Spine ICF - Acute or Subacute LBP with Cognitive or Affective Tendencies

Classification

• Acute and subacute LBP is pain within the first 4-12 wks of onset

• Associated w the presence of negative psychosocial component such as depression, anxiety, fear-avoidance and pain catastrophizing

• Increase in length of time w LBP = increase in deconditioning = increase in secondary impairments

  • ex. altered movement patterns, muscular imbalances, and further deconditioning

Psychosocial components of chronic pain

• Fear avoidance beliefs

• Anxiety disorders

• Depression

• Sleep impairments

Identification of psychosocial contributors

• PHQ-4 (Four item patient health questionnaire)

  • Screens for depression and anxiety

  • >= 6 suggests moderate/severe anxiety or depression

• FABQ-PA (Fear avoidance beliefs questionnaire)

  • Measures fear of physical activity and work

  • >15 indicates high fear of activity

• STarT Back

  • Stratifies risk for chronic disability

  • High-risk category —> strong psychosocial component

• CSI (Central sensitization inventory)

  • Identifies central sensitization features

  • >= 40 suggests central sensitization tendencies

Catastrophizing and fear avoidance

• Pain intensity alone only modestly predicted disability and catastrophizing was a stronger predictor of disability

• Catastrophizing can be used to predict the onset of chronic MSK pain and disability in pts w non-specific LBP

• Fear avoidance behaviors were better at predicting subacute LBP vs acute and chronic LBP

• Higher FABQ scores were correlated w increased risk for work related outcomes (no return to work and more sick days taken)

PT outcomes and implications

• FABQs are likely better measures of disability during subacute phase and screening for fear avoidance behaviors form 4-12 wks of onset of pain

• FAB are cognitive beliefs - therefore modifiable

• Early identification and intervention are crucial during acute-subacute phase

• Pt education important

Pt education

• Promote idea of structural strength inherent in spine

• Neuroscience that explains pain perception

  • Pain doesn’t mean something is necessarily broken

• Favorable prognosis of LBP

  • It will get better w time AND effort

• Active pain coping strategies that decrease fear and catastrophizing

• Early resumption of normal activities, even when still experiencing pain

• The importance of improvement in activity levels, not just pain relief

  • Activity augments healing “motion is lotion”

Graded activity

• Use behavioral goals (quotas) and systematic reinforcement

• Pain levels do not drive exercise dosage

• A baseline activity level is established, then progressively increased session by session

• Reinforcement (ex. verbal praise) is provided when the pt meets the quota

Graded exposure

• A behavioral approach that introduces highly feared activities at a minimal level of fear, then gradually increases the challenge

• Key principles:

  • Pt identifies their most feared activities

  • Activities are introduced at a low level and increased as fear ratings decline

  • + reinforcement is given for participation

  • Exposure must also occur outside the clinical setting