1/26/16 TREATMENT MONITORING. Treatment Monitoring. Psychologically Informed Physical Therapy Practice: Pragmatic Application for Low Back Pain

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1 1/26/16 Treatment Monitoring Jason Beneciuk, PT, PhD, MPH Research Assistant Professor University of Florida Brooks Rehabilitation PHHP Research Collaboration Psychologically Informed Physical Therapy Practice: Pragmatic Application for Low Back Pain Jason Beneciuk, PT, PhD Research Assistant Professor, University of Florida; Brooks Rehabilitation PHHP Research Collaboration Carol M. Greco, PhD Assistant Professor of Psychiatry Licensed Psychologist University of Pittsburgh School of Medicine Steven George, PT, PhD Associate Professor DPT Program Director, University of Florida; Brooks Rehabilitation PHHP Research Collaboration Learning Module TREATMENT MONITORING 1

2 Treatment Monitoring Initial assessment findings are likely to change early during an episode of care Initial Assessment Clinical Reasoning? Support for ongoing treatment monitoring process Dunn & Croft, 2006; Hayden, et al. 2010; Van der Windt, et al Treatment Monitoring Do changes inform clinical reasoning? Initial assessment Early during episode of care Later during episode of care Treatment Mediator (baseline factor level needs to change after treatment to influence outcome) Treatment Pain related fear Outcome Decreased Fear ~ Good Outcome Treatment Mediator (baseline factor level needs to change after treatment to influence outcome) Treatment Pain related fear Outcome Increased Fear ~ Poor Outcome 2

3 Outcomes Measures Numerical Pain Rating Scale (NPRS) MCID: 2 points (Childs, et al. 2005) 30% improvement from baseline (Ostelo, et al. 2008) Oswestry Disability Index (ODI) MCID: 10 percentage points (Ostelo, et al. 2008) 30% improvement from baseline (Ostelo, et al. 2008) Treatment Monitoring Process Initial Assessment STarT Back Tool Follow-up Assessment Options Self-selected unidimensional measures OSPRO-YF Assessment Tool Re-administer STarT Back Tool OPTION #1 3

4 Option #1 Is patient still high risk? Has patient changed from high to medium or low risk? Purpose: Describe changes in SBT categorization following 4-weeks of physical therapy and to evaluate predictive capabilities of SBT categorization when administered at multiple time points Disability Change Patterns Intake SBT Risk SBT Risk Change Pattern 4

5 Clinical Implications Repeated SBT assessment has potential to provide additional prognostic information for 6-month disability Provides follow-up SBT risk status information Administer self-selected unidimensional psychological measures OPTION #2 Option #2 Would require baseline (or near baseline) initial assessment to if changes are observed Useful to detect changes in specific psychological constructs (eg, pain catastrophizing) Treatment Mediator (baseline factor level needs to change after treatment to influence outcome) Treatment Pain catastrophizing Outcome 5

6 Unidimensional Psychological Measures Useful to identify specific treatment targets Changes scores for treatment monitoring Examples FABQ PCS TSK-11 PHQ-9 Administer OSPRO-YF Assessment Tool OPTION #3 OSPRO Yellow Flag Assessment Tool Orthopaedic Physical Therapy Investigative Network (OPT-IN) Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort Study 6

7 OSPRO Yellow Flag Assessment Tool Multiple psychological constructs Negative mood Fear avoidance Positive affect / coping Negative mood Patient Health Questionnaire (PHQ-9) State-Trait Anxiety Inventory (STAI-T) State-Trait Anger Expression Inventory (STAXI) Fear avoidance Fear Avoidance Beliefs Questionnaire (FABQ-PA) (FABQ-W) Pain Catastrophizing Scale (PCS) Tampa Scale of Kinesiophobia (TSK-11) Pain Anxiety Symptoms Scale (PASS-20) 7

8 Positive affect / coping Pain Self-Efficacy Questionnaire (PSEQ) Self-Efficacy for Rehabilitation Outcome Scale (SER) Chronic Pain Acceptance Questionnaire (CPAQ) Development of a Yellow Flag Assessment Tool for Orthopaedic Physical Therapists: Results from the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort OSPRO-YF provides estimate for individual psychological measure scores (upper/lower quartile) 17, 10, and 7 item versions 85%, 81%, and 75% accuracy Scoring algorithms provided Trevor A. Lentz, PT, SCS Jason M. Beneciuk, PT, PhD, MPH Joel E. Bialosky, PT, PhD Giorgio Zeppieri, Jr. PT, MPT, SCS Yunfeng Dai, MS Samuel S. Wu PhD Steven Z. George, PT, PhD Manuscript in press Important to communicate this information with patients 8

9 Treatment Monitoring Suggestions 1. STarT Back Tool Changes from high risk status 2. Unidimensional psychological measures Change scores Requires baseline assessment 3. OSPRO-YF Assessment Tool Upper/lower quartiles Requires baseline assessment THANK YOU Brooks- PHHP Research Collabora2on 9