By Ian Stephens, PT, DPT, OCS
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Low back pain (LBP) is one of the most common reasons patients seek healthcare.
The national direct and indirect cost of care for patients with LBP continues to escalate. This increased cost of care has not been shown to correlate with improved outcomes.1 For most patients, expensive imaging, opiate drugs, injections and extended treatment courses are not medically necessary.
Healthcare reform is driving transition from a volume-based reimbursement system to a value-based one. Organizations that are able to standardize care around best-practice patterns are better positioned to maximize clinical outcomes. Currently, significant opportunity exists to improve the management of LBP via standardization of care.
Physical therapists are healthcare providers who are frequently involved in the management of patients with LBP. Early access to physical therapy services for these patients has been reported to result in reduced healthcare utilization and costs.2,3
Recent research on physical therapy management of LBP has focused on classifying patients into subgroups based on clusters of signs and symptoms and providing targeted physical therapy interventions for each subgroup. Studies that emphasize interventions based on subgroup classification have reported improved treatment effect sizes compared with studies that deliver physical therapy interventions using a one-size-fits-all model.4,5
Physical therapy low back pain care path algorithm.
In 2013, Cleveland Clinic developed an evidence-based care path to standardize physical therapist management of patients with LBP. The care path emphasizes the use of subgrouping to match patients with treatment interventions that have the highest probability of effectiveness.
The state of Ohio allows physical therapists to evaluate and treat patients without a physician’s referral. The care path was developed to guide physical therapists’ management of LBP patients in a direct-access model. The care path and direct access system was built with full integration into the physician-based multispecialty spine group, which employs nine PM&R physicians.
The care path initially guides the therapist through a standardized red-flag screening process to identify patients who are at high risk for serious pathology. Physical therapists are instructed to refer to a physician if they identify clusters of red-flag findings that are suggestive of serious pathology, such as fractures, cancer or infection. Once red-flag screening is completed, the care path guides the physical therapist to screen for yellow flags.
Assessment of yellow flags in individuals with LBP is an important part of the examination process. Kendall et al. used the term “yellow flags” to detail how psychological, social and environmental factors could place someone at increased risk for prolonged disability.6 Early identification of yellow flags helps identify patients who may have increased risk for prolonged disability.
Cleveland Clinic’s care path uses the STarT Back Screening Tool (SBST) to assess for psychosocial factors that could impede progress.7,8 The SBST stratifies patients into low, moderate or high risk for prolonged disability. Patients who score high via the SBST are considered to have a high level of psychosocial prognostic risk factors. Physical therapists are expected to manage these patients following principles described in the graded activity/exposure subgroup detailed later in this article and/or refer for medical or psychological management.
The care path also guides physical therapists to use a two-item depression screen to identify patients with elevated risk for depression.9,10 Patients who are positive are referred for further medical and/or psychological management.
Once red- and yellow-flag screening has been completed, the care path guides the physical therapist to complete the objective assessment. The therapist uses the findings to classify the patient in one of five treatment subgroups. Each subgroup is named based on the primary physical therapy treatment intervention that should be emphasized in patient management. The subgroups are:
Following are brief descriptions of each subgroup.
This subgroup uses repeated movement testing to determine whether patients present with a directional preference for exercise. The presence of centralization and/or symptomatic or mechanical response to end-range therapeutic loading strategies is used to determine whether a directional preference is present, and to guide what exercises patients are instructed in for their home exercise program.
Patients in this subgroup often benefit from skilled mobilization or manipulation of their lumbar spine to restore normal mobility and reduce pain. Patients often present with symptoms of stiffness or loss of lumbar motion, sharp pain at end range of motion, no pain below the knee and recent onset of LBP.11
Patients in this subgroup frequently lack strength, endurance and coordination of the muscles that provide support and stability to the lumbar spine. Interventions that improve the patient’s ability to gain motor control of the lumbar spine are emphasized.
Patients in this subgroup often exhibit signs of psychosocial distress and may show other signs consistent with chronic pain states. Pathoanatomy is de-emphasized in this subgroup, and the focus is on pain neuroscience education and graded exercise.
This subgroup emphasizes unweighting of the lumbar spine via either mechanical lumbar traction or aquatic physical therapy. Unweighting is used to provide relief of symptoms and to allow patients to attempt to progress to functional exercise.
A standardized documentation template has been developed for the care path and is used at Cleveland Clinic to help clinicians effectively classify patients in the appropriate subgroup. Evidence-informed suggestions for duration of plans of care are included in the template to help standardize utilization of physical therapy resources.
Standardized outcome measures are collected during the patient’s initial visit and at predefined intervals during the physical therapy episode of care to track progress. Outcome data currently being collected include:
Data are being collected to assess whether the implementation of the care path’s standardized assessment and treatment method for patients with LBP leads to improved, value-based care.
Dr. Stephens is a clinical team leader in outpatient physical therapy at Cleveland Clinic. His primary areas of practice are with patients with low back pain, headache and chronic pain.