Effect of physiotherapists’ management before specialized medical assessment in chronic low back pain (CLBP) patients: a mixed methods pilot study

Full text

Yes
43%
No
57%
Validation of
Initial
Diagnosis
N = 14
M (SD)
Age
61.4 (14.4)
Questionnaires
SBST
2.4 (0.6)
PCS
26.9 (5.3)
ODI
17 (5.4)
%
Sex
(Women) 57.1
Pain duration
≥ 10 years
57.1
5
-9 years 14.3
< 5
years 28.6
Methods
T-4
•PCS < 30
•SBST
•ODI
T0
•PCS
•ODI
•CMDS
Intervention
•Physiotherapy
•6 x 45min in 12
weeks
•Initial and final
clinical
evaluation (SLR,
Lumbar mobility,
TM6)
T12
•PCS
•ODI
•CMDS
•Medical
evaluation by
anesthesiologist
(if required by the
patient)
T24
•PCS
•ODI
•CMDS
> DEMOGRAPHICS
> QUESTIONNAIRES RESPONSES
MEDICAL EVALUATION
(BY ANESTHESIOLOGIST: TO VALIDATE INITIAL
DIAGNOSIS AND MAKE RECOMMANDATIONS)
200
300
400
500
600
700
T0 T12
Distance (m)
TM6
**
*
0
10
20
30
40
Wrong diagnosis Right diagnosis
Distance (cm)
Lumbar mobility
0
20
40
60
80
100
Most affected side Less affected side
Amplitude (°)
SLR
Wrong diagnosis
0
20
40
60
80
100
Most affected side Less affected side
Amplitude (°)
SLR
Right diagnosis
**
**
> CLINICAL EVALUATION
Question:
Does offering physiotherapy before medical
evaluation in a tertiary pain clinic improve patient
outcomes and change the care trajectory?
Physiotherapy improves chronic low back pain
patients’ conditions1,2 :
INTRODUCTION
Références bibliographiques :
1Critchley, D. J. et al. (2007). Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce chronic low back pain disability: A pragmatic randomized trial with economic evaluation.
Spine, 32(14), 1474–1481.
2Will, J. S. et al. (2018). Mechanical Low Back Pain, 98(7).
3Bekkering, G. E. et al. (2005). Prognostic factors for low back pain in patients referred for physiotherapy: Comparing outcomes and varying modeling techniques. Spine, 30(16), 1881–1886.
Results
CONCLUSION & PERSPECTIVES
•Physiotherapy improves outcomes of patients who had the right initial diagnosis.
•A right initial diagnosis in 1st line is essential to optimize the patient’s care trajectory.
•Medical evaluation by the anesthesiologist is perceived as essential by patients but not necessarily medically relevant.
•Patients expect to meet a physician in a pain clinic; education will be mandatory to change expectations.
•However, 1st line rehabilitation is difficult to access;
•Many patients are referred to pain clinics because
rehabilitation resources are missing;
•2nd and 3rd line care are multidisciplinary but have a
long waiting time;
•Some patients on the waiting list in our pain clinic do
not need to see an anesthesiologist, and their
condition does not require interprofessional care;
•Late management increases the risk of disabilities for
patients3
Anne Marie Pinard1,2,4, Elodie Traverse1,2, Orlane Ballot1,2, Catherine Gauthier2, Jean-François Canuel2, Kadija Perreault1,4, Luc J.Hébert1,4 , Jean-Sébastien Roy1,4, René Quirion3, Marc Perron3, Gabrielle Fortin4, Hugo Massé-Alarie1,4
1Centre de Recherche Interdisciplinaire en Réadaptation et Intégration Sociale –Cirris - QC, 2Centre d’expertise en gestion de la douleur chronique – CHUL –CHUQ, 3CIUSSS Capitale Nationale, QC, 4Université Laval, QC
Effect of physiotherapists’ management before specialized medical assesment in chronic low
back pain (CLBP) patients: a mixed methods pilot study
Future disabilities risks,
catastrophizing level, and
functional abilities of
patients are moderate
Inclusion : Adults with stable CLBP, PCS questionnaire score < 30.
Exclusion : Red flag, Sciatica less than 1 year, deteriorating
condition, conflict with insurance company.
Questionnaires : PCS : Pain Castastrophizing Scale, SBST : Start Back Screening Tool, ODI : Oswestry Disability
Index, CMDS : Canadian Minimal Data Set
Clinical evaluation : TM6: 6-min walking test, SLR : Straight leg raise test
Project funded by the Cirris, Chu de Québec, Fondation du CHU de Québec, and the Canadian Pain Network
Authors report no conflicts of interest
T : Number of weeks
Statistics: All variables analyzed
using non-parametric tests
Many patients did
physiotherapy without the
correct initial diagnosis.
Wrong Diagnosis (N=8) Right diagnosis (N=6)
Mean (SD) pMean (SD) p
Items Score rate T0 T12 T24 T0 T12 T24
PCS 0 -50
15,7 (10,4)
18,6 (10,9) 20,5 (14,5) ns
27,5 (6,6)
19,8 (5,2)
17,3 (8,7)
*
ODI 0 - 100 %
34,5 (10,4)
36,1 (8,4) 36,4 (18,4) ns
35,1 (12,5)
28,8 (12,0)
24,6 (13,8)
**
EQ5D5L 0 - 1 0,7 (0,1) 0,6 (0,1) 0,7 (0,1) ns 0,6 (0,1) 0,7 (0,0) 0,7 (0,0) *
CMDS
Pain
Intensity 0 -10 6,5 (1,0) 5,3 (2,6) 5,0 (2,3) ns 7,2 (0,9) 6,4 (1,7) 4,8 (2,1) *
Pain Interference
4 -20 9,6 (2,5) 11,8 (1,6) 8,6 (2,9) *
12,5 (3,7)
9,5 (3,6) 8,5 (2,4) **
Physical Function
4 -20 9,5 (2,9) 10,8 (3,5) 9,0 (3,3) ns 9,3 (4,0) 8,8 (3,7) 7,6 (3,8) *
Stress Depression
4 -20 8,1 (4,0) 7,8 (3,9) 6,6 (2,5) ns 7,3 (2,8) 7,0 (3,2) 5,1 (1,3) ns
Sleep
4 -20 9,3 (1,4) 10,2 (2,2) 10,1 (1,6) ns 9,3 (1,5)
10,3 (1,4)
10,8 (1,2)
ns
Impact Score
8 -50
25,6 (4,0)
28,1 (4,1) 22,7 (7,1) **
29,1 (7,5)
24,7 (5,6)
21,0 (6,5)
**
•Two groups for analyses (Wrong or Right diagnosis) because
physiotherapy intervention is based on initial diagnosis.
•After physiotherapy :
•92.9% of patients request to meet the anesthesiologist
•53.8% of consultations are relevant in the anesthesiologist’s opinion
Infiltration
49%
Interprofessional
Pharmacological
38%
Anesthesiologist’s recommendations for relevant
consultations