Unit 4: Classification Principles Part 1

Question 1

Treatment Based Classification (TBC)

Answer 1

PITT PSP PROGRAM

1. Medical Mgmt
   a. red flags
   b. comorbidities precluding rehab
   c. leg pain w/progressive neuro deficit
2. Rehab Mgmt
   a. med to high psychosocial risk
   b. low psychosocial risk WITH leg pain
   c. minor/controlled comorbidities
3. Self-Care Mgmt
   a. low psychosocial risk
   b. predominantly axial LBP
   c. minor/controlled comorbidities

Question 2

TBC Medical Management

Answer 2

a. red flags
b. comorbidities precluding rehab
c. leg pain w/progressive neuro deficit

Question 3

TBC Rehabilitation Management

Answer 3

a. med to high psychosocial risk
b. low psychosocial risk WITH leg pain
c. minor/controlled comorbidities

Question 4

TBC Self-Care Management

Answer 4

a. low psychosocial risk
b. predominantly axial LBP
c. minor/controlled comorbidities

Question 5

Mechanical Diagnosis & Treatment (MDT) / McKenzie

Answer 5

Repeated/sustained end range loading to determine:

a. symptomatic responses: centralization or perhipheralization
b. mechanical responses: reduction in deformity or increased AROM

Question 6

Mechanical Diagnosis & Treatment (MDT) Classifications

Answer 6

Derangement
Dysfunction
Postural
Other

Question 7

Pathoanatomic Based Classification (PBC)

Answer 7

Based on clusters of tests/clinical prediction rules to diagnose conditions:

a. symptomatic disc
b. SI Joint
c. Spondylolisthesis
d. disc herniation with nerve root involvement
e. spinal stenosis

Question 8

Pain Phenotypes (IASP)

Answer 8

a. Nocioceptive pain
b. Neuropathic pain
c. nociplastic pain (psychoemotional)

Question 9

Nociceptive Pain
Mechanism?
Characeteristics?

Answer 9

M: mechanical or chemical activation of nociceptors

C: pain is intermittent & affected by specific movements

Question 10

Inflammatory Pain
Mechanism?
Characteristics?

Answer 10

M: chemical activation of nociceptors

C: pain is constant and affected by all movements

Question 11

Neuropathic pain
Mechanism?
Characteristics?

Answer 11

M: neurological injury or disease

C: pain is intermittent or constant, usually affected by specific movements

Question 12

Nociplastic pain
Mechanism?
Characteristics?

Answer 12

M: central sensitization
C: pain is widespread, hyperalgesia and associated with other somatic complaints

Question 13

Psycho-Emotional Pain
Mechanism?
Characteristics?

Answer 13

M: intense emotional distress or psychopathology

C: similar to nociplastic pain with overlap of clinical depression or anxiety; requires co-management

Question 14

Movement System Impairment (MSI)

Answer 14

a. functional classification based on impaired alignment and movements
b. training to induce proper motor control of these impaired movements

(Shirley Sahrmann)

Question 15

Cognitive Functional Therapy (CFT)

3 Components?

Answer 15

1. cognitive training (PNE)
2. graded exposure& functional movement training
3. physical activity and lifestyle change

Question 16

STarT Back Classification by Risk Strata

Answer 16

a. tool to stratify patients on the level of psychosocial distress (5 key psychological factors)

b. provides a psychosocial context for classification:
- high risk: psychological obstacles to recovery, enhanced package of care (complex)
- medium risk: physical obstacles to recovery, F2F conservative treatment
- low risk: advice, reassurance & medication

targeted treatments = patients are not all the same

Question 17

Clinical Reasoning in Spine Care (CRISP)

3 essential questions of diagnosis

Answer 17

Q1: any serious medical concerns

Q2: where is the pain coming from?

Q3: what is happening with the person as a whole that would cause the pain experience to develop and persist (physical & psychological factors - whole person)

Question 18

Nociceptive Pain Phenotype

Answer 18

visceral or serious MSK

Question 19

Bottom UP:

Answer 19

MECHANICAL:
Nocioceptive or inflammatory
ex. sprained ankle, periphery up to the brain

Question 20

Top DOWN:

Answer 20

NERVOUS SYSTEM:

severe PTSD, fibromyalgia, central sensitization syndromes, it’s no longer nocioceptive pain, it’s nociplastic pain

Question 21

4 Shortcomings of Classification Systems:

Answer 21

No single system comprehensive enough

some elements difficult to implement clinically/require expert understanding

none consider possibility that some LBP pts are amenable to self-care and don’t need medical or rehab intervention

degree of consideration of psychosocial factors varies greatly

Question 22

Purpose of classification systems?

Answer 22

review strengths/limitation of TBC approach and use current evidence to update the TBC

initial triage with all first-contact providers for LBP patients

establish decision making criteria to triage into 3 categories:

a. medical mgmt
b. rehab mgmt
c. self-care mgmt

use risk stratification and psychosocial tools to determine who needs psych informed rehab

update decision making criteria for triage process

Question 23

2 Levels of Triage

Answer 23

Initial triage by first-contact provider to determine the patient amenable to rehab

secondary triage by a rehab provider to determine most appropriate rehab approach