Unit 4: Classification Principles Part 1 Flashcards
Treatment Based Classification (TBC)
PITT PSP PROGRAM
- Medical Mgmt
a. red flags
b. comorbidities precluding rehab
c. leg pain w/progressive neuro deficit - Rehab Mgmt
a. med to high psychosocial risk
b. low psychosocial risk WITH leg pain
c. minor/controlled comorbidities - Self-Care Mgmt
a. low psychosocial risk
b. predominantly axial LBP
c. minor/controlled comorbidities
TBC Medical Management
a. red flags
b. comorbidities precluding rehab
c. leg pain w/progressive neuro deficit
TBC Rehabilitation Management
a. med to high psychosocial risk
b. low psychosocial risk WITH leg pain
c. minor/controlled comorbidities
TBC Self-Care Management
a. low psychosocial risk
b. predominantly axial LBP
c. minor/controlled comorbidities
Mechanical Diagnosis & Treatment (MDT) / McKenzie
Repeated/sustained end range loading to determine:
a. symptomatic responses: centralization or perhipheralization
b. mechanical responses: reduction in deformity or increased AROM
Mechanical Diagnosis & Treatment (MDT) Classifications
Derangement
Dysfunction
Postural
Other
Pathoanatomic Based Classification (PBC)
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
Pain Phenotypes (IASP)
a. Nocioceptive pain
b. Neuropathic pain
c. nociplastic pain (psychoemotional)
Nociceptive Pain
Mechanism?
Characeteristics?
M: mechanical or chemical activation of nociceptors
C: pain is intermittent & affected by specific movements
Inflammatory Pain
Mechanism?
Characteristics?
M: chemical activation of nociceptors
C: pain is constant and affected by all movements
Neuropathic pain
Mechanism?
Characteristics?
M: neurological injury or disease
C: pain is intermittent or constant, usually affected by specific movements
Nociplastic pain
Mechanism?
Characteristics?
M: central sensitization
C: pain is widespread, hyperalgesia and associated with other somatic complaints
Psycho-Emotional Pain
Mechanism?
Characteristics?
M: intense emotional distress or psychopathology
C: similar to nociplastic pain with overlap of clinical depression or anxiety; requires co-management
Movement System Impairment (MSI)
a. functional classification based on impaired alignment and movements
b. training to induce proper motor control of these impaired movements
(Shirley Sahrmann)
Cognitive Functional Therapy (CFT)
3 Components?
- cognitive training (PNE)
- graded exposure& functional movement training
- physical activity and lifestyle change
STarT Back Classification by Risk Strata
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
Clinical Reasoning in Spine Care (CRISP)
3 essential questions of diagnosis
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)
Nociceptive Pain Phenotype
visceral or serious MSK
Bottom UP:
MECHANICAL:
Nocioceptive or inflammatory
ex. sprained ankle, periphery up to the brain
Top DOWN:
NERVOUS SYSTEM:
severe PTSD, fibromyalgia, central sensitization syndromes, it’s no longer nocioceptive pain, it’s nociplastic pain
4 Shortcomings of Classification Systems:
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
Purpose of classification systems?
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
2 Levels of Triage
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
