Other psychometric tools for measuring pain include the Vernon-Moir scale, Oswestry, McGill pain questionnaire, Roland-Morris, and VAS scales.
These tools are useful for your clinical reasoning
process as they establish baselines on which to measure treatment
outcome. Moreover, they aid the physiotherapist in the clarification
of yellow, blue, orange and black flags. Similarly, they aid
the client in making sense of what is happening to them and
hence becomes an integral part of the educational process
of rehabilitation.
General musculoskeletal
conditions and pyschometric analysis
Do you remember how much you used to have
to concentrate when you learnt to drive? Eventually,
the task became automated and effortless. However, what
happens when you are in an unfamiliar area, you need to look
at a map, there is lots of traffic and the mobile phone rings
because you are running late for the meeting that you have
to chair? Your cognitive systems are bombarded with
competing information trying to make itself the priority in
your limited processing systems. Similar to RAM in those
old computers which couldn't keep up with newer and better
software programmes, everything starts to slow and grind to
a halt.
Back pain can have similar effects on your
processing capacity. With constant cognitive
hyper-vigilance, a person in pain can have their RAM slow
because they have less redundancy to cope with new stimuli.
The glutamate-NMDA receptors of the prefrontal cortex and
noradrenergic receptors of the locus coereleus may be viewed
as the RAM of pain processing. The locus coereleus in
particular has been considered an integrator of cerebral activity,
helping maintain 'neural synchrony' like a conductor of an
orchestra. However these nuclei can undergo neurocytotoxic
effects in the presence of excessive and ambiguous interoceptive
and exteroceptive inputs. This, may reduce the ability
to cope with fear and anxiety in the amygdala and limbic systems.
Furthermore, the anterior cingulate gyrus may have it's memory
for pain and disability amplified. Connections with
the hypothalamic-pituitary axis can result in hormonal imbalance.
It is probable that interoceptive bombardment of the CNS by
inflamed peripheral nociceptors may be reduced through musculoskeletal
physiotherapy hands-on techniques designed to reduce pain
and muscle spasm. Additionally, clear
explanations by the physiotherapist and structured goal oriented
exercise regimes may filter exteroceptive information and
thereby clarify 'feed-forward' mechanisms.
Fear connotes an identifiable threat (eg King
Brown snake), whereas anxiety connotes the possibility of
threat. Fear-avoidance relates to the behaviour that an identified
activity may have (real or imaginary). Kinesiophobia refers
to the patient experiencing "an excessive, irrational,
and debilitating fear of physical movement and activity resulting
from a feeling of vulnerability to painful injury or reinjury"
(Kori SH et al Pain Management 1990; Jan/Feb:35-43)
Avoidance behaviours occur in anticipation of
pain and generally persist because there are few opportunities
to correct the eroneous expectations which drive them. This
has a deliterious effect in the engagement of ADL which then
in turn can lead to mood disturbances, irritability, frustration
and depression. The fear-avoidance behaviour leads to secondary
consequences of deconditioning whereby normal activity such
as carrying the shopping leads to excessive fatigue, heart
palpitations, nausea and distress.
Factor Web
WHO classification of pain
Hewitt, Hush, Martin, Herbert & Latimer
(2007), AJP, 53, 269-276, established that measures of activity
limitation and pain at 9 weeks, and work status at 6 months
have the greatest predictive accuracy of somone developing
chronic pain and disability.
Psychometric evaluation
It is easy to be overwhelmed by such multiple
factors which could contribute to chronic LBP. However, we
must evaluate what is relevant and use this differentiation
to determine what our strengths and weaknesses are as a profession
and when to refer to other professionals. Importantly, there
will be a significant subgroup of clients who have chronic
musculoskeletal injuries due to mismanagement, which if identified
could be resolved through multi-factorial physiotherapy which
includes passive techniques, exercises and education.
The ICF - WHO has stipulated three seperate
but related dimensions of functioning are defined as body
dimension (functions and structure), individual
dimension (activity), and social
dimension (participation). Body functions are physiological
or psychological functions of body systems. Activity describes
daily purposeful integrated body systems execution of tasks.
Whereas participation deals with the experiential and contextual
setting of the persons life (social relationships, employment,
and economic life), as well as societies response to the person's
level of functioning.
According to Thonnard & Penta (2007), Eur
Medicophys, 43, 525-541, "rehabilitation
can be defined as a reiterative problem solving and educational
process that focuses on disability (altered activities) and
aims to maximise participation in society while minimising
the stress on and distress of the patient and family".
While the outcome of a particular physiotherapeutic intervention
can be stipulated based on functional measures, these need
to be validated not only w.r.t diagnosis but also their meaning
w.r.t the participation of the patient in the community. The
latter hasn't specifically been addressed and has frequently
been assumed to correlate with functional status. Importantly,
functioning and participation in the community are highly
likely to be key measures when it comes to financing treatment
interventions.
Modified Schober Test (MMST) tests range
of movement in the lumbar spine in the ICF dimension of body
function. Validity as correlated to X-ray is 0.67, reliability
as an inter-rater score is excellent (ICC=0.95, 95%CI, 0.44-0.84),
responsiveness (sensitivity) requires a change of over 1cm
to be 95% confident of change.
Thonnard & Penta (2007),
Eur Medicophys, 43, 525-541
Low Back SF-36 tests both ICF dimensions
of body functions and activities. 18 items pooled from the
Australian low back SF-36, modified version of Oswestry and
Quebec back pain disability scale has fewer misfitting items
than the original SF-36 and thus elimates it's floor and ceiling
effects. Unidimensional linear scale developed with the Rasch
partial credit model. Inter-rate reliability were 0.94. The
minimal detectable change is 12 points on a 100 point scale.
Thonnard & Penta (2007),
Eur Medicophys, 43, 525-541
Physical Impairment Index (PII) evaluates
physical impairment in LBP through 7 tests, each scored dichotomously
based on published cut-offs. ICF dimension of body function
and structure. Convergent validity was supported by correlations
with disability (r=51 w.r.t. Roland Morris Q'naire), work
loss in past year (r=0.43), pain (r=0.27), depression (r=0.26
with Zhung depression inventory), somatisation (r=0.32 with
modified somatic perception Q'naire), non-organic signs (r=0.49)
and non-organic symptoms (r=0.35). Correlations were also
found with the physical component of the SF-36 (r=0.28) and
physical activity subscale of the fear-avoidance beliefs questionnaire
(r=0.24). Good to excellent reliability for individual items
(ICC from 0.48-0.96). The overall score demonstrated excellent
inter-rater reliability (ICC=0.89)
Thonnard & Penta (2007),
Eur Medicophys, 43, 525-541
Roland Morris Questionnaire (RMQ) self
administered disability measures in LBP reflecting 24 activities
of daily living. ICF dimension of activities. The responsiveness
is sufficient to detect change after 4 to 6 weeks of physiotherapy
in patients with an initial score in the central portion.
However, the magnitude of error is too large to detect improvements
in patients with a score of less than 4 and deterioration
in patients with scores of greater than 20.
Thonnard & Penta (2007),
Eur Medicophys, 43, 525-541
Sickness Impact profile (SIP) is a behaviourally
based measure of perceived health status applicable across
a spectrum of illnesses and among various demographic and
cultural subgroups, applied in LBP with an ICF participation
dimension. Validity has been reported with various biological
and clinical measures and subcategories of the Minnesota Multiphasic
Personality Inventory. High test-retest reliability coefficient
(r=0.85) in LBP.
Thonnard & Penta (2007),
Eur Medicophys, 43, 525-541
Chronic Pain : Global Physiotherapy Examination
52 (GPE-52) is clinical physical examination in 5 domains
including posture, respiration, movement, muscle and skin
palpation. Good to excellent inter-rater reliability of the
total score (ICC=0.91), and individual components (ICC=0.65
for posture, 0.60 for respiration, 0.89 for movement, 0.83
for muscle palpation, 0.76 for skin palpation). However, requires
3 days of training and some 30 minutes to complete.
Thonnard & Penta (2007),
Eur Medicophys, 43, 525-541
Orebro Musculoskeletal Pain Questionnaire
(OMPQ) is a "yellow flag" screening tool that
predicts long-term disability and failure to RTW when completed
over 4 to 12 weeks following soft tissue injury. A cut off
score of 105 has been found to predict those who will recover
(95% accuracy), those who will have further sick leave in
the next 6 months (81% accuracy), and those who will have
long term sick leave (67% accuracy). In workers with back
injuries, at 4-12 weeks, a cut-off score of 130 correctly
predicted 86% of those who failed to RTW.
The Impact of Event Scale (IES) was developed
to measure current subjective distress related to a specific
life event (Horowitz M et al 1979, Psychosom Med 41, 209-218).Two
response states, avoidance and intrusion are measured. The
IES has 15 items, seven of which are intrusive symptoms such
as thoughts, nightmares, feelings, and images associated with
a specific event. Five of these measure intrusive symptoms
whilst awake, wheras 2 others measure intrusions at night
(insomnia, nightmares). The avoidance subscale has eight items
such as a numbing of responsiveness, and avoidance of feelings
and situations. A cut-off of 26 or above would be grounds
for a psychological referral. However, a few weeks may be
allowed to pass as to allow some natural recovery. Has been
recommended by Dr Michelle Sterling in some people who have
suffered a whiplash type injury. Can be downloaded from Swinburne
University : www.swin.edu.au/victims/resources/assessment/ptsd/ies.html
; or NSW motor accident authority : www.maa.nsw.gov.au/default.aspx?MenuID=95#415
The Pain Self Efficacy Questionnaire
(PSEQ) ask clients to rate how confidently they can
perform the activities despite their pain. It covers a range
of functions including household chores, socialising, work
as well as coping with pain without medication. It is based
on Bandura's (1977) conceptualisation of self-efficacy as
a reflection of a resilient self-belief system' in the face
of obstacles. Takes 2 minutes to complete. Low scores <
20 suggest that the client is focussed on pain whereas high
scores > 40 suggest that the client is likely to respond
well to an exercise regime. Low PSEQ is a predictor of long
term disability and depression.
The Pain Anxiety Symptoms Scale (PASS)
validity has been supported by positive correlations with
measures of anxiety, cognitive errors, depression, and disbaility.
Fear of Work Related Activity = Fear - Avoidance
Beliefs Questionnaire (FABQ) has 2 parts, one on physical
activity, the other on work. The latter has been shown to
have significant predictive validity with disability in ADL
and days off work, more so than biomedical parameters such
as anatomical pattern of pain, temporal pattern, and pain
intensity.
Fear of movement = Tampa scale for kinesiophobia
(TSK) is a 17 item scale to assess the fear of re-injury
due to movement.
Identification of personal and environmental
factors provides the opportunity to incorporate these elements
into treatment strategies with appropriate interventions such
activities based on cognitive behavioural strategies.
Reducing Pain-Related Fear
Peter Lang's bioinformational theory of fear (J Affective
Disorders 2000; 61:137-159) predicts to reduce fear
- the network mediating the fear needs to be activated
- new information needs to be presented to discredit the
expectations that are inherent to the fear memory.
Demystification of the pain through education, appropriate
treatment with graded exposure which includes operant cognitive
behavioural activity parameters are the cornerstone of such
an approach. Paradoxically, verbal re-assurance may have the
opposite affect and lead to increased distress.
Neurolinguistic programming and Cognitive Behavioural
Therapy should be incorporated into the overall management
approach
Link to Neurolinguistic
Programming Ennegram
Non specific low back pain
The 5th international congress in low back
pain concluded last week in Melbourne (Nov 2004). Apart
from the usual palabra, there seemed to be some common sense
coming from the floor into the discussions. The great
proponents of reductionist paradigms for studying so called
'non-specific low back pain' came under fire for the 10 years
of misdirected and misguided research trying to identify specific
variables using a non-specific paradigm. Cognitive factors,
including beliefs, depression, kinesiophobia were thought
to make up around 50% of measurable outcome variables, disability
30% and impairment only 20%. Whilst the statistical methodology
& reasoning was highly commendable, the premise of a lot
of research on the efficacy of treatment interventions was
that all physiotherapists are equal. It would seem ludicrous
that the same proponents of graduate programmes in Musculoskeletal
and Sports Physiotherapy can rationalise that the skill level
of the physiotherapist is irrelevant to outcome. These
arguments seem to have arisen from poorly designed investigations
in the mid 90's.
Impairment measures
are traditionally seen as 'range of movement' and sometimes
neurological impairment. However, more difficult
measures which usually aren't included in impairment measures
are quality of movement, and the muscle activation required
for the distribution of force across joints and between body
segments ( inverse
dynamics and Newtons 3rd Law). Additionally, when
considering the 'mass-spring' analogy of movement and energy
conservation, then perturbations of movement and the capture
of energy from perturbations of movement, such as plyometrics
, become important aspects in the clinical reasoning
paradigm. Yet, how are these measured in the NSLBP paradigm
by traditional 'non-progressive' research.
Those same protagonists also argued in the
1990's that there was no role for dose in manual therapy.
(Dose representing the force, duration, frequency, number
of repetitions, the type of technique used commiserate with
the stage, stability, severity and irritability of the disorder
as well as based on the identification of the 'cause of the
cause' of the dysfunction). Additionally, back
in the 1990's they used placebo constructs which ignored the
fundamental role of higher centres in pain and information
processing. Even the paper which I submitted
to Manual Therapy for publication in the mid 90's on mechanical
traction had the descending modulation and cortical modulation
aspects deleted from it by the co-authors.
Thankfully, multi-modal
treatment approaches are now receiving some credibility as
a research paradigm. Additionally, the biomechanics
and specific treatment intervention for pelvic girdle dysfunction
is being extracted out of the NSLBP paradigm. Progressive
research on impairment and specifically the importance of
muscular forces are being performed by Wim Dankearts under
the guidance of Peter O'Sullivan. They are working towards
a novel classification system for non specific chronic low
back pain patients which includes higher order mental processing.
Specifically, Peter O'Sullivan has put forward 3 sub-categories
-
"Pain disorders associated with movement
impairments are associated with a loss of normal physiological
movement of lumbo-pelvic mobility, and abnormally high
levels of muscle guarding and co-contraction of lumbo-pelvic
muscles with generation of intra-abdominal pressure....[resulting
in].....excessive force closure"
-
"Pain disorders associated with control
impairment are associated with no impairment to the mobility
of the symptomatic spinal segment, but rather present
with impairments or deficits in control of the symptomatic
spinal segment pressure...[resulting in]....reduced force
closure"
-
"......mal-adaptive movement and
motor patterns result in chronic abnormal tissue loading
and ongoing pain and distress......These disorders are
also invariably associated with non-organic factors but
these factors do not dominate the disorder, leaving them
more amenable to physiotherapy intervention based on a
cognitive behavioural motor learning model"
(5th Interdisciplinary World Congress on
Low Back and Pelvic Pain, Melbourne, 2004, Australia p132)
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