Role of Screening for Nonorganic Signs, Depression, & Fear Avoidance Beliefs in Patients with Back Pain

A _______________________ can lead to trust, improved self-efficacy, and positive coping skills.

therapeutic alliance

how do we treat low back pain (educational aspect)?

many ways to control pain, but lasting relief depends on pt effort. Concentrate on maintaining and improving activity to restore normal function and fitness. Use positive attitude and adaptive coping skills therapeutic alliance

SLR

marked difference between leg raising in supine and seated position

_______________ to rehabilitation programs may be necessary for patients with LBP influenced by fear avoidance beliefs

modifications

How do we manage Fear-Avoidance Beliefs?

- Assess for FAB early in course of rehab - Offer appropriate education - De-emphasize anatomical findings - Encourage pt to take active role in recovery - Graded exercise

What are Waddell's Nonorganic Signs?

- axial loading - motor and sensory - overreaction - rotation - SLR - tenderness 3(+) signs indicate pt likely needs to see physician, refer to pain counselor; screen for depression, fear avoidance, and current social situation only need a few factors to consider positive

what are adaptive coping strategies?

- confront problems directly - make reasonably realistic appraisals of problems - recognize and change unhealthy emotional reactions - try to prevent adverse effects on the body

What are the goals of managing fear avoidance?

- improve activity tolerance, not pain abatement - Reinforce a confrontation response - Prescription based on PTs determined quota of intensity, duration and reps; not response to pain - Positive reinforcement given when quotas are met; quota progressed until desired functional level is reached

How do we determine that a patient may have depression?

5(+) signs in bottom box depression screening is also on patient intake form; also asks if they believe they should be treated for their depression

How do we screen for fear avoidance beliefs?

FABQ

How do we know what patients are at risk of developing persistent disabling LBP

Top 3 factors are nonorganic signs, maladaptive coping behaviors, and psychiatric comorbidities

What is the #1 predictor of a person developing persistent disabling LBP?

Waddell's Nonorganic Signs usually patients thought to be malingering or exaggerating symptoms; potentially drug seeking behaviors / no explanation for why symptoms are present - patient usually will say they have never been pain free in the last year - potentially a monetary concern (workers comp) - psychological conditions (depression, anxiety)

rotation

back pain reported when shoulders and pelvis are passively rotated in the same plane

If a patient indicates they do not expect to return to their pre-injury levels of activity, and they do not believe they should do anything that makes their pain worse, this indicates...

avoidant behavior

What condition can lead to chronic disabling LBP

depression; have sx been interfering with pt inability to function without a clear explanation? if pt claims presence of back pain causes their depression, we need to treat that. If pt claims they'll still have depression if LBP is gone, need to be referred to another specialist so they may also be treated psychologically while we treat for physical sx

Fear avoidance beliefs about work are a significant factor in predicting...

disability and return to work in patients with work related LBP -FABQ physical activity scale > 15 -FABQ work scale > 34

motor and sensory

giving way or cog wheeling to motor testing or regional sensory loss in a stocking or non-dermatomal distribution (with peripheral nerve dysfunction ruled out)

when a patients with chronic LBP tells us that there are certain movements they are afraid of, what do we want to do?

gradually expose them to these activities (graded exposure)

overreaction

guarding/limping, bracing, rubbing affected area, grimacing, sighing

STarT Back Screening Tool

helps PT determine whether or not patient may have psychosocial concerns

axial loading

light pressure to skull of standing patient should not significantly increase LB sx

How do we manage a patient that presents with Waddell's Nonorganic Signs?

likely need to have someone else evaluate them psychologically

Do patients with acute/subacute problems commonly present with depression and fear avoidance behaviors?

no; usually just patients with chronic pain. Chronic pain may have been caused by some psychosocial overlay, so these patients are more likely to present with depression and fear avoidance behaviors

Should patients avoid movements that are painful?

only slightly in acute phase; if person with chronic pain avoids behaviors that bring on their pain, this should not be recommended. They should be encouraged to move and confront their symptoms (after being screened for red flags/sinister pathology)

prior to exercise and after exercise, what do we want to assess?

pain intensity; can show the patient that physical activity will likely not increase the patients pain much. It is ok if pain increases 1 or 2 on NPRS. if more should probably back off when quota is met, give positive reinforcement & increase quota

How problematic is LBP (usually)?

rarely suggests permanent or serious damage; spine is strong even when in pain.

What are fear avoidance beliefs?

results in physical disuse, de-conditioning, and guarded movements confrontation and avoidance = extreme responses to fear of pain - avoidance behavior perceived to be a maladaptive response to LBP; associated with chronic disability.

are abnormal imaging findings always concerning?

very rarely a sign of serious disease, and commonly found in people without LBP

exercise program for patient with fear avoidant behavior

very standard program focused mostly on decreasing pt's fear of movement rather than treating the pain

tenderness

widespread sensitivity to light touch of superficial tissue

with regards to patient education, what should PT's emphasize?

• Anatomical/structural strength of the spine • Explain pain perception • Overall favorable prognosis for LBP • Stay active approach (active pain coping strategies, early resumption of activity) • Improvement in activity level, not just pain

with regards to patient education, what should PT's not emphasize?

• Recommend or promote bed rest • Give detailed pathoanatomical explanations for a specific cause of LBP

what does a score of ≤3 on STarT Back Screening Tool indicate? what does ≥4 indicate?

≤3 low risk ≥4 high risk for chronic disability; need to change management strategy