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 [email protected]