Predicting Which Patients Will Not Respond to Physical Therapy

downing

We are lucky to feature a guest post from Christie Downing, PT, DPT, cert MDT, ICLM.  Christie works at Alexian Brothers Rehabilitation Hospital in Elk Grove Village,  IL.  She specialize in musculoskeletal care as well as lymphedema management.  She is a MDT credentialed provider and student in the Diploma level of MDT, focusing primarily in MDT in both spine and extremity problems. 

 

Predicting Which Patients Will Not Respond to Physical Therapy

Now, I love my profession as much as the next PT, but I think I am realistic when I say that PT cannot fix everyone’s problems. I’ve come to realize that predicting positive outcomes of intervention is only one side of the coin, and that we must also be able to predict who will not respond to physical therapy. Often times, the medical community is not privy to such predictors and focus their attention simply on an imaging study or other medical test.

If you have been followed this blog, you will find my previous post about Mechanical Diagnosis and Therapy (MDT) and its ability to predict annular competence in the lumbar intervertebral disc. In MDT, we often focus on the predictive abilities of centralization in those with a derangement syndrome to indicate GOOD outcomes.  This has been shown in several articles, include some of my favorites listed in the below references.1,2,3,4,5 

However, a truly great therapist must also recognize when improvement by physical therapy just “isn’t in the cards.”

For those who practice MDT, this includes those with “irreducible derangement” which has specific diagnostic criteria for inclusion in this category. The predictive ability of failure to centralize in the irreducible derangement has exceptionally high predictors of chronic disability.3,6

Werneke and Hart showed this well in a study of 223 subjects with acute low back pain.  The authors assessed 23 different psychosocial, clinical, and demographic factors in an attempt to determine predictive values of chronic disability.  Of the 23 different variables, the strongest predictive variable to chronic low back pain and disability was noncentralization of pain.  This has been shown by Skytte et al as well.

 

Rapidly Reversible Low Back Pain

I’d like to pause for a moment and briefly discuss Rapidly Reversible Low Back Pain by Ronald Donelson, MD, MS. This was also Mike’s Book of the Week in the past.  In this book, Dr. Donelson critically examines our current state of diagnostic triage of those with low back pain. He takes a painfully realistic look at current practices and investigations among both the medical and allied health professions and highlights their shortcomings. Dr. Donelson has invested much time in investigating conservative care of low back pain and has taken a particular interest in MDT. So why does an orthopedic spine surgeon want anything to do with conservative care of low back pain? Well, you’ll have to read his book to understand the story about how he became acquainted with Greg Silva, PT, Dip. MDT. In my opinion, Dr. Donelson, in both his book and research,7 eludes to the notion that MDT clinicians have been able to help HIM better select patients for surgical intervention.

Imagine that, WE, as PTs, having valuable input as to the need for further intervention! 

Very little frustrates me more than when I feel that a patient will not benefit from further PT only to have the physician continually refer a patient back to physical therapy for the same pointless interventions. Surely, not everyone can be a Dr. Donelson. However, how ready is the medical community to hear our messages? 

Does this happen to you and what resistance have you faced when you predict a poor outcome?  Furthermore, what other pieces of evidence do we have that demonstrate strong predictive abilities for poor outcomes?  If anyone has predictors for poor outcomes of meniscal derangement and any other pathology, I would be particularly interested.

Note from Mike Reinold: Rapidly Reversible Low Back Pain is a great book that is highly recommended for those interested treating low back pain.  I was amazed at how simple, yet highly effective, the concepts are that are outlined in the book.  Definitely one of the best reads for treating low back pain for under $20!  Click here for more information or to purchase from Amazon.com.  Thanks Christie, great post!  If you are interested in guest writing for this website, please contact me.

References:

  1. Aina A, May S, Clare H; The centralization phenomenon of spinal symptoms – a systematic review Man Ther; Aug;9(3):134-143, 2004.
  2. Donelson R, Silva G, Murphy K.; Centralization phenomenon. Its usefulness in evaluating and treating referred pain. Spine; Mar;15(3):211-3, 1990.
  3. Skytte L, May S, Petersen P; Centralization: Its prognostic value in patients with referred symptoms and sciatica Spine; 30:E293-E299, 2005.
  4. Werneke M, Hart DL, Cook D; A descriptive study of the centralization phenomenon. A prospective analysis. Spine; Apr 1;24(7):676-83, 1999.
  5. Werneke M, Hart DL, Resnik L, Stratford PW, Reyes A; Centralization: prevalence and effect on treatment outcomes using a standardized operational definition and measurement method. J Orthop Sports Phys Ther; 38:116-125, 2008.
  6. Werneke M, Hart DL.; Centralization phenomenon as a prognostic factor for chronic low back pain and disability. Spine; Apr 1;26(7):758-65 , 2001.
  7. Wetzel T, Donelson R, : The role of repeated end-range/pain response assessment in the management of symptomatic lumbar discs. The Spine Journal; (3): 146-54, 2003.

Werneke M, Hart DL (2001). Centralization Phenomenon as a Prognostic Factor for Chronic Low Back Pain and Disability Spine, 26 (7), 758-764

7 replies
  1. Mike Reinold
    Mike Reinold says:

    I do not have experience Amy, and I agree that many scales are not developed for athletes. Maybe that is a worthwhile project to start!

    • Tim Buresh
      Tim Buresh says:

      I know it is has been 3 years since this topic was posted, but please read my reply on predicting which patients will not respond to PT.

  2. amy castillo
    amy castillo says:

    Thank you Christie, I always enjoy your posts —confident and clearly supported.

    Our clinic does use the FOTO database but it has not been any easy tool to use and implement. If any one has pointers on how to integrate this database into clinical practice…Please help!

    Most patients dislike it as do the therapist. The questions are often misinterpreted and it can take 30 minutes for some chronic patients with co-morbidities to complete. In my patients who are often athletes or those who perform at a high level, the questions are not always appropraiate and not sensitive to changes. (i.e return to play)

    I have seen studies use The Tampa Scale of Kinesiaphobia as a screening tool, does anyone have experience with this type of tool?

    Thanks

    • Tim Buresh
      Tim Buresh says:

      I agree totally with you Amy Castillo regarding FOTO. The questions are frequently inappropriate and not matched up very well to the patient. For example FOTO frequently will ask geriatric LE patient, even an 85 year old, how good they are with jumping and making sharp cutting turns. The questions are not just occassionally off the mark, but frequently. Plus some of their questions are either easily misinterpreted or hard to understand.
      I strongly agree that assessing functional outcomes is a great and necessary thing to do, but right now FOTO has a lot of work to do to be truly objective.
      We had 30 people working with FOTO at my previous place of employment and I never heard anyone praise it.

  3. Mike Reinold
    Mike Reinold says:

    I dont have them in front me of Trevor, but there are several articles that support your observation that WC patients have poorer outcomes and require longer care for several different injuries and surgeries.

  4. Christie Downing, PT, DPT
    Christie Downing, PT, DPT says:

    Yes, you are correct Trevor. Even Werneke’s article demonstrates this.

    Does anyone use any demographic/fear/avoidance screenings in your assessments?

    Although our clinic does not use it, FOTO does an excellent job of assessing factors such as these. Not only are functional baselines assessed, but beliefs and attitudes as well. I think this is will be a necessary component when we move to more P4P based systems, as it will be harder to rehabilitate someone with poor motivation and high fear/avoidance, external local of control etc. Working in a clinic such as ours where we see a high proportion of patients on public aid and disability who also tend to have many of these psychosocial barriers (in my observation), it would be unfair for a clinic to be reimbursed under P4P without taking these factors into consideration.

  5. Trevor Winnegge
    Trevor Winnegge says:

    Nice post Christie. Unfortunately, I feel that pt demographics and hx can be predictors of a negative outcome. For example, workmans comp status patients can have less motivation to return to good health, and less likelihood of being 100% honest with you. This is a generalization and is no way inclusive of all w/c patients of course, just some trends I have noticed over the past 8 years. Sometimes if they tell you your techniques completely eliminated pain, they fear they will be sent back to work. Additionally, a patients PMH can play a role in their motivation/negative predictive values. I have found some patients with a hx of fibromyalgia, CFS, Lupus, and Lyme disease often have a hard time coping with pain and may have a difficult time rehabbing a legitimate spine condition. Clinically, I find patients with reproduced pain during a SLR in the first 30-40 degrees of motion have a lower success rate in treatment.

    Regarding meniscus pathology, I think that people see how quick and successful arthroscopic recovery is. Therefore when they find out they have a meniscal tear, they are less likely to follow through with your prescribed HEP. Again, motivation becomes an issue, and like everyone else, they look for a quick fix (surgery) as the answer.

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