A cogni-ve func-onal approach to managing disabling back pain

Transcription

1 A cogni-ve func-onal approach to managing disabling back pain Peter O Sullivan ed.com TwiEer: peteosullivanpt BODYLOGIC P H Y S I O T H E R A P Y The research team Anne Smith Leon Straker Kieran O Sullivan Wim Dankaerts Kjartan Fersum Helen Slater Darren Beales JP Caneiro Ivan Lin Sam Bunzli Amity Campbell Leo Ng Angus BurneE Tim Mitchell Alice Kvåle Sture Skouen Mary O Keefe Ian Cowell Rob Waller Ali Thorpe Mar-n Rabey 1

2 CFT educators Prof Peter O Sullivan Dr Kieran O Sullivan Prof Wim Dankaerts Dr Kjartan Vibe Fersum JP Caneiro ed.com TwiEer: peteosullivanpt Common beliefs Your spine is unstable Your pelvis is unstable Your need more core stability Your pain is due to poor posture Your back is worn out with lifting You need to train your transversus and multifidus You have a worn disc Its dangerous to bend Lift with lordosis Brace before you lift 2

3 Belief. the psychological state in which an individual holds a proposi-on or premise to be true (Wiki 2010) Influenced by: Culture Environment Family Peers Religion Experience Education Global Burden of disease 3

4 LBP: biggest burden years lived with disability (Lancet 2012) Current evidence for conserva-ve management of NSCLBP No interven-on is superior Spinal manipula-ve therapy Minimal change in pain Exercise therapy Stabilisa-on Direc-onal preference (McKenzie) Condi-oning Graduated exposure Moderate change in disability Highly resistant to change! Rubinstein et al 2011 Cochrane review Hayden et al 2005 Cochrane review Cogni-ve behavioural treatment Henschke et al 2010 Cochrane review What underlies the disorder? 4

5 Cogni$ve factors - +ve beliefs, high self- efficacy, adap-ve coping, cogni-ve flexibility, acceptance, mindfulness Emo$onal factors stress resiliance, low anxiety, +ve mood Social factors +ve culture, suppor-ve family, work environment, financial security, educa-on Physical factors moderate physical loading, condi-oned, adap-ve func-onal behaviours Lifestyle factors moderate ac-vity levels, minimal sedentary behaviours, good sleep, normal body weight Gene$c / epigene$c factors Tissue structure Psychological Pain processing / sensi-vity Health comorbidi-es Life stages Childhood Adolescence Pregnancy Menopause Elderly System changes Central, peripheral and autonomic nervous system Neuro- endocrine- immune Sensori- motor system Tissue structure Low back pain +/- comorbidi$es Cogni$ve factors - - ve beliefs, fear, catastrophising, vigilance, low self efficacy, poor coping Emo$onal factors - stress, anxiety, mood, anger, grief Social factors - ve culture, life stress events and context, financial, family, work stress, low educa-on levels Physical factors high physical loading, decondi-oning, maladap-ve func-onal behaviours Lifestyle factors high or low ac-vity levels, sedentary behaviours, disrupted sleep, obesity, smoking Adap$ve Maladap$ve BEHAVIOURAL RESPONSES TO PAIN Iden$fy modifiable vs non- modifiable factors influencing pain and behaviours Sub- grouping vs individualised care Clumping vs merging Subgroups Classifica-on Clinical reasoning framework Mul$- dimensional framework for LBP Time course / life stage Specific LBP Non- specific chronic LBP Red Flags Mechanical pain behaviour Mixed Non- mechanical pain behaviour Pain type nocicep$ve, inflammatory, dysfunc$onal, neuropathic, mixed Psychological factors Social factors Lifestyle factors and individual considera$ons General health and co- morbidi$es Pain related func$onal behaviours adap$ve vs mal- adap$ve - control, movement, loading impairments, pain behaviours, condi$oning, body schema Gene$c / familial factors 5

6 Mul$- dimensional framework for LBP Time course / life stage Specific LBP Non- specific chronic LBP Red Flags Mechanical pain behaviour Mixed Non- mechanical pain behaviour Pain type nocicep$ve, inflammatory, dysfunc$onal, neuropathic, mixed Psychological factors Social factors Lifestyle factors and individual considera$ons General health and co- morbidi$es Pain related func$onal behaviours adap$ve vs mal- adap$ve - control, movement, loading impairments, pain behaviours, condi$oning, body schema Gene$c / familial factors Pain vulnerability and life stages Childhood Adolescence Pregnancy Menopause Elderly 100% Spinal pain Prevalence Osteo-arthrosis Osteoporosis Disabling spinal pain 0 % Age Disorder -me course Acute Sub- acute Chronic / persistent 0 2 weeks weeks 3 months + Pain intensity Episodic pain Pain intensity Episodic pain Time Time 6

7 Acute low back pain Traumatic mechanism Es-mate of -ssue damage Context Adap-ve behaviours Nocicep-ve pain Inflammatory pain Management Acute injury management Short period of rest Graded ac-va-on Non-traumatic mechanism Mechanism? Repeated strain Lifestyle factors Psychosocial factors Mal- adap-ve behaviours? Func-onal pain +/- Nocicep-ve pain Management Relaxa-on Assurance Cogni-ve func-onal therapy Mul$- dimensional framework for LBP Time course / life stage Specific LBP Non- specific chronic LBP Red Flags Mechanical pain behaviour Mixed Non- mechanical pain behaviour Pain type nocicep$ve, inflammatory, dysfunc$onal, neuropathic, mixed Psychological factors Social factors Lifestyle factors, comorbidi$es and individual considera$ons Pain related func$onal behaviours adap$ve vs mal- adap$ve - control, movement, loading impairments, pain behaviours, condi$oning, body schema Gene$c / familial factors Low Back Pain diagnosis Chronic Back Pain Disorders Specific Pathology Un- diagnosed LBP Disorders? 7

8 Classification of LBP: red flag pathology Cancer Infection Inflammatory diseases fracture McCullough et al, Radiology 2012 Prevalence of MRI findings in people without back pain: Disc degenera-on 91% Disc height loss 56% Disc bulges 64% Disc protrusion 32% Annular tears 38% Disc Degenera-on and LBP 21yrs) OR: = no DD ç è 4 = severe DD Takatalo ESJ et al

9 Rela-onship between degree of DDD and LBP Cheung et al Spine 2009 Rela-onship between MRI findings pain and disability Radiological imaging for LBP results in: - poorer health outcomes - poor perceived prognosis - more likely to have surgery (Sloan & Walsh 2010) How do we communicate radiological findings? 9

10 The strongest predictor for LBP was depression not MRI findings (2.3x) Annular tears, disc degeneracon and facet joint arthrosis did not predict LBP Disc bulges were associated with a 2.5x lower risk for LBP Jarvick, 2005, Spine 10

11 83% had a complete recovery at 23 months (n=743). Mean ODI improved from 58% to 15%. MRI - 64% reduc-on in disc size. Poor correla-on between ODI and disc resolu-on. Benson et al Orthop 2010 Mul$- dimensional framework for LBP Time course / life stage Specific LBP Non- specific chronic LBP Red Flags Mechanical pain behaviour Mixed Non- mechanical pain behaviour Pain type nocicep$ve, inflammatory, dysfunc$onal, neuropathic, mixed Psychological factors Social factors Lifestyle factors and individual considera$ons General health and co- morbidi$es Pain related func$onal behaviours adap$ve vs mal- adap$ve - control, movement, loading impairments, pain behaviours, condi$oning, body schema Gene$c / familial factors What is pain? An unpleasant sensory and emo-onal experience associated with actual or poten-al -ssue damage, or described in terms of such damage (IASP). The brain Pain responds nociceptor the percep-on ac-va-on of threat 11

12 Pain without pathology No pain with pathology Pain and beliefs Pain influenced by culture and beliefs Woolf J Clin Invest

13 Woolf J Clin Invest 2010 The context? The context? 13

14 Irritable bowel Tension headaches Fibromyalgia CNS pain disorders Woolf J Clin Invest 2010 Central sensi-za-on and persistent spinal pain Increased responsiveness of sensory neurons to normal or sub- threshold input. 14

15 Woolf J Clin Invest 2010 Persistent back pain Mechanical CNSLBP MIXED Non- Mechanical CNSLBP Clear Mechanical Behaviour to Disorder Dispropor-onate response to mechanical stress Clear Anatomical Origin to Disorder NO Clear Anatomical Origin to Disorder Movement hypersensi-vity Linked to posture, loading, movement control, ac-vity, sleep problems, stress Widespread hypersensi-vity to cold Pressure hyperalgesia ñ anxiety, depression, catastrophising stress, sleep problems Persistent back pain Mechanical CNSLBP MIXED Non- Mechanical CNSLBP Clear Mechanical Behaviour to Disorder Dispropor-onate response to mechanical stress Clear Anatomical Origin to Disorder NO Clear Anatomical Origin to Disorder Movement hypersensi-vity Linked to posture, loading, movement control, ac-vity, sleep problems, stress Widespread hypersensi-vity to cold Pressure hyperalgesia ñ anxiety, depression, catastrophising stress, sleep problems 15

16 PPT CPT Pain free Mechanical Non- mechanical Pain free Mechanical Non- mechanical Central group > 15 degrees OR: Ater controlling for depression and sleep O Sullivan et al Man Ther 2014 Pressure hyperalgesia Pressure pain theshold to pressure Compare to other body regions Cold hyperalgesia Apply ice for 5 seconds to back of wrist VAS>5 indicates cold hyperalgesia (>13 ) Allodynia Non- noxious s-mulus = pain response Repeated s-muli = pain summa-on Pain summa$on with repeated movement Repeated s-muli = pain summa-on Summation Summa-on of painof pain - windup (Flexion & Active Extension) (Sullivan et al, Pain 2009) 16

17 Pain memory Chronic back pain pa-ents observing someone liting: experienced pain and ac-va-on of cor-cal areas related to pain and emo-ons (Shimo et al Plos One 2011) Cortical re-organisation with spontaneous LBP altered resting state activation pain matrix reduced endogenous pain inhibition disruptions to sensory motor cortex loss grey matter Moseley Man ther 2008 Wand et al Man Ther 2010 Baliki et al Nat Neurosc 2012 Mul$- dimensional framework for LBP Time course / life stage Specific LBP Non- specific chronic LBP Red Flags Mechanical pain behaviour Mixed Non- mechanical pain behaviour Pain type nocicep$ve, inflammatory, dysfunc$onal, neuropathic, mixed Psychological factors - cogni$ve and emo$onal Social factors Lifestyle factors and individual considera$ons General health and co- morbidi$es Pain related func$onal behaviours adap$ve vs mal- adap$ve - control, movement, loading impairments, pain behaviours, condi$oning, body schema Gene$c / familial factors 17

18 Psychological factors - yellow flags Influences pain and associated behaviors. Psycho- social factors mental health disorders Cogni-ve: - ve beliefs, fear, hyper- vigilance, catastrophising, self efficacy Emo-onal: stress, fear, anxiety, depression, anger Behavioural: avoidance & pain behaviour, poor coping & pacing NegaCve beliefs about LBP, fear of movement, é distress & ê self efficacy are prediccve of disability Influences pain percep-on and func-onal behaviours (Briggs Pain 2010; Costa EJP 2011; Linton Pain 2012) (Sullivan Pain 2009) Nega-ve illness informa-on Your disc is degenerated and you have a weak core I am vulnerable Its dangerous to move.. s Chronic = couple of steps from a wheelchair Instability = liable to pop out not a lot you can do Wear and tear = something's roxng away Barker et al BMC MS

19 Beliefs Emo-onal state Past experience Fear learning Environmental cues Context Zuman et al 2015 Vlaeyen & Linton 2012 Safety? Danger? Meulders et al 2014, 2015 GENERALISATION Fear recall Visualiza-on of painful experiences ac-vates affec$ve and emo$onal brain regions in LBP subjects. Shimo et al, PLOS One, 2011 What underlies avoidance behavior? Avoidance of harm A strategy to control pain High levels of fear is linked to a lack of: Controllability Predictability Pain severity Bunzli (Bunzli et al et 2013 al Clin J Pain 2014) 19

20 Why is a sprained back different to a sprained ankle? The back is like the heart. Too scary to think about when something goes wrong. 32 yr old triathalete Pain catastrophising Fixa-on on pain Magnifica-on of its threat value Adopt a helpless outlook Pa-ents ve beliefs are based on HCP encounters (Sullivan Lin et al BMJ et Open al 2001) 2013 Anxiety, worry and hypervigilance 20

21 Self efficacy "the confidence a person has in their ability to achieve a desired outcome Costa et al 2003 Self efficacy, pain and disability High self efficacy Low self efficacy Costa et al 2003 Pain and coping strategy High Avoidance coping Endurance coping Risk of back pain Low Low Ac-vity High Hasenbring et al Pain

22 Boom bust cycle: le ng pain guide func-on Anxiety Psychological and physiological state characterized by: soma-c emo-onal cogni-ve behavioural responses to situa-ons perceived as uncontrollable May reflect a state or a trait May be linked to panic Characterised by: - Tense, erect postures, - Rapid apical breathing, eyes flickering - Inability to relax - Inability to switch off Fear Pain anxiety Glombiewski et al PAIN

23 Depression - State of low mood May include feelings of sadness, loss, hopelessness, worthlessness, irritability and restlessness. Can affect a person's: Thoughts and feelings low self efficacy, nega-vity Behaviours sleep and inac-vity Physical well- being Characterised by: - Nega-ve affect yes but - Poor sleep - Inac-vity - Poor endogenous pain inhibi-on Stress response = Dysregula$on of the HPA axis 23

24 Distress, behaviours and LBP Tissue sensitivity Stress sensitivity Immune endocrine dysregulation Provoca$ve movement behaviors Altered body perception Provocative health behaviors (Gatchel Psych Bull 2007, Dankeats Spine 2009, Beales 2015, Rabey 2015) Psychological risk profile in primary care (Startback) n= 851 High 28% Low 26% Moderate 48% Ability of clinical experts to iden-fy high risk pa-ents was liele beeer than chance (Hill Clin J Pain Hill et 2009) al 2011 Screening tool... gold standard?? Low score Training is needed Fazio et al 2003; Thorne et al

25 Psycho- social Back pain Psychological Back pain distress Depression: 4x increased risk for future LBP and NP Auvinen et al 2010, Carroll et al 2004, Jarvik et al 2007 Mul$- dimensional framework for LBP Time course / life stage Specific LBP Non- specific chronic LBP Red Flags Mechanical pain behaviour Mixed Non- mechanical pain behaviour Pain type nocicep$ve, inflammatory, dysfunc$onal, neuropathic, mixed Psychological factors Social factors Lifestyle factors and individual considera$ons General health and co- morbidi$es Pain related func$onal behaviours adap$ve vs mal- adap$ve - control, movement, loading impairments, pain behaviours, condi$oning, body schema Gene$c / familial factors Social factors - stressors Influences pain and associated behaviors. Socio- economic status Financial Work Seeking compensa-on Poor family func-oning Life stress events Cultural 25

26 Mul$- dimensional framework for LBP Time course / life stage Specific LBP Non- specific chronic LBP Red Flags Mechanical pain behaviour Mixed Non- mechanical pain behaviour Pain type nocicep$ve, inflammatory, dysfunc$onal, neuropathic, mixed Psychological factors Social factors Lifestyle factors and individual considera$ons General health and co- morbidi$es Pain related func$onal behaviours adap$ve vs mal- adap$ve - control, movement, loading impairments, pain behaviours, condi$oning, body schema Gene$c / familial factors Lifestyle factors, LBP and scia-ca Obesity Sedentary behaviour Sleep deficits > 6 hrs Chronic stress Increased circula-ng cytokines (inflammatory environment) Lower pain thresholds Reduced endogenous pain inhibi-on Immune system changes Bone health Car-lage / IVD / tendon health Auvinen ESJ 2010 Heffner EJP 2011 Egger Obesity 2010 Mul$- dimensional framework for LBP Time course / life stage Specific LBP Non- specific chronic LBP Red Flags Mechanical pain behaviour Mixed Non- mechanical pain behaviour Pain type nocicep$ve, inflammatory, dysfunc$onal, neuropathic, mixed Psychological factors Social factors Lifestyle factors and individual considera$ons General health and co- morbidi$es Pain related func$onal behaviours adap$ve vs mal- adap$ve - control, movement, loading impairments, pain behaviours, condi$oning, body schema Gene$c / familial factors 26

27 Co- morbidi-es with LBP Other pain disorders PGP Headaches Migraine Fibromyalgia Irritable bowel Vulvodynia / Vaginismus Depression Chronic fa-gue Sleep problems BMC MS 2011 NON- MS SYMPTOMS palpita-ons chest pain heart burn breathing difficul-es stomach discomfort diarrhea cons-pa-on eczema -redness dizziness anxiety depression sleep problems Mul$- dimensional framework for LBP Time course / life stage Specific LBP Non- specific chronic LBP Red Flags Mechanical pain behaviour Mixed Non- mechanical pain behaviour Pain type nocicep$ve, inflammatory, dysfunc$onal, neuropathic, mixed Psychological factors Social factors Lifestyle factors and individual considera$ons General health and co- morbidi$es Pain related func$onal behaviours adap$ve vs mal- adap$ve - control, movement, loading impairments, pain behaviours, condi$oning, body percep$on Gene$c / familial factors 27

28 biomechanical factors Physical risk factors for LBP End range strain coupled with: - rota-on / SF / flexion / extension Training volumes Sedentary behaviours Tissue tolerance Altered motor control.linked to sensi-sing factors Adams & Dolan Clin Biom 2005 Hodges et al J Biom 2009 Newlands et al BJSM 2014 Cahalan et al Scand J Med Sci Sports 2015 Bending / liting and LBP Cumula-ve low- back loads are predic-ve of LBP (Coenen et al Occup Environ Med 2014) 28

29 Predictors: Manual tasks heavy, awkward Vigorous physical ac-vity Distracted during liting Mornings Fa-gued / -red + Engaging in physical ac-vity increases risk of back pain if associated with feeling fa-gued or -red (OR 7.7, 95% CI , P 0.001) Stoop vs squat lit which is best? None of the liting techniques was clearly superior.. based on peak shear, flexion, compression forces Kingma et al Clin Biomech 2010 Physical and organisa-onal ergonomic interven-ons were no more effec-ve than no ergonomic interven-on on LBP Mar-mo et al BMJ 2008 Holder L 2013 MSc Thesis 29

30 Training volume and LBP in rowing Newlands et al BJSM 2015 Sagittal postures and spine rotation / side bending Sagittal postures Positions Extension Flexion Neutral Standing * * * Sitting * * * Rota-on is reduced in flexion and extension (BurneE et al MTJ 2006) Side bending is reduced in extension (Ebert et al Man Ther 2014) Functional differences in the spine Thorax vs pelvis Lumbar spine should be considered as 2 func-onal regions Pelvis drives the lower lumbar spine Thorax drives the upper lumbar spine (Mitchell et al BMC MS 2008) 30

31 LBP risk: standing posture sub-groups N=766 Age = 13 years Smith et al Spine % 52% 50% 49% Neutral Sway back Hyper lordosis Flat back Posture influences muscle activation patterns OSullivan et al Spine (2002) Sta-c spine posture predicts dynamic posture (Mitchell et al BMC MS 2008) Posture is a signature on which movement is built 31

32 Forward bending Back muscles Backward bending Back muscles Effect of abdominal bracing on GRF during loading Bracing resulted in greater hip, knee and ankle s-ffness a) vgrf (N) Braced Not braced Campbell et al

33 Motor control strategy depends on task demand MUSCLE CO- ACTIVITION IAP JOINT COMPRESSION & STABILITY COMPROMISE TO RESPIRATION & CONTINENCE TASK (STABILITY) DEMAND Motor control reflects the nervous systems response to pain, threat, emo-on, pathology, lifestyle, environment and task demand It is highly variable May be adaptive or mal-adaptive What is an adap-ve func-onal behaviour? To perform a task in a manner that results in protection of the M/S system in order to reduce pain and disability What is a mal- adap-ve func-onal behaviour? To perform a task in a manner that results in provocation of pain and disability 33

34 What hurts? Directional pain responses Centralisa-on vs peripheralisa-on Pain provoking vs pain relieving Long et al 2005 Dankaerts Spine 2009 Rabey et al 2015 Subgrouping pain responses (>2 NPRS) following repeated movement (CLBP n=294) Group 1 (49%) Group 2 (28%) Group 3 (10%) Group 4 (13%) é Disability é Catastrophising Slower movement é Pain ê PPT ê CPT é Depression ê Self efficacy Pain ameliora-on only observed in 20% of group 2 and 3 All groups reported é fear and é body percep-on distor-on Rabey et al

35 Motor control paeerns.linked to direc-onal provoca-on Flexion Active extension Passive extension Lateral Multi-directional O Sullivan MTJ 2000 Flexion pattern - pain in provoked in flexion/rotation activities and postures - pain eased with reducing flexion loading Posterior pelvic rotation +/- thoracic extension and abdominal bracing Active extension pattern - pain provoked in extension postures (sit / stand / sustained bend) & activities ( sit stand / bending / lifting) Anterior pelvic rotation Back and abdominal wall activation 35

36 Usual Sitting Flexion Degrees Extension Sacral angle Lx C Lower LxC Upper LxC TxC No-LBP Flexion Pattern Active Extension Dankaerts et al Spine 2006 Lumbar multifidus flexion relaxation Usual versus Slumped Sitting semg activity (%submvic) usual slumped Active Extension Pattern no-lbp Flexion Pattern end of range forward bending 20! Forward Bending Q4! Lower Lumbar Lordosis (in degr.)! 15! 10! 5! 0! -5! -10! -15! 8.4! * 6.1! -6.6! -20! -25! NS-CLBP! control Flexion Pattern! Active Extension! control (Flexion & Active Extension) Dankaerts

37 semg of forward bending and return to upright 2.5 LM 3 ICLT %Sub-MVIC Stage of FBRFB task 3 TES No local vs global muscle system differences non- LBP 1.5 AEP 1 FP 0.5 Both movement classifica-on and fear were Dankaerts et al 2011 independently predic-ve of loss of FRP in LM Subgrouping pain related movement behaviours control (Flexion & Active Extension) Sta-s-cal model could accurately classify 96.4% based on EMG (loss of FRR of LM) and lumbar posture and movement Dankaerts et al Spine 2009 Reposi-oning sense: altered body percep-on Sheeran et al Spine

38 Passive extension pattern - pain provoked in extension postures (standing) & activities backward bending and over head activities - maybe associated with multi-directional pain patterns Thoracic flexion Upper abdominal bracing and postural sway Variable pelvic control Lateral control pattern - uni-lateral pain provocation during postures (sit / stand / SLS) & movements involving unilateral loading (usually on side of shift / side bending) - avoidance of loading painful side Thoraco-lumbar lateral shift Trendelenberg pattern +/- extension pattern LBP in tennis players - sensi-sed to extension / side bending - lateral forces (8x greater than running) with combined E, SF, R + lumbar spine s-ffness - associated with pars stress # and LBP Campbell et al MSSE (2013) 38

39 LBP in fast bowlers Ranson et al 2008 LBP associated with stress # (Ranson 2008) Multi-directional pattern Multi-directional pain disorder Variable patterns in different movement directions 39

40 Patterns may be associated with spinal movement impairments Spinal movement impairment in direction of pain Active and passive movement impairment Linked to muscle guarding Belief that pain = harm No movement impairment Flexion movement impairment Direc-onal movement impairments Lumbar flexion Lumbar extension Lateral bending Loading pattern - pain sensitivity related to loading static and dynamic - Maybe related to motor control pattern - Maybe linked to excessive co-contraction of trunk muscles Pain provocation: Excessive trunk muscle co-contraction 40

41 Deconditioning Linked to avoidance and sedentary behaviours Leg weakness results in increase trunk muscle co-contraction Back muscle weakness leads to increased spinal loading Gluteal weakness Popovich et al MSSE 2011 Pain and protective behaviours Slow movement Grimacing Moaning Propping with hands Breath holding Touching and holding Braces / sticks Limping Sullivan et al Pain

42 Autonomic arousal Rapid apical breathing Hyperven-la-on +/- panic Flickering eye lids, tremor Swea-ng Muscle tension / erect postures Inability to relax / switch off Linked to anxiety Body and mind rela-onship Trunk muscle EMG Danakerts et al 2009 Lewis et al 2012 Pain Disability Depression Anxiety Catastrophising Fear ê self efficacy Altered body percep-on Here is a drawing of how my leg felt. Drawing it brought a lot of pain to the leg. The visualisacon exercises reduce it. 30 year old male My leg feels all screwed up 26 year old female Discrepencies between the real and virtual body may be a mechanism for pain and movement dysfunc-on (Wand MTJ 2012) Associated with higher levels of distress (Rabey et al 2015) 42

43 Mul$- dimensional framework for LBP Time course / life stage Specific LBP Non- specific chronic LBP Red Flags Mechanical pain behaviour Mixed Non- mechanical pain behaviour Pain type nocicep$ve, inflammatory, dysfunc$onal, neuropathic, mixed Psychological factors Social factors Lifestyle factors and individual considera$ons General health and co- morbidi$es Pain related func$onal behaviours adap$ve vs mal- adap$ve - control, movement, loading impairments, pain behaviours, condi$oning, body schema Gene$c / familial factors Twin studies (Battie 2009) (ADRB2) OR: 2.5 Gene-cs Environment stress Anxiety Depressed mood HPA axis stress sensi-vity sleep disturbance Spinal Pain at 17 years Skouen et al EPJ 2011 Hocking et al EPJ

44 Predictors of disabling LBP in student nurses Mitchell et al, Clin J Pain 2009 Slump si ng ê BME é Physical ac-vity 11% 8% 5% 6% 9% 6% é Repositioning accuracy Un-accounted History LBP Stress (modifiable vs non- modifiable) Cogni$ve factors - beliefs, fear, catastrophising, vigilance, self efficacy, coping Emo$onal factors - stress, anxiety, depressed mood, anger, grief Social factors culture, life stress events and context, family, work, financial, educa-on levels Gene$c / epigene$c factors Tissue structure Psychological Pain processing / sensi-vity Health comorbidi-es Gender interac-ons Life stages Adolescence Pregnancy Menopause Elderly System changes Central, peripheral and autonomic nervous system Neuro- endocrine- immune Sensori- motor system Tissue structure Physical factors - func-onal behaviours, condi-oning, physical loading, ergonomics Lifestyle factors - sleep, ac-vity levels, sedentary behaviours, diet, smoking Low back pain +/- comorbidi$es BEHAVIOURAL RESPONSE TO PAIN adap$ve vs maladap$ve (modifiable vs non- modifiable) Response to pain Panic, fear of damage, failed treatments, - ve health informa-on - ve beliefs, stress response, vigilance, low self efficacy Central sensi-sa-on Neuro- physiological changes Pain amplifica-on Altered body schema Muscle guarding Sensi-sa-on Context Life stress ++, lack of sleep, anxiety ê self efficacy Behaviours Mal- adap-ve Secondary sensi-sa-on 2nd to sustained peripheral and central drive Nocicep-on 44

45 .. life on hold - Lack of clear understanding of pain mechanisms - Lack of pain control - Lack of pain self efficacy (Bunzli et al CJP 2012) Mul$- dimensional approach to understand LBP Stage: acute, subacute, recurrent, persistent Specific LBP Non- specific chronic LBP Red Flags 1 Mechanical pain characteris$cs Mixed Non- mechanical pain characteris$cs 2 3 Pain type nocicep$ve, inflammatory, dysfunc$onal, neuropathic, mixed Cogni$ve and psychological factors Social factors 4 Lifestyle factors and individual considera$ons General health and co- morbidi$es 5 6 Pain related func$onal behaviours mal- adap$ve pain behaviours, ac$ve extension control impairment, decondi$oned Targeted management for NS- CLBP Mul-- dimensional approach - neurophysiological, physical, lifestyle and psychosocial Person centered Targets modifiable pain mechanisms and behaviours 45

46 Clinical encounter Total combined treatment effect + Non- specific effects of the clinical encounter specific effects of the treatment Pa-ents value the quality of communica-on Lin Bolton Forming a rela-onship is the key listen to the story pa-ent centred empathy - understand the pa-ents concerns, beliefs, fears, mo-va-ons, goals, values, goals mirroring reflec-ve ques-oning roll with resistance iden-fy discrepancies reinforce posi-ve behaviours acknowledging summarise We are usually convinced more easily by reasons we have found ourselves than by those which we have been told. (Pascal) You need to be less fearful and get ac-ve! What do you think You could you do to get ac-ve? The power of reflec-ve ques-oning and behavioral experiments 46

47 Language that harms negative language and beliefs may create fear and catastrophising undue focus on structure belief that pain = harm belief that activity is harmful your back / pelvis is unstable your pelvis is out of place your disc is crumbling you have the back of an 80 year old your posture is terrible your muscles don t work its dangerous to lij Pa-ents need empowering not crushing!! The story Examination process Physical examination Pain history The context Pain area Pain behaviour Pain stage Level of disability Coping strategies Beliefs, values Psycho-social factors Lifestyle factors Goal setting Screening / radiology Examine sensory profile to movement and palpation Analyze functional behaviours Identify adaptive from maladaptive Examine relationship between beliefs, radiology, pain and movement behaviours Behavioral experiments ability to modify behaviours pain controllability Identify factors that mediate pain disorder 47

48 A cogni-ve func-onal approach to managing disabling back pain Peter O Sullivan ed.com TwiEer: peteosullivanpt BODYLOGIC P H Y S I O T H E R A P Y Only In America Changing behavior? You cant change beliefs until you change behaviour (Linton 2006) Changing pain / movement behaviour Cognitive Functional therapy 1

49 Cogni-ve func-onal Therapy O Sullivan MT 2005,JOSPT 2012 Biopsychosocial understanding Changing mindset Hypothesised mechanism: Pain control via behavioral and cognitive change In Old the way context New of way a strong Func-onal therapeutic integra-on alliance Lifestyle changes Therapeu-c alliance CFT interven-on Your disc is damaged and you need to avoid liuing My back is stuffed and he isn t listening to me.. s I hope I don t get a stuffed back.. s If you can t communicate it doesn t ma2er what you know Chris Gardner,

50 1. Understanding pain changing mind- set explain vicious cycle of pain change beliefs / thoughts / responses to pain Reassurance reducing threat goal se\ng behavioural change Challenging beliefs. (Briggs et al 2010; O Sullivan et al 2013, Smith et al 2010) Language that helps positive language and beliefs simple language / metaphors reduce fear and catastrophising promote hope and confidence bio-psycho-social focus belief that pain harm belief that activity is helpful a back strain like an ankle poor rela;onship between structure, pain and disability central nervous system like amplifier focus on normalising behaviours the back is strong! Pa-ents need empowering not crushing!! 3

51 Metaphors for peripheral sensi-sa-on Metaphors for central sensi-sa-on Posi-ve affirma-ons Pain doesn t = harm I can trust my back If it hurts. relax and move normally Its safe to bend My back is strong Mo-on is lo-on 4

52 Challenging beliefs. When to roll with resistance? We are usually more easily convinced by the reasons we have found ourselves than by those told to us.(pascal) You need to be less fearful and get ac-ve! What do you think you could you do to get ac-ve? The power of reflec-ve ques-oning mo-va-onal interviewing McCullough et al, Radiology

53 Individualised understanding of pain 2. Target func-onal behaviours behavioural experiments to reduce and /or control pain breathing / relaxa-on / mindfulness normalise faulty movement paeerns break into component parts (developmental sequence) enhance body awareness discourage pain behaviours target ac-vi-es that hurt or are feared - feedback+++ NO ISOLATED MUSCLE TRAINING Key points of control: head, thorax, pelvis, breathing MANUAL THERAPY USED IN MOVEMENT IMPAIRMENT GROUP Old way New way Movement training Keep it simple and basic Relearning the building blocks of movement Posture is like a signature on which movement is built 6

54 Changing beliefs through behavior change Iden-fy mal- adap-ve behavior linked to belief ( its dangerous to bend ) Mirror behavior to pa-ent Normalise the behavior to reduce pain Iden-fy discrepancy between belief and experience Reflect back New understanding of pain Reinforce new adap-ve behaviors Enhance pain coping and self efficacy Change belief ( bending isn t dangerous ) 7

55 Old way new way Flexion Ac-ve extension Lateral shiu Mul-- direc-onal 8

56 Autonomic arousal / non-mechanical pain Relaxed postures Slow relaxed belly breathing (via nose) Relax face & hands Modula-on of sympathe-c arousal and pain percep-on. - +/- ñ pain body thresholds scan / reduced breath skin into conduc-on pain (based on response) - Integrate reduc-ons in with nega-ve movement feelings (tension, anger, and depression) Busch et al Pain Med 2012 Over riding fear Awareness / understanding / therapist confidence Controllability of pain breathing, relaxa-on, +ve thoughts Graded exposure training Confidence / self efficacy building Change response to pain Extinguishing pain behaviors: responding differently to pain Draw aeen-on to them awareness Reflect on how they may be unhelpful Introduce the new way relaxa-on / aboli-on +ve reinforcement Become vigilant to the behaviors rather than the pain 9

57 Func-onal integra-on normalise movement behaviours integrate new movement skills to func-onal impairments graduated exposure into daily life reduce the threat of movement condi-oning where indicated Feedback Trigger Low back pain Bio- psycho- social profile MINDSET CHANGE DON T PANIC +ve thoughts My back is strong Movement is good Pain damage s Healthy movement & lifestyle behaviours 10

58 Ac-ve extension + flexion MI Ac-ve extension paeern Lateral paeern 11

59 Flexion paeern Study sample Bergen, Norway (Fersum et al 2013 EPJ Private physio prac-ces N=36 GPs N=9 Spine clinics N=57 Newspaper add N=67 Telephone screening Examina-on N=169 Aggravated with specific postures and movements 3 months + VAS > 3 / ODI > 14% Classifica-on N=169 1 Specific low back pain 9.3% Non specific low back pain 90.6% 2 Non- mechanical pain behaviour 0% Mechanical pain behaviour 100% 3 Pelvic Pain Low back pain 7.5% 92.5% 4 Control impairment Movement impairment 87% 5.5% 5 Direc-onal subgroups Direc-onal subgroups cogni-ve / psychosocial factors 32.2% 12

60 Flowchart RCT study Recruitment / Referal /Inclusion Newspaper add Physio clinis Medical centres Back and Neck clinic Haukeland University hospital Hospital at Hagavik Telephone screening Tes-ng/classifica-on Exclusion N=48 Inclusion N=121 Withdrawn N=9 Randomisa-on Treatment N=112 Cogni-ve Func-onal Therapy Manual Therapy/Exercise Baseline characteris-cs CB-CFT (n=51) MT-EX (n=43) Female n (%) 27 (52.9%) 21 (48.8%) Mean (SD) CB-CFT MT-EX Age (years) 41.0 (10.3) 42.9(12.5) Pain duration (years) 12.0 (11.0) 8.9 (7.9) Oswestry (0-100) 21.3 (7.5) 24.1 (8.0) Pain intensity (PNRS) (0-10) 4.9 (2.0) 5.3 (1.9) Pain episodes (PNRS) (0-10) 6.4 (2.1) 7.1 (2.6) HSCL * 1.4 (0.3) 1.6 (0.4) FABQ - physical (0-24) 11.2 (3.9) 11.7 (5.0) FABQ - work (0-42) * 14.2 (9.8) 19.2 (11.3) Ørebro 80.5 (19.5) 89.8 (20.9) kjartan.fersum@isf.uib.no * Sign lower in CFT group Interven-ons Cogni-ve Func-onal Therapy 2 manual therapists and 1 physiotherapist Cogni-ve behavioural principles CFT individualized according to classifica-on 1. Cogni-ve model 2. Specific movement based exercise 3. Func-onal integra-on 4. Cardiovascular fitness Manual Therapy/Exercise 3 experienced manual therapists Cogni-ve behavioural principles Individualised treatment from the therapists clinical decision included: 1. Educa-on 2. Manipula-ve therapy 3. Stabilising exercises 4. General exercise Treatments: 7.7 (2.7) Treatments: 7.7 (3.1) 13

61 Vibe Fersum et al 2013 Cogni-ve Func-onal Therapy Manual Therapy/Exercise 12 weeks interven-on N= weeks interven-on N= 43 Drop out N=18 Retest N= 51 Retest N= 43 Drop out N=3 A linear mixed 15 month model follow- up was used to es-mate 15 month group follow- up differences N= 51 N= 40 in treatment effect and also in change in outcome from 3 (post interven-on) and 12- month follow- up. Treatments (mean- SD): 7.7 (2.7) Treatments (mean SD): 7.7 (3.1) Disability - Oswestry Cogni-ve Func-onal Therapy Manual Therapy Pre Post 15 months post P=0.164 P<0.000 P<0.000 Minimally Important Change Disability at 15 months (> 10 point change in func-on - ODI) 63% Cogni-ve Func-onal Therapy Manual Therapy 31% Ostelo et al

62 Pain intensity Cogni-ve Func-onal Therapy Manual Therapy Pre Post 15 months post P=0.417 P <0.000 P<0.000 Minimally Important Change Pain at 15 months (> 1.5 on pain on VAS) 74% 41% Cogni-ve Func-onal Therapy Manual Therapy Ostelo et al 2008 CFT 3x - no days off work last 12 months Completely sa-sfied at 12 months: CB- CFT - 96% 12 mths (OR: 5) MT/EX - 46% 15

63 Disability - ODI Cogni-ve Func-onal Therapy Manual Therapy Pre Post 12 months post P=0.164 P<0.000 P< months post P< CB- CFT for disabling LBP on pain clinic wait list K O Sullivan et al * * * * ODI (%) Disability Control period 3 months Interven-on 12 weeks Follow- up 3 months Follow- up 6 months Follow- up 12 months 8 NRS (/10) * * * * Pain intensity Control period 3 months Interven-on 12 weeks Follow- up 3 months Follow- up 6 months Follow- up 12 months 16

64 Pa-ent pathways Retain biomedical beliefs Acceptance of biopsychosocial model Achieving Independence ê Control over pain ê Func-on Control over pain Return to normal non- responders responders Bunzli et al 2015 Where to next? Understand mediators of change/ barriers to recovery? Training required? Implementa-on? Replica-on? Cost benefits? Outcome valida-on Laboratory valida-on Clinical valida-on Hypothesized approach 17

65 Limita-ons of CFT Time constraints Level of training required Readiness for change Therapist mindset The research team Anne Smith Leon Straker Kieran O Sullivan Wim Dankaerts Kjartan Fersum Helen Slater Darren Beales JP Caneiro Ivan Lin Sam Bunzli Amity Campbell Leo Ng Angus BurneE Tim Mitchell Alice Kvåle Sture Skouen Mary O Keefe Ian Cowell Rob Waller Kasper Ussing Mar-n Rabey 18

66 Patient ID: Therapist ID: Date: Based on the examination please complete this clinical reasoning form to rate the contribution of different factors associated with the patient s disorder 1. What is the time course of the disorder? Acute Sub-acute Recurrent Persistent 2. Was the onset of the disorder related to a significant traumatic injury? Yes No 3. What is the progression of the disorder? Improving Stable Deteriorating 4. Are there any indicators of Red flag pathology? Yes No Specify: 5. Is the disorder Specific or Non-Specific LBP? Specific LBP (Radiological findings, which correlate with and is considered to be a primary driver of clinical presentation (e.g. disc prolapse, modic changes etc.) If specific LBP specify: Place a vertical line on the line below to rate the relative contribution of the specified pathology to the pain disorder? Small contribution Large contribution Non-Specific LBP (Radiological findings are NOT considered to be a primary driver of clinical presentation) Specify:

67 6. Is the pain area localised (to a small region) or widespread (across a broad region or regions)? Localised Widespread 7. Place a vertical line on the line below to rate the relative contribution of proportionate versus non-proportionate pain responses to mechanical load Proportionate pain responses Non-proportionate pain responses 8. Is the disorder associated with tissue hypersensitivity? Yes No If yes is it: Widespread Localised 9. Are body perception distortions (such as misrepresentation of body region, structure, posture or movement that is out of context with real body) present? Yes No Specify: 10. Do cognitive factors contribute to the pain disorder? Yes No Place a vertical line on the line below to rate the relative contribution of cognitive factors (e.g. beliefs regarding scans, physical factors and hurt v harm; treatment expectations; fear; self-efficacy; catastrophising; coping; hypervigilance etc.) to the pain disorder. Low High Specify:

68 11. Do emotional factors (levels of distress) contribute to the pain disorder? Yes No Place a vertical line on the line below to rate the relative contribution of emotional / affective factors (e.g. stress sensitivity, distress, anxiety, depression, anger, etc.) to the pain disorder Low High Specify: 12. Do social factors contribute to the pain disorder? Yes No Place a vertical line on the line below to rate the relative contribution of social factors to the pain disorder (e.g. life stress events and context, socio-economic factors, work related issues, support structure, culture etc.) Low High Specify: 13. Do lifestyle factors contribute to the pain disorder? Yes No Place a vertical line on the line below to rate the relative contribution of lifestyle & individual to the pain disorder (e.g. sleep deficit / hygiene, activity and sedentary levels, smoking etc) Low High Specify: 14. Do comorbidities contribute to the pain disorder? Yes No Place a vertical line on the line below to rate the relative contribution of comorbidities to the pain disorder (e.g. diagnosed sleep disorder, obesity, respiratory disorders, heart disease, diabetes, fatigue, irritable bowel syndrome, or other pain disorders) Low High Specify:

69 15. Are physical loading demands related to the pain disorder? Yes No Place a vertical line on the line below to rate the relative contribution of physical loading demands to the pain disorder (e.g. occupational and sport related loading) Low High Specify: 16. Is the pain disorder associated with significant physical behaviours? Yes No Are these behaviors adaptive or maladaptive? Adaptive Maladaptive Does the person present with high levels of autonomic arousal (eg. sweating, rapid apical breathing, agitation)? Yes No Specify Is the disorder provoked by: 1. Spinal movement? Yes No If yes what movement direction/s are provocative? Specify: What motor control strategies are demonstrated? (Flexion, active extension, passive extension and/or lateral control): Specify: Are spinal movement impairments associated with the disorder in the region of pain and in the direction of pain provocation Yes No Specify:

70 2. Spinal loading? Yes No Specify: 3. Deconditioning Yes No Specify: 4. Pain behaviours (communicative and protective) Yes No Specify: Are the behaviors identified during the examination modifiable? No at all Completely Is the pain during the examination controllable? No at all Completely 17. State the primary goals based on collaboration between therapist and patient Max of three