Non-Specific Low Back PainUsing Data for Managing Patients

Highlighting a Psychosocially Informed Perspective

Mark Werneke PT, MS, Dip MDT

Annual FOTO Conference

April 5-6 2014

Evidence-Based Clinical Practice

Clinical expertiseScience & data

Evidence-Based Clinical Practice

“integration of the best research evidence with clinical expertise applied to patient values to optimize patient outcomes and quality of life to achieve the highest level of excellence in practice” Sackett et al 2000

Operational Definition

patient values

Evidence-Based Clinical Practice

Clinical expertiseScience & data

What about me? Did you consider the patient’s psychosocial attributes e.g., self-efficacy, fears, motivation, or meaning response such as relationship alliance?

Value

LBP Examination: 2 Data Types

Impairment & Classification data

Physical Performance data Self-Report dataFunction & painPsychosocial data

“Value”

Psychosocial Data

• Survey of routine screening for psychosocial issues in outpatient physical therapy clinics (MD)

• Results– Psychological or social issues (9.5%)– Depression (8.3%) – Excessive fear of movement or fear of physical

activity (0%)

Rabel et al JOSPT 2009

Psychosocial Data

• Results suggest that patient’s “values” and “biosychosocial profile” are not adequately addressed during routine everyday practice:– Psychosocial issues are not objectively quantified

• Patients are not classified by psychosocial risk

• Certain patient subgroups may not be provided the most optimal RX

Psychosocial Data

• Inadequate patient value & psychosocial screening may have direct implications for FOTO users interested in higher performance & reimbursements– Negatively influence:

• Effectiveness

• Efficiency

Outline

• Evidence supporting each data type 1 & 2

What is your intervention strategy when the results from

the different data types head in

different directions during RX?

• 4 possible data type scenarios

• Scenario 4– Two case studies

• Managing patient values to enhance self-report outcomes

Impairment: Data Type 1

• Loss or abnormality of physiological or anatomical structure (deficit at organ level)– Strength, ROM etc..

• Are used as outcomes to justify treatment and reimbursement

Caution: Impairment Challenges

ImpairmentFunction

Poor correlation between impairment & functionImpairment measures inadequate reliability/validity

Simmonds MJ et al. Spine1998

Classification: Data Type 1

• Not reasonable to assume that all patients are the same or would benefit from any one treatment approach

• Physical Therapy Practice Guidelines– Classification system for

NSLBP

• Summary• Preliminary evidence is

promising

• Data support the hypothesis that treatments based on patient classification results in better outcomes when compared to RX not based on classification methods

Common PT Classification Systems

• 5 dominant classification schemes– Mechanical Diagnosis & Therapy (MDT- McKenzie)

– Treatment-Based Classification (TBC- Delitto)

– Movement System Impairment (MSI- Sahrmann)

– O’Sullivan Classification (OCS- O’Sullivan)

– Pathoanatomical Based Classification (PBC- Petersen)

Caution: Classification Challenges

Comprehensiveness

Mutual exclusivity

Discrimination

Caution: Classification Challenges

• Common classification paradigms– May lack the ability to identify homogeneous

subgroups– Place patients into more than 1 category

within and between systems– Lack validation for diverse patient populations

especially chronic impairments and elderly

Discrimination

Mutual exclusivity

Comprehensiveness

• Patient is asked to perform a specific functional task

• Standardized assessment• Predetermined criterion(s):

– Distance, time, exertion, motor control, and/or pain

• PPM’s are used to document outcomes or to justify reimbursement

Physical Performance: Data Type 1

Physical Performance Measures

• PPM - single measurement criterion – e.g. time or distance

• 6 minute walk test

• Stair test

• Time up and go

• PPM - multiple measurement criteria– e.g. time, exertion, pain, &/or motor control

• PILE (lifting test)

• Functional movement screen (FMS)

PILE: Multiple Measurement Criteria

Mayer TG. Progressive isoinertial lifting evaluation. Spine 1988

Time: 4 lifts in 20 sec

Pain: Patient self-terminates: excessive fatigue, discomfort, or inability

Effort: HR = > 75% Max HR

Compensatory movements: therapist terminatesdue to unsafe or poor mechanics

FMS: Functional Movement Screen

• Multiple measurement criteria to judge 7 movement patterns– Pain: score 0/3

– Distance: for shoulder mobility &ASLR tests

– Compensatory movements

Cook G Musculoskeletal Interventions 2006

Caution: Performance Data

• Time consuming

• One performance measure does not adequately capture the breadth of health concepts associated with a patient’s functional status

• Only modest correlation (0.4) between performance and patient’s perceived ability

Stratford, PW et al. Arthritis & Rheumatism 2003

Patient Self-Report: Data Type 2

• Patient values

• Patient’s opinion or experience performing functional tasks

• PRO’s are frequently used to document patient outcomes & to justify reimbursement

Caution: Self-Report Data• Patient’s self-report of function influenced by

more than ability to move• Patient’s cognitive, behavioral, and emotional attributes may

influence self report (Hill JC. Phys Ther 2011)

• Pain may influence self-report– (r=.46 to.56 Stratford PW. J Clin Epidemiol 2006) & (r= -.34 Hart DL. J Rehab

Outcome Meas 1998)

• Patient’s response shift (Anderson et al. The Spine Journal 2009)– Negative shift: overrates their ability & realizes they can not perform as well

– Positive shift: CBT & meaning responses as active RX ingredients

Caution: Self-Report Data• Controlling for (-) response shifts

– FOTO new patient instructions at introduction of survey• Time component• Assessing function related to involved limb

– Standardized instruction to patient by therapist

– Serial status surveys• Assessing patient values over time

What Data? Optimize Patient Outcomes

Impairment & classification

Physical performance

Self-report

Clinical Expertise

Patient Management

Physical performance data Patient self

report data

Classification & impairment data

Knowing what data are useful at what time to make effective RX decisions during that visitis a useful clinical skill

Patient values and self-report

Reality Check

• Self-report is gold standard• Provides the evidence (most RCT/observational studies)

• Efficient and cost effective

• Assess a wide range of functional activities

• Mandated by many payers: e.g. CMS, Aetna, Oxford

• Endorsement by policy makers/organizations• Institute of Medicine

• US Dept of Health & Human Services

• APTA clinical practice guidelines

Reality Check

• Patient self-report is driving

• Alternative reimbursement models for rehab services (P4P)

• Provider & clinician performance– National Utilization Percent Ranking

– Consumer reporting

Lower than Expected

1 2 3

4 5 6

7 8 9

Higher than Expected

Expected

Self-Report Driving: P4P

Increasing Functional Change –Effectiveness

Fewer Visits - Efficiency

28

Risk-adjusted

Lower than Expected

Patient Self-Report Data

• FOTO P4P models– CMS project (2006)

• CentraState Medical Center, NJ

• Presbyterian Healthcare Services NM,

– Health Partners HMO, MN project (ongoing)• Therapy Partners (independent PT practices)

P4P Results

• CMS project– Modest improvement in effectiveness– 12% reduction in rehab costs

• Health partners project (preliminary)– PT’s achieved “higher than expected” or

“expected” value for majority of cases– Less utilization compared to national

benchmark data

P4P Models

• Patient self-report is driving value-based purchasing

• Preliminary results are promising– Provider reimbursement

• effective outcomes achieved efficiently

– Model is a worthy alternative payment method– A win-win-win scenario

• For patients, payers, & providers

Self Report Driving: Ranking% of patients in each

groupings RA: FS change by # visit

Low

ExpectedExpected

HighHigh

977

644

332211

55

8

Do you know your numbers?

Self Report Driving: Consumer Reporting

Do you know your numbers?

National Utilization Percent Ranking

Clinical Expertise

Patient Management

Physical performance data

Classification & impairment data

Patient self-report

&

Clinical Expertise

Know your data

Strengthening

Value & self-reportPhysical performance

Stretches

Manual techniques

Education

Value & self-reportProblem solving

Reassurance Graded exposure CBT

Patient Self-Report Data

• Surgeon General’s Medical warning

“Self report data is critical for managing your health at least as a therapist

outcomes

Enhancing Self-Report Outcomes

The Basic Tenet• Serial status reportsEvidence suggests that therapists who use serial outcome assessments during the RX episode achieve better patient outcomes

(Deutscher et al APMR2009)

Serial Outcome Measurements

• If you are collecting serial status reports– Four possible data type 1 & 2 scenarios

• Each data scenario may help to judge patient’s progress

• May influence your RX strategies

Data Scenarios

Scenario #1: both outcome measures are improving

Scenario #4

• How this often does this happen?

• What does mean?

• What intervention(s) may be beneficial to align the patient’s actual physical ability with the patient’s perceived physical capability?

Scenario #4: How this often does this happen?

• Prevalence on first status: – FOTO data for patients with lumbar

impairments (2013 unpublished data)

– Symptom duration• 16% for acute < 15 days• 32% for subacute > 15 days but < 90 days• 52% for chronic > 90 days

What does Scenario #4 Data Mean?

Self report type 2 data (PRO) are not appropriate“a research tool only”

PRO data subjective and unreliable “not important”

Type 1 data i.e., impairment & performance are more accurate & best capture what I do in the clinic

Scenario #4 Data =

Complex

ity

Scenario #4: What Intervention(s)

EBM

Science

Evidence supports a biopsychosocial management strategy

Science: Biopsychosocial Model

• Screening for patient’s beliefs, fears, expectations, emotions and behaviors regarding his or her pain experience, &

• Targeting patients at high risk for cognitive behavioral therapy (CBT) or (a referral to mental health specialist)

Patient’ behaviors

Scenario #4• Techniques targeting patient value

– Formal cognitive behavioral programs– Meaning response

• “Therapeutic alliance– Patient-practitioner interaction

• Clinician’s communication skills

• Clinician’s mannerisms

Scenario #4

• Techniques targeting patient value

• Formal cognitive behavioral programs– Graded exercise (operant) conditioning program

• Fordyce JC APMR 1973

– Graded exposure (task-specific training)• Vlaeyen JW. Pain 2000 & Behav Res Ther 2001

Scenario #4• Techniques targeting patient value • Meaning responses

– Patient-practitioner interactions• The patient is comfortable approaching you• Collaborative relationship• Patient has trust & confidence in your ability to function effectively on their behalf

Vong et al APMR 2011

Scenario #4• Techniques targeting patient value

• Meaning responses – Communication

• Praise & attention to (+) behavioral change• Ask questions that build self-efficacy beliefs• Patient centered interviewing & goal setting• Positivity & problem framing

Zolnierek et al. Med Care 2009

Scenario #4• Techniques targeting patient value

• Meaning responses – Clinician’s mannerisms

• Enthusiastic vs. lukewarm• Behavioral and verbal messages

Moerman et al. Annals Int Med 2002

Meaning Response vs. Placebo

• Meaning responses– Active ingredients to RX

– Encompasses patient management strategies from a psychosocially informed perspective

• Placebo – RX is inert

– no active RX ingredient

– RX effect is due to patient expectancy

Meaning responses account for 30% outcome variance vs. just 15% from placebo (Heyland BMJ 2008)

Therapists who are skilled at the enhancement of meaning responses while embracing evidence-based interventions are providers of choice to produce best outcomes

Best Patient Outcomes

Summary: Literature Review

Case Study #1

18 year oldSubacute 2 monthsHMOPrimary MDStudentPrior exercise Hx3x week/gymNo pain medsAggravating

Squats Sitting

Case Study #1: Type 1 Data• Impairment

– Neuro signs (-)

– SLR 75 deg

– Back flexion =106 deg

– Back extension 20 deg

– Plank 38 seconds

– Sorensen 45 seconds

• Classification– Derangement

• Centralization

• Extension DP

• Performance– Poor squat mechanics

Case Study #1: Type 2 Data

• Self report– Function

• Intake FS = 63/100

• Predicted = 77/100

– Pain (max 24 hours)• Level 5/10

– Psychosocial• Fear = 15/24

• STarT = 2/9

Case Study #1: Treatment

• Initial visit– Education

• Self care

• Exam results

• Prognosis

– ADL body mechanics• Golfer bend

• ½ kneeling

• Sitting w lumbar support

– Directional preference• Repeated extension

• 2nd visit– Reassessment

– Confirmed working classification hypothesis

– Manual mobilization• Lumbar extension

– Motivation• Self care

• Compliance home program

• 3rd visit– No pain

– Manual mobilization• Lumbar extension

– Performance• Squat techniques

– Motivation• Self care

• Compliance home program

• 4th visit– No pain

– Reassessment

– Impairment• 120 deg flexion

• 35 deg extension

– Performance• PILE = 75# floor waist

– Self report• FOTO status survey

– FS = 69/100 (+6)

– MCII (3rd quartile) = 3

• 5th visit– Communication

• “I’m afraid of squatting in gym and hurting myself”

• Negative response shift

– Graded exposure• Positive thinking

• Problem solving in gym– Practice squatting

– Balance training

– Core trunk strengthening

• 6th visit– Motivation

– Reassurance

– Graded exposure• Positive thinking

• Problem solving in gym– Practice squatting

– Balance training

– Core trunk strengthening

• 7th visit– Reassessment

– Impairment• Plank 85 sec

– Performance• Good squat mechanics

– 2nd Status Report• FS = 94/100

• Fear = 6/24

– Discharged• Home & gym program

Most powerful way of enhancing

self efficacy & reducing fear is

performing a particular task to

allow that person to have some

self-experience of that task

Case Study #2

48 year oldNurse working LD/PTChronicHMOOrthopedic referralPrior exercise Hx 3x/week Tramadol/ativan/ms relaxAggravating factors

Any movement

Case Study #2: Type 1 Data• Impairment

– Neuro signs (-)

– SLR 80 deg

– Back flexion =80 deg (thigh climbing)

– Back extension 20 deg

– Clinical testing limited

– Overt pain behaviors

• Classification– Non centralization

– No directional preference

• Performance– Not tested

Case Study #2: Type 2 Data

Self reportFunction

Intake FS = 38/100Predicted = 57/100

Pain (max 24 hours)Level 8/10

PsychosocialFearPA = 22/24Work = 39/42STarT = 7/9

Case Study #2: Treatment• Initial visit

– Meaning responses• Active RX ingredient

– Support

– Empathy

– Understanding

– Collaborative partnership

– Patient centered interview

– Education/Reassurance• Self care

• Exam results

• Prognosis

• Motivation

• 2nd visit– Reassessment

– Multi-directional stretches

– Graded exposure• Positive thinking

• Problem solving– ADL & work tasks

• 3rd visit– Same pain pattern

– Graded exposure• Positive thinking

• Performance– Light lifting

– Sitting

– Reaching overhead

– stairs

• Exercises– Stretches

– Gentle stabilization

• Problem solving

• 4th visit– Reassessment

– Impairment• 95 deg flexion

• 25 deg extension

– Performance• PILE = 15# floor waist

– Self report• STarT = 7/9

• Fear 39/42

• FOTO status survey– FS = 36/100 (-2)

• 5th & 6th visits– Same pain pattern

– Graded exposure• Positive thinking

• Performance– Work tasks

» Transfers

» lifting

• Exercises– Balance

– Advanced stabilization

• Problem solving

• 7th visit– Reassessment

– Performance• Plank 60 seconds

• Lifting 45# with good squat mechanics

– 2nd Status Report• STarT = 8/9

• Fear work 40/42

• FS = 38/100 (no change)

– Discharged• Independent home program

Mentoring: How to Use FOTO Data

• Maccabi Healthcare Services– 77 PT clinics (550 PTs)

• Started 1:1 mentoring training program– 1 hour weekly sessions between 2 colleagues

• Discuss 2-4 difficult patients

• Patient treatments

• How to use FOTO data for clinical decision making

• Initial results are promising

Mentoring: How to Use FOTO Data

Daniel Deutscher 2013 unpublished data

Summary

A competent rehab professional

• Skilled at:– Evidence-based practice

• Integrating science and clinical expertise with the patient’s values

Summary

A competent rehab professional

• Best patient self report outcomes:• Patient status report on or as close

to discharge date as possible– Preliminary evidence suggests decreased

effectiveness (Daniel Deutscher 2014)

• 25% FS decrease for status 1-3 days before discharge

• 50% FS decrease for status 10+ days before discharge

Thank You mwerneke@centrastate.com