L14: Overview of management Flashcards
What are 4 misconceptions of a back injury?
- If it hurts, it must have been injured
- If its injured, it needs rest to heal
- If its injured something I did or someone else did must have caused it
- I can do something to make sure it never happens again
How we manage in spinal pain is very _____ (similar/different) to other body parts
different
As health professionals we need to take _______________ into consideration when deciding what to say or which treatment to provide or how we explain the treatments we provide. _______ with appropriate explanations are critical Communication and partnership are key
potentially negative consequences; reassurance;
What are 3 things we can do as physios to change negative beliefs from patients with lower back pain?
- shape their beliefs and better contextualise what is happening to their body (e.g. rarely is tissue damage the biggest concern)
- eliminate fears that everyday activities are dangerous even if they are difficult initially
- empower patients to regain control through active selfmanagement strategies such as physical activity.
Participants report being advised to manage their pain by: “adopting certain postures” and “strengthening specific muscles” which can reinforce beliefs that their spine is ‘vulnerable’. The explanatory model that insufficient muscular support results in a vulnerable spine can have a ________.
dramatic impact
Your back is weak, unstable, need to strengthen
“______” strategies may result in increased vigilance, worry, frustration, and guilt for patients with low back pain
protection
What are 3 quotes that come out o interviews about what professionals tell them (negative and misguided beliefs stay with the patient for a long term –> affect their management..etc)
- “I’ve been tested by various different physios, and Pilates, and I’m apparently ridiculously weak…. I had an abortion because I didn’t think I could have a baby. I didn’t think I could handle it…carrying it”
- “Do all those things that the physio told me to do. Or not to do…. She’s told me more about what not to do, rather than what to do”.
- “Lots of reassurance from the [doctor]…made me feel like, “don’t panic —you know, this is OK, you’ll be fine, it’s not the start of something awful”
What are messages from the patient about physios?
ADD
Health care providers with elevated _______ beliefs advised limitation of work and activities to their patients
fear avoidance
Beliefs among physiotherapists about back pain and disability were found to correlate with their _____- to patients
recommendations
Therapists who reinforce patients’ unhelpful beliefs tend to increase spinal ________ and contribute to the development of ______ disability
vigilance; chronic
What are messages from the patient about physios?
What are 2 other things that affect outcomes?
- Physio’s enthusiasm
- Expectation of treatment
_______ practitioners and their optimism or pessimism can have an active effect on the outcome
Enthusiastic
The ______ of a treatment shapes the patient’s pain experience
expectation
Expectation is a significant _____ factor in musculoskeletal pain and is often underestimated by physiotherapists
prognostic
Avoiding or ignoring the patient’s preferences, expectations and previous experiences can ______ (positively/have no/negative) influence outcomes
negatively
What are 8 factors that influence the outcomes of treatment?
- giving clear prognostic information
- effectively explaining the condition
- active listening and verbal expressions of support and encouragement
- Asking if the patient has anything needs for modifications
- humour and sympathy
- empathetic and communicative discussion
- partnership statements
- paraphrasing
- requests for the patient’s opinion
______ SHOULD be used in the management of LBP
Exercise
What is the benefit of returning back to work as soon as possible?
Even if they can’t go back to straight away –> try and find out what can be modified to help get back to work faster
Setting - helpful for engaging (while working form home not as good as work somewhere else but still better than no work
What are 3 purposes of education for patient?
- teach patients to self-manage their condition
- encourage continuing with normal activities (work etc)
- the nature of LBP
Physiotherapists with a biomedical orientation and high levels of ________ beliefs are less likely to adhere to low back pain treatment guidelines
fear avoidance
_____ given SHOULD be tailored to the individuals needs
Exercise
Manual therapy / Manipulation is helpful – especially when used in combination with _____ and _____.
education; exercise
When prescribing exercise, it is important to make it _____ and _____ while still being _____>
Tolerable; accessible
What are 3 things that clinicians should not utilize patient education and counseling strategies for?
- increase the perceived threat or fear
- promote extended bed-rest
- provide in-depth, patho-anatomical explanations for the ‘specific’
What are 6 things that patient education and counseling strategies for patients with low back pain should emphasize?
- understanding of the structural strength inherent in the human spine
- the neuroscience behind pain perception
- Why they are getting a higher level of pain
- the favourable prognosis
- Vast majority have significant recovery in 1-2 weeks 80-90% have full recovery within 4-6 weeks
- the use of active pain coping strategies that decrease fear and catastrophizing
- the early resumption of normal or vocational activities, even with pain
- the importance of improvement in activity levels, not just pain relief
- Not have to have no pain to go back to work
When do you consider manual therapy?
thrust manipulative and mobilisation procedures to reduce pain in acute low back pain
When do you consider centralisation and directional preference exercises?
repeated movements, exercises, or procedures to promote centralization to reduce symptoms in patients with acute low back pain
When do you consider traction?
There is moderate evidence that clinicians should not utilize intermittent or static lumbar traction for reducing symptoms in patients with any back pain.
What are 2 fairly ineffective back guidelines for management?
- EPAs
- lumbar support
When do you consider exercise?
consider exercise to reduce low back pain and disability in patients with acute, sub-acute and chronic low back pain
Physios should provide steps to do so and ensure the patient understands that they don’t need to be ‘_____’ to resume work and normal activity.
pain-free
Physios should try and keep the individual ______ and at work if at all possible, even for a small part of the day to maintain work ____ and work _____.
active; habits; relationships
Physios should provide strategies and encouragement to ________ right from initial consultation
self-manage
Physios should always minimise the overtreatment for pain or reliance on _______.
passive modalities
Make sure that patient is aware that passive treatment is just to help with the pain is not a “cure”
Physios should shift the focus from the symptoms (pain) to _____. Instead of asking ‘how much do you hurt?’, ask ‘what have you been managing with work/school/exercise?’.
function (level of activity)
Physios should maintain an interest in ______.
improvements
If another health professional is involved in treatment or management, specify a date for a progress report at the time of referral.. Why is this important?
Delays can be disabling
Physios should acknowledge difficulties with activities of daily living, but don’t make the assumption that these activities should be ______.
avoided
Physios should make a concerted effort to communicate that having _____ (more/less) time off work will reduce the likelihood of a successful return to work
more
Physios should ensure that appropriate reasoning is given for ____ aspects
treatment
Physios should be alert for beliefs that the patient should stay off work until treatment has provided a ‘_____’; watch for expectations of simple ‘techno-fixes’.
total cure
Physios should promote self-responsibility and self-____. Encourage well behaviours
efficacy
Physios should be prepared to ask for a second opinion ESPECIALLY where a patient is not ________ or a significant pathology is suspected, provided it does not result in a long and disabling delay
improving
If barriers to return to work are identified and the problem is too complex to manage, referral to a ______ team is recommended.
multidisciplinary
Should I tell the patient that they have “non-specific” low back pain? Why?
Medical diagnosis (between health professionals) –> NOT what is used to tell the patient.
Doesn’t really reassure patient (very “vague”)
What are 6 things you tell the patient if you don’t say non-specific low back pain?
- The segment*
- They have not sustained a major injury (we can rule this out or any other serious causes)
- Symptoms are maintained in the area and you seem move pretty well/ moving okay, while you are having some difficulty with X, Y, X and that might be contributing to the pain –> no serious conditions
- Our findings from the physical – contributing factors
- Why they may be getting pain/continuing to get pain
- Talk about nervous system –> Changes over time
- The good outcomes that are expected
- Very common, most people have quick recovery
- What they can do
- Chances for fast recovery and decrease risk to causing persistent back pain
Delivering an explanation of the _______ disorder is appreciated by patients and can influence their satisfaction about the care during the first visit
musculoskeletal
We can be more specific…OR we can (but not necessary) tell the patient that being able to determine the exact tissue structure beyond the segment is not possible and does not help/change what we ____ or their _____
do; outcomes
We can never be sure –> but won’t change management and treatment plans
What are 5 specific actions to reduce the risk of acute LBP changing into chronic LBP?
- Minimise and avoid in-depth patho-anatomical or biomechanical explanations for symptoms
- Minimise and avoid strong biomechanical reasoning for treatments (manual therapy and exercises)
- Avoid inappropriate use of investigations and educate the patient why (simply telling the patient they don’t need imaging is not adequate)
- Downplay the significance of age-appropriate degenerative changes if investigations have been used – ie cite research, give information
- Identify, prescribe and encourage patient-appropriate exercise (what the patient can do, will do and can manage within their lives).
Results of primary care trials show that _____ treatments (such as manual therapy, exercise, education and cognitive behavioural approaches) are more effective than usual or minimal care of back pain.
targeted
A one-size-fits-all management approach is not ideal. Why?
it fails to ignore the wide variation of patient presentations and needs.
Many attempts are made in research to identify relevant subgroups so that patients can be matched to ____ interventions with increased accuracy.
specific
Reliable and valid classification of patients could lead to tailored treatments and ______ outcomes.
improved
The most important finding is that _______ management (selecting treatment based on the patients presentation) shows better outcomes than ______ conventional care.
stratified; non-stratified
What does best physiotherapy management of LBP look like?
