1 Overview of CRISP® Clinical Reasoning in Spine PainJohn Ventura, DC, DABCO NQF, musculoskeletal committee USBJI, board member CMS, technical expert panel University of Rochester, School of Medicine

2 Disclosures/COI Spine Care Partners, LLCPrimary Spine Provider Network, LLC Member of ACA, NYSCA, APHA, NASS National Quality Forum, musculoskeletal committee United States Bone and Joint Initiative, board Center for Medicare/Medicaid Services, technical expert panel for Physician Quality Reporting System 30 yrs in full time clinical practice 17 yrs clinical instructor family medicine University of Rochester School of Medicine 16 yrs clinical instructor New York Chiropractic College 4 yrs assistant clinical professor D’Youville College I did practice full time for 30 yrs, 2 yrs as associate, 6 yrs as solo practitioner and 22 yrs as partner in multi-doctor practice with multiple locations. I also taught part time for most of my career: I spent 17 yrs as clinical instructor in department of family medicine at U of R school of medicine, and 16 yrs as assistant clinical professor at NYCC, and I’ve taught for the post grad program of NUHS; But life isn’t only about what you do, but more about your relationships: I’m also the happy husband of a beautiful school teacher turned real estate agent and proud father to a son and daughter, proud step father to two daughters and the elated and exuberant papa to 5 grandchildren: 4 girls and a boy.

3 “The only purpose of the physician is to amuse the patient while nature cures the disease” VoltaireLet’s assume that Voltaire isn’t completely accurate and there are some things that we can do as primary spine practitioners to enhance and expedite the healing process for spine related disorders; Did you catch the “where’s waldo” in the photo? In this case it’s ‘where’s Mia’?

4 Learn to be Comfortable with Uncertainty“Discomfort with uncertainty…result(s) in a tendency to seek quick answers and dogmatic clinical approaches” The other possibility is that discomfort with uncertainty leads to inaction, unwillingness to do what might be in the best interest of the patient; Slade SC, et al. The dilemma of diagnostic uncertainty when treating people with chronic low back pain: a qualitative study. Clin Rehabil 2012;26(6): Timmermans S, Angell A. Evidence-based medicine, clinical uncertainty and learning to doctor. J Health Soc Behav 2001; 42: 342–359.

5 Much of Primary Spine Care Occurs in the Gray Areas!You need to become comfortable with uncertainty

6 The Diagnostic BalancePatient wants a clear explanation SRDs are a clinical diagnosis but no definite diagnostic test Language is exceedingly important; we will repeatedly come back to this idea;

7 What are the best treatment for spine related disorders??How many of you are familiar with spinal decompression? If you build a traction table that looks like this you can charge substantially more; The real challenge is in subgrouping the patients for each treatment approach – and that is the goal of CRISP;

8 What about the scientific literature?Doesn’t that provide the answers??

9 100’s of Randomized Controlled Trials Many meta-analyses Many systematic reviews of RCTs Systematic reviews of systematic reviews A systematic review is a thorough, comprehensive, and explicit way of interrogating the medical literature. It typically involves several steps, including (1) asking an answerable question (often the most difficult step), (2) identifying one or more databases to search, (3) developing an explicit search strategy, (4) selecting titles, abstracts, and manuscripts based on explicit inclusion and exclusion criteria, and (5) abstracting data in a standardized format. A "meta-analysis" is a statistical approach to combine the data derived from a systematic-review. Therefore, every meta-analysis should be based on an underlying systematic review, but not every systematic review leads to a meta-analysis.

10 What does the research tell us?

11 “nothing really helps very much”(Collective groan from the audience)

12 Traditional Approach to Research on Spinal PainBased on the treatment-outcome model Out- comes Treatment Because of this notion that we cannot diagnose spinal pain, we’re left with applying the treatment du jour, and monitor outcomes; which helps but what we’ll see is that nothing appears to be any better than anything else; there is no subgrouping;

13 “Statistical Relevance” K. Spratt, Ph.D.Out- comes Treatment Assessment Diagnosis Kevn Spratt studied MCID minimal clinically important difference (MCID) One of the consequence of restricting our thinking and topic to “treatment”, we also tend to restrict our research strategies to RCTs that measure outcomes for various treatments set in competition with one another. However, let me draw your attention to a chapter: 3 links (the type and quality of the assessment; does it lead to a reliable diagnosis or subgroup, is there one or more treatments that appear to successfully address that diagnosis, which treatment is most efficacious? Set up the chest pain RCT The ADTO Model Courtesy Ron Donelson, MD

14 Are the small benefits worth the additional costs?Esophageal Pain Cardiac Pain Chest Pain Nothing Anti-acids NTG Outcome Measures 20% Improved 25% Improved When the diagnosis is too heterogeneous, treatment results get washed out; 10% Improved 80% Improved 80% Improved 10% Improved Are the small benefits worth the additional costs? Courtesy Ron Donelson, MD

15 What about “subgrouping” for spine?Pain, disability and suffering experience of each individual patient

16 There are 7,125,000,000 subgroups! I remember being very close to graduation and sitting down with a trusted advisor, and revealing my darkest secret – I didn’t have a clue how to decide where to adjust somebody; I didn’t trust my palpation skills, either static or motion, orthopedic tests in isolation seemed confusing at best and useless at worst (which subsequent research actually bore out), we didn’t seem to address the psychogical issues at all, I wasn’t certain how to determine if the lesion was corrected other than to ask if they felt better, which according to practice management is the kiss of death! The answer: “it depends’ which wasn’t the answer I was looking for; I wanted to know, it depends on what, and how did each variable influence the situation? Shortly after starting practice I had the opportunity to spend a few hours in the practice of a highly respected DC who had embraced the cartesian orthogonal system of identifying the ‘fixation’ or joint restriction – the vertebra is fixated in + theta Y, - theta X, - theta Z (each axis of a 3 dimensional model, then the adjustment attempted to apply those vectors of force in the treatment; I was borderline suicidal now; I was valedictorian of my class and I felt like the most inept chiropractor on the planet;

17 So What’s a Doc to Do? Somatic Neurophysiological Social Psychological

18 CRISP® : Applying the BPS Model CRISP® : Applying the ADTO Modeland T O CRISP is clinical reasoning in spine pain; The initial title, from the publications was Diagnosis Based Clinicial Decision Rule, but clinical reasoning is more broad term; A D

19 The Challenge of Spinal DiagnosisSpinal pain is multifactorial Factors relate to various dimensions (somatic, neurophysiological, psychological, social) Most factors have no objective test Scott haldeman in the 1980s gave a presidential address to North American Spine Society entitled, The Failure of the pathoantomical model to define back pain; How many of you are old enough to remember the Quebec Task Force on LBP back in the 1980s? They attempted a classification system combining historical and clinical findings; in the PT field today we have Julie fritz and chiropractor Jeff Hebert researching Clinical Prediction Rules; typically very specific but lack sensitivity;

20 General Considerations in Spine CareBefore we talk more about CRISP, let’s lay some additional background to frame how we look at spine pain;

21 Basic statistics Reliability ValidityKappa (K): based upon paired observations Intraclass correlation (ICC): based upon groups Validity Sensitivity specificity

22 Interpretation of Kappa: Measure of Reliability reliability after chance has been removed Kappa Agreement < 0 Less than chance agreement 0.01–0.20 Slight agreement 0.21– 0.40 Fair agreement 0.41–0.60 Moderate agreement 0.61–0.80 Substantial agreement 0.81–0.99 Almost perfect agreement Kappa is used for nominal scales and ordinal scales (nominal is more like yes/no scales-neck pain yes or no, ordinal is units but interval between is arbitrary- muscle strength) ICC is used for interval scales such as temperature or NMS;

23 Sensitivity and Specificity: validitySnNout True Positives Eg. ESR for inflammation Specificity SpPin True Negatives Well Leg Raise for radiculopathy in L.E. Please remember that the converse is not true – if a sensitive test is positive, it doesn’t really help you much; if a specific test is negative, it doesn’t help you much

24 SENSITIVE TEST

25 SPECIFIC TEST

26 Is the change clinically meaningful?30% MCID Minimally Clinically Important Difference Most research now suggests that you need to see a 30% change in the score to be clinically meaningful; The IMMPACT group really helped to establish this 30% measurement as the standard for CMMI Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials Dworkin RH,, et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain 2005;113:9–19. Gatchel RJ, et al. Validation of a consensus-based minimal clinically important difference (MCID) threshold using an objective functional external anchor. Spine J 2013;13(8):

27 What is meaningful to the patient?What do you most want to return to that you are unable to because of your condition? Cost (direct and indirect) Does the provider care? Bogduk is credited with developing a questionnaire about identification of most meaningful items (“what would you most dearly”) to patient; Patients are also quite concerned with costs (mostly direct but somewhat indirect)

28 “doctors are from mars and patients are from venus”3 most important attributes of DR: - caring attitude, explains things so easy to understand, takes the time to listen - diagnostic ability, years in practice, attended a well known college Guess which of the two patients reported? Showing your patients that you care is perhaps the most important malpractice protection you can get, other than signing with NCMIC;

29 ‘Patients don’t care how much you know, until they know how much you care’

30 Anti-inflammatory Diet

31 General Principles ?Inflammatory triggers NSS Inadequate sleep StressSugar, white flour Refined oils(corn, seed, soy)-linoleic acid Farm raised fish, cattle, poultry  pro-inflammatory, insulin resistance Metabolic Syndrome Abdominal obesity, high BP, high TG, low HDL, high fasting glucose ?Inflammatory triggers NSS Markers for low grade chronic inflamation, like hsCRP, could indicate future risk of CV event;

32 Metabolic Syndrome marker abnormal finding Fasting BG: >100mg/dLTG: >150mg/dL HDL: <40(m) <50(w) BP: >130/85 Waist: >40”(m) >35”(w)

33 Anti-inflammatory Diet (www.deflame.com)Eliminate ALL grains, esp those with gluten (wheat, rye, couscous spelt, barley oats) (avoid legumes) Eliminate ALL refined sugar Eliminate hydrogenated oils Limit soy and dairy (except cream) Don’t smoke (duhhh!) Are you familiar with the work of David Seaman, DC, now teaching at NUHS-FL? David is certainly the pre-eminent evidence based nutritionist in our profession; I recommend you visit his website for a thorough description of eating an anti-inflammatory diet; A key is reduction of foods which promote production of arachadonic acid; the ideal diet is comprised of a 4:1 ratio of omega-6 fats to omega-3 fats; the US diet is typically 25:1, so we are in a perpetual state of low grade inflammation; and now good evidence that things like heart disease are really diseases of inflammation (hsCRP is good predictor of heart disease);

34 Anti-Inflammatory Diet (cont) (www.deflame.com)Fruits and vegetables Nuts and certain seeds Dark Chocolate (75% or more cocoa) Cold water fish (salmon, mackerel, sardines) Meat, chicken – grass fed and free range Spices (ginger and tumeric) Red wine and stout (assuming no trigger or alcoholism) Heavy cream Omega-3 eggs Olive oil, coconut oil, butter So what can you eat? And add exercise as that is one of the quickest and easiest ways to increase HDL

35 Spreading the Good News!

36 Good News: Injuries Do Not Lead to Long Term Problems!Individuals who have had minor trauma (lift inj, minor fall, MVC) are at no increased risk of long term problems Carragee, et al. Spine 2006; 6(6):624-35

37 Good News: Pre-existing Degenerative Changes Not a Risk FactorIndividuals with degenerative changes on MRI are at no increased risk of long term problems Carragee, et al. Spine 2006; 6(6):624-35

38 Good News: Heavy Lifting Jobs and LBPPersistent, minor LBP likely to occur in workers w/ a heavy job BUT No increased risk of significant LBP or disability – especially with low fear beliefs! Carragee, et al. Spine J 2005

39 Good News: MRI Findings After LB Injury Not Likely Related to InjuryThe vast majority of patients have no change in MRI after LB injury. Carragee, et al. Spine 2006; 6(6):624-35

40 Good News: Chronic Neck Problems After Whiplash about same as general population50% of people with WAD continue to have pain at 1 year; however 20-40% of general population report pain in previous month NP attributed to MVC for longer periods; but not much longer than the general population

41 Essential Messages for EveryoneOvercoming vs getting rid of: self efficacy Activity is good Avoiding activity detrimental LBP is a very painful inconvenience that nearly everyone can overcome (biopsychosocial) Initial visit therapy is an active therapy so that pt’s first experience of relief is something that they do Self efficacy deserves some mention here as it may be most important attribute relative to overcoming spine pain; can have high self efficacy in one area of life (your job) but low self efficacy in overcoming your spine pain; the practitioner provides positive empowering messages to the patient encouraging self-care; Think about the rationale behind NOT providing some passive therapy (CMT, EMS, HMP, etc) on the first visit: practice management use this as a tool to gain control over the patient; but the PSP may do this so that the PSP only gives an active therapy to the patient to do at home so the patient’s first experience of pain relief is something they are able to do for themselves; The Bipsychosocial model includes somatic, neurophysiological, psychological all within a social context .

42 Essential Messages for EveryoneRTW is therapy “You don’t get better in order to go back to work. You go back to work in order to get better” Some pain on returning to activity is normal SPICE – a model from the military for ‘battle fatigue’; the key is the letter P: proximity; they found if they could keep the soldiers close to the front line, they were more likely to recover; seems to be true for ‘work fatigue’ – after an injury, if you can keep the injured worker close to his job (perhaps offer light duty), you have a better chance of recovery;

43 Essential Messages for EveryoneImaging findings are deceiving and usually not reflective of severity of problem Pain severity is not necessarily reflective of severity of the problem Pay attention to how you lift PAIN IS INEVITABLE SUFFERING IS OPTIONAL I first saw this quotation at BCBS offices when Brian and I were invited in to do ergonomic assessment of group who spent day at desks on word processers (preceded computers);

44 Imaging/ Special Tests for spine pain3 - 15% of spine pts should require further investigation Our data from 3 sites suggests that about 15 % typically need some additional testing/consultation; typically about 3-5% go on to surgery; about 15% need advanced imaging; about 5 – 10% need pain management; these were hospital based practices so maybe the morbidity of the population seen could be higher than what we might expect in average field practice;

45 Indications for Advanced Imaging: Severe or progressive neurologic deficit Serious underlying conditions suspected If findings would change course of treatment Chou R, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147(7):

46 Indications for Advanced Imaging in Radiculopathy Patients:ESI considered Surgery considered If the imaging showed a disc change, would it change your treatment approach? Chou R, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147(7):

47 Unnecessary imaging is not only wasteful, it can be harmful!

48 Early MRI leads to higher costs, poorer outcomes, longer disabilityEarly MRI groups - $12, 948 to $13, 816 higher medical costs! A study by Webster et al in SPINE 2013 showed that 40% of non-specific back pain and 80% of radicular symptoms+back pain received ‘early’ MRI (within 30days of onset) (they excluded cases which early MRI was definitlely appropriate based upon the record review) (these were work related injury cases); these were compared to similar cases which did NOT have early MRI; all cases showed improved regardless of the presence of radiculopathy but both early MRI groups cost more per case (>$12,000/case) and took longer to recover with longer disability; Webster BS, et al. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine (Phila Pa 1976) 2013;38(22):

49 Imaging: MRI reports and outcomes237 cases of uncomplicated DDD seen on MRI seen in imaging facility 30% of cases received Epidemiological Info (EI) sheet with the MRI results (“DDD is normal variant”) 70% of cases did not receive E.I. sheet Results E.I. group less likely to receive opiates** E.I. group less like to receive repeat imaging E.I. group less like to receive referral Strongest relationship was between E.I. and decrease in opiate prescriptions; (EI is a sheet explaining the results of the film (ie. DJD is normal variant) these Epidemiological sheets went to the referring doctor; McCullough RADIOLOGY 2012

50 MRI and Spine Surgery Direct correlation between rates of MRI and rates of spine surgery in the US Lurie J, et al. 2003;28(6):

51 “Iatrogenic Imaging Disability”“Spondylosis” “Disc bulge” “Degenerative disc disease” DJD is ‘gray hair of the spine’ The language of the report matters as the McCullough study demonstrated; there is initiative in Rochester, and I’m sure moving to Syracuse, to get radiologists to change their report language; We just wrote a paper on the importance of language the PSP or PCP uses with the back pain patient; I’ll let you know if it is accepted for publication;

52 C.R.I.S.P. (clinical reasoning in spine pain) The Three Essential Questions1. Do the presenting symptoms reflect a visceral disorder, or a serious or potentially life-threatening illness? 2. Where is the pain coming from? 3. What is happening with this person as a whole that would cause the pain experience to develop and persist? Tell story of hearing Murphy lecture;

53 Question #1: Do the presenting symptoms reflect a visceral disorder, or a serious or potentially life-threatening illness?

54 Red Flags noteworthy in spine painPerineal numbness Loss control bowel/bladder History of cancer **** (B, L, P, K) neck pain/HA with 5Ds And 3Ns Abdominal bruit (AAA) Signs/symptoms infection Unable to reduce symptoms mechanically Hx of significant trauma (mild+osteopenia) Family hx inflammatory arthropathy Unexplained weight loss Breast, lung, prostate, kidney most commonly show mets to spine; These red flags have been estimated to be anywhere from less than 1% to up to 3% of spine pain patients;

55 Disorder Detected by Cancer Benign tumor Infection FractureHx CA, no positional relief, fever, unexplained wt loss, blood in stool Benign tumor Local severe pain, no positional relief, relief w/ NSAID, pain percussion Infection Hx fever, chills, febrile, pt tender, red, heat Fracture Hx trauma, hx osteoporosis, pain percussion

56 Disorder Detected by GI disease GI complaints, pain w/ food, abdominal exam GU Disease GU complaints, bleed, spot, discharge, GU exam Myelopathy Gait, bowel/ bladder, UMN, spasticity Cauda Equina Syndrome Bowel/ bladder, saddle anesthesia, anal sphincter tone

57 Cardiac ischemia (common)Dissecting abdominal aortic aneurysm, visceral injury Cardiac ischemia (atypical) Cholelithiasis, peptic ulcer disease, pancreatitis Pyelonephritis, renal stones Deep-seated pelvic pain Pelvic inflammatory disease Ectopic pregnancy Fibroids Endometriosis Prostatitis “Mechanical” low back pain These are referral patterns for some visceral conditions which refer pain to the soma; Refer to case of myocardial infection I saw in practice whose presentaion was only left scapular region, and even had mechanism of onset; and interestingly, he was pale, diaphoretic, just looked sick, some shortness of breath, and whle we waited for ambulance, he begged me to adjust him, so I did – and son-of-gun if he didn’t get some relief from pain; he had successful CABG and became my biggest cheerleader; Activity-related, persistent Severe, tearing Colicky Cramping, spasmotic, abdominal

58 For diagnosis Cancer sensitivity specificity 1.Age>50 .77 .712.Prior CA 3.Weight loss unexplained 4.No relief bed rest 5.Not better 1 mo tx 6. If 1+2 or 3 or Bigos, Acute LBP in adults, AHCPR, 1994 The greatest ability to improve overall sensitivity and specificity is by combining test results

59 Systemic Inflammatory ArthritideMost common polymyalgia rheumatica A.M. stiffness ( minute rule) Generalized joint pain, especially shoulders Older age (50-65+) Flu like symptoms, giant cell arteritis PMR: can have flu like symptoms, weight loss; accompanied by giant cell arteritis (temporal arteritis); unknown cause; controlled by corticosteroids; may resolve in 1 – 3 yrs; probably auto-immune condition; The 30 – 45 minute rule is it takes that much time to loosen up;

60 Spondyloarthropathy Pain often SI Worse in AM AM stiffnessHx of Chrohn’s/ colitis < age 40-45 Uveitis Family Hx Good response to NSAIDs SI – itis on imaging Sed rate/ CRP elevated Negative RA factor HLA-B27 present Can really be anthing from osteoarthritis to RA to ankylosing spondylitis as it is joint disease of the spine; most commonly refers to the seronegative spondyloarthropathies like A. S. also auto-immune; Reiter’s syndrome: can’t see, can’t pee, can’t dance with me/climb a tree urethritis, uveitis, arthritis Ehrenfeld M. Spondyloarthropathies. Best Pract Res Clin Rheumatol 2012;26(1):

61 Suspect Seronegative Spondyloarthropathy if:Berlin criteria:  1. Morning stiffness >30 min  2. Improvement with exercise but not with rest  3. Awakening during the second half of the night only  4. Alternating buttock pain Likelihood ratios: is the change to have (+) or not have (-) a condition from pre-test probability based upon test being positive or negative; If at least 2 of 4 are present: Se 70%; Sp 81%; +LR 3.7 Rudwaleit M, et al. Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis Rheum 2006;54(2):

62 Ankylosing Spondylitis (AS) - RadiographsAnkylosing spondylitis: seronegative spondyloarthropathy; genetic; negative RA; HLA B27 present; involves axial skeleton predominately with SI; early symptoms include morning stiffness, fatigue and weight loss and occ. Fever, difficulty with chest expansion, loss of mobility especially extension of trunk, SI pain, eventually uveitiis and enthesopathy -bone erosion, hyperostosis, fragmentation, and crystal deposition, may allow a precise diagnosis. You can see loss of distinct margins of SI joints due to erosions and sclerosis; X-Ray changes can take years to come on; CT or MRI may be more helpful;

63 AS - Radiographs You can see the syndesmophytes formed in ossification of outer fibrous rings of the iVD; referred to as bamboo spine

64 Cauda Equina Syndrome Bowel/ bladder dysfunction Sexual dysfunctionSaddle anesthesia Decreased anal sphincter tone Bilateral multisegmental neurological deficit How many of you have diagnosed cauda equina syndrome?

65 Modic I change and p. acnes infection?Modic 1 = inflammation and edema; very strong association with LBP that is constant, varying intensity, night pain Modic 2 = infllamation and edema plus fatty infiltration replaces red marrow Modic 3 = rare, trabecular fracture Albert and Manniche in Denmark found 80% of pts with Modic 1 and LBP get “cured” by antibiotics; RCT but very controversial; Albert HB, et al. Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae? Eur Spine J Feb 10.

66 Question #2: Where is the pain coming from?

67 Identify the Primary Pain Generator(s)Disc derangement Joint dysfunction Radiculopathy Myofascial trigger points I’m going to leave a discussion of subluxation for another day and time; We have a colorful relationship to subluxation in the United States; for some, it is their reason for being; for others it defines their scope of practice, for others it defines reimbursement, for others it is a literal headache, for others a figurative headache;

68 Disc Derangement The chief finding of derangement is disruption of the annular fibers; we also know that the post 1/3 of the disc is innervated with nociceptive fibers;

69 Historical Factors Suggestive of Disc PainAcute episode(s) Antalgia Pain with sitting Pain with sit-to-stand Pain with flexion Worse in AM

70 McKenzie Technique Generally low Inter Examiner Reliability (IER) for classifying patients with LBP (includes trained and untrained practitioners) But good IER (k = .60) for fully trained practitioners to identify key characteristics of derangement (lateral shift, centralization, directional preference/ direction of benefit) .60 Kappa is ‘good’, not great, but good; Werneke MW, et al. McKenzie lumbar classification: inter-rater agreement by physical therapists with different levels of formal McKenzie postgraduate training. Spine 2014 Feb 1;39(3):E

71 Validity of Centralization Signs - LumbarLow sensitivity (0.47) and high specificity (1.00) in the lumbar Spine Young S, et al. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine J 2003;3(6): 74% correlation between centralization on exam and positive discogram Donelson, et al. Spine 1997; 22(10): Young’s study is suggesting that if you do see centralization, then you bet the house that this is a derangement; however, if centralization is not present, then you could still have derangement (as seen by low sensitivity) A discogram (hypertonic saline injected into disc should reproduce the presenting symptoms); so if see centralization, then would expect to see positive discogram; Caragee in 1999 published in SPINE a high false positive rate for discography (and here we are using it as the gold standard) But all things considered, it does look like McKenzie is our best tool to identify disc derangement as a cause for the patient’s lower back pain; so become familiar with McKenzie protocol; take a cont. ed. Program;

72

73 Distribution of symptoms

74 Historical Factors Joint Dysfunction (? Reliability/validity/LR)Localized pain Often unilateral Often HA Pain with rotation/ extension Hx trauma (sudden or repetitive) Scientific evidence: neck No systematic reviews were identified which examined the diagnostic accuracy of history-taking in patients with neck pain. Rubenstein Clin Rheum 2008 I really don’t know the sensitivity or specificity of each individual historical factor to dx facet joint pain nor the LR if combine these historical factors;

75 SI Provocation Tests - ReliabilityModerate to high reliability of various SI provocations tests. Laslett & Williams Spine 1994;19(11)

76 Identifying SI Joint Pain (Laslett criteria)Distraction/Compression Thigh thrust Gaenslen's test FABERE Sacral thrust

77

78 SI Provocation Tests - ValidityThree or more positive SI tests: SE = 0.94 SP = 0.78 Laslett, et al. Man Ther 2005; 10:

79 Radiculopathy

80 Historical Factors Suggestive of Nerve Root PainSevere LE pain Pain below knee Claudication (stenosis) Neuro symptoms Severe LBP (herniation) Worse with extension (stenosis) Worse with flexion (herniation)

81 Myofascial Pain

82 Muscle Palpation Signs (Trigger Points)Carol et al J Man Manip Ther 2007 Referred pain – good interexaminer reliability Jump sign – good reliability Nodule palpation – poor reliability Twitch response – poor reliability Jump sign: wincing, withdrawl, vocalizations of pain when palpate TrP Twitch response: presence of palpable or visible local twitch of tissues as roll over TrP

83 Question #3: What is happening with this person as a whole that would cause the pain experience to develop and persist?

84 Perpetuating Factors Believed to Be Important in Spine Related DisordersDynamic instability (impaired motor control) Nociceptive system sensitization Fear Catastrophizing Passive coping Poor self-efficacy Depression etc

85 Hip Extension Test for Dynamic InstabilityPt prone, extend leg lifting up, keeping knee straight, as high as possible (+) = if see lateral shift of pelvis or hyperextension of trunk Rationale is that loss of motor control of lumbopelvic muscles results in compensating and inability to keep pelvis still

86 Hip Extension Test - ReliabilitySubstantial (k=0.72 – 0.76) inter-examiner reliability of the hip extension test. Murphy, et al. J Manipulative Physiol Ther 2006;29(5):

87 Hip Extension Test - ValidityCo-contraction of Transverse Abdominis and Multifidus increases trunk activity and decreases trunk movement during hip extension In this case, the dynamic instability is evidenced by the trunk movement seen in prone hip extension test; when the activity is done which reduces dynamic instability (co-contraction of Transversus Abdominis and Multifidus muscles), then the hip extension test is no longer positive, which indirectly tests the validity of the test; Oh JS, et al. Effects of performing an abdominal drawing-in maneuver during prone hip extension exercises on hip and back extensor muscle activity and amount of anterior pelvic tilt. J Orthop Sports Phys Ther. 2007;37(6):320-4.

88 Nervous System Sensitization – Smart CriteriaPain disproportionate to injury or pathology Strong association with psychological factors Disproportionate, non-mechanical and unpredictable exacerbating/ remitting factors on history Diffuse, nonanatomic areas of pain/ tenderness Good discriminative validity, classification accuracy using these criteria Smart KM, et al. The Discriminative Validity of "Nociceptive," "Peripheral Neuropathic," and "Central Sensitization" as Mechanisms-based Classifications of Musculoskeletal Pain. Clin J Pain 2011, 27(8): Smart KM, et al. Mechanisms-based classifications of musculoskeletal pain: Part 1 of 3: Symptoms and signs of central sensitization in patients with low back (+ leg) pain. Man Ther :

89 Management** CRISP Protocol**The majority are managed at the primary spine care level without need for referral

90 Three Components In response to ques. #1: Further investigationIn response to ques #2: Addressing pain generators In response to question #3: Addressing perpetuating factors Because we have an evidence based subgrouping of patients, we can address each of the components we assessed for as follows:

91 Treatment Decisions Question 2Disc derangement – end range loading, distraction manipulation Joint dysfunction – joint manipulation Radiculopathy – Acute: NSAID, oral steroid, ESI Chronic: neural mobilization Trigger points – myofascial treatments

92 Treatment Decisions Question 3 Instability – stabilization trainingNociceptive system sensitization – education and graded exposure Psych factors – relationship-centered care, education, graded exposure, psych intervention (what is threshold???)

93 This is the diagnostic flow chart, and the numbers represent the average % of cases that fall into each category frpm a study published by Murphy and Hurwitz;

94 This is the treatment flow chart, that is driven by the classification from the diagnostic chart; we have essentially decided upon subgroups to parse into different treatment arms;

95 CRISP = Multi-Dimensional DiagnosisSerious underlying disease Pain generators Disc derangement Joint dysfunction Radiculopathy Myofascial pain Perpetuating factors Dynamic Instability Nervous system sensitization Psychological factors CRISP = Multi-Dimensional Treatment

96 Teaching CRISP University of Pittsburgh Pittsburgh, PA USADeveloping full 100 hr program Southern California University of Health Sciences Los Angeles, CA USA University of Johannesburg Johannesburg, SA

97 Thank You “When you work you are a flute through whose heart the whispering of the hours turns to music.” K Gibran The Prophet