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sentation of these different segments. ey hypothesized that
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the impairments in motor and postural control often observed
in individuals with cLBP could be due to the cortical reorganization of S2, as S2 often exhibits connectivity with the parts of
the brain associated with premotor planning.
Other research has also tried to link smudging of the cortex
with poor motor control. For example, in 2008, Tsao et al
157
recruited 11 individuals with rLBP and 11 asymptomatic con-
154
trols. As in their previous work,
they measured the muscle
activity as generated from the TMS. However, this time, instead of measuring activation in the erector spinae, they assessed
the activity of the transverse abdominis. Additionally, they also
measured the latency of the activation of the transverse abdominis following an upper extremity movement to evaluate the
feed-forward mechanism. e authors had 3 interesting findings: first, they found that in the individuals with cLBP, the
cortical representation for the transverse abdominis was broader
and less pronounced compared to the asymptomatic controls;
second, the feed-forward mechanism was impaired in the group
with cLBP (although keep in mind the potential pitfalls of this
119-121
assessment);
third, that the cortical reorganization and the
impaired feed-forward mechanism were associated. is led the
authors to conclude that the impaired motor control often observed in cLBP is linked to cortical reorganization.
People with low back pain commonly
suffer from psychological comorbidities
Describing the full relationship between psychological comorbidities and LBP could be a monograph in itself. However,
due to their prevalence and impact, depression, fear, catastrophizing, and stress are 4 psychosocial risk factors worth discussing.
First, there is a clear link between cLBP and depression,
158,159
with the general prevalence of depression among those with
cLBP approximately 3 to 4 times that of the general popula-
160
While depression is not a condition that physical thera-
tion.
pists are well suited to address without additional training, the
recognition of depression is important as it is often associated
161
with poor recovery.
Individuals with cLBP who also exhibit
depression experience greater pain severity and have more functional, social, and emotional disability compared to individuals
with cLBP who do not have this psychosocial comorbidity.
162
Early recognition, often through the use of an outcome measure
163
like the Beck Depression Inventory,
can be a powerful tool to
help the clinician direct the patient to receive appropriate care.
One interesting study that assessed depression as a predic-
164
tor of developing LBP was performed by Jarvik et al.
e authors collected lumbar spine MRI data on 123 veterans with no
LBP. At baseline, upwards of 84% of the participants had some
form of abnormality on their MRI (disc signal loss, endplate
changes, disc protrusion, etc). e authors then performed a
3-year follow-up to see if incidental findings on MRI or baseline
depression levels correlated with future LBP. What they found
was surprising. Self-identified depression at baseline was the
strongest predictor of future LBP, with a hazard ratio (HR) of
2.3 (95% confidence interval [CI] = 1.2, 4.4). Furthermore,
disc protrusions were associated with a lower risk for developing
future back pain (HR = 0.5; 95% CI = 0.3, 0.9). One tentative
conclusion that can be drawn from this study and supported by
the research on the prevalence of asymptomatic bulging discs
is that the psychosocial state of an individual might be a better
predictor of future pain than the presence of abnormal imaging
findings.
Pain catastrophizing is the “tendency to magnify the threat
value of pain stimulus and to feel helpless in the context of pain,
and by a relative inability to inhibit pain-related thoughts in
165
anticipation of, during or following a painful encounter.”
One popular approach to measure pain catastrophizing is to
166
complete the Pain Catastrophizing Scale (PCS),
which is a
13-item outcome measure of pain-related catastrophizing. Several systematic reviews have linked pain catastrophizing with
increased levels of pain and disability, treatment mediation, and
167,168
outcomes following physical therapy treatment.
Further-
more, pain catastrophizing has also been linked to decreased
169
GMV in the DLPFC,
170
surgery,
and even overall psychological distress.
persistent pain, disability following
171
Pain catastrophizing has large implications on not only the status of the
patient, but also their prognosis.
172
For example, Kovacs et al
explored the association between pain catastrophizing and disability in individuals with
cLBP. e study included 33 clinicians who recruited 1461
patients. e researchers collected baseline data for not only
psychosocial factors (eg, pain catastrophizing) but also anatomical factors (eg, radiological findings). After collecting the data,
they performed a logistic regression analysis to determine which
factors could best explain disability in individuals. eir global
2
adjusted R
was 0.387, of which catastrophizing explained 28%
of the disability, whereas severity of LBP only explained 3%.
In other words, catastrophizing was almost 10 times better at
explaining one’s disability than pain severity.
Another study that looked at the physiological effects of
173
pain catastrophizing was performed by Meints et al.
In that
study, the authors recruited 167 individuals with cLBP and 33
asymptomatic controls and performed a series of quantitative
sensory tests that included 2-point discrimination, deep-tissue
pain pressure (as assessed by cuff pressure algometry applied to
the left leg), and mechanical punctate pain. In general, those
with cLBP experienced decreased 2-point discrimination, lower pain thresholds, and increased pain with the mechanical
punctate test compared to the healthy controls. Additionally,
the authors found that within the cLBP group, greater catastrophizing was associated with greater pain and worse outcomes
on the quantitative sensory tests. So not only did those with
cLBP demonstrate signs of sensitization (via poor response to
quantitative sensory testing) but those changes were associated
with increased catastrophizing. Clearly, pain catastrophizing is
an important comorbidity that needs to be both measured and
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17
addressed in the patient with cLBP, which is discussed later in
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this monograph.
Another psychosocial comorbidity that needs to be addressed is fear-avoidance behavior. One of the most well-known
models of how fear-avoidance behavior can contribute to chronic pain was first established in 1995 by Vlaeyen et al
174
and since
its initial publication has been revised and updated to include
current evidence.
175,176
e fear-avoidance model describes how
a similar nociceptive event can lead down 1 of 2 paths: either recovery or chronicity. If a patient interprets the nociceptive event
as non-threatening, they will typically resume their normal activities and, after some trial and error, reach recovery or normalcy. On the other hand, if a patient misinterprets the nociceptive
event and magnifies it, then the patient often exhibits excessive
fear of their pain that will then lead to a reduction of all movement to avoid pain.
175
Soon, they become hypervigilant regarding their symptoms and seek to further protect their perceived
injured area from future damage. is leads to disuse, which in
turn might increase their symptoms. Such hypervigilance and
avoidance of activities might be followed by social withdrawal,
predisposing the individual to depression and deconditioning.
is cycle forms a negative-feedback loop that perpetuates their
spiral of pain and disability.
e underlying issue as it relates to cLBP is the strong
relationship between fear-avoidance behaviors and disability.
Crombez et al
177
sought to validate the statement that, “fear of
pain and what we do about it may be more disabling than pain
178
itself.”
In their study, they recruited 35 patients with cLBP
and examined the relationship between pain-related fear, pain
intensity, and disability as measured by the Roland Morris Disability Questionnaire (RMDQ). ey found that disability was
significantly correlated to all pain-related fear measures (FearAvoidance Belief Questionnaire [FABQ] and Tampa Scale for
Kinesiophobia [TSK]) but not to pain intensity. is led them
to support the notion that pain-related fear is more disabling
than pain itself.
Other researchers have helped to clarify the link between
fear-avoidance behaviors and disability. Trinderup et al
179
reported that high fear-avoidance beliefs at baseline were associated with being on sick leave and having no improvement in
disability and pain at 1-year follow-up. A different longitudinal
study with a 12-month follow-up found that higher baseline
fear avoidance was associated with greater pain intensity and
disability.
180
Finally, a systematic review by Wertli et al
181
found
that high fear-avoidance behaviors had a greater association
with pain and disability for individuals with LBP of 6 months
or less in duration compared to individuals with LBP for greater
than 6 months. is finding suggests that early intervention to
improve the fear-avoidance behaviors as opposed to ignoring
them are important for the long-term care of the patient.
ere has also been a recent focus on the role that stress can
play as not just a risk factor for the development of LBP, but
also for duration and severity of LBP.
182
Stress can be defined
as “a perception of threat, with resulting discomfort, emotional tension, and difficulty in adjustment.”
183
It can be triggered
by a variety of circumstances, such as adverse life events, workplace or residential stressors, etc, and while the full physiological mechanisms behind how stress can perpetuate pain and disability are beyond the scope of this monograph, Hannibal and
184
Bishop
wrote an outstanding review on the topic. However,
to concisely summarize 1 mechanism, stress can increase the
descending facilitation of pain via sensitization and overactivation of a number of pain-related areas in the brain. is means
that stress can increase the nociceptive signals coming from the
periphery. is can have obvious consequences for the patient
with cLBP as any nociceptive input from the periphery will be
enhanced. Fortunately, as physical therapists, we have a range
of interventions that can help the patient whose cLBP might
be worsened by the presence of stress, not the least of which is
physical activity.
185
As is evident by now, back pain is more than just back
pain. ere is a plethora of potential psychosocial contributors
that require considerations in the treatment of LBP. Depression, catastrophizing, fear-avoidance behaviors, and stress are
all part and parcel to LBP. is is exciting news for the physical
therapist as it shows us that there are more ways than previously thought to help our patients, and while daunting as it may
sound, with the proper training, evidence does support the idea
of physical therapists being in a great position to help ameliorate all aspects of LBP, not just the related musculoskeletal deficits and impairments.
181
Predictors for transition from acute to chronic low back pain
As explained above, only a small portion of those with
aLBP transition to cLBP. However, that small portion of individuals consumes an outsized portion of health care resources.
erefore, considerable effort has gone into determining the
factors that predict the transition from aLBP to cLBP. e value
of being able to accurately predict who is going to transition
from aLBP to cLBP cannot be overstated. Being able to guide
those most in need of physical therapy to the appropriate services could have large implications for our health care system.
Not only does early adoption of physical therapy services decrease overall use of health care resources,
tentially improve outcomes.
186
186,187
it can also po-
Attempts to identify anatomical predictors for the transition from aLBP to cLBP have largely been unsuccessful. As stated earlier, the link between anatomical abnormality and pain in
the cLBP population is very limited.
164
et al,
the presence of a disc protrusion was actually a pro-
31,114
In the study by Jarvik
tective modulator, even further limiting the prognostic value
of abnormal disc structure. Furthermore, given the high prevalence of asymptomatic findings of spinal degeneration,
67
it is
hard to imagine these to be high-value prognostic factors in any
scenario. Psychosocial factors perform somewhat better in the
prediction of the aLBP to cLBP transition. Several factors including depression, fear avoidance, and catastrophizing have all
18
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been used to try and predict the transition from acute to chron-
a
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ic pain. However, models attempting to measure the predictive
capacity of psychosocial factors have not fared particularly well.
188
For example, a model proposed by Young Casey et al
in 2008,
which included psychosocial measures of cumulative traumatic events exposure, depressed mood, and pain beliefs, was only
able to account for 26% of the variance in those who developed
persistent pain.
Another approach to predict those who are likely to transi-
tion from acute to chronic pain is through the use of functional
189
MRI. Baliki et al
performed a landmark longitudinal study
attempting to determine if there were any neurosignatures that
would predict the transition from sub-acute to cLBP. ey
recruited 52 participants with sub-acute LBP and 17 healthy
controls. ey performed baseline MRI and functional MRI
year. ey found that for those who had persistent pain at 1
year there was an initial increase in the functional connectivity
between the mPFC and the nucleus accumbens (NA). is was
significant because the increased connectivity was only present
at baseline for those who would go on to develop cLBP, and it
had an 81% accuracy rating in determining who would make
that transition. e authors suggested that as the NA
is associated with reinforcement learning (motivation)
while the mPFC is a region that is involved in the interpretation of intensity of LBP (valuation), the “motivation-valuation” circuitry is critical in the transition to
chronic pain. Essentially, the authors hypothesized that
the NA was contributing to “an aversive teaching signal
that lead to sustained pain.”
e obvious downside to using functional MRI to
predict pain is that it is costly, difficult to use, and few
(if any) patients have access to such expertise. erefore, researchers have tried to see if more clinic-friendly
options are available for determining who will transition from aLBP to cLBP. One such study, performed
190
by Muller et al,
recruited 130 patients with aLBP
and used 14 different quantitative sensory tests to see
if any could predict the transition to chronic pain. After correcting for sociodemographic, psychological, and
clinical characteristics they found that none of the 14
quantitative sensory measures were able to adequately
predict those who would transition from aLBP to cLBP.
An additional study has further supported this conclu-
191
sion.
is leaves health care in a difficult position. Obviously, to date, there is no foolproof method to predict
those who will develop persistent symptoms. Furthermore, the best prediction model available as of now is
not economically feasible or practical. However, there
are several clinically available outcome measures that
may assist the health care professional in making clinical
judgements as to who might need behavioral intervention as well as physical therapy intervention. Probably
the best known is the STarT Back Screening Tool (SBT).
e SBT combines questions from previously validated screening questionnaires that address the domains of pain and function, as well as psychosocial domains like fear-avoidance beliefs,
depression, and catastrophization (Figure 2). is 9-item questionnaire can be easily administered and scored in a clinical environment. Based on the score, the patient is then stratified into
1 of 3 groups: low, moderate, or high risk for persistent LBP
related disability. Patients in the high risk category are more
likely to have a greater extent of biobehavioral comorbidities
influencing their condition and a psychobehavioral approach
should be central to the provided interventions. A recent study
by Katzan et al
194
found that the SBT, especially when used in
conjunction with the Modified low back pain Disability Questionnaire (MDQ; also known as modified Oswestry) was able to
adequately predict those who would respond well to treatment
and those who would maintain a high level of disability following physical therapy intervention. A therapist might choose to
use the SBT as a starting point to determine the need for further outcome assessments, and even use the answers which were
indicated as positive by the patient to help drive treatment. For
example, should the patient indicate that, “It’s not really safe for
Figure 2.
a
Reprinted with permission from Jonathan Hill and Keele Univer-
STarT Back Screening Tool
a
sity (https://startback.hfac.keele.ac.uk/)
192,193
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19
a person with a condition like mine to be physically active,” the
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therapist could offer education that the back is a resilient structure and it is safe to move. Other studies have also shown that
the SBT is able to help provide prognostic information to the
physical therapist as well as, when used correctly, help reduce
health care costs and improve overall outcomes.
192,195
Another outcome measure that has been developed to assist
therapists in screening for risks of a poor prognosis is the Orebro
Musculoskeletal Pain Questionnaire (OMPQ).
196
e OMPQ
is a 25-item questionnaire that borrowed items from previously
validated questionnaires to evaluate the main psychosocial risk
factors for chronic musculoskeletal pain. e OMPQ stratifies
the patient into 2 separate categories: “at risk” and “not at risk.”
Several recent systematic reviews have found the OMPQ to be
moderately capable of determining which patient is going to
have higher pain rating scores at 3 and 6 months; however, the
general consensus from the systematic reviews was that in most
instances the SBT was the superior instrument.
197,198
A word of caution: these instruments are not perfect. Until
future research provides a “perfect” tool in determining which
patient needs which intervention, the SBT might be the best
option available to the clinician. However, both the SBT and
the OMPQ can have a tendency to under-estimate the risk of
an individual developing chronic pain.
199
erefore, it is important for the clinician to not solely rely on the outcome measure but to synthesize all available information obtained from
the evaluative process to come to the best possible prognosis for
the patient.
Take Home Messages
• Acute LBP has a very favorable prognosis with about 72%
of individuals experiencing complete recovery within 1
year of diagnosis; however, recurrence is common.
• Chronic LBP has a less favorable prognosis with only
about 41% recovering within a year; however, only
about 11% experience prolonged disability.
• Anatomical variations (eg, bulging/herniated discs, stenosis, Modic changes, etc) are very common and do not
regularly denote pain.
• Structural changes in the DLPFC are common in individuals with cLBP, indicating a decreased capacity to
mitigate the magnitude of perceived pain. ese changes
can be reversed with successful treatment.
• Non-structural changes associated with LBP include
changes in motor control, enhanced ascending nociceptive and descending facilitatory pathways, decreased
descending inhibitory pathways, and altered brain activation. is results in poor movement and a heightened
pain response to nociception.
• Changes in cortical organization (ie, smudging) are related to both the magnitude of pain and motor control
deficits.
• People with LBP frequently suffer from depression, pain
catastrophization, fear, and stress.
• While there are no guaranteed methods to predict who
will transition from acute to chronic LBP, the SBT is
an easily used screening tool that has promise to classify
patients.
EVIDENCE-BASED GUIDELINES
What Makes the “Best Evidence”?
Evidence-based practice revolves around 3 primary pillars:
empirical research, clinical expertise, and patient perspectives
and values. However, one important question to ask is, “what
makes up the evidence?” e most foundational type of evidence comes from mechanistic studies that seek to address the
mechanisms of actions at the tissue or cellular level. For example, these studies seek to elucidate the mechanisms of spinal
manipulation on cortical activity or how electrical stimulation
can help inhibit the transmission of nociception to the brain.
e next step generally revolves around efficacy studies. is
form of evidence seeks to assess the effects of an intervention
on a specific outcome in a very controlled manner. It seeks to
determine if it is plausible that the intervention will work in the
predicted manner. By necessity, these studies often limit their
external validity (occasionally to the point where it is no longer
clinically feasible) to ensure that they are truly assessing if the
intervention will work or not. Effectiveness studies, the next
step, generally measure outcomes for treatments that are applied
in a more realistic clinical environment. Often these studies use
a semi-standardized approach that allows for subtle changes
based upon the unique aspects of the patients. Finally, there
are trials that look at the comparative effectiveness between interventions. ese studies seek to address which intervention
when applied in a pragmatic clinical environment produces the
optimal results. e creation of evidence-based guidelines requires the thoughtful integration of the outcomes of all these
research designs.
The Benets of Evidence-Based Guidelines
Evidence-based guidelines are generated by a panel of ex-
perts who make treatment recommendations based on summaries of high quality research. ey are meant to be a resource for
clinicians who want to provide evidence-based interventions in
hopes of providing optimal outcomes for their patients. With
the number of randomized controlled trials (RCTs) in LBP
doubling since 2010, guidelines need to be updated on a regular
basis to ensure that the best available evidence is making its way
toward the physical therapist.
for clinicians to adequately adopt guidelines
200
is can often make it difficult
201
even when evi-
20
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dence has shown that when clinicians adhere to the guidelines,
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clinical outcomes improve and costs decrease.
202,203
While it is beyond the scope of this monograph to review
each of the current guidelines available for the physical thera-
200
pist, Oliveira et al
in 2018 published an updated overview.
In their review several key factors stand out. For example, they
noted that all of the guidelines recommended against the use
of routine imaging, with 58% of the guidelines recommending
imaging only in the presence of red flags. Assessment of yellow
flags (eg, psychosocial factors) was highly recommended during
the first or second patient visit in the majority of the guidelines.
Education and reassurance were also important. e majority
of guidelines recommended education for aLBP on the central
theme that the condition “is not a serious illness regardless of
the duration of symptoms” and that for the patient with aLBP
their prognosis is favorable. Furthermore, most guidelines also
endorsed the use of cognitive behavioral and multidisciplinary
approaches for cLBP. Other key findings included exercise being almost universally supported for cLBP while support for
acupuncture and spinal manipulation were generally mixed.
200
Before concluding their overview, Oliveira et al
noted
that there were generally very few changes in the recommenda-
204
tions since their last overview in 2010
despite a near doubling
of the available research. More guidelines now recommend
using validated screening tools like the SBT or OMPQ and
recommend non-steroidal anti-inflammatory drugs (NSAIDs)
and antidepressants (where needed) over paracetamol. However, exercise remains the mainstay of physical therapy treatment.
In summary, they concluded that for aLBP the best treatment
options based on current clinical practice guidelines remain patient education and reassurance regarding the favorable prognosis for their condition, avoidance of bed rest, resumption of
normal activities, and the use of NSAIDs or weak opioids for
a short period of time. For cLBP, they concluded that the best
treatments include use of NSAIDs and antidepressants where
needed, exercise, and psychosocial interventions. Furthermore,
in the event of a serious pathology or if there is no improvement
after 4 weeks, a referral to a specialist is recommended.
Limitations of Evidence-Based Guidelines
A common concern with clinical guidelines is the heterogeneity of non-specific LBP. As such, the strict application of
guidelines (or any treatment for that matter) may not be the
best available treatment for a particular patient. Each patient
presents with unique biases. Remember, one of the pillars of the
evidence-based model is patient perspectives and values. erefore, a clinician must take into consideration a specific patient’s
unique characteristics, presentation, and treatment preference
when deciding upon a plan of care. For example, if a patient
with aLBP is presenting with all the criteria for the spinal ma-
205
nipulation clinical prediction rule
(eg, duration of LBP of
less than 16 days, no symptoms beyond the knee, greater than
19 points on the FABQ, 1 or more hypomobile segment in the
lumbar spine, 1 or both hips with greater than 35° of internal
rotation range of motion [ROM]) but has an aversion to spinal
manipulation, then a clinician obviously should not perform
the technique.
Take Home Message
• Evidence-based guidelines have remained relatively stable over the past 10 years and generally recommend exercise as a mainstay of physical therapy treatment and
patient education that aims to reassure the patient and
encourage resumption of regular activities
PHYSICAL THERAPY EVALUATION
Physical Therapist Screening Flags
Red flags and their use to screen for
serious medical conditions
As every state now has some form of direct access for phys-
ical therapy services, it is imperative that clinicians know how
to properly identify which patients require a referral for medical evaluation. Failure to identify when a patient’s symptoms
are not of musculoskeletal origin puts the patient at risk for
more serious health conditions and can delay important medical treatment. With physical therapists being recognized as
first-line providers for treating musculoskeletal conditions,
the responsibility for adequate screening grows. Fortunately,
physical therapists have a long history of performing medical
screening. For years physical therapists have been providing direct-access medical screening in the United States military setting as is done in many other countries. Studies have suggested
that physical therapists are able to successfully screen for more
207
serious pathological conditions
hood of missed serious conditions.
performed by Mintken et al
and do not raise the likeli-
208,209
208
found that over the course of a
In fact, a recent study
10-year data collection period there was not a single reported
case where a physical therapist treating in a University Student
Health Center missed a serious medical pathology. During this
time period, approximately 13 000 patients were seen without
referral. By having physical therapists perform medical screening in the direct access clinic, there is the potential for rapid
intervention in a relatively low-cost scenario with decreased reliance on radiographs and diagnostic tests.
Effective screening of the orthopedic patient requires the
correct interpretation of red flags, ie, those specific findings
that have been associated with increased likelihood of serious,
non-musculoskeletal pathologies. For some patients, this is easy,
as they will have obvious signs and symptoms such as fever, skin
rash, worsening of neurologic signs, or weight loss, for examples. ese signs and symptoms are clear indicators that there is
something occurring that is beyond the scope of physical therapy that requires referral to a physician. As LBP is one of the
leading diagnoses seen in the physical therapy clinic, it is imper-
206
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21
ative for the physical therapist to appropriately screen each and
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every patient. As such, the identification and documentation of
red flags have become a core component of entry-level physical
210
therapy curricula and part of the standard evaluation.
As the sheer number of red flags have grown over the years
and the time constraints on the physical therapist grow, a concise review-of-systems screening tool, the Optimal Screening
for Prediction of Referral and Outcome – Review of Systems
211
(OSPRO-ROS), was created by George et al.
To create the
OSPRO-ROS, they first reviewed the literature to develop a
comprehensive list of previously reported red flag symptoms
and signs. After an exhaustive search, they found a total of 97
potential red flags that could indicate a patient’s symptoms or
signs are not of musculoskeletal origin. ey recruited a total
of 431 patients with musculoskeletal pain to complete a survey
including these 97 potential red flags. Of those who completed the survey, 91.2% reported having at least 1 red flag. From
these data, they were able to condense the 97 potential red flags
into a 10- and 23-item review of systems screening tool that
captured 94.7% and 100% of all positive responders, respectively. e authors suggested that the clinician use this tool in a
2-step manner. For example, the first step could be in giving the
patient the 10-item tool. If the patient had a positive response,
the clinician could then perform a more in-depth review of
systems. If the patient had a negative response, they clinically could choose to then proceed with the 23-item tool if they
wanted to be fully confident that a further review of systems is
not necessary.
While it is important for physical therapists to correctly
identify red flags, it is equally important to know that the presence of a single red flag may have limited diagnostic value. For
212
example, Henschke et al
performed a study to assess the prevalence of red flags and serious spinal pathologies in patients presenting to primary care with spinal pain. ey recruited a total
of 1172 patients and upon their initial evaluation recorded the
patients’ response to 25 red flag questions. Only about 1% of
the population seeking care for spinal pain had a serious pathology (the majority of which were spinal fractures) while 80% had
at least 1 red flag. is indicates that some red flags have a very
high false-positive rate, limiting their use in isolation. Because
of this, clustering red flags to create diagnostic prediction rules
might be a better alternative than using single red flags.
212
Henschke et al
proposed a cluster of red flags aimed at
diagnosing spinal fractures. Based on data from the above study,
the authors found that only 3 of the 4 “classic” red flags for fracture had an informative positive likelihood ratio (+LR). ose
were: prolonged use of corticosteroids (+LR = 48.5), significant
trauma (+LR = 10), and age greater than 70 years (+LR = 11).
From these 3 variables, plus the variable female sex, they created
a diagnostic rule for vertebral fracture. If 1 variable was positive,
the +LR was 1.8, with 2 positive variables the +LR increased to
15.5, and with 3 positive variables the +LR increased to 218.3.
ey were unable to calculate 4 positive variables as no one in
their cohort exhibited all 4.
It needs to be stressed that the use of red flags does not
excuse the physical therapist from using clinical judgement. As
an example, in a recent study, 64% of patients with spinal ma-
213
lignancy had no associated red flags.
by Henschke et al,
212
none of the red flags had a negative like-
Similarly, in the article
lihood ratio (-LR) that even remotely came near 0, meaning
that a negative finding cannot rule out the presence of a spinal
fracture. Simply stated, if a clinician was using only red flags to
guide their clinical judgement, there is a strong chance that they
would have missed one of these patients with serious pathology,
resulting in delayed treatment. Red flags are simply one piece of
the puzzle that need to be interpreted in the broader context of
the whole patient. Nothing can replace a thorough medical history, and if safe, a thorough physical examination. For a further,
more in-depth and recent analysis of red flags as it relates to
potential serious spinal pathologies, the reader is encouraged to
review the recent international framework for red flags that was
put forth by Finucane et al.
214
However, red flags should only
supplement the rest of the clinical findings.
Yellow flags can help with patient prognosis
Yellow flags are generally defined as psychosocial risk factors for the development of persistent pain. ey can include
such domains as fear-avoidance behaviors, incorrect beliefs regarding one’s condition, pain catastrophizing, hypervigilance,
depression, and social withdrawal (Table 3). We have already
established the importance of assessing for psychosocial risk factors when evaluating the patient with cLBP. To reiterate, several
studies have demonstrated that psychological factors are more
strongly associated with the patient’s outcome than physical
factors. For example, one study has found that depression has
a stronger link to the development of chronic symptoms than
the presence of degenerative changes on spinal imaging,
164
while
another demonstrated that psychosocial variables are better able
to predict disability than vertebral end plate changes.
215
However, despite their apparent success in being able to assist the
therapist in the prognosis of a patient, they are not widely used
in the clinic.
216
One reason may be that, much like red flags, the
shear breadth of yellow flags makes it difficult to assess each one.
As stated above, they cover a wide variety of domains and limiting assessment to pain catastrophizing, fear-avoidance behavior,
and depression is not enough to adequately screen for all yellow
flags. To address this lack of implementation and to standardize
the process, Lentz et al
216
devised a yellow flag assessment tool
they called the OSPRO – Yellow Flag (OSPRO – YF) assessment tool. Using a similar approach to the development of the
OSPRO – ROS, they identified validated questionnaires that
were representative of 3 separate domains of psychosocial distress: negative mood, fear avoidance, and negative affect/coping. After initially incorporating 136 unique questions from 10
validated questionnaires, they were able to narrow the scope to
22
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Table 3.
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Common Yellow Flags Encountered in Physical erapy Practice
Yellow Flag Clinical Presentation
Fear-avoidance behaviors Reluctance to participate in any activity that might increase symptoms
Incorrect beliefs regarding exercise Belief that any exercise or movement that hurts their low back causes physical harm
Pain catastrophizing Constant ruminating on one’s pain while magnifying the threat the pain poses
Hypervigilance Constantly on guard for threats to one’s safety and well-being
Depression Persistent feeling of hopelessness or sadness that can result in a loss of interest in
one’s previous endeavors
Social withdrawal Reduction in social interaction with friends, family, or other supportive interper-
sonal relations
10 or 17 items depending on the version. Upon a separate validation study, they found that the OSPRO-YF was able to help
assist in the prognosis of patients with cLBP.
217
A great tool for the clinician is the OSPRO-YF Assessment
Tool Scoring Portal that can be found on the Academy of Orthopaedic Physical erapy website (https://www.orthopt.org/
yf/). is tool helps the clinician not only score the OSPRO-YF
but to help derive the psychosocial domains that might be pertinent to the patient by allowing the physical therapist to see
which positive responses correlate to which parent questionnaire. is allows the therapist to know which domain, be it
fear, pain catastrophizing, anxiety, depression, etc, the patient is
most affected by; thus allowing the clinician to tailor the treatment specific to the patient’s needs.
ere are some clear clinical concerns relating to the
screening of yellow flags. Just as is true for red flags, not all yellow flags necessitate an immediate referral to a behavioral health
expert. While a consultation is appropriate for a patient having
a serious mental health disorder, it is normal for people with
cLBP to experience some depression, inappropriate beliefs, pain
catastrophizing, etc. A more appropriate role for the physical
therapist in many situations is to provide specific advice and
support tailored to the patient.
218
is is best addressed through
the use of a psychologically informed physical therapy (PIPT)
approach. Immense work and number of studies have gone into
the development of PIPT practice and how it can be integrated
in one’s practice to address the psychosocial factors that act as
potential obstacles to a patient’s recovery. is work will briefly
be outlined later in this monograph.
In addition to yellow and red flags, orange, blue, and black
flags have been described. Orange flags indicate that the psychosocial symptoms of the patient reach the level of psychopathol-
219
ogy.
Blue flags relate primarily to injured workers and how a
patient’s perception of their work might impair their return to
work status.
220
Examples include physical job demands, ability to modify work, job stress and satisfaction, workplace social
support/dysfunction, and fear of re-injury. ese occupational
factors clearly influence low back related disability and should
be identified when possible. Black flags encompass the broader environment or context in which the other flags operate.
221
Examples can include professional culture, reimbursement, or
health care policy, as well as cultural and economic factors.
Components of the Assessment
e challenge of using special tests to
diagnose pathophysiology in the spine
As was made evident in the preceding section, the contribution of abnormal anatomy on an individual’s symptoms is
tenuous at best. is makes it difficult to correlate any particular components of a physical examination to a specific pathoanatomical diagnosis. Even if a test was able to rule in or out
the presence of abnormal anatomy (which is highly suspect),
it would still be unknown if the abnormal anatomy is what is
responsible for the patient’s pain due to the high prevalence
of asymptomatic spinal abnormalities. Furthermore, due to
the high prevalence of asymptomatic spinal abnormalities, the
clinimetrics of current special tests in the spine may be over-inflated. For example, studies that attempt to assess the sensitivity
of a provocation test (eg, straight leg raise) in the diagnosis of
a pathoanatomical finding by their very nature exclude asymptomatic participants. A specific example of this can be found
222
in a recent systematic review performed by Tawa et al
that
pooled data from 12 studies that assessed the diagnostic accuracy of clinical neurological test in diagnosing lumbar radiculopathy due to disc herniation or other pathoanatomical variations
in the lumbar spine. Not a single one of the 12 studies included
asymptomatic participants. By doing so, each of these studies
will artificially inflate the sensitivity of each test because they
are excluding a large portion of the population who might have
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23
the “pathoanatomical” feature but, due to being asymptomatic,
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would test negative.
Neurological examination
Clinical tests whose primary objective is to determine the
nature and location of the neurological involvement do not do
well when held to rigorous investigation. Hancock et al
223
performed a study where they recruited 283 patients with sciatica
and confirmed disc herniation to undergo a clinical examination that included tests for sensation (dermatomes), muscle
strength (myotomes), and reflexes. ey found that the diagnostic accuracy was low for each of the index tests in predicting the location of the lumbar herniation. Even when used in
combination with other index tests, the accuracy never reached
levels that could be considered clinically meaningful. Interestingly, a high proportion of the study participants had absent
patellar reflexes bilaterally and had to be rated as normal due to
the difficulty of eliciting a reflex. is conclusion is bolstered by
other studies that have found the clinical utility of neurological
testing procedures in diagnosing disc herniations or nerve root
impingements to be of limited value.
222,224-226
As it relates to radicular pain, and in particular the capacity
to diagnose a patient based on the dermatomal location of the
radicular pain, the evidence has demonstrated that dermatomes
are largely unreliable. In fact, a recent study performed by Furman and Johnson
227
found that the buttock, posterior thigh,
and posterior calf are all equally likely to experience pain when
an individual receives a fluoroscopically guided lumbosacral
transforaminal epidural injection to either L3, L4, L5, or S1
level. is clearly differs from the dermatomal distributions that
physical therapists have been previously exposed to where one
might expect the anterior knee or medial leg to be affected by
an L3 radiculopathy. Other studies have demonstrated that L5
and S1 are especially difficult to differentiate from one another
and tend to refer pain down the entirety of the posterior lower
extremity.
228,229
is should not be interpreted as an argument
against the value in assessing the integrity of the patient’s sensory system. Quite the opposite, in fact, as the one thing that
all the above studies demonstrated was that when a nerve root
has been proven to be compromised, pain radiates down the
leg. In fact, in the study by Hancock et al,
223
almost every participant experienced either a dermatomal, myotomal, or reflex
abnormality, indicating that the physical therapist absolutely
should perform neurological screening in patients with LBP.
ese studies simply demonstrate that an abundance of caution
should be taken when trying to make diagnostic conclusions
about the exact nature and location of the patient’s pathology
based on the findings of a neurological examination.
Physical examination
e role of postural assessment in the examination of low back
pain. Postural assessment, both static and dynamic, is a com-
mon evaluative technique that is used in the physical therapy
clinic. Often, patients are given extensive education on the
proper (optimal) way to sit or bend with the stated purpose to
keep the spine as safe as possible. e problem is that as physical
therapists we do not always agree on what proper (optimal) posture is. As it relates to sitting, a study performed by O’Sullivan
230
et al
surveyed 295 physical therapists and asked their opinion
on which of 9 presented postures was the most optimal. Almost
85% of the respondents chose the same 2 of the 9 postures,
but these 2 most popular postures were very different from one
another. is finding was later supported by a follow-up study
in which 544 physical therapists differed on their opinions of
what proper sitting and standing postures are.
231
Furthermore,
as it relates to bending, a recent systematic review with a meta-analysis found that there was low quality evidence that greater
lumbar spinal flexion was not a risk factor for developing LBP.
Further research is needed to better understand this link and the
clinical utility, therefore, currently linking greater lumbar spine
flexion to LBP is tenuous.
232
For a better understanding of how
a physical therapist can integrate posture into their evaluation
and treatment of LBP, the reader is encouraged to review the
excellent viewpoint written by Slater et al.
233
However, there is
one particular message that should be highlighted. As it relates
to treating patients with LBP, helping them find a posture that
is more relaxed and comfortable, and coupling that with education on how their posture is safe, can provide symptom relief.
Range of Motion. While it is not the intent of this monograph to review every aspect of the standard physical examination, the ROM assessment deserves extra attention for 2 reasons.
First, as stated above, people in pain move differently. In addition to alteration in muscle timing and stiffness, several studies
have found that when compared to asymptomatic individuals,
those with cLBP demonstrate greater lumbar spine excursion
during the initial portions of functional tasks like forward
bending.
234,235
ose with LBP tend to display greater upper
lumbar excursion during the initial 25º to 50º of motion while
limiting the amount of concurrent hip flexion. Furthermore,
this increase in early lumbar motion correlated with self-reporting of functional limitations.
236
Clinically this matters as the
majority of functional activities performed throughout the day
primarily use the first 50º of motion in the lumbar spine. us,
as proposed by Marich et al,
235
if an altered lumbopelvic rhythm
is observed during ROM assessment, targeted exercise that provides challenging, repetitive practice with the aim of modifying
the altered movement pattern may be called for. However, it
should be noted that efficacy of such an approach has not been
studied and that based on the current evidence, it is difficult to
determine if the change in lumbar flexion causes the LBP or if
LBP causes the change in lumbar flexion.
Second, when assessing ROM for the quality of the movement, it is also important to note if a particular motion can
reproduce a patient’s chief complaint. First developed by Geoffrey Maitland,
237
the concept of a comparable sign (CS) and
its relationship to a patient’s chief complaint is often used to
direct treatment.
238
When trying to find a CS that reproduces
24
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a patient’s chief complaint, research has found that the ROM
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assessment is the aspect of the physical examination that is most
238
related.
erefore, when trying to assess what is functionally
contributing to a patient’s pain, it is important to do a thorough
ROM assessment.
Take Home Messages
• Serious diseases masquerading as LBP are relatively rare
with a single red flag having limited diagnostic value. It
is better to base clinical decisions on clusters of red flags
and professional judgement.
• Yellow flags can assist the therapist in the prognosis of
patients with LBP and can be readily identified by the
OSPRO-YF. Additionally, with a better understanding
of the psychological variables underpinning the patient’s
condition, yellow flags can help guide the therapist’s
treatment. However, just like red flags, a single yellow
flag does not necessitate a referral to a behavioral health
expert.
A neurological examination is an important part of the
•
lumbar spine evaluation. However, it should not be used
to infer a specific pathoanatomical diagnosis or to determine where the problem is in the spine.
• A thorough ROM assessment that evaluates both quality
and pain reproducibility can provide important information during the examination.
Movement-Based Classication Systems
One of the difficulties facing physical therapist treating
LBP is that the patient population is very heterogeneous. To
address the heterogeneity and to individualize treatments, researchers have attempted to develop movement-based classification (MBC) systems to subgroup patients based on specific
characteristics, and then match those subgroups with tailored
239
interventions.
Common MBC systems include Mechanical
Diagnosis and Treatment (MDT); Movement System Impairment; O’Sullivan Classification; Pathoanatomic Based Classifi-
239
cation; and Treatment-Based Classification (TBC).
Due to its
popularity and the fact that the treatment approaches within are
linked to the American Physical erapy Association’s clinical
practice guidelines for LBP, the TBC will be discussed in further
240
detail.
et al
2016 by Alrwaily et al.
e TBC was originally developed in 1995 by Delitto
241
and has been updated in 2007
240
While this monograph will provide
242
and most recently in
a discussion outlining the key characteristics and the strengths
and weakness of the TBC, the reader is encouraged to review
the original papers to get a broader appreciation for the sys-
240
In its current form, the TBC describes 2 levels of triage:
tem.
the first being at the initial contact of a health care provider
while the second occurring at the level of the rehabilitation provider. Triage at the first level can be completed by any health
care provider and seeks to direct care to 1 of 3 different avenues:
medical management, self-care, or rehabilitation management.
Medical management is reserved for those patients who have
positive clusters of red flags or where the presence of serious
comorbidities, like central sensitization, is suspected. Self-care
is reserved for those patients who have a favorable diagnosis and
are unlikely to develop disabling or cLBP. ese patients can
be identified using the tools described earlier (eg, the STarT
Back Screening Tool, the OMPQ, etc). e TBC recommends
that these patients be treated similarly to what is proposed by
200
Oliveira et al;
that is with reassurance, education regarding
the favorable prognosis for aLBP, and advice to resume regular
activity. e final level of triage is the one most frequently used
and is reserved for those patients who are appropriate for rehabilitation management.
Once referred to rehabilitation management, the physical therapist then confirms that the patient is appropriate for
physical therapy by screening for red flags and using outcome
measures to ensure that the patient would not be better served
with self-care. Once the therapist is assured that rehabilitation
management is the correct venue for the patient, the patient
is then matched to 1 of 3 rehabilitation approaches: symptom
modulation, movement control, or functional optimization.
240
Symptom modulation is reserved for those who, during the
initial evaluation, report high pain, high disability, and a volatile symptom status. ese individuals are initially treated with
directional preference exercises, manual therapies, traction,
and active rest. Once the disability level has reduced to a more
moderate level, with the symptoms being stable and the pain
moderate to low, individuals move into the movement control
approach. Individuals within this group are treated with sensorimotor, stabilization, or flexibility exercises. Once the disability level is low, the symptoms controlled, and the pain low
to absent, individuals then proceed to functional optimization
where they are given strength and conditioning exercises, work
or sport-specific tasks, aerobic exercises, and general fitness exercises. It should be stated that one need not start in the symptom modulation group and linearly proceed down the chain;
rather, the individual is placed in the group dictated by their
symptoms and can change treatment paradigms based on their
current presentation.
e most recent iteration of the TBC has addressed several flaws of the previous versions. First, this updated version
takes into account that there are individuals who might not be
appropriate for rehabilitation management, and could either
self-manage or are in need of medical management. Second,
it takes into account the biopsychosocial model and stresses
the importance of risk assessment and the need to address psychological comorbidities. ird, in the 2016 edition, individuals can only be classified into a single subgroup whereas the
243
previous versions allowed for substantial overlap.
Lastly, the
TBC has linked the recommended treatment approaches to the
American Physical erapy Association’s most recent clinical
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25
practice guideline for LBP. However, despite all these advances,
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there are still some lingering concerns about the TBC.
One concern regarding the most recent iteration of the
TBC is that there is not a lot of evidence to support the efficacy
of such an approach. While evidence suggests that classification based on previous iterations is reliable between raters and
244-246
that most patients are able to be classified,
the evidence for
the 2016 iteration is lacking. Furthermore, recent studies have
called into question the efficacy of the TBC approach, showing
that patients who received matched treatment care did no better
239,247,248
than those who received unmatched care.
ese findings
are similar to other studies that have found no difference when
comparing matched care to unmatched care in other MBC sys-
239,249,250
tems.
PHYSICAL THERAPY INTERVENTIONS
Physical Therapists are Effective
in Treating Low Back Pain
While there is much work to be done in improving physical
therapy’s efficacy in treating LBP, do not think too little of what
physical therapists can offer our patients. Physical therapists are
among the best options in the current health care environment
for the treatment of LBP. In fact, the long-term outcome between physical therapy and surgery for pain reduction is similar
in many instances.
a study performed by Delitto et al
compared the effectiveness of surgery or physical therapy in the
treatment of lumbar spinal stenosis. A total of 169 patients were
enrolled in the study. ey found that function, as measured by
the Short Form-36, was remarkably similar between the surgery
group (mean [95% CI] = 49.5 [43.1, 55.9]) and the physical
therapy group (47.6 [40.7, 54.4]) at 2 years follow-up, with
the difference between the groups not statistically significant.
What is even more interesting is that the success rate (defined
as a greater than 0.5 standard deviation improvement at 2-year
follow-up relative to baseline) was similar between the surgical
group (61%), the physical therapy group (52%), and for those
who crossed over from the physical therapy group to surgery
(55%). is suggests that cLBP is a complicated condition for
which successful treatment, for nearly 40% to 50% of the patients, currently eludes both surgeons and physical therapists
alike. Another interesting finding from this study was that
among the total eligible patients, 65% declined to participate
citing the fact that they were reluctant to take the 50% chance
of being assigned to the physical therapy group, electing to undergo surgery instead. Also, 57% of the patients in the physical
therapy group crossed-over to the surgery group over the 2-year
period. Even though physical therapy and surgery ended up
having similar outcomes (with physical therapy having fewer
and less severe complications), many patients were reluctant to
try the non-surgical approach. is shows that as a profession
physical therapists need to do better informing the public of
the value physical therapy brings to health care. e primary
251
An excellent example of this was shown in
252
published in 2015. ey
message of conservative, nonsurgical treatment of cLBP being
equivalent to surgical care for the treatment of lumbar spinal
253
stenosis has been reinforced by both a Cochrane Review
a recent meta-analysis.
251
and
While the physical therapist has numerous tools in the
proverbial toolbox for treating LBP, this monograph will focus
on the most common. Specifically, it will focus on therapeutic exercise (stabilization, motor control, directional-based, and
general), manual therapy (mobilization, manipulation, and dry
needling), aerobic exercise, and education.
The Evidence (For Once) is Conclusive:
Exercise is Good
As stated earlier, the most current clinical practice guidelines recommend a general return to activity for those with
aLBP. erefore, as almost all guidelines recommend exercise
therapy for the treatment of cLBP, the following section will
be dedicated to the research for that population. While the
need for higher quality studies with longer follow-up times is
the mantra of all systematic reviews and meta-analysis, there
is a general consensus that exercise is good for cLBP.
254
A 2017 systematic review by Wong et al
states, most guide-
200,254-258
lines for treating cLBP recommend staying active and exercising. Furthermore, several meta-analyses and systematic reviews
have found exercise, especially when combined with education,
255-257
is capable of preventing LBP.
In fact, a recent meta-analysis
that analyzed individual data of more than 3500 study participants found that exercise was more effective than no treatment
or usual care on pain reduction, improvements of functional
258
limitations, and global recovery.
So clearly the question is
not, “should I give my patient some exercise?” as the unequivocal answer is, “yes, you should.” e better question becomes,
“which exercise should I give my patient?”
Motor control exercises are a valid and effective treatment
259-261
for cLBP.
As mentioned above, individuals with LBP move
differently and exhibit alterations in their motor control. e
general premise behind motor control exercises is that the alterations in motor control and muscle activation in individuals with cLBP will result in altered spinal loading, which will
ultimately result in spinal pain. Motor control exercises aim
to target the deep trunk muscles to actively stabilize and im-
116
prove cLBP symptoms. While first described in 1996,
they
have steadily gained in popularity in the clinic. Fast-forward
to 2009, a systematic review of 14 studies demonstrated that
motor control exercises are superior to minimal interventions
for pain reduction at all time points and for disability at longterm follow-up.
259
Furthermore, a 2016 Cochrane Review
260
that examined the effectiveness of motor control exercises for
nonspecific LBP found that, when compared to minimal intervention, the evidence demonstrated that motor control exercises improved pain and function. e one caveat in both of
these systematic reviews is that motor control exercises perform
26
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