false-positive rate) unrelated to the patients con­ dition or prognosis are uncovered ( 1 2,24,59,60,6 1 ,66). Amazingly, most tests used in the physical examina­ tion of musculoskeletal patients are unreliable. For instance, orthopedic tests such as Kemp's or Patrick Fabere's have not been shown to be reliable or to have predktivevalidity ( 1 02,140, 1 4 1 ) . To avoid basing treat­ ment decisions on often-misleading imaging proce­ dures, unreliable orthopedic tests, or merely on the patient's subjective self-report of symptoms, the focus of evaluation has gradually been shifting toward iden­ tification of functional or physical performance deficits (93- 1 0 1 ). One exception is that with the use of diagnostic injections at least 50% of chronic spine pain patients presen ting to specialist diagnostic centers can have the pain generator successfully identified (see chap­ ter 6) ( 8 , 1 40, 1 4 1 ). However, the cause of the tissue's sensitivi ty m ay not be revealed and therein lies the added value of both physical performance and func­ tional testing in such patients. Psychosocial factors are also very important in car­ ing for chronic pain patients and predicting which acute patients are most likely to have chronic pain (see Chapter 9). However, physical performance test­ ing may reveal salient impairments that were at least partial ly responsible for the pain in the first place (87). This can help to focus the patient on the i mpor­ tant goal of reactivation and functional restoration. The physical examination can be used for diagnos­ tic, prescriptive, and outcome purposes. The exami­ nation of physical performance abi l i ty ( PPA) is a key part of the physical examination because i t can help identify specific impairments responsible for bio­ mechanical overload of various pain generators (67). Additionally, it can identify impairments related to specific functional limitations that affect an individual in performing their daily tasks at home, work, or sport (4 1 ,9 1 ). This chapter discusses the rationale (why), indications (when), methods (what), and implementa­ tion (how) related to performing a PPA assessment.

Rationale-Why

The World Health Organization (WHO) h as opera­ tionally defined f'unction in i ts International Classifi-

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cation of I mpairments, D isabil i ties, and Handicaps ( I C D H ) document ( 5 7) . Most significan tly, the I C D H document distinguishes between general functional ability and specific functional deficits. General func­ t i onal a b i li ty rela tes to activi ty l evel or di sabi l i ty, whereas specific functional ability i s related to im­ pairment i n body function. General f,mctional ability or disability is what the patients can or cannot do (or perceive they can do!) in their daily l i fe. This is assessed with activity intolerance questionnaires (i.e., Oswestry, Matheson's activity sorts) (see Chapter 8) or tests of actual patient's general functional abi l i ties such as walking, reaching, carrying, etc. (see Chapter 1 2) . I n contrast , specific functional deficits are found only on clinical examination and may or may not be related to the patient's symptoms or functional abi li­ ties ( 1 8,34). I n this case i t is the clinician's perception that influences the significance of the find ings. The PPA testing i n this chapter i s m ainly tests of such i mpairments or specific functional deficils. Because t he relationship between specific functional i mpair­ ments and disability is indirect, the PPA evaluation is but one tool in the evaluation of patients. Evaluation of PPA does not substitute for the lra­ ditional h istory and examination of orthopaedic, neurologic, or vital signs. Diagnostic triage to iden­ t i fy patients with "red flags" of serious disease and nerve root compression syndromes is a firs t step in evaluation and requires a focused approach (see Chapter 8) ( 6) when "red flags" are present imaging or laboratory investigations are indicated. If imaging tests are ordered i n the absence of "red flags," they can be m isleading because of t heir h igh false-posi tive rates for clinically insignificant age-related degenera­ tive findings (9, 1 2, 59, 60,66). Because less than 1 0% of acute patients can receive an accurate, specific d i agnosis, mosl recent guidelines label the remaining 90% as having "non­ specific" low back pain ( LB P ) ( 6, 1 3 8, 1 42, 1 48). This failure to more accurately d iagnose or classify 90% of L B P has not been deemed a l i m i tation because the condition's favorable natural h istory has been louted. Recent epidemiological studies show that t he course of these "non-specific" low back pain ( L B P ) cases is longer-lasting and more recurrent than previously supposed ( 2 3 ) . The use of the "non-specific" label has been i nterpreted to mean that the majority of patients are a homogenous group who share a uniform cl ini­ cal picture and prognosis. H owever, what i t more l ikely indicates is that we are not very good at sub­ classifying a heterogenous group into discreel groups requiring individualized care (70,7 1). Current attempts at providing better care for LBP patients have empha­ sized i mproving our abil i ty to d iagnose or classify patients into meaningful subgroups (see Chapter 34) (36, 3 8,88, 1 09, 1 50, 1 60- 1 62, 1 69).

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The most i m portan t reasons for perform ing a PPA evaluation are to i dent i fy treatment targets­ prescri p tive-and establish basel ine levels of func­ tional i m pairment from which to judge future progress by-outcom es. Establ ish ing a "functional diagnosis" is an i nvaluable clinical guide that can innuence treatment decisions and steer care toward meani ngfu l end points of care . T he PPA evaluation should focus on relevan t functions that can be safely and rel iably measured. Where normative data bases exist, this is most helpful and, whenever possible, us ing tests that include quan t i fication is i deal for outcomes-based reporting. The most val i d tests are those that most closely resemble the actual way we use our bodies in performing activi ties of daily l iving (ADLs). The most valued characteri stic of a fimc­ tional measure is its u ti l i ty. The u t i l i ty or usefulness of the procedure is the degree to which it meets the needs of the patient, referrer, and payer. Five issues pertaining to a test's u t i l i ty have been described in hierarchical order (Table 1 1 . 1 ) (50,92). H igh-tech instrumentation and dynametric assess­ ment of the low back have been considered the "gold standard" of lumbar spine functional assessment. This is largely because of their reliabi lity and repro­ ducibi lity. However, the validity of some of the h igh­ tech tes ting approaches h as become a source of con troversy (45, 1 20, 1 35). Matheson says, "the inter­ pretation of the test score s hould be able to predict or reflect the eval uee's performance in a target task" (90). If an e ffort factor can be measured, this will help

Table 1 1 . 1 Key Features of Functional! Performance Tests U t i l i ty (50, 90) 1 . Safety: Given the known characteris tics of the patient, the procedure should not be expected to lead to i njury 2 . Rel iabi l i ty: The test score should be dependable across the evaluators, patients, and the date or time of admin istration 3 . Responsiveness: The test s hould detect clinically meaningful change i n a condition or attri bute over time over and above random improvement 4. Val idity: The interpretation of the test score should be able to predict or reflect the patien t's performance in a target work setting 5. Pract ical i ty: The test should be easy to adminis­ ter and in terpret. The cost of the test procedure should be reasonable. Cost is measured in terms of the direct expense of the test procedure plus the amount of time required of the patient, plus the delay in providing the information derived [Tom the procedure to the referral source

unmask a malingerer. However, as Dvir has pointed out, t h is is very di fficult to accomplish, especially with strength testing ( 29). Grabiner et a l . has demonstrated that normal strength measurements from a h igh-tech approach do not necessarily correlate with normal human function (45). In t h is study, electromyography (EMG) was used during isometric trunk extension . The results revealed decoupling, or asym metric lumbar paraspinal m uscle activi ty, was present in low back pain subjects who were considered normal on high­ tech dynametric testing. This decoupling phenom­ enon was able to differentiate between pain and non-pain subjects. This study suggests t hat muscu­ loskeletal function i nvolves not only strength but also coordination during the performance of a spec­ ified task. Because spinal movement and cOOl-dina­ tion use complex neuromuscular functions, simple strength assessment by high-tech dynamometer does not necessarily correlate with assessment of spinal function. As Lewi t puts i t , " . . . in many fi elds of medicine the i m portance of ch anges in function is now well recognized, whereas i n the motor system, where function is paramou nt, this fundamental aspect is rarely considered. H owever, the functioning of the locomotor system i s extremely complex, . . . and diagnosis of disturbed function is a highly soph isti­ cated proceeding carried out, as i t were in a cli nical no man's land" (7 8). LaRocca in a Presi den t i al Address to the Cervical Spine Research Soc iety Annual Meeting in Decem­ ber of 1 99 1 crit ic izes his colleagues for jumping to a psyc hological diagnosis when th ey cannot fi nd a structural cause [or a patient's persistent pai n , ". . . The error here is t h e automatic leap t o psyc hol­ ogy. I t assumes that all organic factors have been considered, when in reality the clinician's apprecia­ tion of t he complexity of such factors in often severely l i m i ted" (73). N ewton and Waddell said, "There is no convi ncing evidence t hat isokinetic or any other iso­ measure has greater cl inical util i ty in the patient wi th low back pain t han either cl inical evaluation of phys­ ical i mpairment , isometric strengt h, si mple isoiner­ tial liFting or psychophysical testing" (56, 1 20). At t h e present time, t h e qua l i ty of high-tech tests is not demonstrated sufficien tly to lead to the aban­ donment o f l ower-tech qual ifiable tests of spinal function. Many rel iable low-tech ways to iden tify functional pathology have been identified. The incli­ nometer is an example of a very simple tool that can safely provide a great amount of val id and rel iable information. Often a patient's musculoskeletal func­ tion cannot be quantified. However, qual ifiable tests may be performed that give insight i n to clinically rel­ evant muscle i mbalances, joint s t i ffness, postural

Chapter Eleven: Quantification of Physical Performance Ability

dysfunctions, and movement incoordination (38, 1 09, 1 1 0,160). Many chiropractors, osteopaths, and manual ther­ apists use tools that lack reliabili ty such as motion palpation of the accessory movement of joints-com­ monly called "end feel." Lack of reliability may be caused by a multiplicity of factors (79) and is not a suf­ ficient reason to abandon a test that is simple, time­ efficient, and theoretically able to test something i n a way not possible with more accurate or sophisticated means. However, such tests must at least be targeted for research i nto their reliability and val idity or their users risk being considered "cultists" ( 1 25 ) . Rissanen e t al. found that non-dynamometric tests correlated better wi t h pain and disability than did isokinetic tests (88, 1 35 ) . They concluded, "The non­ dynamometric tests are sti ll useful in clinical prac­ tice in spite of the development of more accurate muscle strength evaluation methods." Reliability has been reported i n several low-tech tests that do not provide numerical quantification resul ts. For example, the N IO S H Low Back Atlas identified 1 9 tests with sign i ficant reliabi l ity «0.74 Cohen's Kappa and >0.79 coefficient for i nterclass correlation, coefficient [ICC]) ( 1 1 7 , 1 1 8) . M o ffroid et al. studied the ability of the 5 3 N I O S H tests to discri m i nate between low back pain and non­ painful subjects (90, 1 09). It was found that 2 3 of the 53 tests coul d not d iscrim inate adequately between the two groups and when the seven strongest tests were grouped together, a sensitivity of 87% and specificity of 93% were obtained. I nterestingly, the most i mportant measurements were those t h a t assessed passive mobility, dynamic mobility, strength, and symmetry. H arding et aI., as well as o t hers, reported a group of low-tech tests were determi ned safe, reliable, and val i d for assessment of physical dysfunction in chronic pain subjects (49,9 3 ) . A series of simple trunk and lower extremity endurance tests have been shown be rel iable ( 1 , 1 03 , 1 06 ) . A nor­ mative database segregated by age, gender, and vocation (blue collar versus w h i te coll ar) were de­ term i ned for some of these tests on more than 500 individuals ( 1 ) .

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229

identify key functional pathologies that shou l d be addressed with reactivation care. M ooney reports that the functional capac i ty evaluation shou l d be manda tory for any patient still experienc i ng pain after 6 to 7 weeks ( 1 1 2 ) .

Are Functional Tests Predictive of Short-Term Outcome? •

Fritz et al. reported that a Physical Impairment Index performed on acute patients (<3 weeks duration) was predictive of outcome 4 weeks later (39).

•

The tests were found to be reliable and responsive to change (although less responsive than the Oswestry disability i ndex) o

Flexion R O M ( s ingle i n c l inometer at T 1 2/Ll)

o

Extension R O M ( s i ngle i nc l i nometer at T 1 2/Ll)

o

o

o

o

o

Lateral flexion R O M (average of each side­ s i ngle i nclinometer at T9-T 1 2) Straight leg raise R O M (average of each s ide­ inclinom e ter at superior tibial crest w i t h the k nee held in extension) Spinal tenderness (any superficial or deep tenderness is noted) Bilateral active straight leg raise (raised 6 i nches u p and held for 5 seconds) Active sit-up ( knees flexed 90 degrees and feet held flat by the exami ner. Patient s i ts up until fi ngers touch t h e k n ees and holds for 5 seconds)

Are Functional Tests Predictive of Long-Term Outcome? •

Enthoven et al. reported that functional tests are not predictive of 1 2-month outcome i f performed i n the early acute phase ( 3 5 ) .

•

However, i f performed at t h e 4-week mark they are significant predictor of future pain and disability.

•

The best predictors were thoraco-lumbar ROM, isometric trunk extensor endurance, and fi nger t i p

Indications-When

According to M ooney, a PPA evaluation is recom­ mended 2 weeks after i njury to identify the "weak functional l i n k" ( 1 1 2 ) . Triano suggests 4 weeks as an appropriate time to begin testing ( 1 5 9 ) . Functional testing is not terribly helpful in the acute stage and, in fact, may be contraindicated. However, as soon as the patient is out of the acute "guarding" stage, a PPA evaluation can provide ideal outcomes as well as help

to floor distance.

H art et al . , report i ndications for functional testing i nclude the following (50): 1. Plateau of treatment progress 2.

Discrepancy between subjective and objective findings

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Part Three: Assessment

3. Difficulty in returning the patient to gainful employment 4.

Vocational planning or medical-legal case settlement

The PPA assessment will allow objective confirma­ tion of patient status to complement the patient's subjective sel f-report of their symptoms. I t also al lows the health care provider to document patient progress over time. It will help to motivate the patient to pursue reactivation after i nj ury. Prolonged passive care (e.g., hot packs, massage, ultrasou nd) directed at providing symptomatic relief may only achieve short-term resul ts . When symptomatic not func­ tional outcomes are t h e patient's only goal, depen­ dency on pall iative treatments rather than reactivation advice can result (86, 1 38). The "sports medicine" approach that measures hmctional i m pairment and uses reactivation advice and active exercise to rehabi li tate i njured tissues is recognized as the "standard o[ care" [or soft tissue injuries ( 2 1 ,47,86, 1 38, 1 49, 1 64). This active approach is better suited to alleviating pain, completing soft tissue heal ing, and preventing reoccurrences.

Physical Performance Ability Test Methods-What

A number o[ sop histicated high-tech measurement devices have been developed to enhance patient evaluation ( M edX, Cybex, Iso B-200, I soTrak, EMG). Research is driven by the use of such devices ( 1 9 , 82- 1 0 1 , 1 24, 1 26, 1 29 , 1 30, 1 37, 1 43 , 1 58). However, eval­ uation o[ PPA can be performed with m i ni m a l if any special equi pment or high cost . Though high-tech testing equipment is always an option, it is not nec­ essary and in many instances may actually correlate less well with actual functional disabi lity than sim­ pler low-tech approaches ( 1 2 0, 1 3 5 ) . Si mple, low­ tech tests have evolved to a poin t at which m any are reliable ( 1 , 5 , 1 03 , 1 1 7, 1 1 8, 1 3 5 , 1 5 2 ) . T h e best tests are quantifiable and have establi shed normative databases that allow comparison by sex, age, occupation, and history of back pain ( 1 ,49, 1 03 , 1 06, 1 4 5 ) . Ideal ly, maximal performance (sincerity o f effort) can b e differentiated from feigned perfor­ mance although this is usually not possible especially with strength testing (30,48).

Flexibility/Mobility Introduction

Evaluation of mobi l i ty and flexib i l i ty i s a common practice for most m usculoskeletal medicine practi-

t ioners. Range of motion (ROM) is usually restricted in acute situations and is one of the pri mary objec­ tive outcomes that can be tracked to show progress over time. However, in chronic patients ROM testing may be o[ less value. Sinceri ty of effort is an i m portant consideration during ROM testi ng. I n the Guides to the Evaluation of Permanent Impair111.ent the validity of a patient's effort is based on the repeatability o[ scores obtained over a seri es of measures ( 2 5 ) . For i nstance in the Guides each measure must be within 5 degrees of t h e average of at least t hree measures that are l ess t h an 50 degrees. H t he average is more than 50 degrees, then each measure must be wi thin 1 0% of t h at average. Thus, each measure must be within a certai n standard deviation (SD ) from the mean. Another measure of val idity called the coefficient or variation (CV) has been shown to be even more use­ foul . The CV is obtai ned by divi d i ng the SD by the mean of the scores. The CV range [or i n traobserver goniom etric measurements in the extremities has been shown to be between 4% and 1 0% ( 1 1 , 3 3 , 1 46, 1 47). T h e CVs for lumbar motion are in t he range of 6% to 1 4% ( 1 0 1 , 1 02 ) , with patients havi ng a greater range than asymptomatic individuals ( 1 07 ) . CVs for the cervical spine range are reported t o be up to 5% (29,30,72 ) . Dvir has shown that i n healthy individuals si ncer­ i ty of effort for cervical ROM may be judged from the CV (29). Using the AMA Guides protocol for deter­ m in i ng insi ncere effort in lumbar spine ROM assess­ ment, an u nacceptable rate of false-positives was reported. The AMA guides recommendation regard­ i ng using ROM for determining impai rmellt is con­ sidered i nval id ( 1 73 ) . G i l ford showed that t h e circadian rhythm inOu­ enced flexibi l i ty, wit h muscle length or joint ROM measures are more rel i able in the a fternoon (42). Others have verified this diurnal variation i n lumbar spinal ROM (36, 1 70). Similarly, Porter reported sim­ i lar variance with orthopedic testi ng such as the straight leg raise (SLR) orthopedic test i n which the SLR was round to be tigh ter i n the morning ( 1 27). When performing ROM tests, i t is important to perform each test as preci sely as possible. For exam­ ple, Ekstrand, et al. observed an improvement in the CV from 7 . 5 ± 2.9 to 1 .9 ± -0.7 after using the tests for 2 months and subsequent refinement, paying atten­ tion to the details regard ing ( 3 3 ) : 1 . Standardized i nclinometer placement a nd make sure the pendulum of the gravity type swings freely 2.

Stiffening up the exam i nation table (plywood with Velcro bands)

Chapter Eleven: Quantification of Physical Performance Ability

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23 1

3. Identify bony anatom ical landmarks (mark on skin) 4.

The exam ination bench height was standardized for each visit

The quantity of motion is perhaps of less importance than its quality (85,88, 1 05 , 1 08). Velocity and symme­ try of motion characteristics can be reliably identified with a simple and inexpensive ttiaxial goniometer sys­ tem called a B Tracker ( Iso technologies, H i llsbor­ ough, NC) (85). Marras' (88) more sophisticated and expensive system utilizing t he l umbar motion moni­ tor to monitor three-dimensional k inematics of t he lumbar spine during performance of i ndustrial tasks has been shown to predict future i ndustrial back injury clai m . A novel technique for evaluating relative motion at C7-T1 and T 1 -T2 segments has found that a synchronous pattern of greater mobility at the higher segment is normal and that a non-synchronous or i nverse pattern with greater mobi li ty at the lower seg­ ment is pred ictive of future of neck-shoulder pain i n a 2-year prospective follow-up study ( 1 22). This low­ tech method utilizes skin markings and a flexible tape measure. Table 1 1 . 2 shows t he ROM tests that will be de­ scribed in detail.

Ankle Dorsiflexion Mobility/

Figure

Test •

•

Gastrocnemius Length •

Tightness of the gastrosoleus has been shown to be correlated with i ncreased knee i njury risk in male college athletes ( 3 3,68). This test evaluates the length or tension of the gastrocnem ius muscle and/or t he articulation o[ t he ankle joint ( Fig. 1 1 . 1 ).

•

Patient Position •

Patient stands uprigh t, feet parallel, and knees straight

Table

11.2

Mobil i ty Tests

1 . Ankle dorsiflexion mobil i ty/gastrocnemius and soleus length 2. Knee flexion mobili ty/quadriceps length (Nachlas test) 3. Hip flexion mobility/hamstring length (Straight leg raise test) 4. Hip extension mob i li ty (mod ified Thomas test/psoas-rectus femoris length) 5. Hip rotation mobility ( i n ternal and external) 6. Lumbar spine mobili ty 7. Cervical spine mobility

1 1 . 1 Ankle dorsiflexion mobil i ty/gaslrocnem i us

length.

The inclinometer is positioned above the lateral m al leolus and "zeroed" i n upright standing position The patient leans forward, placing the hands on a wall The tested leg i s moved backwards until a l unge posi tion is assumed and the heel begins to l i ft from the floor; the [Tont knee will be in a flexed position. The subject pushes t he heel down or sl ides slightly forward until the heel is flat on the floor; when t he of max i m u m ankle dorsiflexion i s achieved, the angle is recorded

Quantification •

The normative data reveals 2 2 . 5 degrees

•

Standard deviation (SD) 0 . 7

•

Intra-assay CV 2 . 2%

•

I nter-assay CV 2 . 5 % ( 3 3 ) .

Soleus length/Ankle Dorsiflexion Test

This soleus length/ankle dorsiflexion test ( 3 3 ) evalu­ ates the length or tension of the soleus muscle and/or the articulat ion of the ankle joint (Fig. 1 1 .2). Patient Position •

The patient position in this test is prone.

232

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Part Three: Assessment

•

Intra-assay CV 2.2%

•

I nter-assay CV 2 . 6% (33).

Knee Flexion Mobility/Quadriceps Length (Nachlas Test)

The knee flexion mobi l i ty/quadriceps length ( Nach­ las test) ( 3 3 ) evaluates the length or tension of t he quadriceps femoris muscle and/or the articulation of the knee joint ( Fig. 1 1 . 3 ) . Patient Position • •

•

The patient is prone on table The inclinometer i s posi tioned at the posterior aspect of the m id-calf and zeroed (alternate posi tion is on anterior shin after being zeroed to bottom of table or desk) The pelvis is stabil ized

Test Figure

1 1 .2 Soleus length/ankle dorsiflexion test.

•

•

Test •

•

•

The knee is flexed and t he ankle is dorsiflexed to a maximum angle maintaining heel-to-noor contact Al ternatively, the patient may stand on the non­ tested leg and place the tested foot on a bench and the ankle is dorsi flexed to a maximum angle maintaining heel-to-bench contact The incl i nometer posi tion is the same as the first test (see Fig. 1 1 . 1 )

Quantification •

The normative data reveals 24.9 degrees

•

SO 0 . 8

Figure 1 1 .3 Knee flexion mobi l i ty/quadriceps length (Nachlas tes t ) .

Patient's knee is passively flexed (approximate heel to buttock) The angle is measured at point just before lumbar spi ne begins to extend or hip raises up

Quantification •

The normal angle equals 1 47 . 9 degrees

•

Standard deviation of 1 . 6

•

I ntra-assay CV (%) 0.5%

•

I nter-assay CV (%) 1 . 1 (33)

Hip Flexion Mobility/Hamstring Length­ Straight Leg Raise Test (SLR)

The hip flexion mobili ty/hamstring length-straight leg raise test (SLR) (33 ,40, 1 65) evaluates the length or tension of the hamstring muscle and/or the artic­ ulation of the hip joint ( Fig. J 1 .4).

Chapter Eleven: Quantification of Physical Performance Ability

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233

tremi ty was correlated wi t h future L BP i n col lege athletes ( 1 1 3 , 1 14) . The mod i fied Thomas test eval u ates t he range of motion of t he h i p and/or t he length or tension of t h e hip flexor muscle group ( i l iopsoas muscle) ( Fig. 11 .5). Patient Position •

•

Figure

1 1 .4 H i p nexion mobili ty/hamstring length .

Slraight leg raise lesl (SLR).

Patient Position •

The pat ient lies supine on a firm table and the i ncH nometer is placed just superior to the patellae (or al ternatively on m id-tibia or strapped to lower leg with Velcro) and then zeroed

•

•

The patient's calf is placed i n the crook of the doctor's el bow or rests i n the doctor's hand The patient's hip is flexed wi t hout permi t ting any knee Jlexion to occur

The knee and h i p are flexed and the knee is drawn up tight to t he c hest to eliminate l u mbar lordosis and the patient is lowered to a supine position mai ntai n i ng the knee-to­ chest position

Test •

•

•

Test •

The patient perches at the end of bench i n a manner where t he ischial tuberosities are supported on the end of the table's edge

•

The inclinometer is zeroed to the horizontal of the table top The leg bei ng tested is allowed to extend towards the floor and hang freely fu lly relaxed The knee should be brough t to the chest to ful ly remove the slack and flatten the l umbar lordosis firmly to the table Place the i n c l inometer on the an terior thigh just below the ASIS. Record the angle when tested leg is fully relaxed, hip extended, and t he lumbar lordosis is removed

The angle is recorded j ust before pelvic movement or knee flexion

Quantification •

Normal ROM is 70 to 90 degrees (use 80 degrees as the mean for patient comparison)

Hip Extension Mobility/Psoas-Rectus Femoris Length (Modified Thomas Test)

This tests tigh tness i n the i l iopsoas ( 3 3 , 1 65), which has been shown to be correlated with i ncreased knee i nj ury risk in male college ath letes ( 6 8 ) . Reduced ROM i n h i p extension has been reported fTequent ly in LBP subjects (69, 16 1 , 1 65). Preli m i ­ nary data from McGill suggest t h a t decreased h i p extension mob i l i ty may b e predictive of d i sabl i n g LBP ( 104 ) . Van D i l lon reported t h a t chronic L B P subjects h ad less passive h i p extension R O M t h a n asymptomatic subjects ( 1 6 1) . Studies i n adoles­ cents have documented t hat future episodes of L B P are correlated w i t h decreased h i p extension R O M (69, 1 6 1 ) . Some controversy exists, however, because Nadler reported t hat hypermobil i ty in the lower ex-

Figure

1 1 .5 H ip extension mobil ity/psoas-reclus femoris length ( m od i fied Thomas lesl).

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Part Three: Assessment

Quantification •

The normative data is 6 . 5 degrees

•

SD 1 . 1

•

Intra-assay CV 0.7%

•

In ter-assay CV 1.2% ( 1 65 )

Al terna ti vely, E ks trand publ i shed the following met hod (33). Patient Position •

Patient l ies supine with the knees straight on the bench

Test •

•

•

Place the incl i nometer 5 cm above the patella on the lateral t high and set to zero The leg being tested is passively flexed to 90 degrees using the ini tial inclinometer o degrees reading and the inclinometer reset to zero

•

The normative data is 8 3 . 5 degrees

•

SD 1 . 1

•

Intrassay CV 0.7%

•

In terassay CV 1 . 2% ( 3 3 )

Note A qualitat ive screen for the hip flexors can also be performed to di fferentiate muscle tightness in the iliopsoas from the rectus femoris (RF) (see chapter 1 1 ) ( 1 4 ).

•

•

Patient Position •

• •

Hip flexor muscle group tightness exists if the extended leg fails to reach horizontal ( has <0 degrees hip extension ROM) RF is tight i f knee has < 90 degrees flexion passively or < 1 1 0 degrees flexion with over­ pressure when the h i p is maintai ned i n o degrees extension Ili opsoas i s tight if hip does not achieve degrees extension when leg is tested with RF slackened by extending the knee

The patient lies prone with non tested leg i n 30 degrees abduction and tested leg at 0 degrees abduction The pelvis i s firmly stabilized The patient's knee is placed in 90 degrees flexion so that sole faces the cei l i ng

Test •

•

•

The rest of the test is the same as the last three steps desclibed previously

Quantification

•

that b i lateral loss of h i p i n ternal rotation is associ­ ated with LBP, whereas a uni lateral restriction is associated with signs of sacro-il iac i nvolvement (20) ( Fig. 1 1.6).

The i nclinometer is placed on the distal tibia i n the frontal plane and zeroed The hip is passively internally/externally rotated until opposite pelvis starts to move ( usually rises upwards) The measurement is taken j ust before the opposi te pelvis rising upwards and the angle is recorded

Quantification •

•

The normal range is 38 to 45 degrees in ternal rotation The normal range is 35 to 45 degrees external rotation

Note •

•

•

The AMA Guides to the Evaluation of Permanent Impairment test hip rotation supine, w i t h knee extension and no pelvic stab i lization ( 2 5 ) The hip ROM may also be tested in seated position A supine test with the hip and knee flexed at 90 degrees may be used to estimate mobility o

This will also al low [or test i ng of hip capsule i ntegrity (capsular dys[-u nction presents with pain i n i n ternal rOlation in this position)

o

•

Tensor fascia lata (TFL) is t ight if thigh abducts [Tom a neutral position when being tested

Hip Rotation (Internal and External) Mobility

Decreases in hip in ternal rotation have shown correla­ tion to LBP (20,32,33, 1 17, 1 1 8 , 132). Cibulka reported

Lumbar Spine Mobility

With lumbar spine mobil ity (93,98, 10 1), there is con­ troversy ovel' t he accuracy of spinal range of motion because of i ntrinsic and extrinsic operator error ( 100, 1 0 1 ) . Thus far, the most accepted "low-tech" assessment method for measuring spinal range of motion is the use of dual i ncli nometric ROM assess­ ment ( 1 00). The clinical significance in non-acute

Chapter Eleven: Quantification of Physical Performance Ability

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235

A

B

Figure

1 1 .6 Hip rotation ([A] i n ternal and [B] external) mobility.

patients of reduced mobili ty is controversial. Gronblad found that t here was a lack of significant correlation between spinal mobility and either self-report of activ­ ity i ntolerances (Oswestry) or pain i n tensity (46). This was particularly true for sagittal plane motions such as trunk flexion. However, asymmetry i n lateral flexion may be correlated (46). Biering-Sorenson found that increased trunk flexion mobil i ty not hypomobility pre­ dicted future LBP in men (5). I t has also been recently reported that patients with spondylolisthesis tended to be hypermobi le, whereas those with spinal stenosis, disc prolapse, or degenerative disc disease tended to be hypomobile ( 1 05).

Lumbar ROM and Functional Ability are not Correlated in LBP Individuals

Subjects: chronic LBP patients M ethods: a three-di m ensional l umbar motion moni tor and 4-hour functional battery i ncluding isometric and dynamic pull/pull, carry, and l i ft i ng assessments. Results: Weak or nonexistent correlation between ROM and functional ability Parks KA, Crichton KS, Goldford RF, McGill SM. A compari­ son of lumbar mnge of motion and functional ability scores in patients with low back pain. Spine 2003;28:380-384.

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MoffToid demonstrated that i f patients are clustered i n to subgroups, an i nflexibili ty group can be identi­ fied (109 ) . A problem with many scienti fic studies is that non-specific back pain patients are considered one large homogenous group. This leads to the i ncor­ rect conclusion based on statistical evidence that parameters suc h as mobility are not relevant. How­ ever, it has been poi nted out that such large groups should be considered heterogenous with many small subgroups within them (70) . I f subgroups are not stud­ ied independen tly then a cli nical variable such as decreased mobi l i ty will be mistakenly concluded to be uni mportant. Flexion (erector spinae flexibility) (Fig. 11.7A)

•

" Note: If t he tigh test SLR exceeds the sum of the sacral h i p motion measured in flexion and extension by more than 15 degrees, t he lumbosacral flexion test is i nvalid ( 2 5 ) . Extension (Fig. 11.7B)

Patient Position •

The patient stands with the knees straight and feet sligh tly apart.

The starting position is the same as for flexion

Test •

Patient Position •

I f the hamstrings are tight patient may bend knees

The patient is requested to extend maximally, and the angle is recorded

Lateral Flexion (Fig. 11.7e)

Patient Position Test •

•

•

A "warm-up" of several repetitions in each direction is recommended after which time the measurements can be calculated The incli nometers are placed on the sacral apex and T12 spinous process (use skin marking penci l ) and are oriented vertically The incli nometers are zeroed and patient is requested to flex maximally and the new angle is recorded

Figure

1 1 .7 Lum bar spine mobility. (A) Flexion (ereclor spinae nexibilily). (B) Exlension. (C) Laleral nexion.

•

•

The starting posi tion is the same as [or flex ion The incli nometers are oriented horizontally

Test •

•

•

The patient is requested to side bend maximally to the right/left To minimize rotation patient is i nstructed to slide fingers along the side of thei r leg The angle is recorded

Chapter Eleven: Quantification of Physical Performance Ability

Figure

1 1 .7 (Continued)

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237

238

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Part Three: Assessment

Quantification (93, 98)

•

The normal range is as follows:

•

Trunk flexion 65 degrees Trun k extension 30 degrees

•

Trunk lateral flexion 2 5 degrees

•

Lateral Flexion (Fig. 11.BB)

Patient Position •

Cervical spine mobility (97, 171)

Flexion/Extension (Fig. 11.BA)

Patient Position • •

The patient s i ts erect i nto t he chair back The inclinometers are placed a t Tl and t he other on the occiput (or strap to head with Velcro strap)

The patient i s requested to extend neck maximally and the angle is recorded

The patient position same as flexion/extension and t he i nc l inometers are placed in the frontal plane at the same bony landmarks, occiput , a n d T1

Test •

The patient is instructed to side-bend maximally to the left and right and the angles are recorded

Rotation (61) (Fig. 11.BC)

Position Test •

•

The patient is requested to flex neck maximally and angle the i s recorded

Figure

1 1 .8 Cervical spine mobil i ty. (A) Flexion/extension. (B) Lateral flexi o n . (C) Rotation.

Accord ing to the AMA protocol, this i s tested this supine w i t h only one gravity incli nometer

Chapter Eleven: Quantification of Physical Performance Ability

Figure

239

1 1 .8 (Continued)

Test •

-

The supine patient rotates head fully and angle is recorded

Quantification (98 ) The normal range is as follows: •

Cervical flexion 50 degrees

•

Cervical extension 63 degrees

•

Cervical l ateral flexion 45 degrees

•

Cervical rotation 85 degrees

Shoulder Mobility

Rel iabi l i ty of upper quarter ROM tests has not been studied as extensively as it has i n the spine or lower quarter. However, it is a necessary part of t he clini­ cal exa m i nation to c heck for asymmetrical ROM,

240

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Part Three: Assessment

obvious l i m itations, and mechan ical sensItIvItIes there. In particular arm abduction , flexion, i nternal rotation, and external rotation ROMs are i mportant to observe. Gon iometric assessment of shoulder flex­ ion and abduction has been shown to be reliable for both passive and active ROM testing i n either the sit­ ting upright or supi ne positions ( 1 39 ) .

Strength/End urance Introduction

Gronblad reported that t here i s a higher correlation between strengt h/endurance tests and activity i n tol­ era nce or pain in tensity than with mobi l i ty tests (46). Endu rance testing in particular has been shown to be prom isi ng. Decreased endurance of the tru n k extensors has been shown not only to corre­ late with pain (5,74 ,121) but also to predi ct recur­ rences (5) and chronicity (35), as wel l as first-time onset o f epi sodes i n healthy i n dividuals ( 81 ) . One study has disputed that t h i s test correlates w i t h low back trouble ( 1 56 ) . T h e test, if performed i n the man ner described b y Biering- Soren sen, has been shown to be reliable in various populations­ asym ptomatic ( 7 4 ) , symptomati c (1 1 0) , and t hose with a his tory of L BP ( 7 4 ) . One study clai med the test was u n reli able, but a small sample ( 1 2 subjects) and a di fferen t procedure using a Roman Chair was u t i l ized ( 9 9 ) . I t h a s also been found t h a t reduced endurance of the deep neck flexors has been correlated wit h neck pain after whi plash or concussion (4,63, 1 44 , 1 57, 1 67). Normal rat ios of tru n k flexor, extensor, and side support m uscles h ave been estab li shed (103 ) . A re­ duced ralio of trunk extensor to flexor strength/ endurance discri m inates between LBP patients and con trol subjects. The normal ratio is approximately 1.3: 1 , with the extensors bei ng stronger (94,95). N adler et al. demon strated that hip m uscle i m ­ balance is assoc iated both retrospect ively and prospec ti vely with LBP i n female ath letes ( 1 1 4 , 115). In part icular, asymmetric hip extensor strength was significantly correlated with LBP i nc idence. Those with LBP had a 1 5% strength i m balance com pared wi t h only a 5.3% i mbalance i n those wi thout L BP. This same asym metry was not found i n male at hletes, but i t i s i n teres t i n g to note t h at N a tional Collegiate Athletic Association I nj u ry Surve i l lance Data from 1 997 to 1 998 s howed t hat female ath letes were almost twice as l i kely as m ales to have L BP develop ( National Collegiate 1 997- 1 99 8 ) . Other consistent fi ndi ngs i nclude i ncreased fatiga­ b i l i ty of the glu teus m ax i m u s in i n d ividuals w i t h c h ronic L BP ( 65,75).

It is known that trunk strength is related to effort. It has been suggested that preferential motion that is submaximal is a preferred mode of testing (7). The extent to which strength measurements can di fferen­ t iate maximal (sincere) performance from feigned performance has been studied extensively. Consis­ tency of effort as determined by the CV is significantly higher i n feigned weakness as opposed to maximal performance; however, the sensitivity and speci ficity of t he measures have not been shown to be h igh enough be considered medico-legally valid (26-28,48, 77, 1 46). Two studies compared the performance of physical capacity tests to t he nonorganic signs (22,52 ) . Using l u mbar dynamometry to measure strength , Cooke and colleagues demonstrated that patients with three or more Waddell Signs had lower performance values than t hose with two or less. Similarly, Hirsch et al reported in a 5-week or greater LBP sample of 85 men aged between 18 and 60 years old, physical perfor­ mance was significan tly poorer when three or more Waddell signs were present. Table 1 1 . 3 shows the strengt h/endurance tests that are described in detail.

Squat Endurance Tests

Repetitive Squa t Test (1) (Fig. 11.9)

Patient Position •

Standing with feet 15 cm apart.

Test •

•

The patient squats until thighs are horizontal and retu rns to upright position The speed is approximately 2 to 3 seconds/repeti tion

Table 1 1 . 3

Strength/Endurance Tests

1. Squat endurance test a. Repetitive b. Static 2. Trunk flexor endurance tests a. Repetitive sit-up endurance test b. Static quarter sit-up endurance test c. Isometric trunk flexor endurance 3. Side bridge tests 4. Static trunk extensor endurance test a) Sorensen b) Back Strong c) Ito variation 5. Grip strengt h

Chapter Eleven: Quantification of Physical Performance Ability

Figure

Static Squat Test (106)

The patient continues until unable, pain i n knee or back becomes signi fican t , or 50 repeti tions are ach ieved

Patient Position •

Quantification ( 1 )

•

Count number or repet it ion Normals: The following chart is used to determine the normal for L he subject being evaluated (Table 1 1 .4).

Table 1 1 .4

24 1

1 1 .9 Repet itive squat endurance test.

Termination Criteria •

--

Head , shoulders, and bu ttocks against a 90-degree wall Feet far enough away from t he wall Lo allow h i ps, knees, and ankles to flex Lo 90 degrees w i t h the k nees not pass ing i n fronL of the toes .

Repet itive Squat Test Normative Data (1) Males ( n=242) White Collar

Blue Collar

Age

Females

White Collar

Blue Collar

All

(n=233) All

X

SD

X

SD

X

SD

X

SD

X

SD

X

SD

35-39

39

13

46

8

42

12

24

11

27

12

26

12

40-44

34

14

45

9

38

13

22

13

18

8

20

12

45-49

30

12

40

11

33

13

19

12

26

13

22

13

50-54

28

14

41

11

33

14

13

10

18

14

14

11

35-54

33

14

43

10

37

13

20

12

23

12

21

12

x

Average SD Standard deviation Note: The last row represents the average or all the ages (35-54) =

=

242

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Part Three: Assessment

Test •

•

•

•

•

Instruct the subject to slide down the wall un til the h i ps, knees, and a nkles are flexed at 90 degrees.

Table 1 1 .5 Age

Static Squat Test Normative Data (106) M a l es

Females

19-29

Mean 99.454 N = 98 SD 45 .201

Mean 92.607 N = 97 SD 64.202

Instruct the subject to breathe normally duri ng the test .

30-39

Record t h e duration i n seconds that the subject is able to sustain the wall squat posi tion.

Mean 103 .51 N = 75 SD 72.179

Mean 87.646 N = 69 SD 63.621

40-49

Mean 94.855 N = 42 SD 64 .071

Mean 55 .653 N = 43 SD 44. 891

50-59

Mean 96.226 N = 34 SD 104 .30

Mean 47.392 N = 38 SD 47.26 1

60+

Mean 45 .204 N = 23 SD 2 7 .081

Mean 39.059 N = 29 SD 3 5 . 830

Instruct the subject to sustain the pos i tion for as long as possible.

Normative data are shown in Table 1 l . 5 .

Termination Criteria •

•

Subject is unable to assume the starting position. Subject is no longer able to mai ntain the wall squat posi tion.

•

Subject term inates the test.

•

Subject refuses to attempt t he test

Trunk Flexor Tests

and then curls back down to t he supine position at 2 to 3 seconds/repetition

Repetitive Sit- Up Test (1) (Fig. 11.10)

Patient Position •

Termination Criteria

Supine, knees flexed 90 degrees, ankles fixed.

Test •

The patien t sits up until the thenar pad of the hand touches the superior pole of the patella,

Figure

•

Count t he total number of repetitions achieved up to a maximum of 50

The normative data for trunk strengt h segregated by age, sex, and occupation are i n Table 11.6 (1).

1 1 . 1 0 Repetitive sit-up endurance test.

Chapter Eleven: Quantification of Physical Performance Ability

Table 1 1 .6

-

243

Repeti tive Sit-Up Test Normative Data (1) Females (n=23 3)

Males ( n=242) White

Blue Collar

Age

White

Blue Collar

All

Collar

All

Collar

X

SD

X

SD

X

SD

X

SD

X

SD

X

SD

35-3 9

29

13

35

13

32

13

24

12

30

16

27

14

40-44

22

11

34

12

27

13

18

12

19

13

19

]2

45-49

19

11

33

15

24

14

17

14

22

15

19

14

50-54

17

13

36

16

23

16

9

10

20

13

11

11

35-54

23

13

35

13

27

14

17

13

24

15

19

14

X = AVERAGE SD = Standard deviation

Static Qua rter Sit- Up (1 06)

•

Patient Position •

•

•

Supine lyi ng o n a n exercise mat, with knees flexed at approxi mately 90 degrees and heels in contact with the floor. Arm straight and parallel to spine, palms of hands in contact with the mat Head in contact with the mat

•

Subject's feet do not main tain contact with the floor. Subject terminates the test.

Isometric Trunk Flexor Endurance Test (103) McGill and colleagues establ ished normative data for a heal t hy, youn g group of males and females for a simple curl -up test (Table 11. 8 ) . This test requi res a wedged piece of wood or thick foam to support the patient at a fixed angle of 50 degrees. (see Fig. 32 .17)

Test •

•

•

•

•

•

Measu re a distance of 12 em ( 8 em if the subject is older than 40) fyom the caudal edge of the mat. At the fingertips of the subjects, attach two strips of tape to the mat at right angles to the trunk. Instruct the subject to raise the head and shoulders by sliding the pal ms forward from the tape until the fingertips touch the end of the mat. Instruct the subject to main tain the partial sit­ up posit ion [or as long as possible. I nstruct the subject to breathe normally during the test. Record the duration i n seconds that the subject is able to sustain the partial sit-up posi tion. The normative data are shown in Table 11. 7 .

Table 1 1 .7 Static Quarter Sit-Up Normative Data ( i n seconds) (106) Males

Females

19-29

M ean 72.6 N = 98 SD 67.3

M ean 66.9 N = 97 SD 54 . 7

30-39

Mean 73.2 N = 75 SD 7 3 .1

Mean 68.9 N = 69 SD 66.0

40-49

Mean 77.8 N = 42 SD 89.3

M ean 70.0 N = 43 SD 86.3

50-59

Mean 94.1 N = 34 SD 12 9.4

M ean 55.0 N = 38 SD 57.1

60+

M ean 54.9 N = 23 SD 75.6

Mean 55.0 N = 29 SD 97.9

Age

Termination Criteria • •

Subject is unable to reach the end of the mat. Subject is u nable to sustain the partial si t-up position.

244

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Part Three: Assessment

Table 1 1 . 8

McGi l l's Side Bridge, Trun k Flexor, a n d Trun k Extensor E ndurance Normative Data ( 1 03) Women

Men

Mean

SD

Ratio

1.0

177

60

1 .0

99

0.79

147

90

0.86

72

31

0.38

81

34

0.47

77

35

0.40

85

36

0.5

Mean

SD

1.0

189

60

76

0.99

149

94

34

0.64

97

35

0.66

Mean

SD

Ratio

Extensor

146

51

Flexor

144

Side bridge, righ t Side bridge, left

Task

Both knees and h ips are flexed 90 degrees

•

Arms are folded across chest

•

Toes are anchored ei t her with a strap or by t he tester

•

•

Test • •

The support is pulled back 10 em (4 i nches) The subject holds the isometric posture as long as possible

Termination Criteria •

When any part of the subjects back touches the support

The mean endurance for you ng healthy men and women is 134 seconds, with standard deviation ( SD ) of 7 6 (Table 1 1. 8 ) . T h e ratio o f t runk flexor to exten­ sor endurance i s 0.77 normally (0.84 i n you ng males and 0.72 in young females).

Side Bridge (1 03)

The side bridge endurance test is illustrated in Figure 11.11.

Ratio

bendi ng. It should be held in a l i ne with a long axis of the body supporting the weight between t he feet and elbow.

Patient Position •

All

Subject statically maintains this elevated posi tion I f the subject is fatigued and drops part-way, give one additional cue to raise t he spine back up

Termination Criteria •

Subject is unable to l i ft body up from the floor

•

Subjects thigh touches the floor

•

•

The second time t he subject drops the pelvis or t h igh part way fTom t he start i ng heigh t Sign i ficant LBP causes t he test to be stopped

Quantification The mean endurance for young healthy men and women is 84.5 seconds, wi th a SD of 34.5 (103 ) . The ratio of right side bridge to left side bridge endurance is normally 0.96 (103 ) . Accordi ng to McGill, a side to side d ifference of greater than 0.05 suggests unbal­ anced endurance (104) . The side bridge-to-extensor endurance ratio is normally 0.49 (103 ) . See Table 11. 8 for t hese comparative data.

Patient Position •

•

•

The subject lays on one side supported by the pelvis, lower extre m i ty, and forearm (elbow bent with hand facing forward) The top leg is placed i n fron t of t he lower leg with both feet on the floor The upper arm is placed against the chest with t he hand touchi ng t he anterior lower shoulder

Static Trunk Extensor Endurance Test

Sorensen Test (1, 5) (Fig. 11.12)

Patient Position •

•

Test •

The pelvis is raised off the table as high as possible so long as the spi ne is not side-

Prone with the i nguinal region/anterior superior i l i ac spine (ASIS) at the end of the table. Arms at sides, ankles fixed (by strap or hands), holding horizontal posi tion. o

Plump l ine can be used to ensure horizontal position

Chapter Eleven: Quantification of Physical Performance Ability --

!

245

" o

I I

\

Figure

1 1 . 1 1 Side bridge endurance test.

dropping below horizon tal a second time, t he duration is recorded

Technique •

•

•

The patient maintains t he horizontal position as long as possible Timing begins when horizontal and unsupported Subjects are verbally encouraged to hold this position as long as possible

Termination Criteria •

•

Time t he duration the position can be held, up to a maximum of 240 seconds If patient drops below t he horizontal position, give one additional chance to regai n i t . But on

•

I f t he patient reports low back pain or cramping in the legs, t he test may be stopped and t he ti me recorded

Quantification See Table 11.9. A dynamic variation on t h is test is the repet i tive arch-up test (1). I n a prospective study of Finnish workers between the ages of 30 and 65 years, reduced repetitive trunk extensor endurance s trong­ ly correlated w i t h an i ncreased risk of work disabil­ i ty caused by c hron ic back disorders over a 12-year period (13 6 ) .

246

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Part Three: Assessment

Figure

1 1 . 1 2 Static trunk extensor endurance. SOl-e nsen test. Reproduced with per­ m ission from Yeomans S. Clinical Appl ication of Outcomes Assessment. I n : Yeomans S, cd. Stamford , CT: Appleton and Lange, J 999.

Variable Angle Roman Chair Isometric Extensor Endurance Test ( 1 63) (Fig. 1 1 . 1 3)

Trunk

•

•

Patient Position •

• •

•

•

Angle on variable angle Roman chair ( Back Strong) u n i t set at 0 degrees ( hori zontal) •

Posit ioned with ASIS aligned to the superior edge of the pelvic restra i n t pad Subject's an kles are positioned under the ankle pad

When torso drops 1 0 degrees below horizon tal, the t ime is recorded in seconds

Ito 's Trunk Extensor Endurance Test (58): Ito et al. reported a rel iable assessmen t of the low back extensor endurance strength that can be used as an alternative to the static back endurance (58). The Ito test is a timed test performed by instructing the prone subject lying on a pelvic pillow to fu lly flex the cervical spine and con tract the gluteal muscles to

Legs held as straight as possible

[ nstruc ted to elevate torso to a position horizontal to the f]oor

Table 1 1 .9

Subjects are verbally encouraged to hold this posi t ion as long as possible

Tennination Criteria

Subject keeps hands a t sides

Test •

T i m i ng begins when horizon tal and unsupported

Static Trunk Extensor Endurance-Sorensen Test Normative Data ( 1 ) Males (n=242)

Age

Blue Collar

Females (n=233)

White Collar

Blue Collar

All

White Collar

All

mean

SD

mean

SD

mean

SD

mean

SD

mean

SD

mean

SD

3 5-39

87

38

1 13

47

97

43

91

61

95

48

93

55

40--44

83

51

1 29

57

1 01

57

89

57

67

51

80

55

45--49

81

45

13 ]

64

99

58

90

55

122

73

102

64

50-54

73

47

121

56

89

55

62

55

99

78

69

60

3 5-54

82

45

123

55

97

53

82

58

94

62

87

59

Chapter Eleven: Quantification of Physical Performance Ability

Figure 1 1 . 1 3 Slack l runk extensor endurance. Back Slrong Sorensen adaptalion pholO, permission of Back Slrong Inlernational.

stabi lize the spine, and extend the tru nk so that it is i n l i ne with the pelvis. L i ke the Sorenson test, the I to test has been reported to be able to discri m i nate between subjects with and without low back pai n (58, 1 09). The normative data ror the Ito test is shown in Table I Ll O.

Grip Strength

Grip strength ( 1 53 ) dynamometry is primarily used to evaluate upper extrem i ty strength of the grip ( Fig. 1 1 . 1 4 ). I t can be used to evaluate motor function in cervical nerve root compression or carpal tunnel syn­ drome or as a general evaluation for fitness. In heal thy 45- to 68-year-old men studied in the Honolulu Heart Program, grip strength was Found to i ndependently

Table 1 1 . 1 0

Figure

--

247

1 1 . 1 4 Grip strenglh.

predict future f-u nctional i ndependence at a 25-year follow-up ( 1 3 1 ). Classically, this test is perrormed in a sitting or standi ng posi tion with the test elbow flexed 90 degrees. However, allowing the patient to locate a pain-free arm position i f the 90-degree elbow-f1exed position is pa i n fu l can avoi d a " false-pos it ive" test caused by p a i n - i n d uced weakness. A J a mar hand dynamometer was used i n the normative data study (153 ) . Therefore, it is i mportant to evaluate and cali­ brate non-Jamar dynamometers to a Jamar standard i f the normative data tables are needed. Patient Position • •

Seated There are five handle posi tions on a J amar gri p dynamometer, of which the second

Ito's Prone Trunk Extensor Endurance Test Normative Data (58) Healthy

Extensor Endurance

CLBP

Males

Females

Males

Females

208.2 66.2 ( .97)"

12 8.4 53.0 ( .94 )'"

85.1 55. 6 ( .93)"

70. 1 5 1 . 8 ( . 95)'"

"'The test-retest correlation (r). CLBP = chronic low back pain The mean endurance streng/h of /he flexor and extensor trunk muscles a re reported with the corresponding tes/-retest corre­ Ia/ion (r) values. All tes/-retes/ correlatiol1s {or bOlh groups for the corresponding endurance measure men/s were signifi­ call1ly high (p < 0. 01).

248

--

Part Three: Assessment

(4 cm) or third posi tion (6 cm) is the strongest and, therefore, most often used, depending on hand size. Test •

•

The patien t is i nstructed to squeeze t he grip as hard as possible This is repeated two additional times with verbal encouragement to make a maximum effort

Quantification ( 1 53) •

•

The average of three readings are taken and considered normal i f the scores are within 20% of each other, usually switching between the left and right hands for each of the three repetitions. U there is a 20% or greater variation i n the

three readings, differentiation between ful l effort (i .e. , psychosocial issues) versus pain­ induced weakness is necessary (153 ) . •

Most commonly, the normal upper extremity is compared to the abnormal and, therefore, there is no reason to use normative data unless bilateral u pper extremi ty problems exist (25,153 ) .

Balance/Motor Control Introduction

M otor control is considered to be essential to spine stabil i ty. I t is bel ieved to be more i m portant than strength. Mannion suggests new aspects of physical f·unction relating to motor control should be i nvesti­ gated as a possible cause of the approximately 50% of disabling pain that is unaccounted for by psycho­ logical, structural, or voluntary performance measures (87). These i nclude t hose i nvolved i n non-voluntary reflex control of movement such as position sense, delayed reaction times, and balance tests ( 87,104). Ki nesthetic awareness of position sense (13 ,43, 119,155) has been shown to be compromised i n LBP individuals and neck pain patients (51, 80,13 3 ) . This is the abi l i ty to reproduce positions i n space and is called reposi tioning ability or error. Al tered reaction ti mes of muscles has been corre lated with L BP (53 ,54,82 ,84,129,130,154,16 8 ) . Work at Yale U niver­ s i ty demonstrated a slow reaction time, i ncreased activation, and slow relaxation after u nexpected pert urbations (12 9 ,130). Finnish researchers have reported that anticipa ted loads to the arms i n un­ supported standing resu l t i n delayed reaction t i mes in patients with c hron i c sciatica but not in heal t hy con trol subjects ( 76 ) . Austral ian researchers have

reported that a delayed activation of the transverse abdom inus muscle during arm or leg movements has been found to distinguish LBP patients fTom normal subjects (53,54 ) . Finnish scient ists have reported that reaction t imes to visual stimuli have been shown to be slower in chronic LBP patients than in asymp­ tomatic i ndividuals (83,84). I n coordination i s correlated with LBP (2 ,55,56, 45,124) and neck pain ( 31,62 ,63 ,116) . O'Su ll ivan foun d that an i ncreased ratio of rectus abdom inus to transverse abdomi nus/obJ ique abdominal activation i s correlated with L BP (12 3 ) . Control subjects were able to preferentially activate i nternal oblique and transverse abdomi nus muscles wi thout signi fican t rectus abdomi nus activation. LBP patien ts could not do this. Nedherhand found that a decreased abil ity to relax the upper trapezius muscles during static tasks and after exercise disti nguished between chronic whiplash-associated d isorder (WAD) classi fication I I patients and healthy con trol subjects (116). Sterli ng et al reported that WAD II or III patients evaluated w i t h i n 1 month of injury had i ncreased EMG activi ty of superficial neck flexors (SC M ) dur­ ing performance of the cervico-cranial flexion test than asymptomatic control subjects (151) . Jull et al has reported similar resu lts in both WAD and i nsidi­ ous onset neck patients (64). Balance defi c i ts have been demonstrated to be related to L BP (15,83,111,156) . Byl showed that excessive an terior to posterior body sway on an unstable surface or poor single leg standi ng balance ability is correlated with LBP (15). Mok et al demon­ strated t hat L BP patien ts had poorer balance than age- and gender-matched controls when vision was removed or a smaller base of su pport was used (111). Poor balance was correlated with future LBP by Takala (156) . Table 11.11 shows the motor control tests that are described i n detail.

One-Leg Standing Balance Test

The one-leg standing balance test (3,10,15,16,17) is i l lustrated in Fig. 11. 1 5) . Patient Position •

Standing

Table 1 1 . 1 1

Balance/Motor Con trol Tests

1. One-leg standing balance 2. Prone abdominal hollowing cuff test 3. Cervi co-cranial flexion test of Jull

Chapter Eleven: Quantification of Physical Performance Ability

--

249

Figure 1 1 . 1 5 One-leg standing balance test. (A) Eyes open-preparation (B) Eyes c losed-test

Test •

•

•

•

•

The patient stands on one leg with the opposite leg flexed at the hip and knee. The patient should be i nstructed to fix their gaze at a point on the wall directly in fyont of them . The patient s hould practice with eyes open once [or up to 1 0 seconds.

Abdominal Hollowing (Cuff Test)

The Prone Abdominal Drawing-In Test or Abdominal Hollowing Test ( 1 34) is Shown in Figure 1 1 . 1 6.

Patient Position • •

They should then attempt to balance as long as possible on one leg with eyes closed for up to 30 seconds. The subject may repeat the test up to a maximum of five times in an attempt to reach t he 30-second target successfully. If the subject can stand for 30 seconds on t he first eyes­ closed attempt, t hey may discon tinue t he test.

•

Prone Feedback u n i t is placed under abdomen with navel i n the center and distal edge of the pad i n l i ne with right and left an terior superior i liac spines Pad i n flated to 70 mm Hg

Test •

Breathe in and ou t, and then without breathing in to slowly draw the abdomen i n so

Termination Criteria •

Reach i ng out

•

Hopping

•

Putting foot down

•

Touching foot to weight-bearing leg

Quantification •

•

The best score w i t h eyes closed for each leg should be recorded. The normative data are shown i n Table 11.12.

Table 1 1 . 1 2 Si ngle-Leg Stance Eyes Closed Normative Data ( 1 0)

Eyes Open (seconds)

Eyes Closed (seconds)

20-59

2 9-30

21-2 8 . 8

60-69

22.5

10

70-79

14.2

4.3

Age (years)

250

--

Part Three: Assessment

•

•

If the movement occurs wi th head retraction or l i ft i ng of the head, t hen passively model the appropriate movemen t . Active assistance, l arge ampl i tude movements, or eye movements may also be used. I f the pattern is inadequate, then delay formal testing. When the patient can actively perform the noddi ng movement with cervico-cran ial flexion they can proceed to t he test.

Patient Position •

Supine with head in "neutral" position so that head is not extended on the neck or chin j ut t i ng forward Use a small fol ded towel to al ign head i f necessary The towel should be placed under the occiput and leave t he cervical spine [Tee Place an inflatable cushion (Stabil izer™ , Chattanooga South Pacific) under t he neck suboccipi tally to support it without push ing it up o

o

•

Figure

1 1 . 1 6 Prone abdominal hollowing test. Drawing-in from 70 m m Hg to 66 m m Hg

• •

it l i fts off the pad (draw abdomen away from waistband of pants) • •

•

•

•

Don't change spinal posi tion Then breath normal ly without losing the drawing i n maneuver Try for a few repetitions to be sure the patient has given i t their best shot Perform ] 0 ti mes

•

Fail if more than 10-m m Hg decline in cuff pressure or less than 4-mm H g drop i n cuff pressure during 10-second hold (a 4- ] O-mm Hg range is acceptable) Fail if thoraco-lumbar hypertonus, l umbar extension, posterior pelvic tilt, or breath holding occurs

•

•

•

•

Pre-Test Routine •

•

The pressure cuff dial is turned towards t he patient and t he patient should confirm that that they can see t hat the dial is set to 20 mm Hg. The patien t i s i nstructed to place the tongue on the roof of t he mouth Uust behind t he fron t teeth), l ips together but teeth sligh t ly separated ( this i n h ibits the jaw depressors , hyoid or platysma). The patient is asked to gen t ly nod to a target of 22 mm Hg on the cuff and to hold the needle steady for 5 seconds while breathing norm al ly I f successful, the patient is instructed to relax back to 20 m m Hg again and then perform the chin nod movement to 24 m m Hg I f the patient does not return to 20 mm Hg, t he c l i n ician can reposition the head to achieve t he 20 mm Hg starting poi nt. This is repeated until a maximum of 30 mm Hg i s achieved o

Supine patient with knees bent and feet flat (crook lying) Ask patient to move t heir head as i[ noddi ng "yes" (cervico-cranial flexion)

Re-in flate and repeat the gentle squeezing a few times until the pressure stabilizes at 20 m m Hg

1st phase

Cervico-Cranial Flexion Test of Jull

This test (62,63) is i l lustrated in Figure 1 1 .17.

Gently squeeze the sides of the bag to distribute t he air-the pressure should decrease

Test

Quantification •

Inflate the bag to 20 m m Hg

•

Chapter Eleven: Quantification of Physical Performance Ability

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25 1

Figure 1 1 . 1 7 Cel-vico-cranial flexion test of Jull. (A) I ncorrect head/neck al ignment (B) Correct head/neck alignment (C) Begi nning position with stabi l i zer cuff inflated to 20 m m Hg (D) Successful nodding motion to 28 m l11 Hg

Quantification •

•

The abi l i ty to target and hold the position steady (based on the pressure record i ng) is measured while observi ng activi ty i n the superficial neck flexor m m (SCM, anterior scalenes) Failure occurs if any of the fol lowing occurs o o

o

I nabi l i ty to reach target pressure I nabi l i ty to hold target pressure steady for 5 seconds (e.g. , i f stabi lizer pressure needle oscillates) Superficial m uscle substitution is observed

2nd phase •

The maxi mum pressure that the patient can hold steady, without superficial m uscle activity i s then tested for endurance ( i .e., their

abi lity to maintain the pressure for 10 seconds for 1 0 repetitions) Pain-free subjects on average can successfully tar­ get and hold pressure s teady a t 2 6 mm Hg without superfi c i a l muscle actlvlty (62, 6 3 ) . C h ronic headache or neck pain WAD patients can usually only target 22 to 24 m m Hg and cannot hold the dial s teady a t any pressure level ( 6 2 , 6 3 ) . Ideal per­ formance is to be able to hold pressu re s teady for 1 0 seconds at 2 8 or 30 mm Hg. K i nest hetic aware­ ness of head/neck position is also measured by the patien t's abi l ity to return to 20 mm H g of pressure in between repeti tions. B o t h i nsidious onset neck pain and w h i pl ash patient were shown to h ave sig­ n i ficantly greater SCM activity ( w i t h EMG) than control subjec ts at each test level (P<0.05) regard­ less of whether the pain was acute or c hronic (64).

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Part Three: Assessment

Falla et al have s hown t h a t reduced performance i n this test i s associated w i t h dysfunction o f the deep neck flexor muscles ( 3 7 ) .

Aerobic Fitness Introduction

Cardiovascular or aerobic fi tness i s extremely i m ­ portant to measure t o estab l i s h fi tness baseli nes. Healthy aging and good aerobi c fi tness go hand i n hand. Patien ts w i t h heart disease, depression, c h ro n i c pai n , c h ronic fatigue syndrome, or fibro­ myalgia may need aerobic fi tness more than strength , endu rance, motor control , o r flex i b i li ty tra i n i ng. Aerobic capaci ty tes t i ng with a submaximal b icycle ergometer test has not been shown to predict fu­ ture outcome ( 1 2 8 ) . However, the test results h ave been shown to i mprove wi t h a m u l tidiscipli nary rehabi l i tation program for work-re lated back prob­ lems ( 1 2 8 ) . I deally, direct measures o f maximum oxygen uptake wou ld be performed. However, this requi res expensive, speci alized equipment and is risky for cer­ tain elderly groups and cardiac patients. Thus, other i ndirect measures have been developed for l arge­ scale screening of cardiovascular fitness and/or pre­ diction of maximal oxygen uptake. Both maximal and submaxi mal exercise protocols are used. M axi­ mal procedures provide a better est imation of V02 and are of part icular value with younger populations or i ndividuals w i t hout risk factors for heart disease. Submaximal procedures are safer for elderly popu­ lations, symptomatic i ndividuals, or those with car­ diac ri sk fac tors. Most sub maximal tests are based on the measure­ ment of heart rate ( H R) . There are a few l i m i tations o f this approac h . HR can vary i ndependently of V02 because of l evels of exci tement or emotional state. This section will presen t a few examples of submax­ imal tests. HR i s not a l i near [unction of V02 relative to submaximal workloads up to m ax i m u m loads. Table 1 1 . 1 3 s hows the aerobic fi tness tests that are described in detail .

Step Tests

The Harvard Method ( 1 66) This 5-minute step test is a simple, i nexpensive, reli­ able method for assessing cardiovascular fitness. This i s a n excellent test for a relatively fit popul a­ tion. However, i t may be too strenuous for an older or less fit population. Also, the 20-inch step height required may lead to leg fatigue before aerobic fatigue i n shorter or h eavier i ndividuals. The equipment requ ired is: • •

Metronome

•

Timer

Patient Position •

Aerobic Fitness Tests

1. Step tests a. Y MCA 3-minute bench step test b. Harvard step test 2. Bicycle test 3. Treadmill test

Standing in [Ton t of step

Test •

•

Set the metronome at 1 20 beats per minute (BPM) to elicit a stepping rate of 30 steps/minute Stepping cycle o o o

o o

A four-count beat Count I -one foot on step Count 2-other leg l i fted on step and subject straightens both the back and legs Count 3-first foot is brought back down Coun t 4-second foo t is brought back down

Tennination Criteria • •

Maxi mum of 5 m i n u tes or until exhaustion. Subject i s considered exhausted when he or she cannot maintain the pace for 1 5 seconds.

Quantification •

•

Table 1 1 . 1 3

20-inch step

At completion of test the subject sits down and the pulse is counted from 1 to 1 . 5 , 2 to 2 . 5 , and 3 to 3 . 5 minutes into recovery. The n umber of h eartbeats duri ng the three 30-second periods is recorded. Calculation

I ndex

=

1 00

x

duration in seconds -+- 2

x

sum of pulses

Example: subject steps for 3 minutes and 1 0 seconds ( 1 90 seconds) with pulses of 8 2 , 80, and 70 beats for the t hree recovery periods. 1 00 x 1 90 -+- (2

x

232)

=

4 ] . This subject is thus "poor."

Chapter Eleven: Quantification of Physical Performance Ability

Index

Classification

>90

Excellent

80-89

Good

65-79

H igh average

55-64

Low average

<55

Poor

YMCA 3-Minute Bench Step Test (44) This alternative to the Harvard method is shown i n Figure 1 1 . 1 8 . This test uses a shorter 1 2-inch bench and a metronome set at 96 bpm (24 steps/minute). The test duration is also shorter-3 m i nutes. At the end of the 3 mi nutes of stepping, the patient i mmedi­ ately sits down and the recovery heart rate is counted for a ful l m inute. It is important that the recovery heart rate be counted within 5 seconds of ending the 3 mi nutes of exercise. An esti mated V02 max can be estimated from the 3-minute step test (44, 1 72 ) . A 2- t o 3-mi nute bi ke test very similar to step tests can also be used (44, 1 72 ) , i .e . , t he cycle ergome ter test. A disadvantage of this test i s that not all adults are familiar with cycling. A third option for aerobic fitness evaluation uses a treadmill ( 1 72 ) . An advantage of treadmill testing is that most individuals can wal k comfortably. A disad­ vantage is that the equi pment is more expensive. Before beginning, the patient should receive i nstruc­ tions descri bing the test. Wal king or run n i ng shoes

Figure 1 1 . 1 8 Y M CA 3-minute bench step test. Repro­ duced with permission [yom Yeomans S. Clinical Applica­ tion of Outcomes Assessment. Stamford, CT: Appleton and Lange, 1 999.

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253

should be worn. The treadmill should have rails for the patient to use i f needed (especially at first) and there should be an emergency stop button or switch mechanism. The patient should i nitially straddle the belt and start "pawing" or "pedali ng" the belt using one foot as it begins to move. Patients will often look down at the belt , walk with a very short stride, and drift to the rear of the belt at first. They should be encouraged to look forward, walk with a more length­ ened normal stride, and walk in the center of the belt. The patient's heart rate will need to be measured while exerc i s i n g . Relatively i nexpensive accu rate heart rate monitors made by companies such as Polar ( 1 -800-227- 1 3 1 4 or http://www. polar.fi/sampola/) are recommended .

Implementation-How

Funct ional assessments yield relevant targets for treatment and thus are prescriptive. This is of par­ ticular value because most diagnostic procedures i dentify only pathoanatomy or t he pain generators, not physiological information about the patient's source of "instabil ity" or mechanical overload. Assess­ i ng i mpairment, functional capacity, or PPA is also invaluable as an outcome to objectively show progress, document the need for further treatment , a nd deter­ m ine appropriate end points of care. The quan t i fi ­ able assessment of function complements the u s e o f other outcome tools s u c h a s subjective questionnaires that i dentify self-report of activity intolerances (see C hapter 9). The PPA should be used in conjunction with func­ tional assessments such as of actual activities per­ formed (see Chapters 1 3 and 1 4), movement sensitivity (Chapter 1 6 ) , muscle i mbalan ces ( Chapter 1 1 ) , and joint play (Chapter 22) help complete the patient's clin­ ical picture. Such a functional assessment yields a "fu nctional diagnosis" t hat is of val ue i n the cli nical management of patients, especially those slow to recover from acute pain or those with chronic pai n . Many q uantitative tests of function suffer fTom having very large standard deviations for their ranges of normal responses. For example, when assessing abdomi nal strength using the repetitive sit-up test ( 1 ), the normative data for a blue-collar, 46-year-old man is a mean of 1 9 repetitions with a standard deviation of 1 1 . To deal with this wide range, using a cutoff of 85% of the normative mean , such as 1 6 repeti tive sit-ups of the 1 9 mean, results in a more sensitive approach (by i n creasi ng the num ber of true-positives in a LBP population) . Using a 95% confidence inter­ val , a range of normal between 1 9 plus or minus 1 0.45 or 8 . 5 5 to 2 9 .45 repeti tions can be expected when testing 95% of 46-year-old, blue-collar males. The 95%

254

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Part Three: Assessment

confidence i nterval illustrates the expected variation i n scores caused by biovariability ( i . e. , ectomorphic, mesomorphic, and endomorphic). Th is approach will reduce the speci ficity ( nu m ber of true-negatives i n a normal population) of the tests but it adds to the u t i l i ty and practicali ty. The balance between sensitivity, specifici ty, practicali ty, and util­ ity allows for use of a method by adjusting the mean normative data so i t can be appl ied i n a clinical set­ ting. Other methods have been reported such as using a percentile of the mean (106) or breaking the normative data i nto five categories ranging from extremely poor to extre mely good ( 1 72 ) . I n a c l i n i cal setting, certai n tests t h a t m i nimally stress injured or pain [·u l tissues can be used to quan­ t i fy dysfu nction from the begin n i ng of acute care. These i nclude ROM/muscle length tests and balance tests. Other tests such as endu rance tests i nvolve moderate levels of biomechan ical load and thus should NOT be used during the acute phase. Al though it is common to perform a comprehen­ sive P PA eval uation to profile patients i n many c ir­ cum stances, i ndividual tests or small clusters of tests can also be used. For i nstance, concern about lower quarter function i n a l um bar spine patien t might lead to squatting and balance tests being performed. I n another i nstance, a construction worker might benefit from a test battery t hat might include trunk fl exor, extensor, and side bridge tests, along with a squatting test to u nmask a "weak link." An athlete who is very strong might be unaware of motor con­ trol issues and therefore can be a candidate for bal­ ance and abdom i n al coordi nation tests (abdom i nal hol lowing) . A subacute LBP patient may N OT be a candidate for strength testi ng, but the abdom inal hol lowi ng test may be particular useful. Asym ptomatic i ndividuals are starting to presen t t o m uscu loskeletal health care clinics seeking pre­ ventive advice. In such cases, a performance evalua­ tion using the PPA can give a risk assessment or stabi l i ty profile that can resul t in some preven tive prescriptive exercise advice. Tests that are positive should lead to a speci fic pre­ scription of exerc ises matched to the functional deficits identified. Re-evaluation at regular i ntervals ( 4-6 weeks) should then be performed to re-assess progress toward establ i shed goals. Thus the iden t i fi­ cation of functional deficits is an ideal way to estab­ lish goals for care or endpoints of care.

They can complement the other evaluation bench­ marks such as orthopedic/neurological findings, i maging resul ts, sel f-report of activity i n tolerances, and diagnostic anaesthetic blocks. The un ique value of these tests is that they measure f1-ll1clional ability t hat is clini cally relevant because the goal of care is restoration of [1-mclion !

Audit Process

Self-Check of the Chapter's Learning Objectives •

What is the normal range in seconds [or endurance i n d ifferen t populations for the trunk extensor and side bridge tests?

•

What i s the normal range in seconds for the single leg standing balance test in d ifferen t age groups and sexes?

•

What is the normal range for pressure on the feedback cuf{ during t he cervico-cranial flexion and prone abdominal hollowing tests?

•

During what stage of patient care should strength/endurance tes t i ng be performed and why?

•

During what stage of patient care should motor control testi ng be performed and why?

• REFERENCES I . Alaranta H, Hurri H , Heliovaara M, et al. Non­

2.

3.

4.

5.

6.

• CONCLUSION

PPA tests are proving to be valuable tools for both iden t i fying [1-mclional l i m i ta ti ons and establish i ng realistic goals i n the m anagement of LBP patients.

7.

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Chapter Eleven: Quantification of Physical Performance Ability

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45. Grabiner M D , Koh TJ , Ghazawi AE. Decoupling o f bi lateral paraspi nal exci tation in subjects with low back pain. Spine 1 992; 1 7 : 1 2 1 9- 1 223. 46. Gronblad M, H urri H, Jouri J P. Relationships between spinal mobi l i ty, physical performance tests, pain i ntensity and d isabi l ity assessments in chronic low back pai n patients. Scand J Rehab Med 1 997;29: 1 7-24 . 4 7 . H agins M , Adler K, Cash M , Daugherty J , M i trani G . Effects o f practice on t h e abil i ty to perform lumbar stabil i zation exercises. J Orthop Sports Phys Ther 1 999; ( 9 ) :546-555. 48. H a m i l ton-Fai rfax A, Balnave R, Adams RD. Review of si ncerity of effort testing. Safety Sci 1 997;25: 237-24 5 . 49. H arding V R , W i l liams AC de C , Richardson P H , e t a l . The development o f a baltery of measures for assessing physical functioning of chromi c pain patients. Pain 1 994; 5 8 : 367-3 7 5 . 50. H art D L, Isern hagen S J , Matheson L N . Guidelines for functional capacity eva l uation of people with medical condi t ions. J Ort hop SPOI-tS Phys Ther 1 993; 1 8: 682-686. 5 1 . Heikkila H , Astrom PG. Cervicocephalic kinesthetic sensibi l i ty in patients with whiplash i njury. Scand J Rehab Med 1 996;2 8 : 1 33- 1 38 . 52. H i rsch G , Beach G N , Cooke C, Menard M R , Locke S. Relationsh ip between performance o n l umbar dynamometry and Waddell score i n a popul ation with low back pain. Spine 1 99 1 ; 1 6: 1 039- 1 043. 53. H odges PW, Richardson CA. Delayed postural con­ traction of transversus abdominis in low back pain associated with movement o[ the lower l i mb. J Spinal Disord 1 998; 1 1 ( J ) :46-56. 54. Hodges PW, Richardson CA. Altered trunk muscle recru i tment in people wi t h low back pain with upper limb movement at di fferent speeds. Arch Phys Med Rehabi l 1 999;80( 9 ) : 1 005- 1 0 1 2 . 5 5 . H.ussei n T M , Simmonds MJ, Olson S L , et a l . Kine­ matics of gait in normal and low back pain subjects. Boston, MA: American Congress of Sports Medic i ne 45th Annual Meet ing, 1 998. 56. H ussein T M , Simmonds MJ, E tnyre B , et a l . Kine­ matics of gait i n subjects with l ow back pain with and withou t leg pai n . Washington, DC: Scientific Meeting & Exposi tion of the American Physical Therapy Association, 1 999. 5 7 . l CD H-2. I n ternational Classification of Functioning and D isab i l i ty. Beta-2 D raft. Full Version, World Health Organization, Geneva, 1 999. 58. [ to T, Shirado 0 , Suzuki H, Takahashi M, Kaneda K, Strax TE. Lum bar tru n k m uscle endurance testi ng: An inexpensive alternative t o a machine [or evaluation. Arch Phys Med Rehabil 1 996;77: 75-79. 59. Jar'Vi k J G , H o l l ingworth W, Heagerty P, Haynol- DR, Deyo RA. The longitudinal assessment of i m aging and disabil ity of the back ( LA I D Back) study. Spine 200 1 ;26: 1 1 58-1 1 66. 60. Jarvik J G . Editorial. Don't duck the evidence. Spine 200 1 ;26: 1 306- 1 307. 6 1 . Jensel M C, Brant-Zawadzki MN, Obuchowki N, et a l . Magnet ic resonance imaging of the l u m bar spine in people without back pain. N Engl J Med 1 994; 2:69.

6 2 . J u l l G , Barret C, Magee R, H o P . Further cli nical clarincation of the m uscle dysfu nction i n cervical headache. Cephalgia 1 999; 1 9: 1 79- 1 85 . 63. Jull GA. Deep cervical flexor muscle dysfunction i n whi p lash . J M usculoskel Pain 2000;8: 1 43- 1 54. 64. Jul l G, Kristjansson E, Dalll'Alba P. Impairment in the cervical flexors: A comparison of whi plash and i nsidious onset neck pai n patients. Man Ther 2004;9: 89-94. 65. Kankaapaa M, Tai mela S, Laaksonen D , et al . Back and hip extensor fatigab i l i ty in chronic low back pain patien ts and controls. Arch Phys Med Rehabil 1 998;79:4 1 2-4 1 7. 66. Kendrick D , Fielding K, Bentler E, Kerslake R, Mil­ l ler P, Pringle M . Radiography of the l u m bar spine in primary care patients wi t h low back pain: Ran­ domi zed controlled trial . BMJ 200 1 ;322 :400-405. 67. Kibler WB, Herring SA, Press J M . Functional Reha­ b i l i tation of Sports and M usculoskeletal I njuries. Aspen, 1 998. 68. Krivickas LS, Feinberg JH. Lower extremity injuries in coll ege athletes: Relation between l i gamentous laxity and lower extremity muscle t ightness. Arch Phys Med Rehabi l 1 996;77: 1 1 39- 1 1 43 . 6 9 . Kujala U M , Tai mela S, Sal m inen J J , Oksanen A. Base l i ne anthropometry, flexibi l i ty and strength characteristics and future low-back-pain in adoles­ cent athletes and nonathletes. A prospective, one­ year, follow-up study. Scand J Med Sci Sports 1 994;4:200-205. 70. Laboeuf-Yde C, Lauritsen JM, Lauritzen T. Why has the search for causes of low back pain largely been nonconclusive? Spine 1 997;22:877-88 1 . 7 1 . Laboeuf-Yde C , Mann iche C . Low back pai n: Time to get off t he treadmill. J Manipulative Physiol Ther 200 1 ;24: 63-65. 72. Lantz CA, Chen J , Buch D . C l inical val idity and sta­ b i l i ty of active and passive cervical l-ange of motion with regard to total and unilateral uniplanar motion. Spine 1 999;24: 1 082-1 089. 73. LaRocca H. A taxonomy of chron ic pain syndromes. 1 99 1 Presidential Address, Cel'Vical Spine Research Society Annual Meeting, December 5, 1 99 1 . Spine 1 992; 1 0S:S344-S35 5. 74. Lati m er J, Maher CG, Refshauge K, Colaco I. The reliabil i ty and val id i ty of the B iering-Sorensen test in asymptomatic subjection and subjects reporting current or previous non-specific low back pain. Spine 1 999;24:2085-2090. 75. Leinonen V, Kankaanpaa M, Airaksinen 0 , et al. Back and h i p flexion/extension: E ffects of low back pain and rehab i l i tation. Arch Phys Med Rehabil 2000;8 1 :32-3 7 . 7 6 . Leinonen V, Kankaanpaa M , Luukkonen M , Hanni­ nen 0 , Airaksinen 0 , Taimela S. Disc herniation­ related back pai n i mpairs feed- forward control of paraspinal muscles. Spine 200 1 ;26: E367-E372. 77. Lemastra M , Olszynsi WP, Enright W. The sensitivity and specincity of functional capacity evaluations i n determining maximal effort . Spine 2004;29:953-959. 78. Lewit K. Manipulative therapy in rehabi l i tation of the motor system, 2nd Edit ion. London: Butler­ worths, 1 99 1 .

Chapter Eleven: Quantification of Physical Performance Ability

79. Lewit K, Liebenson C. Palpation-problems and implications. J Manipulative Physiol Ther 1 99 3 ; 1 6 : 586-590. 80. Loudon JK, Ruhl M , Field E. Ability to reproduce head position after whiplash injury. Spine 1 997;22: 865-868. 8 1 . Luoto S, Hel iovaara M, Hurri H , Alaranta H. Static back endurance and the risk of low-back pain. Clin Biomech 1 995; I 0:323-324. 82. Luoto S, Taimela S, H u rri H, et al. Psychomotor speed and postural control in chronic low-back pain patients: A controlled fol low-up study. Spine 1 996;2 1 : 262 1 -2627. 83. Luoto S, Aalto H , Taimela S, et al. One-footed and externally d isturbed two-footed postural control in chronic low-back pain patients and healthy con­ t rols: A controlled study with follow-up. Spine 1 998;23 :208 1 -2090. 84. Luoto S, Taimela S, H u rri H , et al. Mechanisms explain i ng the association between low back trouble and deficits in information processing. A controlled study with fol low-up. Spine 1 999;24( 3 ) : 2 5 5-26 1 . 85. Magnusson M L, Bishop JB, H asselquist L , Spratt KF, Szpalski M, Pope M H . Range of motion and motion patterns in patients with low back pain before and after rehabil i tation. Spine 1 998;23: 1 63 1 -2639. 86. Manniche C, et al. Dan ish H ealth Technology Assessment ( D l H TA ) . Low back pain: Frequency Management and Prevention from an H A D Perspec­ tive, 1 999. 87. Mannion AF, Junge A, Tai mela S, M untener M, Lorenzo K, Dvorak J . Active therapy for chronic l ow back pain. Part 3 . FactOl-s influencing self-rated dis­ abi l i ty and i ts change following therapy. Spine 200 1 ;26:920-929. 88. Marras WS, Ferguson SA, Gupta P, et a l . The quan­ t i fication of low back disorder using motion measures. Met hodology and val idation. Spine 1 999;24(20) :209 1 -2 I 00. 89. Matheson L. An introduction to l i ft capacity testing as a component of functional capacity evaluation. IRG, 1 99 1 . 90. Matheson L . Basic requirements for util ity in the assessment of physical disab i l i ty. American Pain Society 1 994;3: 1 95 . 9 1 . Matheson L M , Gaudi no WA, M ael F , Hesse BW. I mproving the val id i ty o f the i m pa i rment evaluation process: A proposed t heoretical framewOl-k. J Occup Rehabil 2000; 1 0:3 1 1 -320. 92. Matheson L, Kaskuta VK, Mada D . Development and construct val idat ion of the hand function sort . J Occup Rehabil 200 1 ; 1 1 :75-86. 93. Mayer TG, Tencer AF, Kristoferson S, Mooney V. Use of noni nvasive techniques for quantification of spinal range-of-mot ion in normal subjects and chronic low-back dysfunction patients. Spine 1 984;9:588-595 . 94. Mayer T, Gatchel R , Kishino N , e t a l . Objective assessment of spine function following i ndustrial injury: A prospective study with comparison group and one-year follow-up. Spine 1 98 5 ; I 0:482-493. 95. Mayer TG, Smith S, Keeley J , Mooney V . Quantifi­ cation of lumbar funct ion part 2 : SagitLal plane trunk strength in chronic low back patients. Spine 1 985; 1 0: 765-772.

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Chapter Eleven: Quantification of Physical Performance Ability

1 44.

1 45 .

1 46.

1 47 .

1 48.

1 49.

1 50.

1 51.

1 52 .

1 53 .

1 54.

1 55 .

1 56. 1 57.

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Physical Performance Tests: An Expanded Model of Assessment and Outcome

II

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Maureen J. Simmonds and Ellen Lee

Introduction Functional Assessment Methods Patient Self-Reports Clinician-Measured Tests of Function

Learning Objectives

After reading this chapter you should be able to understand: •

Physical Performance Test Battery Psychometric Properties

•

Factors That Influence Task Performance Biomechanical and Electromyographic Task Analysis

•

That impairment tests and functional ability are not equivalent. How to perform a standardized battery of quan­ tifiable functional tests. The influence of back pain versus leg symptoms on task performance, including gait.

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261

Introduction

Patient Self-Reports

Traditionally standard clinical assessments were largely based on a narrow biomedical model. In pa­ tients with low back pain (LBP), clinical tests focused on physical impairment. Impairment tests such as spinal range of motion, strength, and specific joint movements are described in great detail (20), en­ trenched in current practice, and have apparent clini­ cal usefulness. Yet many are unreliable (10,18) and the constrained manner of testing may have little to do with the patient's problem of pain and dysfunction, especially when the problem is chronic or recurrent. In the case of spinal problems recurrence is the norm (19). Unfortunately, the functional ability of patients with LBP has often been inferred [Tom the results of these tests. The incongruence between impairment test results and fl.mctional ability of patients can con­ fuse and frustrate both clinicians and patients. Treatment plans are guided by clinical assessments. A nan-ow focus biomedical assessment framework will inevitably lead to a narrowly focused treatment. It is, therefore, not surprising that the outcomes of back­ specific exercise treatment regimes in patients with chronic LBP are often inconclusive (14). The prob­ lem of back pain, especially disabling back pain, is greater than a problem of the spine, its muscles, and its range o[ motion; therefore, assessment rationale and tests should be expanded. Recognition o[ the importance o[ function and the Iimitations of the narrow biomedicallbiomechanical model has led to a shift towards an expanded bio­ psychosocial model of assessment. This conceptual model recognizes salient factors beyond the anatom­ ical and biomechanical aspects of the spine that can affect the functional ability of the person as a whole. It takes into account psychosocial factors in addition to physical [actors. These factors have intricate and interwoven relationships that ultimately influence the function of a whole person. For example, psy­ chosocial factors such as depressed mood, negative or passive coping, fear of pain and reinjury with con­ sequent avoidance of activity, stress or anxiety, low educational level, medicolegal compensation claims, and substance abuse are predictive of chronic phys­ ical disability (27). The actual level of spinal impair­ ment can play a minimal role in predicting disability. This assessment and management model focuses on the integration and consideration of functional activity, physical pathology/impairment, and psycho­ social factors (49).

Patient self-reports of physical function are commonly used in clinical settings because they are relatively quick, simple, and practical to administer and score (see Chapter 8). This method uses questionnaires that are generic, disease-specific, or patient-specific. The Medical Outcomes Study 36-i tem Short Form Health Survey (SF-36) (52) is an example of a generic questionnaire that is widely used and has established psychometric properties (30,31). It can be used in a variety of disease groups including LBP. However, the degree of validity varies across the different disease groups (3 1). Disease-specific questionnaires tend to be more relevant to the target disease group. Roland Morris Disability Questionnaire (RMDQ) (38) and Oswestry Disability Questionnaire (15) are examples of such disease-specific questionnaires. They sample a range of different activities, including self-care, mobility, the performance of household chores, and other work-related activities that are relevant to LBP. They have accepted norms and established reliability and validity (2,3). However, patients' needs and nor­ mal functional level are idiosyncratic. Therefore, patient-specific questionnaires have also been devel­ oped. The Patient-Specific Questionnaire (PSQ) is an example. This questionnaire samples up to five impor­ tant activities that patients identify they are unable to do or have difficulty doing because of their problem. The patient then scores each activity on a scale of 0 to 10. Moderate to excellent reliability, validity, and sen­ sitivity to change have been established in patients with knee dysfunction (5) and LBP (42,48). Although patient self-reports using standardized questionnaires of physical function have clinical use­ fulness, they still may not be a valid reflection of a patient's actual functional status (17), especially when an external reference is unavailable. Self­ report measures are more closely associated with other self-report measures than with physical capa­ bilities observed or measured by clinicians (9). Even with psychometrically sound patient self-reports and clinician-measured tests of the same functions, the test measures are moderately correlated at best (16, 26). This can be partly explained by findings that show patients and clinicians or normal subjects often misjudge estimates of distance walked or the time that an activity takes (40,41). Likewise, estimates of the time that an activity or static position can be tolerated is influenced by so many factors that the accuracy or validity of the estimates must be seri­ ously challenged. Reporting bias may also vary with situational demands, memory, and verbal ability (6). Therefore, it is evident that complementation of patient self-report of function with clinician-measured tests of physical function is necessary. Each method

Functional Assessment Methods

There are two major approaches in assessing physical function: patient self-reports and clinician-measured tests.

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of measurement taps a different aspect of physical performance. Self-report measures of f'unction are important to use as assessment tests to help identify functional clif­ ficulties and as outcome measures to determine the effectiveness of the intervention. Self-report measures that assess why an activity is limited are also essential. It is beyond the scope of this chapter to address the many different constructs that can influence physical function or are a consequence of physical dysfunction. However, a couple of points are noteworthy. For exam­ ple, measures of pain (intensity, quality and location) must be obtained through the patient's self-report. Practitioners' estimates of a patient's pain are known to be inaccurate and are generally underestimated. Pain behavior is usually more indicative of a patient's distress and culture than their pain per se. It is also helpful to find out about the patient's beliefs (and false beliefs) about their spine and the anticipated effect of physical activity. The beliefs of the patient and the impact of the physical dysfunction help to identify problems and direct treatment. For example, fear of injury or activity (50,51) is a problem relevant to reha­ bilitation that can be assessed using the Tampa Scale of Kinesphobia (50,51). Clearly, a different treatment approach is necessary for those patients who are unable to complete an activity because of fear of pain or fear of re-injury, rather than a physical impairment.

Clinician-Measured Tests of Function

Clinician-measured tests of physical function provide a useful, quick, simple, quantitative method of deter­ mining a patient's physical function. This method involves the use of a range of tasks or a standardized battery of tasks that essentially sample the construct of physical function. The tests are simple, everyday tasks that are easy for the patient to perform and easy for the clinician to measure and interpret. In the next section of the chapter, we describe a simple clinical perfor­ mance task battery that can be used to assess physical function in individuals with LBP. We then summarize the experimental evidence that supports the reliability and validity of the test battery. Secondly, based on the premise that optimum management of physical func­ tion is based on optimum understanding of how LBP impacts task performance, we present the results of biomechanical experiments that have characterized physical performance on specific tasks.

Physical Performance Test Battery

Recently, Simmonds and colleagues developed, tested, and refined a comprehensive but simple and standardized battery of performance tests for indi-

viduals with LBP. The battery includes tasks that are fundamental components of day-to-day activi­ ties commonly compromised by LBP. For example, most individuals with LBP have difficulty with­ standing compressive and shear spinal loads, and generally move more slowly than pain-free individ­ uals (28,29,39,43). Therefore, performance on the task battery is mostly based on how quickly a task can be performed or how far a subject can reach forward (an indirect test of spinal load). The only equipment needed for these simple clinical tests is a stopwatch, a tape measure or meter rule, and a few 1-kilogram/2-kilogram weights. The tasks are outlined in Table 12.1 and shown in Figures 12.1 through 12.5.

Psychometric Properties

Reliability

The psychometric properties and clinical usefulness of these performance tests are established (47). Test­ retest, inter-rater reliability, day-to-day stability, and validity were tested in 48 healthy pain-free control subjects and 44 subjects with LBP. All tests have excellent inter-rater reliability. Intraclass correlation coefficients (ICC 1.1 ) were all equal or greater than 0.95. The simplicity of the tasks and the method of testing (stopwatch or tape measure) probably con­ tribute to the excellent level of inter-rater reliability. Test-retest (within session) and day-to-day stability is also adequate to excellent for all tests. Examination of the reliability results revealed an interesting phe­ nomenon. The two tasks that involved repeated movements (repeated Oexion and sit-to-stand) have relatively lower levels of stability, suggesting that per­ formance changes during the task. Reduced fear of the activity and/or physiological warm-up are the most likely explanations because the speed of performance increased with repetitions, and the change was much more marked in the LBP group. The lower level of stability of the two tasks that require fast dynamic performance is an interesting observation and important point. Some authors and many clinicians have asserted that within subject variability of task performance is indicative of insin­ cerity of effort. Despite the dearth of credible evi­ dence supporting this simplistic view and some evidence that refutes the notion (32), the search for the physical performance "lie detector" has remained a popular quest. Our results suggest that variability in task performance is not a "lie detector." Variabil­ ity in performance during a repeated movement is a characteristic of the task itself, and thus is not an indication of questionable patient motivation. None of the patients in our study was involved in litigation

Chapter Twelve: Physical Performance Tests

Table 12.1

�-

263

Simmonds Physical Performance Battery for Patients with Low Back Pain

Task

Procedure

Measure

Repeated sit-to-stand (see Fig. 12.1)

Subjects rise to standing and return to sit­ ting as quickly as possible five times; after a brief pause, the task is repeated

The average of the two task times is recorded

Repeated trunk flexion (see Fig. 12.2)

The subjects are timed as they bend for­ ward to the limit of their range and return to the upright position as fast as tolerated five times; after a brief pause, the task is repeated

The average of the two task times is recorded

Loaded reach (see Fig. ] 2.3)

Subjects stand next to a wall on which a meter rule is mounted horizontally at shoul­ der height; they hold a weight that is 5% of their body weight (up to maximum of 5 kg) at shoulder height and close to the body and then reach forward

Maximum distance reached in centimeter is recorded

50-Foot walk

Subjects walk 25 feet, turn around, and walk back to start as fast as they can

Time taken is recorded

5-Minute walk

Subjects walk as far and as fast as they can for 5 minutes

Distance walked is recorded

360-Degree rollover (see Fig. 12.4A to 12.4D)

Subjects lie supine on a treatment bed and they roll over 360 degrees as fast as they can; after a brief pause, they roll 360 degrees in the opposite direction

The time to complete a rollover in both directions is summed and recorded

Sorensen fatigue test (see Fig. 12.5) (for patients with minimal dysfunction)

Subjects lay prone on a standard treatment table with thighs and calves stabilized; they lift their upper body and hold the position for as long as possible

Time taken to fatigue is recorded

or was receiving workers compensation payments. Also, it seems unlikely that patients would have pur­ posefully exerted a less consistent effort during the repeated flexion and sit-to-stand task but performed consistently for the other tasks. Thus, variability in task performance must be judged within the context of the task itself.

Responsiveness

Responsiveness of the task battery was measured and compared with the RMDQ and PSQ. Twenty­ eight patients attending physical therapy were assessed initially and after 4 to 6 weeks of physical therapy. Standardized response means (SRM) were 1.39 to 1.98 for each of the five activities identified by the patient. Three performance tasks were com­ parable to the RMDQ in regards to responsiveness.

The SRM of the RMDQ was 0.81. The SRMs of the 5-minute distance walk, loaded reach, and timed repeated flexion task were 0.81, 0.73, and 0.73, respectively (42).

Validities

The importance of reliability of the tests becomes moot if the tests are not valid. Therefore, face valid­ ity of the tasks was evaluated by examining group differences. A multivariate analysis of variance re­ vealed that pain-free subjects outperformed subjects with LBP on all the tasks in this battery (F10,65 3.52, p <0. 0001). Validity was further established through the examination of correlational patterns between the performance and external (impairment and pain) tests. High correlations between tests pro­ vide evidence of convergent validity suggesting that

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Part Three: Assessment

Figure 12.1 Repeated s i t-to-stand.

Figure 12.2 Repeated tnll1k flexion.

the tests are assessing a similar construct. However, low correlations between tests show discriminant validity suggesting the tests are assessing dissimilar constructs. The task battery shows good convergent and discriminant validity through stronger correla­ tional patterns among the performance tests (r=.41 to 0.89) and weaker correlations between perfor­ mance and external tests (r=0.12 to r=0.36). Tasks

that comprised similar performance characteristics correlated most strongly. For example, tasks that in­ volved walking were most highly con-elated (1'=0.89). In contrast, tasks that comprised dissimilar perfor­ mance characteristics were less strongly correlated. For example, the correlation between the loaded reach task that is performed relatively slowly and the repeated flexion task that is performed relatively

Figure 12.3 Loaded reac h .

Chapter Twelve: Physical Performance Tests

A

B

c

o

--

265

Figure 12.4 360-Degree rollover.

(A) (B) (C) (D)

Starting posit i on. Roll from back to right side. Roll from [Tont to left s i de . End posit ion.

quickly was r=-0.53. Both tasks involve different stresses on the trunk but clearly the speed of postural adjustment to those stresses is differentially chal­ lenging. Finally, pain and performance tests were better predictors of disability (r2=0.61) than pain and impairment tests (r2=0.47) (46). Further validation of the task battery was investi­ gated through factor analysis. This statistical tech­ nique examines the number of underlying constructs

Figure 12.5 Sorensen fat igue test.

measured by the task battery. Novy and colleagues (33) examined the factor structure of the task battery in 103 patients with back pain. They derived two factors, namely speed/coordination and endurance/strength that underlie the Simmonds battery of physical per­ formance tasks. The speed/coordination factor was identified by 50-foot speed walk, repeated trunk flex­ ion, sit to stand, and rollover. The rollover task had a 0.86 loading on this factor and appears to be a strong

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indicalor of speed/coordination. The second factor, endurance/slrength, was identified by 5-minute walk and loaded reach task. In contrast to the other tasks lesled here, the Sorensen fatigue test was not associ­ ated with salient loadings on either factor and is dis­ cussed further. The two derived factors are not only meaningful but also may be helpful in guiding rehabilitation. When scores of physical performance tasks indicate patients are compromised in speed/coordination of movement, clinicians could design exercise protocols to targel the underlying factor (Table 12.2). Likewise, patients who demonstrate a poor performance on indicators of endurance/strength may benefit from a training protocol that targets and enhances these deficils (Table 12.2). DeLooze and colleagues have shown that reduced strength compromises the capa­ bility o[ the spine to withstand a mechanical load (7). Therefore, patients may have better endurance in wilhstanding spinal loading in both the 5-minute walk and loaded reach tasks after the training. The Sorensen test has been removed from the slandard lest battery for a few reasons. First, it is the least "functional" test. Second, it is a physically chal­ lenging test that pain-free healthy controls find diffi­ cult. Third, based on its statistical properties on the factor analysis, the Sorensen test can be removed withoul compromising the factor structure. Finally, we also question the validity of the test as one of back muscle endurance. Kankaanpaa et al. sug­ gest lhal there is load-sharing between back and hip extensors during the test because both muscle groups fatigue significantly in pain-free individuals during the test (25). Although short hold times (low perfor­ mance) of the Sorensen test are related to poor mus­ cle endurance and are predictive of future LBP in normals (4,8,24), these results cannot be generalized to individuals who already have LBP. We have found that although the majority of pain-free individuals (80.5%) stop the test because of fatigue/weakness,

Table 12.2

only 29.6% of individuals with LBP stop for this rea­ son. Rather, most individuals with LBP (63%) stop the test because of pain. Thus, we suggest the Sorensen test for individuals with back problems as a test of pain tolerance, not back muscle endurance (44).

Factors That Influence Task Performance

A variety of factors influence lask performance we have examined a non-modifiable factor, gender, and a modifiable factor, pain location. Gender

Although men outperform women on most physical tasks, LBP changes performance ability. The poten­ tially differential impact of LBP on the physical per­ formance of men and women has received little scrutiny. Novy and colleagues (34) examined per­ formance differences in men and women with and without low back pain. They examined performance on the task battery of 33 men and 46 women with non-specific mechanical LBP, and 21 men and 25 healthy control subjects. They used a discrimi­ nant function analysis and found that the four groups of subjects performed the physical tasks sig­ nificantly differently in two major ways. The first di[­ ference irrespective of gender was lhal lhe healthy control subjects outperformed lhe patients with LBP on tasks (sit-to-stand, repeated trunk flexion, Sorenson fatigue test, 50-foot speed walk) that involve trunk control, coordination, and stability while withstanding heavy or quickly changing loads on the spine (i.e., healthy men outperform healthy women, LBP men, and LBP women, respectively). The second difference irrespective of patient or non­ patient status was that men outperform women on tasks involving anthropomelric reatures of limb length (distance walk and loaded reach), i.e., healthy men outperform LBP men, heallhy women, and

Physical Performance Battery Normative Database

Test

Mean

SD

Minimum

Maximum

Repeated sit-to-stand (seconds)

7.35

1.42

4.45

11.54

Repeated trunk flexion (seconds)

7.44

1.04

5.17

9.59

67.62

6.43

55.50

84.03

50-Foot fast walk (seconds)

8.30

0.85

6.80

10.78

5-Minute distance walk (m)

514.10

70.25

284.68

683.97

6.33

1.24

4.15

]0.08

Loaded reach (cm)

360-degree Roll-over (seconds)

Chapter Twelve: Physical Performance Tests

LBP women, respectively. Thus, expectation of treat­ ment outcome must consider the specific demands of the task as well as gender. Location of Pain

Physical performance is also influenced by location of pain. Patients with radiating or referred leg pain are generally outperformed on physical performance tasks by patients with back pain only. However, per­ formance differences are again task-specific (45). We tested a total of 60 patients with LBP on the physical performance battery. Twenty-nine patients had back pain and 31 patients had leg pain. Patients with back pain outperformed those with leg pain on the 50-foot speed walk, repeated trunk flexion, 360-degree roll­ over, and the loaded reach. There was no performance difference between groups on the 5-minute walk, sit­ to-stand, or Sorenson test. Thus, it appears that indi­ viduals with leg pain have much greater difficulties with tasks that involve high compressive spinal loads or high-velocity movements. Biomechanical and Electromyographic Task Analysis

Physical performance tasks are complex movements. A better understanding of all performance task com­ ponents and the manner in which they operate may ultimately lead to simple mathematical rules that explain the complex movement patterns. At present these rules are still elusive. It is axiomatic that the optimal management of task performance difficul­ ties requires a sound understanding of the physical demands of the task and the physiological (neuro­ muscular and biomechanical) requirements of task performance. Walking, rising from sitting, bending, and reaching are dynamic tasks that are frequently compromised for patients with LBP. However, there has been little systematic, quantitative study on func­ tional movement patterns, especially in the context of clinical rehabilitation. This final section of this chapter will focus specifically on movement charac­ teristics during task performance. The general dearth of empirically derived data on normal and altered motor performance and the sta­ bility and the short-term and long-term implications of altered motor performance have led to the use of treatment approaches that frequently lack a scien­ tific rationale. For example, many treatment regi­ mens (especially orthopedic regimens) are designed to "normalize" movement and obtain symmetry in posture and performance. However, normal move­ ment in the presence of impairment may be neither possible nor desirable, and asymmetry of posture and movement is the norm. So it is unreasonable to

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267

assume asymmetry is a problem or that it warrants "normalizing," except in extreme cases. It is plausible that many altered movement strate­ gies expressed by patients with impairments are actually the most efficient and effective for that patient. For some patients, it may be more important for them to be able to complete a task than to be con­ cerned with how they complete it. Other patients may lack flexibility in motor patterns and be unable to modify a movement pattern enough to accommo­ date their impairment and still complete the task. Patients with LBP tend to move slower and with less force compared to pain-free individuals. The decrease in performance speed can be a useful strategy if it results in tasks being performed and being performed with less pain. However, if a task is performed too slowly it becomes very costly and burdensome in terms of time taken. Thus it a less useful strategy and an alternative one should be sought. Improved knowl­ edge of task demands and of normal and altered motor performance patterns in patients with different eti­ ologies can help therapists identify task difiiculties and the component of the task that is specifically dif­ ficult. Therapy can then focus more appropriately on modifying the task, modifying the patient's task per­ formance, or modifying the patient's impairment, atti­ tude, and/or beliefs toward disability. Some research on motor performance patterns has been performed. However, most research has been descriptive and cross-sectional and has characterized and compared motion and muscle performance characteristics in subjects with and without LBP during specific task performance. For example, movement patterns differ between subjects with and without LBP as tasks are performed, e.g., walking (1 ,22,23), wheel turning (39), symmetric and asym­ metric trunk flexion (28), reaching (37), and rising from sitting (11-13). Altered postural control and muscle reaction times may be some of the factors that contribute to the alteration of movement patterns in individuals with LBP. Radebold et al. demonstrated these phenomena in patients with chronic LBP dLll-­ ing unexpected movement perturbations in sitting (36). However, further systematic investigation of the mechanisms, the factors that influence changes in motor pattern, and the stability of altered patterns during dynamic movements (e.g., walking, trunk flex­ ion, reaching, and rising from sitting) is necessary. Marras and colleagues (28) measured anguJar posi­ tion, velocity, and acceleration of the trunk as ] 7] subjects with LBP and 339 healthy control subjects wore a triaxial goniometer and flexed and extended their trunk in five different planes. The tests correctly classified 94% of subjects into LBP or control groups. The authors suggested that motion signatures dif­ fered among patients with LBP of different etiology.

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Although validation is clearly necessary, the work is intriguing given the diagnostic conundrum of LBP. Arendt-Nielsen et al. (1) conducted a series of gait studies and examined electromorphic (EMG) activ­ ity in the erector spinae in subjects with clinical and experimentally induced LBP. They found differences in amount and timing of EMG activity between patients and control subjects during all phases of gait. Most importantly they showed that experimen­ tally induced muscle pain modulated EMG activity and gait patterns in a similar manner to that of clin­ ical LBP. In our laboratory, we are conducting integrated, biomechanical, and EMG analyses of the walk, sit-to­ stand, and loaded reach tasks in an effort to under­ stand the effect of LBP on physical performance.

Walking- Temporal and Spatial Parameters

We have compared the gait characteristics of 44 sub­ jects with LBP and 47 healthy control subjects walk­ ing at their preferred and fastest speed (23). Patients walked significantly slower at both preferred and fastest speed. The velocity of the fastest walking speed of the patients was similar to the preferred speed of the control group. It was also interesting to note that patients increased their walking speed by increasing their cadence, whereas control subjects increased their speed by increasing stride length. The difriculty associated with stride extension may account for patient's inability to walk as fast as their pain-free counterparts. However, LBP does not result from a single etiology. The altered gait strategy appears to be related to pain and especially to the location of pain. Location of pain can of course con­ tribute to diagnostic decisions. Hussein et al. (22) examined the effect of pain location on gait patterns in individuals with LBP. He measured and analyzed the gait of 60 subjects with LBP grouped according to the presence of back pain (BP) or leg pain (LP) (21). Significant group differences were revealed. Patients with LP had an asymmetrical gait pattern (i.e., different step lengths) and were outperformed by those with BP only in terms of walking speed and stride length. They were particularly limited in step length on the affected side. Limitation in step length and walking speed would of course be related. How­ ever, whether the limitation in walking speed was caused by anticipated pain or actual pain is not clear. A variety of factors could account for these gait difficulties. Impairment level problems include limitations in range of spinal rotation, tight ham­ strings, and sensitivity of the sciatic nerve to stretch. Further investigations are clearly indicated and are ongoing.

Figure 12.6 Gait analysis.

Walking-Ground Reaction Force, Muscle Control, and Motion Parameters

A more detailed and comprehensive analysis of gait (Fig. 12.6) in patients with BP, LP, and an age-matched and gender-matched control group is ongoing. In this experiment, subjects walk at their preferred and fastest speeds. A force platform is used to measure the ground reactions forces (GRF). Electromyographic activity is recorded from the paraspinal, glutei, ham­ strings, quadriceps, gastrocnemius, and pretibial mus­ cles during one gait cycle (i.e., from the first initial contact at the force platform to the second initial contact of the test leg). And the Ariel Performance Analysis System (APAS) is used to quantify motion parameters (angular displacement of lumbar spine, unilateral hip, knee, and ankle). The preliminary data from one subject in each group are presented. Preliminary GRF data revealed that the normal subject had the highest before/after (Fig. 12.7) and vertical GRF (Fig. 12.8), followed by BP and LP sub­ jects, respectively. This was expected because faster walking speed produces more GRF (35). Interest­ ingly, the LP patient seemed to have somewhat dif­ ferent GRF patterns. The LP patient had slightly more backward force at preferred speed walking (Fig. 12.7A) and also more vertical GRF at loading response (Fl) at prefelTed and fastest speed walking (Fig. 12.8A and 12.8B) than the BP patient despite having the slowest walking speed (Fig. 12.9). This may have been partly caused by altered sensory input at the lower limb and step length asymmetry in the LP patient (step length difference between non­ test and test leg at preferred speed: normal 0.97 cm, =

Chapter Twelve: Physical Performance Tests

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Figure 12.7 Before/after ground react i on forces during a gai t cycle. (A) At preferred wal k i n g speed.

(B) At fastest walk i n g speed.

BP 0.12 cm, LP 2.33 cm; and at fastest speed: nor­ mal 1.24 cm, BP 4.34 cm, LP 3.52 cm). In general, both patients had more average mus­ cle activity than the normal subject in most muscle groups at both preferred and fastest walk speeds (Fig. 12.10A and 12.10B). However, between patient differences were observed. The patient with BP had higher average muscle activities than the LP patient. Specifically, the BP patient recruited more contra­ lateral paraspinal and hamstrings muscles of the test leg during preferred speed walking and more ipsilat­ eral paraspinal and pretibial muscles during fastest speed walking. Despite having lower levels of EMG activity in the paraspinals compared to the subjects with spinal problems, the normal subject still exhibited a greater magnitude of spinal motion at both preferred and fastest walk speeds (Fig. 12.1 1A and 12.11B). The preliminary results are intriguing, but it needs to be =

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established whether these individual differences are representative of group differences (i.e., BP, LP, and normal).

Sit-to-Stand

The sit-to-stand (Fig. 12. 12A-D) and loaded reach tasks (Fig. 12.13A-B) are also being investigated in pain-free individuals and among patients with LBP with and without a history of surgery. Preliminary findings from the biomechanical analyses have revealed some interesting insights into movement differences and/or compensations in the presence of LBP. For example, during rising from sitting, patients with LBP use less hip (flexion/extension) motion compared to control subjects and appear to compen­ sate through an increase in the motion of the knee ( 13). Further, patients with a history of spinal fusion

270

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Part Three: Assessment

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Figure 12.8 Vertical ground reac t i on forces dUl-­ ing a gai t cycle. (A) At preferred walking speed. (B) At fastest walking speed.

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Figure 12.9 Gait speed.

Chapter Twelve: Physical Performance Tests

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(B) At fastest wal king speed.

(>6 months postoperative status) exhibit restrictions in center of grayjty displacement during this task, pos­ sibly because of limited trunk mobility. They com­ pensate by increasing the displacement of their head to achieve standing (11). It is worth noting that all subjects (with and without LBP) were asymmetrical regarding their performance of the task (12). In the loaded reach task, we have found that pain­ free subjects reach fl.lrther forward and withstand a greater magnitude of spinal load than patients with LBP regardless of surgical status (37). Not surpris­ ingly, patients with lumbar fusion compensate for spinal restriction by increasing motion at the hip, knee, and ankle motions compared with the other two groups. They also exhibit relatively lower EMG activity in paraspinal and rectus femoris muscles but greater EMG activity in gluteus and hamstrings mus-

cles compared with control subjects or with non­ surgical patients. The interdependency in the relationship between movement and EMG activity makes it difficult to determine whether differences in EMG activity be­ tween groups are causes, correlates, or consequences of altered movement patterns. More importantly, the adaptive strategies distant from the trunk (e.g., be­ tween group differences in ankle movements) empha­ size the need for "whole person" assessment rather than spinal assessment. Interestingly, non-surgical patients with LBP ex­ hibit significantly greater lateral sway as they move forward (22.36 em, compared to 10.88 em and 11.11 em for spinal fusion and control groups). It is possible that this increased lateral sway is pain related because of the relatively high level of pain in

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Part Three: Assessment

A At preferred walking speed

60 o

50

Norm

.BP o LP

40 30 20 10 o Ankle

Knee

Hip

Lumbar

Lumbar

Flex/Ext

Side Flex

B At fastest walking speed

60 o Norm • BP

50 40 30 20 10 o Ankle

Knee

Hip

Lumbar

Lumbar

Flex/Ext

Side Flex

Figure 12. 1 1 Total range of motion during a gait cycle. (A) At preferred walking speed. (B) At fastest walking speed.

the non-surgical patients. It could also be caused by the relatively slow rate of forward movement in the LBP group resulted in greater lateral sway (similar to riding a bicycle slowly). The fact that this study was cross-sectional in design limits the interpretation of these findings.

• CONCLUSION

Physical performance and LBP are complex multi­ dimensional constructs. They can be influenced by physical, cognitive, emotional, social, task, and environmental factors. The physical performance task battery appears to provide a psychometrically sound and meaningful basis for physical therapy

assessment, treatment, and outcome measurement. It is plausible that physical performance tests will also provide a reasonable basis by which patients are divided into homogenous subgroups. Thus, individual treatment protocols for the subgroups can be developed based on a theoretically credi­ ble and testable foundation. Monitoring physical performance over time may ultimately facilitate clinical decisions regarding optimum timing and duration of physical therapy interventions. Another advantage 0f using physical performance tests for assessment is that clinical decisions can be driven into a mode that is more holistic, that focuses on physical function and activity, that identifies move­ ment difficulties, and that has a credible, theoreti­ cal basis.

Chapter Twelve: Physical Performance Tests

A

B

c

D

Figure 12.12 B iomechan ical analysis of sit-to-stand task.

(A) (B) (C) (D)

Condition I: Arms pus h i n g fl-om chair. Cond ition 2: Arms crossed. Cond i t i o n 3: Arms fl-ee. Cond i t ion 4: Arms push i ng knees.

A

B

Figure 12.13 B i o mechanical analysis of loaded reach task.

(A) Starting posit �on. (B) End pos i t i o n .

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Audit Process Self-Check of the Chapter's Learning Objectives •

Why are i m pairment tests not related significantly to the actual phys i ca l performance o f tasks?

•

What tests are part of the standardized battery of fu nctional tests?

•

H ow can t h i s functional battery i n fluence the type of care delivered?

•

How are functional tests affected by back pain and sciatica?

•

How i s gait affected by back pain and sc iatica?

• REFERENCES 1 . Aren dt-Niel sen L , Graven-Nielsen T, Svarrer H , et al . The i n Auence of low back pai n on muscle activi ty and coord i nation during gait: a c l inical and experi­ mental study. Pain 1 996;64: 2 3 1 -240. 2.

Beurskens AJ , de Vet HC, Koke AJ. Responsiveness o f fu nct ional status in low back pai n : A comparison o f d i fferent instru ments. Pain 1 996;65 : 7 1 -76.

3.

Beurskens AJ, de Vet H C , Koke AJ, et a l . Measuring the flmctional status of patients w i t h low back pain. Assessment o f the qual i ty o f four d i sease-specific questionnaires. Spine 1 99 5 ; 20: 1 0 1 7- 1 02 8 .

4.

Biering-Sorensen F , Thomsen CE, H ilden J . R i s k i n d i cators for low b a c k trouble. Scand J Rehabil M e d 1 989;2 1 : 1 5 1 - 1 5 7 .

5 . Chatman A B , Hyams S P , Neel J M , et a l . The Patient­ Spec ific Functional Scale: measurement propert ies in patients w i t h knee dysfunction. Phys Thel" 1 99 7 ; 7 7 : 8 2 0-82 9 . 6 . Craig KD, Prkach i n K M , G m n a u R V E . T h e facial expressi on of pain . I n : Turk DC, Melzack R , eds. The facial expression of pain. Gu i l ford Press, 1 992:257-2 7 6 . 7 . de Looze M P , Z inzen E , Caboor D , et al . M uscle stren gth, task performance and low back load in nurses. Ergonomics 1 998;4 1 : 1 095-1 1 04. 8.

Dedering A, Nemeth G , Harms-Ringdahl K. Correla­ tion between electromyograph i c spectral changes and subjective assessment of l u m bar muscle fatigue in subjects wi t h out pain from the lower back. Clin Biomech ( B ri stol , Avon) 1 999; 1 4: 1 03- 1 1 1 .

9.

Deyo RA, Centor RM . Assessing t he responsiveness o f fu nctional scales to c l i n ical c hange: An analogy to d i agnos t i c test perform ance. J Chro n ic D i s 1 986 ;39:8 97-906.

1 2 . E tnyre B R , Sim monds M J , Radwan H. Comparison o f electromyographic duration and frequency c har­ acteristics between low back pain patients and a con­ trol group. Third I n terdiscipli nary World Congress on Low Back and Pelvis Pain. Vienna, Austria, 1 998. 1 3 . E tnyre B R , Sim monds M J , Radwan H , et a l . H i p and knee d isplacements during s i t -to-stand movem ents between low back pain patients and a control group. 1 3t h I n temational Congress of World Confederation for Physical Therapy. Yokohama, Japan, J 999. 1 4. Faas A . Exerc ises: Which ones are worth t ry i ng, for which patients, and when? Spine 1 996 ; 2 1 :2 874-287; d i scussion 2 8 8-2 89. 1 5 . Fairbank JC, Couper J , Davies J B , et al. The Oswestry low back pai n disa b i l i ty quest ionnaire. Physiother­ apy. 1 980;66: 2 7 1 -2 7 3 . 1 6 . F i s her K, Johnston M . Validation of t h e Oswestry Low Back P a i n Disab i l i ty Questionnaire, its sensitiv­ ity as a measure o f change following treatment and its relationship w i t h o t her aspects o f the chronic pain experience. Physiother Theory Pract 1 997; 1 3:67-80. 1 7 . Fordyce WE, Lansky D , Calsyn DA, et al. Pain mea­ surement and pain behavior. Pain 1 9 84; 1 8 :53-69. 1 8 . Freburger JK, Riddle DL. U s i ng publ ished evidence to guide the exam i nation of the sacroil iac joint region. Phys Ther 200 1 ;8 1 : 1 1 3 5- 1 1 43 . 1 9 . Gatchel R J , Pol a t i n P B , Mayer T G . T h e dom i nant role of psychosoc ial risk factors in the development of chron ic low back pain disab il ity. Spine 1 99 5 ; 20:2702-2709. 20. Grieve GP. Mobil izat ion o f the Spine, 4th ed. New York, N Y: Churc h i l l Livi ngstone, 1 984. 2 1 . Hussein TM. Kinematic gait characteristics: A com­ parison o f patients with chronic low back pai n with and w i t hout refelTed leg pa i n ( D issel-tation). Hous­ ton, TX: Texas Woman's U n i versity, 1 999. 22.

Hussein T M , Si m m onds MJ , Et nyre B , et al. Kine­ matics o f gait i n subjects w i t h low back pa i n with and w i t hout leg pain. Washington, DC: Sc ien t i fic Meeting & Expo s i t i on of the American Physical Therapy Association, 1 999.

23. H ussei n T M , S i m monds MJ , Olson SL, et a l . Kine­ matics of gait in normal and low back pain subjects. Boston, MA: American Congress of Sports M edicine 45th Annual Meeti ng, 1 99 8 . 2 4 . I to T, S h i rado 0 , Suzu k i H , et a l . Lumbar trunk mus­ cle endurance testi ng: An i nexpensive altemative to a mach ine for evaluat i o n . Arch Phys Med Rehabil 1 996;77:75-79. 25. Kankaanpaa M, Laaksonen D , Taimela S, et al. Age, sex, and body mass i ndex as determ inants of back and h i p extensor fat igue in t h e isometric Sorensen back endurance test. Arch Phys Med Rehabil 1 998; 79: 1 069- 1 0 7 5 .

1 0 . Donahue MS, Riddle DL, Sull ivan MS. I ntertester rel iability of t he modified version o f M c Kenzie's lat­ eral s h i ft assess ments obtai ned i n pat i e n ts with low back pai n . Phys Ther 1 99 6 ; 7 6 : 706-7 1 6 .

26. Lee CE, S i mmonds MJ , Novy D M , et a l . Self-reports and clin ici an-measured physical perform ance among patients with low back pain: A comparison. Arch Phys Med Reha b i l 200 1 ;8 2 : 1 n press.

1 J . Etnyre BR, S i m monds M J , Lee C E , et al . Head and center of gravi ty motion during s i t - to-stand between back pain pa tients and a con trol grou p . 1 3 t h I nterna­ t i onal Congress of World Confederati o n for Physical Th erapy. Yokohama, Japan, 1 999.

2 7 . M a i n CJ , Watson PJ . Screening for pat ients at ri sk of developing chron ic i ncapac ity . J Occup Rehabil 1 99 5 ; 5 :207-2 1 7 . 2 8 . M arras WS, Parnia npour M, Fel"guson SA, et al. The classification of anatomic- and symptom-based low

Chapter Twelve: Physical Performance Tests

back disorders using motion measure models. Spine 1 995 ;20:2 5 3 1 -2 5 46 . 2 9 . MalTas WS, Wongsam P E . Flex i b i l ity and velocity o f t h e normal a n d i m paired l u m bar spine. Arch Phys Med Rehabil 1 9 86;67:2 1 3-2 1 7 . 30. McHorney CA, Ware JE Jr, Lu JF, et al. T.he MOS 36-i tem Short-Form H ea l t h Survey (SF- 3 6 ) : I I I . Tests of data qua l i ty, sca l i ng assumptions, and rel i a b i l i t y across diverse patient grou ps. M e d Care 1 994;32:40-66. 3 1 . McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): I I . Psy­ chometric and c l i n ical tests of validity in measuring physical and mental health constructs. Med Care 1 993;3 1 :247-2 6 3 . 3 2 . Newton M , Thow M , Somerville D , et a l . Trunk strength testing w i t h iso-mach i nes. Part 2 : Experi­ mental eval uation of the Cybex II Back Tes t i ng Sys­ tem i n normal subjects and pat ients with chronic low back pai n . Spine 1 99 3 ; 1 8 : 8 1 2-824. 33. Novy D M Sim monds MJ, Lee CE Physical Perfor­ mance Tasks: What are t he Underlying Constructs? Arch Phys Med RehabiI 2002 ;8 3 ( I ) :44-47. 34. N ovy D M , Simm onds M J , Olson SL, et a l . Physical performance: di fferences i n men and women with and wi thout low back pai n . Arch Phys Med Rehabi l 1 999;80: 1 95-1 98. 3 5 . Perry J. Gait Analysi s : Normal and Pathological Functi o n . Thorofare, NJ: SLACK Inc, 1 99 2 . 36. Radebold A, Cholewicki J , Polzhofer GK, et a l . Impaired postural control of the l u mbar spine i s associated with delayed muscle response t i mes i n patients w i t h chronic idiopathic l o w back pain. Spine 200 1 ; 26:724-7 30. 3 7 . Radwan H A . Motion patterns, electromyographic activity, and ground reaction forces during a loaded functional reach task: A comparison among subjects with low back pai n , subjects w i t h l u mbar spine fusion and a control group ( D issertat i o n ) . Houston, TX: Texas Woman's U n i versity, 1 999. 3 8 . Roland M , M orris R . A study o f the natural h i story of back pa i n . Part I : Development of a rel iable and sen­ sit ive measure of disabi l i ty in low-back pa i n . Spine 1 98 3 ; 8 : 1 4 1 - 1 44. 39. Rudy TE, Boston JR, Lieber SJ, et al. Body motion patterns duri ng a novel repetit ive wheel-rotation task. A comparative study of healthy subjects and patients with low back pai n . Spine 1 995 ;20:2 547-2 554.

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40. Sanders SH. Automated versus self-moni toring of 'up-ti me' i n chronic low-back pain patien ts: A com­ parative study. Pain 1 98 3 ; 1 5 : 3 99-405 . 4 1 . Sharrack B , H ughes RAC. Rel i a b i l i t y o f di stance esti­ mation by doctors and patients: Cross sec t ional study. BMJ 1 99 7 ; 3 1 5 : 1 652- 1 654. 42 . Simm onds MJ, Campbell A , Wang WT. Assessing functional change i n pat ients w i t h low back pain: A comparison of measures. Yokohama, Japan: 1 3 t h I n ternati o nal Congress o f the World Confedera­ tion for Physical T herapy, 1 999. 43 . Simmonds MJ, Claveau Y . Measures of pain and physical function in patients with low back pai n . Physiother Theory Pract 1 99 7 ; 1 3: 53-6 5 . 44. S i m monds M J , Lee CEo The Sorensen endurance test: a test of fatigue or pai n ? Phoenix, AZ: American Pain Society, 200 1 . 45. S i m m onds M J , Lee C E , Jones Sc. Pai n distri bution and physical fu nction i n patients w i t h l ow back pain . Yokoh a m a , Japa n : 1 3 t h I nternati onal Con­ gress o f the World Con federation for Physical Therapy, 1 999. 46 . Simmo nds M J , Olson S , N ovy D M , et al. D i sa b i l i ty pred i c t i o n i n patients w i t h back pain using perfor­ mance based models. C h arleston , SC: Nort h Amel-ican Spine Society/American Pain Society Meeting, 1 99 8 . 4 7 . S i mmonds M J , O l s o n S L , Jones S, et a l . Psyc homet­ ric c haracteristics and c l i nical usef'u l ness o f physical performance tests i n patients w i t h low back pai n. Spine 1 998;23:2 4 1 2-242 1 . 48 . Stratford P , G i l l C , Westaway M , et aJ. Assess ing d is­ ability and change on i nd ividual patients: A report o f a patient specific measure. P hysiot her Can 1 99 5 ;47:2 58-263. 49. Turk DC, Rudy TE, Stieg RL. The d i sabi l i ty determ i ­ n a t i o n d i lemma: Toward a m u l t i axial sol ution. Pain 1 988;34:2 1 7-229. 50. Vlaeyen JW, Kole-Snijders A M , Boeren RG, et a J . Fear of movementl(re ) i nj u ry i n c h ronic l o w back pain and i ts relation to behavioral performance. Pain 1 99 5 ; 62 : 3 6 3-372 . 5 1 . Waddell G , Newton M , Henderson I , e t a J . A Fear­ Avoidance B e l iefs Quest ionnaire ( FA B Q ) and t h e role of fear-avoidance beliefs in chron i c low back pa i n a n d d i sabi l i ty. P a i n 1 99 3 ; 5 2 : 1 5 7- 1 68 . 5 2 . Ware J E Jr, Sherbourne C D . T h e M O S 36-i tem short­ form health survey ( S F- 3 6 ) . I . Conceptual framework and i tem selecti o n . Med Care 1 99 2 ; 3 0 : 473-48 3 .

Employment Screening and Functional Capacity Evaluation to Determine Safe Return to Work

-

Leonard Matheson and Vert Mooney

Introduction

Learning Objectives

Validity of Pre-Employment Pre-Placement Screening Pre-Placement and Fitness for Duty Screening

On completion of this chapter you should be able 10: •

Americans With Disabilities Act

•

Fitness for Duty Evaluation

•

Pre-Placement Screening Screening by Health Care Professionals

•

Role of the Treating PhYSician Role of the Evaluating Physician

•

Functional Capacity Evaluation

•

•• 276

Assess the validity or pre-employment and pre-placement screening. Define fitness for duty evaluation. Explain the American and Disabilities Act restrictions and protections. Define the roles of the treating physician versus the evaluating physi cian. Assess the validity of a Functional Capacity Evaluation and be aware of what it can tell about job capacity. Assess the appropriate physical therapy and the expectations of physical therapy reporting.

•

Chapter Thirteen: Employment Screening and Functional Capacity Evaluation

Introduction

This chapter describes the historical background of employment screening from a health care perspec­ tive, beginning with the use of spinal x-rays to screen for risk of injury. Medical examination is less useful and justified for employee selection than it is for baseline comparisons. The use of technologies such as spinal MRI procedures may provide a basis for avoiding expensive and needless surgery when a problem such as an asymptomatic degenerative spine is found to be present before employment. The use of functional capacity evaluation is more often justi­ fied, both to identify applicants for employment who will be the most productive workers and to assist the physician and plant manager to properly place a worker returning from sick leave. Validity of Pre-Employment Pre-Placement Screening

It is self-evident that an employer would like to avoid hiring those who have greater liability of injury than the average. Recent estimates of direct costs of work related injuries and illnesses in the United States are in excess of $65 billion. In addition, the indemnity costs are $106 billion to American Industry (48). What can be done at the onset of employment to reduce the incidents of the employed? This chapter addresses employment screening for new employees and those who are returning to work after experi­ encing lost time because of injury or illness. The earliest form of pre-employment testing was the use of back x-rays. In early years it was felt that abnormal findings could predict those who would have injuries at work. However, when scientific stud­ ies were initiated, it was found that in asymptomatic people, 10% had disc degeneration, spondylolysis, or spondylolisthesis (25). Actually, when studied, it turned out that people with "normal" radiographs actually had a higher rate of injury compared to those who showed radiographic abnormalities (43). In another study in a steel plant where the workers were performing heavy work, abnormalities seen in x-ray did not predict a higher incidence of low back injuries (1 3). This is to be expected of course. The incidence of spondylolysis is approximately 5% in the U.S. general population, but the rate of significant disabling back pain in Americans with spondylolysis is only approxi­ mately 0.5% (2). Thus, because of the lack of predictive validity, and with the additional awareness of the threats of radiation, pre-employment radiographs have not been demonstrated to be cost-effective. Of course the more modern imaging technique is the MRI. This is extremely sensitive to soft tissue changes in the disc, but no study has showed that

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abnormalities noted in MRI are predictive of later pain symptoms. There is, however, a possible ratio­ nale that can be applied to a lumbar MRI if it could be performed cheaply enough. It is well-recognized that degenerative changes in the spine increase in a rate approximately correlated with age. Currently, when a worker is injured, the MRI shows a significant degen­ erative change and the individual does not respond to undefined physical therapy, a justification is made for fusion, whether there is causal evidence for impair­ ment. If it can be demonstrated that the degenerative changes that are suggesting the need for fusion were actually found in the MRI when the worker was hired (and the worker had been successfully employed in the interim), the enthusiasm for surgery is decreased. This strategy apparently has been successful in reduc­ ing the incidence of the very expensive spinal fusions at the Steelcase company (39). It is not clear whether in the future that the safer, but the more expensive, imaging tool MRI compared to plain x-rays will be more helpful than the now discarded x-ray screening. If imaging studies are not predictive of spinal dis­ ease, then how about physical strength testing? There only has been one study that purports to demonstrate that strength testing could predict an incidence of back injuries (24). The workers studied in this group performed extremely demanding physical work in the tire manufacturing business. They had to lift heavy tires off of workplaces, twist, and put them down in a constant repetitive manner. The heavy job demands facing that group of workers is somewhat unique. Using essentially the same testing method, a more recent study of pre-employment testing of air­ craft workers for Boeing indicated that isometric testing of total body lift function could not predict of incidence of back injury (3). Selection for employment on the basis of lifting tests is not possible unless the specific demands of the job are being tested. In another recent study, careful strength testing using isokinetic technology was performed on 33 experienced warehouse work­ ers to measure back strength. The pre-placement individuals had to meet that minimum standard before they were hired in that job category. There was a significant reduction in back pain claims as a result of this strategy (44), but such a study may bring up another aspect of pre-placement testing. An applicant for the job, when it is recognized that spe­ cific testing is being performed, may not persist with the application for that job if he/she feels physically poorly qualified or has a history of workers' com­ pensation claims. Pre-placement strength testing can give a baseline that would question the validity of an individual's claim for injury later. Is there evidence that back strength is a predictor for back injury? We conducted a study to investigate

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Part Three: Assessment

that proposition (35). Using specific isometric testing over 7 points of range, we tested 1 52 shipyard work­ ers as to their lumbar extensor strength. These indi­ viduals were all veterans in their job, had not had back claims for at least 3 years, and were followed-up for an additional 2 years. Nine percent of that study group had a back claim over the next 2 years. It was noteworthy that all but two of these injured workers had higher strengths than the average. Thus, back strength itself was not a predictor of injury. These workers were classified also regarding PDC levels of medium, heavy, and very heavy work. Even though they performed various types of work with varying physical demands, the back strengths did not vary among these three groups. Thus, even the demands of the job did not apparently affect back strength. Are there factors that can predict work injury? Chaffin and Clark found a threefold increase of injuries and the risk of back problems in subjects with a history of back pain (8). Sciatica is a predictor of back pain (38,4). A prospective study by Lloyd and Troop (27) found four historical factors to be predic­ tive of recurrent low back pain. These were residual leg pain on work placement, history of sickness absence of 5 weeks or more, falls as a cause of back pain, and a history of two or more previous episodes of back pain. Thus, we do have some predictors of who might get industrial back pain. With this knowledge, is it possi­ ble to disCliminate in hiring practices? In 1984 the American Medical Association summarized the objec­ tives for pre-placement examinations as follows ( 1 5): •

•

•

•

To evaluate the medical fitness of individuals to perform their duties without hazard to themselves or fellow workers. To assist employees in maintaining maintenance or improvement of their health. To detect the effects of harmf·ul working conditions and to advise corrective measures. To establish a record of the medical condition of the employee at the time of each examination.

However, there was a considerable question as to whether the employees or the employer benefited from medical evaluation programs at all (16). Actu­ ally, there never has been a scientific study demon­ strating the levels of success or risk of avoidance accomplished by medical evaluations in the past. In fact, the case was being made that even evaluation was discriminating in preventing people with dis­ abilities from entering the workplace. Thus, the American with Disabilities Act (ADA) passed in 1 990. It prohibits disability-based discrimination in all

aspects of employment and mandates that medical examinations be conducted only after an offer of employment is made to an applicant. An employer cannot reject a candidate because of medical con­ cerns about insignificant or uncertain future risks or inability to perform non-essential job functions. Employers are required to maintain the confiden­ tiality of medical information and to provide reason­ able accommodations for qualified applicants who have disabilities. In the past it was possible for physicians to rec­ ommend to employers that they do not hire appli­ cants because of speculative risks of injury or costs of accommodation. Under the ADA, the incorrect medical advice can result in significant and costly lit­ igation. Thus, any medical advice has to be specifi­ cally based on appropriate evidence. Employers may require an applicant to undergo the physical examination before beginning employ­ ment, but only after a job has been offered. The rea­ son for conducting such an evaluation may include medical determination of the ability to meet job per­ formance requirements or medical standards. The ADA allows an employer to reject a person only after stringent criteria are met. An applicant may be rejected if he poses a direct threat to himself or oth­ ers in the workplace. He may be rejected if a disabil­ ity prevents performance of essential job functions or when accommodations cannot be made without undue hardship. This phase of the legislation may result in litigation as to what is accommodation that would create undue hardship to the employer. Specifically, also, the ADA prohibits employers to inquire about a history of back problems, which the job applicant may choose not to disclose, before a job offer. The Equal Employment Opportunity Commis­ sion (EEOC) notes that 46% of back impairment charges have come from discharged employees ver­ sus 1 5% in the hiring process (22). Let's take a closer look at the laws and guidelines surrounding health care practice in employment screening.

Pre-Placement and Fitness for Duty Screening

Increasingly, health care professionals are being asked to provide pre-placement screening and fitness for duty screening services. It is important to recog­ nize that these services must be provided within the context of the laws that govern employee placement and selection. This legal context is quite different from that in which all other laws based on the Eng­ lish Common Law heritage are found. That is, the laws governing employee placement and selection are frequently concerned with establishing parity for

Chapter Thirteen: Employment Screening and Functional Capacity Evaluation

disadvantaged individuals. The Equal Employment Opportunity (EEO) laws in the United States, and similar laws in Canada and most industrialized countries, are intended to precipitate social change. As such, the laws and the rules governing those laws have developed so that they favor the employee or potential employee who chooses to use them. In all other aspects of the law, the individual against whom an action is brought (the defendant) does not have the burden o[ proof. The plaintiff or applicant who brings the action maintains the burden of proof and, if the plaintiff is not able to establish beyond a rea­ sonable doubt that the defendant is at fault, the defendant will win the lawsuit. The difference in the EEO arena is that the burden of proof is on the defen­ dant. In an EEO action, the defendant must demon­ strate that there was no unfair discrimination in the defendant's hiring, placement, or promotional procedures. The EEO laws have been developed in recognition of the fact that discrimination exists within society based on factors other than ability. The basic tenet of these laws is that one must not unfairly discriminate. Discrimination in selection for employment and [or placement after hiring is only acceptable as long as it is fair and appropriate to the situation. If a selec­ tion procedure is used and decisions for placement are made based on the results of the selection proce­ dure, it must be able to be demonstrated that the selection procedure is relevant to the decision that was made. For example, it is entirely appropri ate to use a test of typing speed and accuracy to select indi­ viduals to be placed in a job in which typing is a nec­ essary and important job [unction. However, this same test would not be appropriate for individuals applying for a job as a warehouse worker if typing is not a necessary part of that job. To use another example, a test of infrequent lifting from floor to eye level would be appropriate as long as the evaluation task can be demonstrated to predict subsequent com­ petence and/or safety in the warehouse worker's job. It would only be appropriate to use that same test of lifting with a secretary if the secretarial job descrip­ tion required lifting as a usual and necessary job [·unction. In either case, the test must be such that the individual's performance can be shown to be related to subsequent performance on the job. It is important to appreciate that the applicant's competence in performance of job functions must be considered separately from the applicant's safety i n the job. Although in most health care professionals' minds these are linked, competence and safety are separate issues and must be considered separately. The important point here is that assessment of com­ petency is much easier to perform and defend than assessment or safety. The health care professional

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who is providing pre-placement evaluation services probably will be best able to provide tests of compe­ tency rather than tests of safety when one considers the legal context within which all of the testing must be conducted. Stated another way, the evaluator must be prepared to defend his or her recommenda­ tions against a challenge based on one or another (or perhaps several) of the EEO laws. It is much easier a priori to develop an effective defense if the recom­ mendation for placement is based on competence than i f the recommendation is based on safety. In addition, if, for some reason, an a priori defense has not been developed and the evaluator is unprepared, a defense based on competence will be possible to reconstruct, whereas a defense based on safety will be impossible to put together after the fact. The defense that an employer will use has to do with: 1. Whether the individual is a member of a pro­ tected group. 2.

Whether the use of the selection device brought about an adverse i mpact.

3. Whether the use of the selection device can be demonstrated to be based on a business necessity.

If an i ndividual is not from a protected group, and/or there i s no adverse i mpact, and there is a business necessity for use of the test, then the employer will prevail. However, if an individual is a member or a protected group and there is adverse impact without business necessity, the plaintiff will prevail. Even if the employer puts forth an adequate defense, individuals in the United States who are members of the disabled protected group have still another set of protections based on the legal require­ ment that the employer provide reasonable accom­ modation. That is, the employer must demonstrate that i t is not reasonable to make changes in the work place or manner of work that would sufficiently accommodate the handicap presented by the prospec­ tive employee so that job performance would not be affected. Because each of the States in the United States can develop laws that extend beyond the basic re­ quirements of the federal EEO laws, various defini­ tions have come up that are relevant in certain states. For example, the definition of "handicapped worker" includes individuals who are hypertensive in Cal i­ fornia but does not apply in any other states, includes individuals who are alcoholics in Wisconsin but does not apply in any other states, and includes i ndividuals with glaucoma in North Carolina but does not apply in any other states. Conversely, cer­ tain states have delimited the term. The important point to appreciate is that there is great variability.

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Part Three: Assessment

The laws briefly outlined should be considered basic. The protections that are described for workers may have been expanded by a particular state or munici­ pal government. Title VII of the Civil Rights Act of 1964 prohibits discrimination on the basis of race, color, national origin, sex, or religion. This Act is enforced by the Equal Employment Opportunity Commission. Title VII includes employers that have 15 or more employees that are engaged in "an industry affecting commerce," all state and local governments and schools, almost all unions, and almost all employ­ ment agencies. Executive Order 11246 (1965) amended by Execu­ tive Order 11375 (1968) prohibits discrimination on the basis of race, color, religion, or national origin by contractors doing business with the federal govern­ ment. This is administered by the Secretary of Labor through the Office of Federal Contract Compliance Programs. Any employer who has a contract of $10,000 or more or who does business with the fed­ eral government worth $50,000 or more is covered. The Age Discrimination and Employment Act of 1967 (ADEA) was amended in 1978 and protects employees and applicants for employment between the ages of 40 and 70 years. Employers with 20 or more employees for 20 or more weeks of the year are included. Enforcement of the ADEA is vested with the Equal Employment Opportunity Commission. The Equal Pay Act of 1963 is an amendment to the Fair Labor Standards Act of 1938 and is the basis behind the "Equal Pay for Equal Work" movement, which requires that employers provide wages to employees at a rate that is not gender-specific. This is currently under the jurisdiction of the Equal Employment Opportunity Commission. The Health Care Act of 1973 is similar to Execu­ tive Order 11246 and Executive Order 11375 but extends the protection to individuals who are handi­ capped and expands the threshold for coverage to any contractor who has more than $2,500 of busi­ ness with the federal government. A handicapped person is covered if he or she has a physical or men­ tal impairment that substantially limits one or more major life activities or has a record of such impair­ ment or is regarded by others as having such an impairment, even though the person may not, in fact, have such an impairment. Under Section 504 of the Act, an employer may not inquire about whether the applicant is handicapped or about the nature or severity of a handicap unless two criteria are met: 1.

A pre-employment medical examination is required of all applicants.

2.

The information sought is relevant to the appli­ cant's ability to perform job-related functions.

Although, originally, individuals with alcohol or drug abuse problems were considered handicapped, subsequent amendments by Congress have excluded this as a handicapping condition. The Health Care Act is administered by the Office of Federal Contract Compliance Programs. The OFCCP has administra­ tively expanded the concept of handicap to include, for instance, obesity and epilepsy. In addition, the concept of reasonable accommodation has been developed by the OFCCP. The Health Care Act itself does not require the employer to make reasonable accommodation. The Vietnam Veterans Readjustment Act of 1974 covers disabled veterans and non-disabled veterans of the Vietnam era and is similar to the Health Care Act of 1973 and the Executive Orders 11246 and 11375 in that it covers contractors with the federal government wherein the value of the contract is $10,000 or greater. This is also under the jurisdiction of the Department of Labor, administered through the Office of Federal Contract Compliance Programs.

Americans With Disabilities Act

The Americans with Disabilities Act was signed into law by President George Bush on July 26, 1990. The Act states that: No covered entity shall discrimi nate aga inst a quali fied individual w i t h a disabi l ity because of the disab i l ity of such ind ividual in regard to job application procedures, the h iri ng, advancement, or disch arge or employees, employee compensation, job traini ng, and other terms, conditions, and privi leges or employment.

Purpose of the ADA

In the ADA, Congress attempted to address several important issues that had been introduced and less effectively addressed in the Health Care Act of 1973. These include: 1. To provide a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities. 2.

Provide clear, strong, consistent, and enforceable standards that address discrimination against individuals with disabilities.

3. To insure that the federal government plays a central role in enforcing the standards in the Americans with Disabilities Act on behalf of indi­ viduals with disabilities. 4.

Invoke Congressional authority, including the power to enforce the 14th Amendment and to regulate commerce to address the major areas

Chapter Thirteen: Employment Screening and Functional Capacity Evaluation

of discrimination faced by individuals with disabilities.

Types ofDiscrimination Targeted by the ADA Congress recognized that discrimination against indi­ viduals with disabilities takes several forms and exists in a number of areas. Discrimination limits individu­ als with disabilities in areas of employment, housing, access to public facilities, and access to public trans­ portation and communication. With regard to dis­ crimination against individuals with disabilities in the area of employment, Congress specifically identified the following as covered by the Act: 1 . Limiting, segregating, or classifying the disabled. 2.

Participating in a contractual relationship that has the effect of subjecting employees to discrim­ ination prohibited by the Act.

3. Utilizing standards that have the effect of dis­ crimination based on disability. 4.

Basing employment decisions for a qualified individual on the known disability of the person with whom the qualified individual is known to have a relationship.

5. Not making reasonable accommodations to the limitations of the qualified individual unless the covered entity can demonstrate that this would pose undue hardship on the operation of the business. 6. Using qualification standards that screen out or tend to screen out individuals with disabilities, unless the standard is shown to be job-related and is consistent with business necessity. 7.

Using employment tests that reflect the individ­ ual's impairment rather than providing a valid measure of the job's demands.

Definitions Provided by the ADA As is necessary with every law, certain definitions are developed and provided by Congress to be used by agencies enforcing the law. Those that relate specifi­ cally to the employment aspects of the Act include: Disability-A physical or mental impairment that substantially limits one or more major life activities; a record of such impairment; or being regarded as having such impairment. Covered entity-An employer, employment agency, labor organization, or joint labor action committee. Employer-A person engaged in an industry affecting commerce who has 15 or more employees in each of 20 or more calendar weeks in the current or preceding year. For 2 years after

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28 1

the effective date, "employer" is a person engaged in an industry affecting commerce who has 25 or more employees in each of 20 or more calendar weeks in the current or preceding year. The effective date for the legislation is July 26, 1990. Therefore, employers with 25 or more employees are covered as of July 26, 1992, and employers with 15 or more employees are cov­ ered as of July 26, 1994.

Qualified Individual with a Disability An individual with a disability who, with or without reasonable accommodation, can perform the essen­ tial functions of the job that he/she holds or desires. The Act provides a non-exhaustive set of conditions or disorders that are specifically excluded fTom the definition, including homosexuality, bisexuality, transvestitism, pedophilia, transsexualism, exhibi­ tionism, voyeurism, gender identity disorders not resulting from physical impairment, other sexual behavior disorders, compulsive gambling, kleptoma­ nia, pyromania, and psychoactive substance abuse disorders resulting from current illegal use of drugs. In addition, an amendment to the Health Care Act of 1973 states that "individual with handicaps" does not include an alcoholic whose current use of alcohol prevents performance of job duties or constitutes a direct threat to property or to the safety of others. Direct threat-As part of a qualification stan­ dard, an employer may exclude a qualified indi­ vidual from employment if that individual can be shown to pose a direct threat to the health and safety of others in the work place. This must be a significant and identifiable risk, not merely an elevated risk. The employer must demon­ strate that the individual poses a direct threat. The plaintiff is not required to prove an absence of risk. Essential functions of the job-Consideration shall be given to the employer's judgment as to what functions of the job are essential. A written job description, prepared before advertising or interviewing, shall be considered evidence o[ the essential [unction. However, there is no pre­ sumption in favor of the employer's judgment. The weight that evidence based on job descrip­ tion will be given will depend directly on how closely it is tailored to the essential duties of the actual job. Reasonable accommodation-This is not specifi­ cally defined. As was the practice with the Health Care Act of 1973, reasonable accommodation takes many forms and is dependent on the employee, job, covered entity's facility, and

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covered entity. Reasonable accommodation is based on procedures that have been developed to implement the Health Care Act of 1973. The Amer­ icans with Disabilities Act introduces reasonable accommodation with the phrase, "the term 'rea­ sonable accommodation' may include. . . ." The act provides specific examples, including making existing facililies readily accessible to and usable by individuals with disabilities. In addition, other methods of restructuring include job restructuring, part-time or modified work sched­ ules, reassignment to a vacant position, acquisi­ tion or modification of equipment, modification of examinations, training materials, or policies, provision of readers or interpreters, or other similar accommodations. Undue hardship-An action requiring significant difficulty or expense. This is considered in light of the accommodations and how they are to be implemented, involving both the direct cost and net cost of the accommodations. In addition, the facility's financial resources, number of persons employed, and impact on operations is taken into account. Beyond the individual facility, the covered entity's resources are considered based on the financial resources of the entity, the num­ ber of persons employed, and the impact on operations of the entity. Finally, the composi­ tion, structure, and function of the work force at the entity and the facility's geographic separate­ ness fTom administrative control, along with the physical relationship of the facility to the covered entity will be taken into account. Determination of undue hardship is factual and is made on a case-by-case basis. The burden of proof is on the employer.

Fitness for Duty Evaluation

As the disabled individual concludes his treatment program and is released by his physician, determi­ nation regarding return to work at the usual and cus­ tomary employment, requirement of reasonable accommodation, or a decision of no return to employment despite accommodation, is based on a fitness for duty evaluation (FFDE). The FFDE is a content-valid functional capacity evaluation based on the previously conducted physical demands job analysis. The FFDE is conducted by a health care professional with proper education, training, and experience. The FFDE is based on the critical job tasks of the target job. These are identified by review­ ing the physical demands job analysis in light of the employee's impairment. The FFDE process follows these steps:

1 . Physical demands job analysis review-The fit­ ness for duty evaluation begins with review and confirmation of the physical demands job analy­ sis in consultation with the supervisor, employee, and treating physician to identify the critical job tasks that will be the focus of the evaluation. 2.

Medical records review-A review of pertinent medical records is undertaken, facilitated by contact with the evaluee's physician if the eval­ uee is in active treatment. Confirmation that the impairment is stable and identification of work restrictions that may affect subsequent testing are the focus of these activities.

3. Structured interview-A structured interview between the evaluator and evaluee is confidential and focuses on the evaluee's injury and medical history. In addition, the evaluee's perception of current functional limits is reviewed. The pur­ pose of the interview is to begin screening out individuals who cannot be tested safely and to identify performance limits that may not be apparent. 4.

General health questionnaire-The evaluee must complete a general health questionnaire and injury history. A questionnaire such as the Cor­ nell Medical Index or the EPIC Health Question­ naire (12) provides a broad overview of health status. The questionnaire is reviewed by the eval­ uator to identify problems that may underlie per­ formance in the testing situation.

5. Perceived functional limits test-Whereas most of the critical job tasks have been identified by interaction between the treating physician and evaluator, it is necessary to screen for tasks that have been missed through the use of a test of perceived functional limits. The Spinal Function Sort and Hand Function Sort are used effectively to perform this task (Figs. 13.1 and 13.2). 6. Screening examination-Depending on the eval­ uee, his or her impairment, and the specific demands of the job, pre-evaluation screening should review active or passive range of motion, sensibility, muscular spasm, local swelling, cog­ nitive function, resting blood pressure and heart rate, or other pertinent musculoskeletal, neuro­ logic, or physiologic [unction. 7.

Progressive functional testing-A protocol based on progressive functional testing of the evaluee's ability to perform critical job tasks is designed based on the physical demands job analysis, physician's prophylactic restrictions, evaluee's health, evaluee's perception of his or her limits,

Chapter Thirteen: Employment Screening and Functional Capacity Evaluation

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Pre-Placement Screening

Figure 13.1 Spi nal [u nction sort-carry i n g a 3 0 - l b bucket 30 feel. W i t h perm i ss i on from Matheson L, M atheson, M. Spinal Function Sort. W i l dwood, MO: Employment Poten t i al Improvement Corpo­ ration, 1989.

Pre-placement screening has attracted substantial attention from employers in recent years because of its value in assisting employers to maintain a cost­ effective work force by assuring that workers are selected who are likely to perform job tasks in a safe and productive manner. The Americans with Dis­ abilities Act allows pre-placement screening as long as it is job-related, conducted after a conditional offer of employment is made to the applicant, is uni­ versally applied, is a valid indicator of essential func­ tion, and is a business necessity. Pre-placement screening is conducted by prop­ erly trained evaluators who use simulations of essential work demands that are content-valid or validated performance tests that have been statisti­ cally demonstrated to predict performance in these work simulations. Pre-placement screening is conducted using a pro­ tocol based on a physical demands job analysis. A content-valid test is used or a testing protocol is devel­ oped and a validation study conducted to demon­ strate that the protocol is statistically related to the essential job demands. A scientific validation study is necessary to objectively establish the statistical relationship between test demands and essential job

and the results of the screening examination. The most conservative of these parameters is used as a performance target and may be exceeded only with the utmost consideration given to the evaluee's safety. 8.

Next-day follow-up-A telephone or in-person follow-up must be conducted the day after the evaluation to elicit the evaluee's symptomatic response to the activity of the examination. This becomes a formal record that is added to the evaluee's file. This addresses the evaluee's readi­ ness to return to work.

9. Report preparation-The evaluator prepares a formal report that describes the Fitness for Duty Evaluation. This report is maintained in the confidential file. A synopsis that includes recommendations for the employee, employer, and treating physician is excerpted and pro­ vided to the employer for distribution. If the evaluation results in a recommendation against returning to the previous employment, reason­ able accommodation options must then be addressed. If viable options do not exist or are insufficient, the evaluator must provide ratio­ nale for a recommendation of no return to employment.

Figure 13.2 Hand function sort-pi c k out one l arge paper c l i p fyom a group of small paper c l i ps. With permission fyom Matheson L, Matheson M, Grant J. Hand Function Sort. W i l dwood, MO: Employment Potential I mprovement Corporation, 1 995.

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Part Three: Assessment

demands. Additionally, the validation study sets standards that minimize disparate impact for identi­ fied groups, including, but not limited to, individuals with disabilities, minority groups, females, and older workers. The validation study is conducted by a team that is composed of professionals such as an industrial psychologist, physiologist, ergonomist, and job ana­ lyst. Additionally, with proper training, an occupa­ tional therapist, physical therapist, or vocational evaluator can provide a validation study.

Development of Testing Procedures Employee selection procedures must be developed within the context of the Uniform Guidelines on Employee Selection Procedures (18). The Guidelines provide several important definitions. These include: Selection procedure-Any standard that is used as a basis for any employment decision is consid­ ered a selection procedure. The exact quote from the Uniform Guidelines is:

ate. Generally speaking, this means that the test bears an easily observable relationship to neces­ sary job demands. 2.

3. Development of selection procedures-Although the employer may utilize a standard "off the shelf" selection procedure, the employer has the burden of demonstrating the relevance of that test procedure to the particular circumstance. It is often less troublesome to develop a selection procedure specifically based on the employer's situation. 4.

. . . any measure, combination of measures, or pro­ cedure used as a basis for any employment dec ision. Selection procedures i nclude the ful l range of assess­ ment tec h n i ques from t ra d i t ional paper and pen c i l tests, performance tests, training progra ms or pro­ bationary periods, and phys i cal , educat iona l , and work experience requi rement t h rough i n formal or casual i n terviews and unscored app li c a t i o n forms. ( 1 2 [page 2 1 5 ] )

Adverse impact-There is no adverse impact if the worst performing group is achieving at a rate 80% as well as the best performing group, the groups defined as blacks, Native Americans, Asians, Hispanics, females, and males. Adverse impact is usually based on review of the mix of employees who are success­ fully hired. That is, it is not usually a question of one or another selection criterion, but the selection process as a whole. Content validity-This has to do with the con­ cept that the test is a "piece of the job." As such, the test may be considered content valid. Content validity cannot be used for issues such as person­ ality or intelligence but can be used when the test sample focuses on the necessary knowledge, skill, or ability to successfully complete the job. The EPIC Lift Capacity Test (30,21) can be used as a content-valid test. The Uniform Guidelines list these nine factors that must be considered in the use of a content valid test: 1.

Appropriateness of content validity studies-If a test is a representative and fair sample of job tasks or demands, it will be considered appropri-

Job analysis for content validity-A formal job analysis that identifies important work behaviors must be conducted. The job analysis must demonstrate that the worker characteristics are necessary for successful job performance.

Standards for demonstrating content validity­ The test user must demonstrate that behavior measured in the test constitutes a representative and fair sample of that which is required to suc­ cessfully perform the job and that the knowl­ edge, skill, and ability that is measured is that which is minimally necessary for successful job performance and that the test actually measures these factors.

5. Reliability-One of the advantages of the con­ tent valid approach is that validation tests based on statistical significance are not necessary. However, the Uniform Guidelines require that "whenever feasible, appropriate statistical esti­ mates should be made of the reliability of the selection." 6. Previous training or experience-This simply has to do with the need for the employer to demon­ strate that any requirement for previous training or experience is justified by demonstrating the relationship between this experience and the content of the job. 7.

Content validity of training success-This has to do with the use of a training program as a selec­ tion device and simply means that the content of the training program must be demonstrated to have relationship to the content of the job.

8.

Operational use-The selection device must be a measure of usual and customary duties.

9. Ranking based on content validity studies­ Uniform guidelines require that employers not use a ranking system unless the ranking system can be demonstrated to relate to job perfor­ mance. That is, if a ranking system is used, higher-ranked employees must be shown to do better in terms of job performance than lower­ ranked employees.

Chapter Thirteen: Employment Screening and Functional Capacity Evaluation

Screening by Health Care Professionals

Pre-placement screening that is performed by health care professionals will usually be based on content validity using a careful and weIl-documented job analysis to establish the business necessity of the test. The business necessity defense rests on five issues: 1.

The examination, test, or procedure on which the employment decision is based is found to be job-related.

2.

The examination, test, or procedure has a high predictive value and is the most accurate test that is feasible to use. This will often not be pos­ sible to establish initially and will require a lon­ gitudinal study if the employer is to have confidence that a subsequent EEO action will be defensible. Reliance on a cross-sectional study is to be discouraged in that if adverse impact is already current, the cross-sectional study will be confounded.

3. The examination, test, or procedure indicates that the applicant has a strong likelihood for the development of a serious injury or illness in the foreseeable future and the likelihood of injury or illness represents a significant variation from the general worker population, or discriminates effectively between individuals of varying degrees of productivity. Because the former, hav­ ing to do with job safety, is so difficult to estab­ lish, the latter, having to do with job competency, is more frequently used. When a test is being used to predict successful job performance, the length of time that is required to pass before the individual is judged to have been successful or unsuccessful on the job is finite and predictable. However, when the test is being used to screen for potential injury, considerably more time must pass before an individual is judged to be free fl-om injury. This length of time is open to wide variance and interpretation. 4.

The disqualification or other adverse personnel action is based on an individualized determina­ tion of fitness. Use of a simple cutpoint is not acceptable. This requires that each personnel decision involve a multifaceted review of the employee. Professional judgment must be exercised.

5. No reasonable accommodation will permit the disabled individual to perform the necessary job function. If the applicant qualifies as a disabled individual, the employer must be prepared to demonstrate that reasonable accommodation is not possible and/or sufficient. This, of course,

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does not hold when the applicant does not qual­ ify as a handicapped individual.

Role of the Treating Physician

The treating physician should be aware of predictors of back injuries and recurrence once the individual was employed. Even though there is no evidence that back strength alone is a predictor of back injury, there remains the question as to the role of diminished back strength in recurrence of back pain. In a recent study we investigated the role of strength training to reduce incidence of back injury in an industrial setting (36). The strip mining company had an average 9-year his­ tory of 2.94 injuries per 200,000 employee hours. This was devastating with their insurance rates. They initi­ ated a once per week back-strengthening program. The participants in the program were asked to volun­ teer. Eventually approximately half of the 400 employ­ ees volunteered. Ninety percent (90%) of those who did volunteer stated that they had some history of back problems, although they had no current workers' compensation claims. After the 20-week lumbar extensor strengthening program, they increased their strength an average of 54% in flexion and an average of 104% in extension. At the I -year follow-up, those who did not partici­ pate in the once per week 5-minute exercise program had an incidence of injuries of 2.55 per 200,000 employee hours, whereas those who did participate had one short injury, which came out to 0.52 injuries per 200,000 employee hours. The insurance liability dropped precipitously. A more recent study using similar back strength­ ening protocols in the airline industry demonstrated similar results (11). In this report, 622 participants in the exercise group were compared to a non-exercise group of 2,937. The back injuries in the exercise group analyzed were 5.7 per year and non-exercise group were 179 per year. Put another way, there were nine injuries per 1,000 in the exercise group, and 61 per 1,000 in the non-exercise group. The cost of back injuries in the exercise group was $206 participants per year, whereas the cost of back injuries in the non­ exercising group was $4,883 for non-participants. The exercises were once per week lumbar extensor strengthening for 5 minutes on MedX equipment, which isolates the appropriate muscles (Fig. 13.3). Obviously it is apparent that there is a relationship between strength and back injury prevention. Thus, a rational treatment program has been developed by several preferred provider organizations in the Southern California area (Table 13.1). One aspect of the treating physician's role is to encourage speed of initiating appropriate treatment.

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Part Three: Assessment

Figure 13.3 MecIX Lumbar Extension Machi ne.

Of course many doctors interweave decisions as to how rapidly a person can resolve their back problem and how long they remain on disability with how soon they get to see the patient. A recent extensive study by McIntosh et a1. has tried to clarify the pre­ dictive issues (34). In this study, 2,007 workers in

Table 1 3. 1 •

•

•

•

•

•

•

•

Ontario were analyzed from onset of claim to 1 year after the accident. Prolonged disability and delay in return to work was found to be predicted by several factors. Three or more positive Waddell signs and pain referral to the leg were physical examination predictors. Older age groups and working in the con­ struction industry were also predictors of prolonged disability. Interestingly, however, one of the most significant predictors was lag time from injury to treatment initiation. Even though it is recognized that many back problems are self-limiting, initiation of an active program certainly can place the patient into a framework of being able to control his pain. Along with the recurrence history, duration of cur­ rent symptoms increases the fear that the problem will not resolve. A recent study clearly documents the psychological barriers to an affective active treatment program (28). Marras et a1. performed a fascinating study on normal subjects, which has significant implications concerning the respect of for psychological barriers necessary in evaluating the efficacy of an active exer­ cise program in its potential to return workers to the workplace. In this particular study, students were being tested as to lifting performance under very spe­ cific evaluation conditions. Their muscle activity, spinal range, and speed were evaluated by special­ ized testing. Two tests were performed. The first test the students were encouraged and supported in their exercise. On the second round of tests, the students

Treatment of Medical Back Problems

A program of progressive exercise should be initiated after no more than 2 to 3 days of bed rest. Passive methods (either ice or hot packs) are only useful as an adjunct to exercise. Other techniques are not appropriate. An objective, reproducible functional assessment should occur if more than 2 weeks of treatment are required. Most patients need instruction on appropriate exercise but do not need a formal program of physical therapy. When physical therapy is indicated, duration should not exceed 6 weeks and frequency should not exceed three treatments weekly. Diagnostic radiographs are seldom appropriate initially and, with rare exceptions, are not appropriate at intervals during treatment. Unless neurologic function has deteriorated or progressive exercise has failed, specific diagnostic tech­ niques (e.g., CT scan, magnetic resonance imaging, bone scan, EMG, nerve conduction studies) are not appropriate. More than 7% of employed patients with medical back problems return to work within 4 weeks of onset. Careful re-evaluation of the treatment plan is warranted if the patient has not progressed significantly in 4 weeks. If treatment lasts 6 weeks, the patient should be evaluated by an appropriate medical specialist. The eval­ uation should include objective measurement of functional status, reassessment of treatment goals, and confirmation of appropriateness of treatment. If the patient has not returned to work within 3 months, the patient should be referred to a specialized center for computerized reassessment and care planning.

Chapter Thirteen: Employment Screening and Functional Capacity Evaluation

were criticized and psychologically stressed. All the students were psychologically tested before the lift­ ing tests. It turns out that those who on testing earlier were introverts showed significantly more co­ activity of muscle [·unction and thus had additional spinal loading compared to the extroverts who did not internalize the criticisms and lifted more effi­ ciently. These findings may explain why people with psychological barriers, such as demonstrated with positive Waddell findings in the McIntosh study, have delay in returning to work. Few treatment programs have expert psycholo­ gists and psychotherapists associated with them. Although certainly it would be an asset, that addition greatly increases the costs and certainly is not appro­ priate for every chronic and subacute patient. Gen­ erally, programs that have a comprehensive physical, as well as psychological, approach to management of chronic musculoskeletal problems are known as ter­ tiary care centers. They may have an inpatient com­ ponent to create an environment that is conducive to controlling psychological factors. The simpler alternative for treating individuals with fear, anxiety, and insecurity is the recognition that providing objective unbiased feedback of per­ f01-mance is an asset to treating their anxiety. Thus, treatment programs that use specific equipment, which can measure performance such as resistance training, offer a concrete maneuver to assist patients in recognizing that they can take control of their chronic pain problems. This equipment at least will provide feedback baselines in terms of range of motion, amount of resistance being used, and num­ ber of repetitions. By scoring performance on each occasion, the individual can document their progress without any extraneous factors. In addition, with the use of equipment that isolates various muscle groups and joints, the extraneous muscle activity, again noticed in the Marras study, can be blocked out to allow more efficient effective exercise programs. This can docu ment progress in a measurable manner. Thus, the treating physician has the responsibility to keep focused on objective measures of improving performance and the rate of improvement. If the treatment program plateaus, then some change has to occur. Here the individual is ranked as having reached maximum medical improvement or another strategy has to be initiated. This strategy might be injection procedures, consideration of surgical inter­ vention, or a complete change in format for the treat­ ment program. Although the treating physician generally does not control the physical treatment program being per­ formed by physical therapists and exercise science people, he/she must expect these treatment programs to offer sufficient information on which to make a

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judgment as to progress or alternative strategies. The report must be crisp and offer sufficient information on which to make judgments. It should give informa­ tion that would assist the treating physician or the evaluating physician criteria on which to make judg­ ments in terms of function. It also should include total number of visits, the type of treatment, and the subjective and objective findings. Finally, a brief note as to assessment and future plans should be available. An example of such a report is in Figure 1 3.4. A recent study clearly documents the role of objec­ tive testing in modifying physical therapy practice (9). This study notes the change in physical therapy practice after the State Labor Commission in Utah requested a report from therapists before more treat­ ment would be authorized. After every six visits, a report identifying changes in at least three essential physical functions, such as lifting, carrying, range of motion, sitting tolerance, etc., was requested. If no improvement is noted, restorative services will not be continued to be authorized. There were approxi­ mately 30,000 claims in 1997 and approximately 33,000 claims in ] 999 after the initiation of the new report form. Associated with the institution of this form, the frequency of treatments decreased 34% from 17 in 1997 to 1 1 .4 in 1999. Hot pack usage decreased 45%, electrical stimulation decreased 22%, and massage decreased 38%. However, therapeutic

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Figure 13.4 Report form.

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Part Three: Assessment

exercise increased 3 1 % and joint mobilization in­ creased 27%. The carriers' cost-savings were approx­ imately $ 1 . 1 million per year. No attempt from the State Labor Commission was made to control phys­ ical therapy practice, just the request that objective measures be incorporated in their report form. More efficient treatment was encouraged by focus on func­ tional measurement. One final responsibility of the treating physician is to define the return to work status. Certainly the sooner the person returns to work, the more likely a successful completion of the health care process can be expected. The probability of return to work decreases as length of time off increases (45). One strategy to return the worker to work sooner is to return them to modified duty. Trying to make a judg­ ment regarding whether the worker can perform full duty or modified duty is difficult. It must be recog­ nized that a correlation does not always exist between the patient's ability to accomplish physical activities and the pain (42). Moreover, there is no conclusive evidence that early return to work causes additional harm to the back. In fact, the patients absorbed in work gain con­ siderable periods of pain relief (49). Also, if a treat­ ing physician does not focus on return to work, the patient's view of himself begins to become one of dependency and incapability (7). Disabilities are con­ sidered to be a learning behavior; thus, the shorter time the individuals have to learn, the less that they might become disabled ( 1 0). The problem still remains concerning modified work versus regular work. Hall et al. performed a study that did focus on that problem (17). In this study, 1,438 consecutive workers with back pain and undergoing treatment were in the study group. In the control group, after an active treatment program, patients were returned to work according to the esti­ mate o[ their pain. Modified work is recommended when the patients had pain symptoms. In the exper­ imental group, pain was not allowed to be a restric­ tion to regular work. The persistence of pain in the absence of any objective findings was not judged as an acceptable reason for suggesting a limited return. Only objective findings such as nerve root irritation, sciatic scoliosis, and objective reduction in range of motion below job requirements, were recognized as a cause for restriction. In follow-up, a significantly larger number of patients returning to unrestricted work in the experimental group compared to the control group of usual care. The probability of suc­ cessful outcome decreased with age in the study group. Other studies have shown that age is an addi­ tional deterrent to rapid return to work. The study, however, did demonstrate the problem of using pain alone as the definition of work status. It demon-

strated also that the expectation of normal activity was a positive ingredient in returning the individual to non-restricted work. Thus, in summary, the treating physician has the responsibility to initiate rational treatment as soon as possible. He has the responsibility to expect feedback of progress from the treatment program to which he has referred the patient. He must continually focus on return to normal activity as the expectation [or the soft tissue injury. Psychological support with feed­ back of progress is a reasonable "carrot" for the anx­ ious patient.

Role of the Evaluating Physician

The evaluating physician and the treating physician may on occasion be the same. However, in many jurisdictions, especially when litigation is involved, the treating physician is thought to be biased. After all, that clinician is receiving compensation for the care of the patient and continuing requests for treat­ ment can be interpreted as self-serving. Also, of necessity, that physician has sought to achieve good communication with the patient and, therefore, has never acted in an adversarial manner. Obviously, the testing physician would be a patient advocate and may be willing to overlook significant history or symp­ tom magnification. The Independent Medical Evaluator specifically is restrained from performing medical treatment. In the report, it is more important to refer to the indi­ vidual being examined as the examinee or the appli­ cant, rather than the patient. Usually the report is quite a bit more detailed and expansive than a typi­ cal report fTom the treating physician, even on the occasion of declaration of maximum medical benefit (or P&S in California terms). The job skills of the Independent Medical Evaluator (IME) have been outlined by the American Board of Independent Medical Examiners (ABIME) (40). Often the IMEs are performed to provide information for case man­ agement and for evidence in hearings and other legal proceedings (6). They are common components of all workers' compensation statues, but they may vary fTom state to state (47). In that the evaluation is often being performed For disability, a thorough description of the patient's past and current job with its physical demands is necessary. A significant amount of social history is necessary to offer some insight into psychophysio­ logic problems. A review of medical records is also quite necessary. The treating physician seldom takes into account the past medical records in that they usually do not assist in the current treatment plan. However, the evaluating physician is assembling

Chapter Thirteen: Employment Screening and Functional Capacity Evaluation

data on which to make a definitive statement regard­ ing diagnosis and prognosis. All past medical infor­ mation, therefore, is valuable. In addition to the usual physical examination, ideally a functional capacity test is performed. It must be recognized that especially in the spine, the physical examination is seldom helpful in clarify­ ing impairment and disability. The only f·unctional examination advocated in the AMA Guidelines (14) is a test for range of motion. The accuracy of this test is often questioned. Recently, a far more accurate range test using Optoelectric Motion Analysis System per­ formed by the same technician (far more accurate than the inclinometer method advocated in the JAMA Guidelines) was not predictive. This test, when applied to 111 patients with work-related back pain, at the beginning and conclusion of treatment, was not pre­ dictive of the disability at follow-up (41). Obviously, if objective evaluation of function is necessary, a far more comprehensive system needs to be developed. The evaluating physician ultimately has to identify the impai rment with associated causation issues. The evaluator also has to identify the functional deficits, especially as related to job, and identify whether alternative work is possible and if vocational health care is necessary. In most jurisdictions, the clinician is paid more for this type of evaluation than is the treating physician who is expected to present similar information. Thus, the specialty of evaluating physi­ cians has grown. Up to this point, however, the spe­ cialty has not placed emphasizes on standardized functional testing but rather prefers to rely more on history and typical physical examination. This is a significant problem. In a study from Wash­ ington, they found that onJy 5% of their compensation claims were from individuals with non-verifiable mus­ cle and back symptoms (46). Unfortunately, these accounted for 84% of the cost. There certainly is a place for objective flmctional capacity evaluation.

Functional Capacity Evaluation

Information fTom functional capacity evaluation (FCE) has been used in the return to work decision­ making process for persons with medical impair­ ment for many years (19,31). FCE information is used to translate the effect of the impairment in terms of ability to perform work tasks. FCE is a "detailed examination and evaluation that objectively mea­ sures the client's current level of function in terms of the demands of competitive employment" (1). In this context, the primary purpose of the FCE is to com­ pare a client's safe functional abilities to the demands of work (1 [page 47]) to facilitate the return-to-work decision (18,19).

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One example of a standardized functional capac­ ity evaluation that is designed to be time-efficient is the "California Functional Capacity P rotocol" (Cal­ FCP) (37). The Cal-FCP is a 120-minute, 11-part test of functional capacity designed to develop an esti­ mate of lost work capacity to be used in a case-man­ agement process and to address disability rating. The Cal FCP allows measurement of the injured worker's work capacity by the treating physician or by other health care practitioners. It is administered 30 days after the injury if the injured worker either has not returned to work or continues in active treatment. Frequently, because of its low cost, it is administered on a serial basis, every 3 weeks, to measure response to treatment. This pattern of use addresses a concern of the treating physician to maintain case control. Additionally, the involvement of the treating physi­ cian to interpret the results of the Cal-FCP l-ecog­ nizes that he or she is the best professional to consider the test results in light of issues such as t he injured worker's motivation, fears, and goals, and to integrate other medical findings. The information derived from the Cal-FCP is presented to the treating physician as a recommendation, along with all of the data collected during the examination. Once the Cal-FCP test protocol was developed, training of experienced health care clinicians was undertaken at five centers in various parts of Califor­ nia. A demonstration project was designed to evalu­ ate the feasibility of implementation o[ the protocol across a broad spectrum (33). The duration of the Cal-FCP protocol in hands other than its developers, the internal consistency of the protocol, and its usefulness in measurement of work capacity were addressed. Sixty-four subjects (32 females and 32 males) were studied. Subjects in the study in­ cluded adults who were undergoing treatment [or work-related soft tissue musculoskeletal injuries as part of the California workers' compensation pro­ gram. Lumbar spine patients predominated (n=46), with knee (n=5) and cervical patients (n=4) also rep­ resented. The remaining subjects had a variety of soft tissue injuries. Subjects reported onset of symptoms 1 month to 10 years before program entry, with a mean (SD) of 1 .82 (2. 1 ) years. Only two' o[ the sub­ jects were tested within 30 days of injury onset, whereas 23 subjects were tested within 1 year of injury. The Cal-FCP test battery was administered by exercise physiologists, a registered nurse, physical therapists, and occupational therapists who had par­ ticipated in a special 2-day training program that included a knowledge test and required demonstra­ tion of reliability on the EPIC lift capacity test (ELC) (Fig. 13.5) (32). This study 33 found no new injuries or exacerbation of current impairment. The mean duration of test administration was 84 minutes. This sample demonstrated a mean loss of lift capacity of

290

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Part Three: Assessment

Figure 13.5 EPIC l i fting capacity.

41%, wi th no significant difference between men and women. Seven of the subjects (four men and three women) had no loss of lift capacity. An additional 1 1 subjects (six men and five women) had a loss of lift capacity that was less than 25%, which is interpreted by the California disability determination model as indicating no residual disabili ty. Thus, 18 of the sub­ jects were found to not qualify for disability benefits! Because of the protection of human subjects' rights guidelines under which the study was conducted, this information was not revealed to their employers or insurance carriers or physicians. Twelve of the 64 sub­ jects had effort ratings by the evaluator that were less than full effort. There were no significant differences between groups based on age, time since injury, dura­ tion of testing, pinch, or grip. Significant differences were found between the f-ull effort and less than full effort groups for Spinal Function Sort (29) score and loss of lift capaci ty. Interestingly, SFS score predicted absolute lift capacity and capacity considered as a per­ cent of body weight on ELC test 3. The SFS score also predicted lost work capacity. This study demonstrated the usefulness of the Cal-FCP in evaluating injured workers. There are several o ther functional capacity evaluation protocols that are useful (5,20,23,26).

described the historical background of employment screening from a health care perspective, beginning with the use of spinal x-rays to screen for risk of injury. As we have noted, medical examination is less useful and justified for employee selection than it is for baseline comparisons. The use o[ technologies such as spinal MRl procedures may provide a basis for avoiding expensive and needless surgery when a problem such as an asymptomatic degenerative spine is found to be present before employment. The use of functional capacity evaluation is more often justified, both to identify applicants [or employment who will be the most productive workers and to assist the physician and plant manager to properly place a worker returning from sick leave. Although these methods are promising, peer-reviewed studies are needed to provide scientific justification. In the interim, individually conducted validation studies that focus of the use of FCE to select workers based on productivity will suffice, although the expense of such studies is likely to limit their use to large com­ panies with expensive self-insured workers' compen­ sation systems.

Audit Process

Self-Check of the Chapter's Learning Objectives •

W ha t are the criteria for assessing the val id i ty of pre-employment and pre-placement screeni ng procedures?

•

Can you describe what the fitness for duty evaluation i s ?

•

Explain t h e American a n d D i sabilit ies A c t restrictions and protect ions.

•

Define the roles of t h e treati ng physician versus the evaluat i ng physician.

•

What tests are involved i n t h e Functional Capacity Evaluation presented in t h i s chapter and w ha t i s its relevance to job capacity?

•

What are realistic expectations [or reporting on the del ivery of conservative care approaches for managing spinal problems?

• REFERENCES • CONCLUSION

Employment selec ti on and placement is an impor­ tant service area for health care professionals and is becoming increasingly complex. This chapter has

I . A PTA. Occupational heal th guideli nes: Eval uating fu nctional capacity. Alexandria, VA: American Physical Th erapy Assoc iation, 1 997. 2.

Bailey W. Observation on the etiology and frequency of spondylo l i st hesis and i ts precursors. Radiol ogy 1 947;48 : 1 07- 1 1 2 .

Chapter Thirteen: Employment Screening and Functional Capacity Evaluation

3. Battie M C , Bigos SJ, Fischer LD, et al. Isometric l i ft i ng strength as a pred ictor of i ndustrial back pain reports. Spine 1 989; 1 4: 8 5 1 -856. 4. B ieri ng-Sorensen F, Thomsen C E , H i lden J. Risk i ndicators for low back trouble. Scand J Reh a b i l M e d 1 9 89;23: 1 5 1 - 1 5 7. 5 . B l a n kensh i p K. The Blan kensh i p system fu nctional capacity evaluation procedure manual. Macon, GA: The Blankens h i p Corporation, 1 994. 6 . Brigham CR, Bab i t s ky S, Mangrav i t i JJ. The I n de­ pendent Medical Eval uation Report : A Step-by­ Step Guide w i t h M odels. Falmouth, M A : SEAK, Inc, 1 996. 7. Catchlove R, Cohen K. E ffects of a d i rective return to work approach in the treatment of workman's com­ pensation patients with chronic pain. Pain 1 982; 1 4 : 1 8 1 - 1 9 1 . 8 . Chaffi n D B , Park KYS. A l o ngitudinal s t udy o f low­ back pain as associated with occupationa l weight l i ft i ng factors. Am I nd Hyg Assoc J 1 9 7 3 ; 3 4 : 5 1 3-5 2 5 . 9 . Col ledge AL, H u n ter SJ. U s i ng functional i m prove­ ments to promote active therapy and determ i n e the length of treatment of workers' compensation patients, a 3-year analyzes of 63 ,000 c l a i ms. J Occu p Med ( Submit ted). 1 0 . Derebery VJ, Tullis WHo Del ayed recovery in the patient with a work compensable i njury. J Occup Med 1 98 3 ; 2 5 : 829-8 3 5 . I I . Driesi nger T E . Does prevention work. San D iego, CA: San Diego Comprehensive Care Sympos i u m , July 2000. 1 2 . EEOC. U n i form guidel i nes on employee selection procedures ( 1 97 8 ) . Federal Register 1 993 ;July 1 : 2 1 2-2 39. 1 3 . G i bson ES, Mart in R H , Terry CWo I n c i dence of l ow back pain and pre-placement x-ray screen i ng. J Occup Environ Med 1 980;22 : 5 1 5-5 1 9. 1 4 . The Gu ides to the Evaluation of Permanent I m pair­ ment, 4th ed . C h icago, I L : American M edical Association, 1 993. 1 5. Guiding pri nci ples for medical exa m i nations in industry. Ch icago, I L: American Medical Assoc iation, 1 984: 1 . 1 6. Hai ner BL. Pre-placement evaluations [review]. Prim Care Clin Office Pract 1 994;23:2 37-247. 1 7.

Hall H, McIntosh G , Mel les T, H o l owac h u k B, Wai E. E ffect of discharge recommendations on outcome. Spine 1 994; 1 9( 1 8 ) : 2033-2037.

J 8. Hart D , Berl i n S , Brager P , et al. Standards for per­ forming fu nctional capacity eva l uations, work condi­ tioning and work hardening programs state of Maryland. Annapol is, MD: Joi n t Com m i ttee on I ndustrial Services, 1 993. 1 9 . H art D, I serhagen S , Matheson L. Guidelines for fu nctional capacity eval uat ion of people w i t h med­ ical cond i t i ons. J Orthop Sports Phys Ther 1 993; 1 8 ( 6 ) : 682-686. 20. Isernhagen SJ. Functional capacity evaluation. I n : Isernhagen SJ, ed. Work i nj ury: Management and prevention. Rockvil le, M D : Aspen, 1 988. 2 1 . Jay M , Lamb J, Watson R, et al. Sensi tivity and speci­ ficity of the ind icators of sincere effort o f the EPIC

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L i ft Capac i ty test on a previously i njured population. Spine 2000 ; 2 5 ( 1 1 ) : 1 405- 1 4 1 2 . 22. Johns RE, B l oswick D S , E l egante J M , Colledge AL. C h ronic, recurrent low back pain: A methodology for analyzi ng fi t ness for duty and managing risk under t he Americans with D isab i l i ties Act . 1 994;36( 5 ) : 5 37-547. 23. Key G. Key functional assessment procedu res manual. M i n neapolis, MN: Key Functional Assess men t , I nc, 1 986. 24. Keyserl i ng WM, H errin GD, C haffin DB. I sometric strength test i ng as a m eans of con t ro l l i ng medical i nc i dents on strenuous jobs. J Occu p Med 1 980;22: 332-336. 2 5 . Lawrence JS. D i sc degenerat i o n : Its frequency and relationship to sym ptoms. Ann Rheum D i s 1 969; 2 8 : 1 2 3- 1 27. 26. Lechner D , Jackson J, Roth D , Straaton K. Rel iability and val i d i ty of a newly devel oped test of physical work performance. J Occup Med 1 994;36( 9 ) : 997- 1 004. 27. Lloyd D C E F , Troup JDG. Recurrent back pain and i t s prediction. J Soc Occup M ed 1 9 83;33 :66-74. 28. M a rras WS, Davis KG, Heaney CA, M a ro n i t i s AB, A l l read GW. The i n fluence of psychosoc ial stress, gender, and personali ty on mechanical load ing of the l u mbar spi ne. Spine 2000 ; 2 5 ( 2 3 ) : 3045-3054. 29. Matheson L. Development of a measure o f perceived functional a b i li ty. J Occup Rehabil 1 99 3 ; 3 ( 1 ) : J 5-30. 30. Matheson L. E P I C L i ft Capacity Test Exa m i ner's Manual. Fort Bragg, CA: Work Evaluation Systems Technology, 1 994. 3 1 . M a t heson L , Ogden L. Work tol erance screen ing. Trabuco Canyon, CA: Rehab i l i tation T ns t i t u te of Southern Cal i fornia, 1 983. 32. M a t heson L , Mooney V, Grant J, et al. A test to mea­ sure l i ft capaci ty of physically i m p a i red adults ( part 1 ) : Development and rel iab i l i ty test in g. Spine 1 99 5 ; 2 0 ( 1 9) : 2 1 1 9-2 1 2 9. 33. Matheson LN, M ooney V , Grant JE, Legget t S , Kenny K . Standardized evaluation o f work capacity. J Back M usculoskel Rehabil 1 996;6:249-264. 34. McIn tosh G, Frank J, H ogg-Joh nson S , Bombard ier C, Hall H . 1 999 You ng i nvestigator research award w i nner: Prognost i c factors for t ime receiving work­ ers' compensation benefits in a cohort of patients w i t h low back pain. Spine 2000 ; 2 5 ( 2 ) : 1 47- 1 57. 3 5 . Mooney V, Kenney D , Leggett S , Hol mes B. Rel a t ion­ s h i p of l umbar strength in s h i pyard workers to work­ place i nj ury clai ms. Spine 1 996;23( 1 7 ) : 200 1 -2005. 36. Mooney V, Kron M, R u m merfield P, H ol mes B. The e ffect of workplace based strengthen i ng on low back i nj ury rates: A case study in the strip m i n ing i n dus­ try. J Occ Rehab J 995 ; 5 ( 3 ) : 1 5 7- 1 67. 37. Mooney V, Matheson L . Cal i fornia Functional Capac i ty Protocol (Cal-FCP) Exami ner's Manual. San D i ego, CA: Ort h o M ed Fou nda t i o n , 1 994. 38. Pedersen PA. Prognos t i c i n d i cators in low back pain. J R Coll Gen Pract 1 98 I ; 3 1 : 209-236. 39. Personal commun ication. Dr. Lester Sac hs, M ed i cal D i rector. 40. Peterson KW, et al. The American Board o f Indepen­ dent Medical Examiners. J Occup Environ Med 1 997;39(6) :509-5 I 4.

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4 1 . Poitras S, Loisel P, Prince F, Lem a i re J. D isab i l i ty measurement i n persons with back pai n : A val id i ty study of spinal range of motion and velocity. Arch Phys Med Rehabil 2000 ; 8 1 : 1 394- 1 400.

45. Spitzer WO, LeBlanc FE, Dupuis M . Scientific approach to the assessment and management of activity-related s p i nal disorders. Spine 1 987; 1 2 (suppl ) : S l -S59.

42. Rainville J, Ahern DK, Phalen L , Chi lds LA, Suther­ land R. The association of pain w i t h physical activities in chronic low back pain. Spine 1 992; 1 7 : 1 060-1 064.

46. State of Washington Department of Labor and Industries. Attend i ng Doctor's Handbook. 1 996:4.

43.

Redfield JT. The low back x-ray as a pre-employment screeni ng tool i n the forest products industry. J Occup Environ M ed 1 97 1 ; 1 3 : 239-226.

44. Reimer DS, Halbrook BD, D reyfuss PH , Tibi letti C. A novel approach to pre-employment worker fi tness eval uations i n a material-hand l i n g industry. Spine 1 994; 1 9 :2026-2032.

47. To mpkins N . Independent medical examination: The how, when and why of t h i s useful process. OSHA Compliance Advisor. 1 99 2 ; 2 3 5 : 7- 1 2. 48. Walton M. The Demm i ng M anagement Method. New York: Putnam, 1 9 86. 49. Wynn Parry CB. Pain in avu l s ion lesions of the brachial plexus. Pai n 1 980;9:4 1 -53.

PART

AC,ute Care Management (first 4 weeks) CHAPTER 14

ApPENDIX 1SA

Active Self-Care: Functional

Exteroceptive Therapy

Reactivation for Spine Pain Patients

Helena Hermach

Craig Liebenson

CHAPTER 19

CHAPTER 15

Manual Resistance Techniques

McKenzie Spinal Rehabilitation

Craig Liebenson, Pamela Tunnell, Donald R.

Methods

Murphy, and Natalie Gluck-Bergman

Gary Jacob, Robin McKenzie, and Steve Heffner

ApPENDIX 19A

The Role of Active Release

CHAPTER 16

Technique in Rehabilitation

Brugger Methods for

Clayton Skaggs and Charles Poliquin

Postural Correction Dagmar Pavlu, Sibyle Petak-Krueger, and

CHAPTER 20

Vladimir Janda

Neuromobilization Techniques­

CHAPTER 17

Neurodynamic Tension

Evaluation and Treatment of Adverse

Rehabilitation of Breathing

Michael C. Geraci, Jr., Martin Lambert, and

Pattern Disorders

Mark R. Bookhout

Maria Perri

CHAPTER 21

CHAPTER 1S

Manipulation Techniques for

Soft Tissue Manipulation

Key Joints

Karel Lewit and Alena Kobesova

George DeFranca

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Part Four: Acute Care Management (first 4 weeks)

Editor's Note While acute patients recover quickJy with minimal or no care, the minority who become chronic are notoriously difficult to treat. Therefore, modern approaches attempt to prevent chronicity BEFORE it is established without over-treating the majority of acutes who would get better on their own. There­ fore, the current "state of the art" in spine care is to encourage early patient reactivation. This is both a

cian should make a concerted effort to educate the patient that their back problem is more of an ill­ ness like a cold than an actual disease process. Then a gradual re-activation process guided by symptoms as in the McKenzie model is com­ menced. The patient's first steps in returning to activities includes simple spine sparing activity modifications. No model of acute spine care would be complete without the sure anchor of manipula­ tive therapy. Its role in pain relief and functional

cognitive-behavioral and physical approach. This

reactivation is far from controversial. Not only

involves reassuring patients that they are not injured

joint manipulation but also soft tissue, muscle, and

or damaged, providing them with simple pain reliev­

nerve mobilizations are all integrated into the con­

ing modalities, and focusing them on the safety and

servative care of patients in this section. However,

value or gradual reactivation and self-management.

as with all passive modalities these should be

This section introduces a model that begins from the patient's mind and emotions. The clini-

offered in a time-limited manner as adjuncts to self-management.

Active Self-Care: Functional Reactivation for Spine Pain Patients

Craig Liebenson

Introduction

Learning Objectives

Fear-Avoidance Beliefs and Chronic Disabling Pain

After reading this chapter you should be able to:

Step 1: Reassurance and Reactivation Advice Identify Back-Related Worries and Fears As Well As the Patient's Goals Assurance That There is No Serious Disease­ Doesn't Severe Pain Signify Serious Damage? If Pain Is Not Caused by Serious Disease, Then What Is Causing My Pain? (Doesn't Severe Pain Signify Serious Damage?) Specific Reactivation Advice-UWhat Should and Shouldn't I Do?"

•

•

•

•

Understand the value of sel f-care in managi ng spinal conditions. Understand the behavioral psychology under­ pinning motivating patients to change their l i festyle. Identify faul ty biomechanics during activi ties of daily living. Understand the di fference between a biomedical and biopsychosocial report of findi ngs.

Pain Relief Options How Long Will It Last?-Recovery Expectations Summary

Step 2: Cognitive Behavioral Approach Social Cognitive Theory and Behavioral Change Graded Exposure Training Cognitive Behavioral Therapy Neurophysiologic Aspects

Step 3: Multidisciplinary Biopsychosocial Approach Motivation Issues Compliance With Ongoing Active Treatment

295

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Introduction

Activity is effective therapy for a large variety of health care conditions (e.g. , heart disease, arthritis, low back pain, osteoporosis, depression, etc . ) ( 1 9,36, 40,84, 1 78). Physical i nactivity is an i ndependent risk factor for cardiovascular and other diseases ( 1 24). When patients are i n pain, they typically worry that they will cause more harm than good if they are active ( 1 7 1 ). Physicians typi cally prescribe overly restrictive activity restrictions, which are responsible for i nterferi ng with the recovery process and pro­ m o t i ng c h ronic pain behaviors ( 2 6 , 2 7 , 80 , 1 1 4). Frequently, advice to "let p a i n be your guide" is given, which only reinforces attitudes and beliefs that roster pain-avoidance behavior and deconditioning (83). In contrast, the idea that "hurt doesn't necessarily equal h arm" and that rest is bad for t issues has not received as much attention. Such reactivation advice has been shown to be more effective than tradi ­ tional, more passive advice for low back pain (LBP) (26,27,83 , 1 1 4) and for neck pain ( 2 3 , 1 20, 143). Active self-management coping styles have been s hown to be superior to passive coping styles for back and neck pai n as well as other chronic pains (20,35). A stepped-care approach involving i ncrementally more structured and comprehensive patient education i s requ i red t o i nfluence a patient's belief systems and concerns about activi ty. The clinician's goal i s to modify the patien t's healt h behavior in the direct of reactivat ion. Back pai n has traditionally been viewed as pri­ marily an acute, self-l i mi t i ng condition. However, it is now recognized to i nvolve frequent recurrences or even a chronic course (44). Biomedic i ne i s better sui ted for acute than chronic conditions. Research has emphasized the value of sel f-management skills ror management of chronic i l lnesses (20,78,79, 1 1 2, 1 25 , 1 52). This i nvolves such t h i ngs as exercise, min­ im i zation of activit i es of daily livi ng l im i tations, monitori ng of illness, and managing flare-ups. Hol­ man and Lorig ( 2 8 ,7 9 , 1 1 1 , 1 1 2 ) found that a sel f­ management approach decreased pain and reduced the use of medical services by 43%. Self-care has also been recom mended for both acute and c hronic low back pai n ( 1 27 , 1 54). Unfortunately, most management approaches for back problems are concerned only with diagnostic triage and pain management. Borkan called for research on whether "educat i ng and empowering patients to treat their own problems would counter­ act the negative i mpact that medicalization of the problem has had on i ndividuals and society" ( 2 5 ) . Today, a swell of research validates t h a t s u c h pre-

emptive patient education is effective for low back pain (26,27,83, 1 1 4). Turner poin ts out that interventions encouraging resumption of normal activities have been more suc­ cessful than those that only taught i mproved body mechanics and l i fting techniques (e.g. , traditional back school) ( 1 63). Von Korff has reported that an i ntervention that addressed patient worries about back pain, enhanced sel f-care confidence, and encour­ aged an active problem-solving approach was suc­ cessful i n reducing activity l i m itations ( 1 73). Whereas pain-relief modalities will always be in vogue, patient education about self-care through gradual reactiva­ tion is rapidly gain i ng scientific traction as the stan­ dard of care for prevention of disability associated with LBP.

Fear-Avoidance Beliefs and Chronic Disabling Pain

Pat i e n ts who are at the greatest risk for c h ronic, disabling pain often have poorly developed coping skills (94). They m ay tend to catastrophize their ill­ ness and feel powerless to help themselves. When pati e n ts fear pain , or catastroph i ze by fearing the worst possible outcome, they are less likely to re­ sume activity or perform exercise ( 1 67). It is easy for them to become dependent on short-term symptom­ relieving approaches such as manipulation, massage, medication, and various physical therapy modali ­ ties. A key to getting a patient to become active in their own self-care program i s to shih t hem from being a pain avoider to a pain manager (100, 1 02 , 1 4 1 , 1 62 ) . Fear-avoidance behavior leads t o deconditioning. Two-thirds of acute L B P patients believe that a wrong movement will cause serious harm ( 1 23, 1 73 ) . An indivi dual w h o perceives that a n activity w i l l be painful will have a reduced physical capacity (98). In fact , the cogni tive association of activity with pai n or anticipation of pain has been shown to be more pre­ dictive of physical performance than purely nocicep­ tive factors (4) . Council asked patients to anticipate how much pain they would expect to have when per­ formi ng 1 0 simple tasks (42) . Substantial correla­ tions between expectancies and performance were found. Crombez used a standard exercise task and found that i njury expectancies explai ned 1 6% of the variance in work disab i l i ty in chronic patients and 33% in acute subjects (45). H eu ts e t a1. reported that patients' pai n i ntensity and pain-related fear accoun ted for 40% of the variance i n functional l i m i tations ( 7 5 ). Two aspects of pain-related fear were most relevant-activity

Chapter Fourteen: Active Self-Care

avoidance-"the belief that activity may resu l t i n (re)injury or i ncreased pain," and somatic focus-the bel ief in an underlying somatic medical problem. Flynn et al. also found t hat fear-avoidance beliefs pre­ dict return to work in patients with acute LBP (51). The risk of prolonged work restriction i ncreased from 29% to 58% with a score more than 34 on the Fear-Avoidance Beliefs Questionnaire. For a score of less t han 30, the risk of prolonged work restriction decreased from 29% to 3%. Equating hur t with harm is a disabl i ng form of thi nking for a back pain patient ( 1 1 3, 1 66, 1 6 7 ) . It promotes decondi tion i ng and thus leads to less sta­ bility. It is i mportant to identi fy t he patient who i s fearful and t o avoid encouraging them to take o n a "sick role." Accord i ng to Troup, "If fear of pai n per­ sists, unless it is speci fically recogni zed and treated, it leads inexorably to pai n-avoidance and thence to disuse" ( 1 62 ) . T h e goal w i t h the fearful pati e n t i s to i ncrease con fidence in normal act ivities and/or exerci ses ( 5 1 ,96) . Certa i n activities should be avoi ded, such as early morning flexion ( 1 5 3 ) . But other activities such as brisk walking and McKenzie centralization maneuvers or gradual stabil ization t rai ning are safe and effective ( 54 , 7 7 , 83, ] 1 0, 1 5 7 ) . In chronic patients, t he target of treatment may be the stiffness and atrophy caused by the patient overprotec t i ng h imself or herself duri ng the acute phase. Muscles and joints, which lose their mob i l i ty while t he patient rest ri c ts their activities during acute pain , should b e expected t o cause discomfort a n d re­ mobilizing them may h u rt but certainly won't harm . It is user-ul to reassure patients by expla i n i ng that their pain i s caused by dysfuncti on, not t issue damage or pathology ( i . e . , herni ated disc or arthri­ tis) ( 2 2 , 1 7 8 ) . Alongside t he individual's attitude toward pain (e.g., catastrophi z i ng), external i n fl uences such as the transmission of beliefs by t he hea l t h care provider are crucial ( 1 3 8 ) . Sulli van has shown that i f pain is viewed as a s ign of danger, it i s perceived as more i ntense (\6 1 ) . Ostelo developed a scree n i ng questionnaire for cli n i cians to determ i n e their ori­ entation (bi omedical versus b iopsychosocial) ( 1 3 5 ) . The biomedical orientation i s i n l i ne wit h persistent back pain myths, which Deyo has u n masked (48). These include the need for an accurate diagnosis of the structural cause of pain, the need to res t u n t i l pain is gone, and the belief that back p a i n l eads to chronic disability. Houben et al. recently used this screening tool and found that clinician orientation predicts both the c l i n ic ians harmfulness ratings of physical activit ies and their recommendations for physical activi ty that they give their patients (80, 1 70).

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Step 1: Reassurance and Reactivation Advice What: Brief educational approaches i ncluding advice to gradually increase activi ty from a cog­ n i tive-behavioral (CB) perspective. Who: Patients in the acute phase of a pai n ful episode.

It has been shown how val uable appropriate patien t advice can be (30). In particular, when that advice is given i n a biopsychosocial context, which reduces pain-related anxiety and encourages patients to grad­ ually resume normal activities (56,95, 1 0 1 , 1 03, 1 ] 4). Such advice focuses on t he consequences of pain­ such as activity limitations, rather t han the pain i tself. There are six fundamental t h i ngs that patients want reassurance about that s hould be addressed in the ini tial report of findings (ROF) (Table 1 4. 1 ) .

Identify Back-Related Worries and Fears As Well As the Patient's Goals

Back-related worries and fears are perhaps the most i m portant t h i ng to identify in acute patients. Patients typically worry how long their pain may persist and what its i mpact w i l l be on their activities. Most patients recover, but those with signi ficant worries require a unique approach to prevent disabling dis­ use atrophy. Accord i ng to Balderson and Von Korff ( 1 3 ) , simple, brief educational approaches are needed to address fear-avoidance beliefs and assu re resumption of normal activities: •

Ident i fy and address patient worries and support self-care ( 1 23, 1 7 3 )

Table 1 4. 1

Six Key Points i n the Initial Report of

Findings 1 . What are the patient's concerns/goals? Identify back-related worries and fears 2 . Is i t serious? Assurance that t here is no serious disease. 3. What is the cause? I njuries and degenerative processes can precipi tate pai n, but pain persists because of controllable factors. 4. What should the patient avoid and what should they do? Specific activity modification and reactivation advice. 5. What can make the patient more comfortable? Pain relief options. 6. How long w i l l i t l ast? Recovery expectations.

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Part Four: Acute Care Management (first 4 weeks)

Two-thirds of patients h ave concerns that a wrong movement m ight cause a serious problem H a l f bel ieve avo i d i ng certain movements i s t h e safest way t o preven t L B P from get t i ng worse To solicit patient worries, ask open-ended questions about the pain or activity concerns Explore these so you h ave a better understanding of your patient's concerns and motivations for avoidance behavior Then patient is evaluated for common concerns Then patient is given relevant i n formation, individuali zed to the unique needs Further d iscussion is encouraged to promote understanding and i n tegration i n to the patient's personal belief system. Patient is given written i n formation to take home-this can be shared with fam i ly members

Goal Setting

Accord ing to Bandura, healt h promotion should begin with goals, not means. Goal sett i ng should be mu tual and related to activities deemed i mportant to the patient ( 1 5 ) . It works best when patient i s in pain and the goal is to reduce pain (62, 1 48, 1 49). Accord­ i ng to a study by Turner et aI, patients seeking care for back pai n apparently have two major goals: to receive i n formation about h ow to manage their symptoms and to receive advice about how to re­ sume normal activi ties ( 1 63 ) . The primary goal i n pai n management i s t o reduce any pain-related dis­ abi l i ty the pat ient h as ( 1 8, 1 79, 1 80). In the AHCPR guidelines, i t was stated that "the m a i n goal for treat­ ment of back pai n has s h i fted fTom treatment of pain to treatment of activi ty intolerances related to pain" ( 1 8). In acute LBP disorders i n whi c h an exact cause of symptoms can only be identified 1 5% of the t ime, the pat ient's participation in the treatment program is absolutely essential ( 1 76, 1 78). Speci fi c activity modification advice aimed at reducing exposure to repetitive strain is one aspect of patient education ( 1 8,43, 1 1 6, 1 5 5 , 1 5 8 ) .

Assurance That There I s N o Serious Disease-Doesn't Severe Pain Signify Serious Damage?

A powerful myth i n m odern back pain culture i s that structural pathology i s responsi b le for pain . Carte­ sian t h i nking promoted the view t hat t he pain one

experiences is d i rectly related to t issue damage or i njury. H owever, Melzack and Wall's gate control t heory of pain led to the discovery that t here are descend i ng i n fluences on the nociceptive pathways that directly i n fl uence pai n perception ( 1 2 1 , 1 40). Pain not only is the result of ascending nociception but also is a result of a dynamic process of percep­ tion whereby some painful stimuli are interpreted as potentially harmful and some are not . The Cartesian approach can be summed up in the adage "let pain be your guide." This i s now considered to be respon­ sible for promoting u nnecessary fear and functional l i m i tations. Most patients who have chronic back pain or are experiencing a stubborn acute episode have had some i maging of their spine. They usually come into our o[-fjces with their films and courageously bear their label of h aving a serious problem such as a her­ n iated disc, spinal stenosis, or degenerative arthritis ( 2 2 ) . They have found the cause of their pain and now they want us to "fix" them. What they have usually not been told is that such structural pathology is present in an unusually large percentage of asymptomatic i ndividuals (Fig. 1 4. 1 ) (34). Also, i t does not even predict future problems when found in younger people (24). Therefore, it may be a coincidental finding. Whereas it is bad news that the cause of pain may still be a mystery, the good news is that surgery is l i kely NOT indicated and the long-term disabling potential of their condi tion is significantly lessened.