Dear colleague,

Your question is essentially 3 parts: (1) How many times a physiotherapist use a questionnaire in clinics to change his behavior towards a patient with chronic low back pain? (2) What are mostly used questionnaire in CLBP clinically? (3) Which one of these tells us patient's "feeling or getting better"?

Several colleagues have provided already valuable answers. With the risk of being repetitive I give a response based on Practice Guideline Low Back Pain of the Royal Dutch Society for Physical Therapy*.                                                                                                                                              Based on prognostic factors the course of LBP is defined as ‘normal’ and ‘abnormal’. A 'normal course' means that the patient's activity level and degree of participation  gradually increase over time to the level present before the episode of low back pain. In many cases, the pain will also diminish. This does not mean that the LBP disappears always completely, but that it no longer limits the patient's activities and participation in society. Based on history taking and findings of physical examination, the physiotherapist assigns the patient to one of the following profiles:

Profile 1. Non-specific LBP with normal course of recovery.

Profile 2. Non-psecific LBP with abnormal course, without dominant presence of psychological factors impeding recovery.

Profile 3. Non-psecific LBP with abnormal course, with dominant presence of psychological factors impeding recovery.

The course of LBP is considered 'abnormal' if the patient's activity limitations and participation restrictions do not decrease over time but remain unchanged or even increase. An abnormal course with delayed recovery is defined as no clear Increase in activity level and reduction in participation after 3 weeks. The definitions are based on the International Classification of Functioning, Disability and Health (ICF) with the construct for Functioning and Disability 'changes in body functions and structures', 'capacity' and 'performance'.

The choice of recommended instruments in the Practice Guideline is based on the constructs of ICF beside the psychometric properties of reliability, validity and responsiveness. The severity of the pain and other patient-specific complaints should be assessed using the Numeric Rating Scale (NRS 0-10 points, average pain over the Past 24 hours) and the patient Specific Complaints instrument (PSC 0-10 points), while the functional status should be evaluated using the Quebec Back Pain Disability Scale (QBPDS). The NRS, PSC and QBPDS should be administered at the beginning and end of the treatment episode, while the NRS and PSC can also be administered in the course of the treatment, for instance every 3 weeks.

In summary.

Question 1: How many times a physiotherapist use a questionnaire in clinics to change his behavior towards a patient with chronic low back pain? The frequency of the use of measuring instruments (questionnaires) is at least at the beginning and the end of the treatment episode or more frequently, for instance every 3 weeks.

Question 2: What are mostly used questionnaire in CLBP clinically? Based on the construct of the ICF and psychometric characteristics the Dutch Practical Guideline LBP recommends three measurement instruments: NRS-pain, PSC and QBPDS.

Question 3. Which one or these tells us about patient's "feeling or getting better"? The PCS tells patient and therapist an aspect of feeling or getting better.

Hope this helpls.

Nijmegen, March 7, 2015

prof. Rob A.B. Oostendorp, PhD, MSc, PT, MPT.

* Staal JB e.a., KNGF Clinical Practice Guideline for Physical Therapy in patients with low back pain. Amersfoort, KNGF, 2013

Dear Anirban,

There are several questionnaires that you may use in CLBP patients. The question is, what construct are you trying to measure? You may want to measure patient's quality of life (I would indicate SF36 or SF12, then). Or you may want to assess disability, which can be objectively measured with the Rolland-Morris or the Oswestry Disability Index questionnaires. If you want to measure specific psychosocial aspects of your patient, such as fear and avoidance behaviors, you can use the Fear-avoidance Beliefs Questionnaire (FABQ). Conversely, you can measure if your CLBP patient has catastrophic thoughts about their pain by using the Pain Catastrophizing Scale (PCS). That is, you need to know what specifically you want to measure.

Once you have this answer, you need to check what are the values of the Minimal Clinically Important Difference (MCID). This values, which are specific for each instrument, show us whether any change in a given score is indeed clinically relevant.

Hello Anirban,

did I understand it right, you would like to assess PT's attitudes towards the patient or the patients behaviour? If it's the second part, I believe Giovanni has given sufficient reply. If you would like to assess the PTs, you should read the work by Annette Bishop in Pain 2007, November 2007, Pages 91–101.

Best regards

Thanks Giovani and Markus for such informative answers.

I am interested to measure constructs, such as, pain, disability, fear avoidance, coping, depression, anxiety and mindfulness.

But my question is to the clinicians who work with CLBP. How often they reply on a questionnaire rating for changing their behaviour or the course of treatment?

I believe this is a major  problems: the clinicians not assess the effect of treatment with validated instruments. I believe this may be an important step to increase the credibility of the treatment of patients with low back pain. Have objective data to track progress should be a major objective.

I agree with the colleagues suggestions.

Dear Anirban, 

1. What instruments are used. It may be a good idea to have a look at the international organisation: ICHOM (www.ichom.org). This is a non-profit organisation, and the goal is to agree on a "core data set" in all diagnostic enteties within the next five years. I have been part of this projekt since 2013 in the LBP-group. It could be a good idea to use the same variables, including outcome instruments in order to be able to make valid comparisons both nationally and internationally (its difficult anyway with respect to different versions, cultural differences and so forth). You can have a look at the LBP variables at this link: http://www.ichom.org/wp-content/uploads/2014/08/LBP-Reference-Guide-8.20.14-TP.pdf 

2. Are we changing our behaviour based on the answers we get from our outcome instruments? Yes, this is an important question that we should discuss also within the ICHOM-cooperation. So far we have not.

Perhaps an interesting example of behavioural change based on outcome (you need a registry for this one). In Sweden, as a result from registering outcome after surgery for spinal stenosis (among other diagnoses) in a national registry (Swespine, 90% coverage and 80% 1-year completeness), we have noticed that decompression alone gives the same result as decompression plus fusion, even if there is an olisthesis. This has been discussed within the profession since 2009, and as a result (sic) the bigger and more costly procedure (where fusion is added) is today performed in less than 20% compared with 30% in 2009. Is there a causal relationship? We dont know for sure, but we think there is. These findings has by the way been confirmed in a large RCT that will be published later this year.

And again, this shift has been noticed, and the reason not specifically asked for using a questionnaire to the physicians.  You can read about this in the last annual Swespine report (page 107).

http://www.4s.nu/pdf/Report_2014_Swespine_Engl_ver_141204.pdf

Peter 

I am interested to measure pain every time when the patient come to visit.  But measure disability, fear avoidance will be evaluated once a week.

Hope it dose help.

Dr. Rain bow

A tool widely used in Australia is the Orebro Muskuloskeletal Pain questionnaire. It is not CLBP specific but has excellent validity and is used for screening and monitoring. It captures many of the domains you are interested in and is easy to administer and score.

David

Article A Systematic Review of the Predictive Ability of the Orebro ...

Appreciates your suggestions and references! 

The questionnaires on pain and disaiblity, along with other on health resources consumption (i.e., diagnostic procedures and treatments used on these patients) are included in a registry routinely used in the Spanish National Health Service to assess outcome, with > 95% follow-up (see, for instance, Spine J 2012;12:1008-1020, Int J Technol Assess Health C 2014 (30);2:153-164, Spine J 2014;14:1588-1600).

Dear Anirban,

In our environment, the answer to your question is "yes". In the Kovacs Foundation, the clinicians change the diagnostic procedures and treatments they prescribe depending on patients' answers to specific questionnaires. Clincians use the responses to these questionnaires to assess indication criteria for specific diagnostic procedures and treatments.

The previously validated Spanish versions of the following questionnaires are used on each patient's visit; two VAS (for low back pain and referred pain, separately), the Roland-Morris Questionnaire, and a questionnaire on the presence of "red flags" for systemic diseases or surgical indication criteria. Questionnaires on fear-avoidance beliefs (FAB) and catastrophizing (PCS), are not used any longer, because all the studies conducted with Spanish patients have shown that they are useless in clinical practice, at least in our environment (see, for instance, Spine J 2012;12:545-555, Spine 2007;32:2133-2138).

Hope this helps,

Francisco 

Thanks Francisco and Brad

Dear colleague,

Your question is essentially 3 parts: (1) How many times a physiotherapist use a questionnaire in clinics to change his behavior towards a patient with chronic low back pain? (2) What are mostly used questionnaire in CLBP clinically? (3) Which one of these tells us patient's "feeling or getting better"?

Several colleagues have provided already valuable answers. With the risk of being repetitive I give a response based on Practice Guideline Low Back Pain of the Royal Dutch Society for Physical Therapy*.                                                                                                                                              Based on prognostic factors the course of LBP is defined as ‘normal’ and ‘abnormal’. A 'normal course' means that the patient's activity level and degree of participation  gradually increase over time to the level present before the episode of low back pain. In many cases, the pain will also diminish. This does not mean that the LBP disappears always completely, but that it no longer limits the patient's activities and participation in society. Based on history taking and findings of physical examination, the physiotherapist assigns the patient to one of the following profiles:

Profile 1. Non-specific LBP with normal course of recovery.

Profile 2. Non-psecific LBP with abnormal course, without dominant presence of psychological factors impeding recovery.

Profile 3. Non-psecific LBP with abnormal course, with dominant presence of psychological factors impeding recovery.

The course of LBP is considered 'abnormal' if the patient's activity limitations and participation restrictions do not decrease over time but remain unchanged or even increase. An abnormal course with delayed recovery is defined as no clear Increase in activity level and reduction in participation after 3 weeks. The definitions are based on the International Classification of Functioning, Disability and Health (ICF) with the construct for Functioning and Disability 'changes in body functions and structures', 'capacity' and 'performance'.

The choice of recommended instruments in the Practice Guideline is based on the constructs of ICF beside the psychometric properties of reliability, validity and responsiveness. The severity of the pain and other patient-specific complaints should be assessed using the Numeric Rating Scale (NRS 0-10 points, average pain over the Past 24 hours) and the patient Specific Complaints instrument (PSC 0-10 points), while the functional status should be evaluated using the Quebec Back Pain Disability Scale (QBPDS). The NRS, PSC and QBPDS should be administered at the beginning and end of the treatment episode, while the NRS and PSC can also be administered in the course of the treatment, for instance every 3 weeks.

In summary.

Question 1: How many times a physiotherapist use a questionnaire in clinics to change his behavior towards a patient with chronic low back pain? The frequency of the use of measuring instruments (questionnaires) is at least at the beginning and the end of the treatment episode or more frequently, for instance every 3 weeks.

Question 2: What are mostly used questionnaire in CLBP clinically? Based on the construct of the ICF and psychometric characteristics the Dutch Practical Guideline LBP recommends three measurement instruments: NRS-pain, PSC and QBPDS.

Question 3. Which one or these tells us about patient's "feeling or getting better"? The PCS tells patient and therapist an aspect of feeling or getting better.

Hope this helpls.

Nijmegen, March 7, 2015

prof. Rob A.B. Oostendorp, PhD, MSc, PT, MPT.

* Staal JB e.a., KNGF Clinical Practice Guideline for Physical Therapy in patients with low back pain. Amersfoort, KNGF, 2013

Several standardized and validated survey instruments are available and that are helpful in determining the outcomes in CLBP treatment.  They include:

I. To assess Pain Interference:

-Quebec Back Pain Scale (Kopec, et al., 1996).

-Oswestry Disability Index (Fairbanks, et al., 1980). 

II. To assess Emotional Distress:

-Beck Depression Index (Beck, et al., 1961)

-Beck Anxiety Index (Beck, et al., 1988)

-Tampa Scale for Kinesiophobia (Miller, et al., 1991)

III. To assess Patient Satisfaction:

-Pain Outcomes Questionnaire-Pain Treatment Satisfaction Scale (Clark, et al., 2003)

IV. Multidimensional Measures

-West Haven-Yale Multidimensional Pain Inventory (WHYMPI; Kerns, Turk, and Rudy, 1985)

As a practical application, in a small, pilot study here in Ann Arbor intended to determine CLBP, post-manual treatment outcomes, the following surveys were used to reveal significant reductions in:

-mean self-reported, disability score (Quebec Disability Survey)

-mean anxiety score shift from moderate to low (Beck Anxiety Survey).

-a decrease in pain severity and an increase in life control (WHYMPI)

Anirban,

This is an interesting question. As you can see we may at times agree in the constructs to be measured but not always in the instrument to measure them. Our experience with Oswestry for example, in a clinical setting has shown that repeating it every two weeks was enough to detect changes. However, we have to be mindful of the patient burden. And if I can recall we never had more than three data points during treatment.