REHABILITATION MANAGEMENT OF LOW BACK PAIN – IT’S TIME TO PULL IT ALL TOGETHER!

Review written by Dr Bronwyn Thompson info

BACKGROUND & OBJECTIVE

There have been many models used for clinical reasoning in low back pain, and this paper proposes another one. The difference between this model and previous ones is that it attempts to incorporate the multiple factors known to influence both pain and disability associated with low back pain. The authors use the International Classification of Functioning, Disability and Health as a way of framing the various factors and argue that clinicians should assess for the presence of elements included in each of the five domains to establish those that might contribute to the person’s presentation. Further detailed assessment could then be used to determine where treatment should be directed.

This paper details how the model was developed, basing it on current research but also incorporating classification systems for what they deem “nociceptive” pain drivers, along with “nervous system dysfunction” drivers. Distinguishing between the two factors is a key element in determining treatment focus. Once the primary “drivers” are identified, clinicians are directed to also identify comorbidity factors such as mental health problems, and other physical health problems such as diabetes or other painful musculoskeletal problems.

Cognitive-emotional “drivers” are also identified, incorporating tools such as the StartBack questionnaire or Orebro Musculoskeletal Screening Questionnaire. There is some attention paid to behavioural factors (such as Waddell’s signs and the BAT-Back). Domain five is identified as “contextual drivers” in which workplace and family contributors are identified. Aspects such as job satisfaction, the presence of modified work, the person’s relationships with those at work can be identified, along with the influence of family relationships, though relatively little attention is paid to social factors outside of employment.

Finally, the paper discusses how this model might be applied in practice, using two case studies to demonstrate how it might be used. Responses within each of the five “drivers” can be mapped on a pentagonal diagram, indicating where the clinician might put his or her effort – or refer to other members of the team.

The authors argue that this model provides for integration of various factors that until now have not been readily synthesised within physiotherapy clinical reasoning models. The authors acknowledge that much physiotherapeutic intervention is based on biomechanical or deficits of body functions and structures and suggest that by clearly identifying other factors that are also present, clinicians might have greater success.

Much physiotherapeutic intervention is based on biomechanical or deficits of body functions and structures

METHODS

This paper does not have a methods section as it is not an experimental paper, but rather a description or synthesis.

RESULTS

The paper presents a useful overview, and a pragmatic approach to assessing and integrating biopsychosocial factors known to influence outcomes in musculoskeletal pain (not just low back pain). The two-tiered approach where common and important factors are screened first, on

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