Treatment monitoring as a component of psychologically informed physical therapy: A case series of patients at high risk for persistent low back pain related disability

Application of Algorithm-Based Treatment Approach to Low Back Pain in the Emergency Department

Low back pain accounts for nearly 4 million annual emergency department (ED) visits, and patient outcomes following an ED visit for low back pain are poor. Additionally, only a small portion of patients visiting the ED for low back pain follow up with outpatient physical therapy within 3 months, despite established benefits of early versus delayed physical therapy referral such as improved patient outcomes, less opioid use, and reduced downstream health care utilization. Integrating a physical therapist directly into the ED care team can facilitate evidence-based guideline concordant care and improve patient outcomes, however, physical therapists who are staffed into this role from other settings may lack experience with evaluating and managing patients with acute low back pain. Additionally, there are several unique considerations of the ED care environment which may make existing treatment-based classification approaches difficult to apply in this setting, including physical constraints (eg, delivering care in stretchers and hallways), higher symptom severity and psychosocial stressors necessitating an emergency visit, and greater likelihood of alternative medical diagnoses (eg, kidney stone, aortic aneurysm) contributing to symptoms of low back pain. This perspective presents a modified ED treatment-based classification system (ED-TBC) for low back pain with 3 illustrative case examples. The ED-TBC for low back pain can be used to facilitate guideline concordant care, increase physical therapist confidence in evaluating low back pain in the ED, and reduce clinical practice variation.

Pain phenotyping and investigation of outcomes in physical therapy: An exploratory study in patients with low back pain

Phenotypes have been proposed as a method of characterizing subgroups based on biopsychosocial factors to identify responders to analgesic treatments. This study aimed to, first, confirm phenotypes in patients with low back pain receiving physical therapy based on an a priori set of factors used to derive subgroups in other pain populations. Second, an exploratory analysis examined if phenotypes differentiated pain and disability outcomes at four weeks of physical therapy. Fifty-five participants completed psychological questionnaires and pressure pain threshold (PPT). Somatization, anxiety, and depression domains of the Symptom-Checklist-90-Revised, and PPT, were entered into a hierarchical agglomerative cluster analysis with Ward's method to identify phenotypes. Repeated measures ANOVAs assessed pain ratings and disability by phenotype at four weeks. Three clusters emerged: 1) high emotional distress and pain sensitivity (n = 10), 2) low emotional distress (n = 34), 3) low pain sensitivity (n = 11). As an exploratory study, clusters did not differentiate pain ratings or disability after four weeks of physical therapy (p's>0.05). However, trends were observed as magnitude of change for pain varied by phenotype. This supports the characterization of homogenous subgroups based on a protocol conducted in the clinical setting with varying effect sizes noted by phenotype for short-term changes in pain. As an exploratory study, future studies should aim to repeat this trial in a larger sample of patients.

Pain Catastrophizing Scale Associated With Other Patient-Reported Outcome Measures in Plantar Fasciitis and Chronic Ankle Instability Patients

BACKGROUND

The Pain Catastrophizing Scale (PCS) is a measure of how patients emotionally respond to pain. It is composed of 3 subscales-rumination, magnification, and helplessness-which address intrusive thoughts of pain, expectations of negative outcomes, and inability to cope with pain. Our purpose is to compare baseline PCS scores with other baseline patient-reported outcome measures (PROMs) in patients with plantar fasciitis (PF) or chronic ankle instability (CAI).

METHODS

We retrospectively reviewed 201 patients who reported at least 1 pretreatment PCS subscore and were diagnosed with PF or CAI between 2015 and 2020 in a single fellowship-trained foot and ankle surgeon's clinic. Demographics, comorbidities, treatments, other baseline PROMs (i.e., visual analog scale [VAS], Pain Disability Index [PDI], 12-Item Short Form Survey [SF-12], 8-Item Somatic Symptom Scale [SSS-8]), and postoperative outcomes were recorded.

RESULTS

The PCS total score and its subscores significantly correlated with the total score and/or subscores of each PROM. Higher PCS total score significantly correlated with worse VAS (P<.001), SF-12 mental (P=.007), PDI total (P<.001), and SSS-8 (P<.001) scores. Only the PCS magnification subscore was significantly greater among patients who did (n=41) undergo surgery (P=.043). Those who had previously undergone foot and/or ankle surgery had significantly higher PCS rumination (P=.012), magnification (P=.006), helplessness (P=.008), and total (P=.003) scores. Likewise, those with a history of substance abuse also had significantly higher PCS scores (P=.005; P=.003; P=.006; P=.003).

CONCLUSION

The correlations between PCS scores and other baseline PROMs indicate that strong pain catastrophizers with PF or CAI may be at risk for poor treatment outcomes. PCS scores could be used to help with treatment for such high-risk patients.

Dose-escalation by hypofractionated simultaneous integrated boost IMRT in unresectable stage III non-small-cell lung cancer

Background

To explore the maximum tolerated dose (MTD) and evaluate the safety of dose escalation using hypofractionated simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) concurrent with chemotherapy for unresectable stage III non-small cell lung cancer (NSCLC).

Methods

Four escalating radiation dose levels were used. This study included 25 patients with previously untreated NSCLC who received six concurrent weekly chemotherapy cycles comprising cisplatin and docetaxel. Dose-limiting toxicity (DLT) was defined as any acute toxicity that interrupted radiotherapy for more than 1 week. MTD was defined as the highest dose level that didn’t induce DLT or grade 5 toxicity in two patients.

Results

All 25 patients received the prescribed escalating radiation dose from the start dose up to LEVEL 4. Two patients experienced DLT at dose LEVEL 4. One patient died because of upper gastrointestinal hemorrhage within 6 months after radiotherapy, whereas another patient among the additional five patients died because of grade 5 radiation pneumonitis within 2 months after radiotherapy. Dose LEVEL 3 was defined as MTD. The 1- and 2-year local controls were 82.8 and 67.8%, respectively. The median progression-free survival was 15.4 months, whereas the median overall survival was 27.3 months.

Conclusions

Dose escalation was safely achieved up to LEVEL 3 [the planning gross target volume (PTVG) 60.5 Gy/22 Fx, 2.75 Gy/Fx; the planning clinical target volume (PTVC) 49.5 Gy/22 Fx] using SIB-IMRT concurrently with chemotherapy for unresectable stage III NSCLC, and the acute toxicities were generally well tolerated. Further prospective studies on long-term outcomes and late toxicities are warranted.

Trial registration

Retrospective registration, ChiCTR1900027290(08/11/2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-09099-3.

Screening for Yellow Flags in Orthopaedic Physical Therapy: A Clinical Framework

BACKGROUND

Psychological factors influence or are associated with physical function, pain, and health care costs among individuals with musculoskeletal pain conditions. Recent clinical practice guidelines recommend screening for psychological factors (also referred to as "yellow flags") in physical therapy practice to help understand prognosis and inform shared decision making for treatment.

CLINICAL QUESTION

Despite the urgings of clinical practice guidelines and evidence of the influence of psychological factors on clinical outcomes, screening for yellow flags is uncommon in clinical practice. Clinicians may feel uncertain about how to integrate screening tools into clinical practice, and how screening results might inform decision making and care coordination.

KEY RESULTS

We outline a 3-step framework for routine yellow flag screening in physical therapy practice: (1) establish a standard first-line screening instrument and process, (2) interpret the results to inform shared decision making, and (3) monitor treatment progress. Four case examples illustrate how yellow flag screening can help clinicians and patients decide whether the patient might benefit most from standard physical therapy, psychologically informed physical therapy, psychologically informed physical therapy with referral to another health care provider, or immediate referral.

CLINICAL APPLICATION

Consider incorporating a standard yellow flag screening process into usual musculoskeletal health care. We present a framework to guide yellow flag screening in practice (1) to help inform treatment pathway selection and (2) to enhance interdisciplinary communication. J Orthop Sports Phys Ther 2021;51(9):459-469. doi:10.2519/jospt.2021.10570.

Longitudinal Monitoring of Pain Associated Distress With the Optimal Screening for Prediction of Referral and Outcome Yellow Flag Tool: Predicting Reduction in Pain Intensity and Disability

OBJECTIVE

To investigate the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool for longitudinal monitoring of pain associated distress with the goal of improving prediction of 50% reduction in pain intensity and disability outcomes.

DESIGN

Cohort study with 12-month follow-up after initial care episode.

SETTING

Ambulatory care, participants seeking care from outpatient physical therapy clinics.

PARTICIPANTS

Participants (N=440) were seeking care for primary complaint of neck, low back, knee, or shoulder pain. This secondary analysis included 440 subjects (62.5% female; mean age, 45.1±17y) at baseline with n=279 (63.4%) providing follow-up data at 12 months.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A 50% reduction (baseline to 12-mo follow-up) in pain intensity and self-reported disability.

RESULTS

Trends for prediction accuracy were similar for all versions of the OSPRO-YF. For predicting 50% reduction in pain intensity, model fit met the statistical criterion for improvement (P<.05) with each additional time point added from baseline. Model discrimination improved statistically when the 6-month to 12-month change was added to the model (area under the curve=0.849, P=.003). For predicting 50% reduction in disability, there was no evidence of improvement in model fit or discrimination from baseline with the addition of 4-week, 6-month, or 12-month changes (P>.05).

CONCLUSIONS

These results suggested that longitudinal monitoring improved prediction accuracy for reduction in pain intensity but not for disability reduction. Differences in OSPRO-YF item sets (10 vs 17 items) or scoring methods (simple summary score vs yellow flag count) did not affect predictive accuracy for pain intensity, providing flexibility for implementing this tool in practice settings.

Are Changes in Fear-Avoidance Beliefs and Self-efficacy Mediators of Function and Pain at Discharge in Patients With Acute and Chronic Low Back Pain?

OBJECTIVE

To examine the mediating role of changes in fear-avoidance beliefs and self-efficacy on pain and physical functioning at discharge in patients with acute and chronic low back pain (LBP).

DESIGN

Retrospective study.

METHODS

Baseline and discharge data from 418 participants with acute and chronic LBP were analyzed. At discharge, functional status and pain intensity were analyzed to assess their role as a predictor of acute and chronic LBP status and as a mediator of fear-avoidance beliefs and self-efficacy from baseline to discharge.

RESULTS

In multivariable analyses, patients with chronic LBP had lower discharge functional status (β = -7.4; 95% confidence interval [CI]: -10.5, -4.3), lower self-efficacy for physical function (β = -5.3; 95% CI: -10.2, -0.4), higher pain intensity (β = 0.9; 95% CI: 0.3, 1.5), and no difference in discharge fear-avoidance beliefs compared to patients with acute LBP. Change in self-efficacy for physical function had a small indirect association (β = -1.1; 95% bias-corrected CI: -2.5, -0.004), mediating the relationship between chronic LBP and discharge functional status.

CONCLUSION

Fear-avoidance beliefs were not a mediator of pain or function at discharge in patients with chronic LBP. Self-efficacy may be an important mediating factor for function at discharge in patients with chronic LBP who receive physical therapy. J Orthop Sports Phys Ther 2020;50(6):301-308. Epub 6 Jan 2020. doi:10.2519/jospt.2020.8982.