Transcript Overview of CRISP® Clinical Reasoning in

Overview of CRISP®
Clinical Reasoning in Spine Pain
John Ventura, DC, DABCO
NQF, musculoskeletal committee
USBJI, board member
CMS, technical expert panel
University of Rochester, School of
Medicine
Disclosures/COI
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Spine Care Partners, LLC
Primary Spine Provider Network, LLC
Member of ACA, NYSCA, APHA, NASS
National Quality Forum, musculoskeletal committee
United States Bone and Joint Initiative, board
Center for Medicare/Medicaid Services, technical expert
panel for Physician Quality Reporting System
30 yrs in full time clinical practice
 17 yrs clinical instructor family medicine University of
Rochester School of Medicine
 16 yrs clinical instructor New York Chiropractic College
 4 yrs assistant clinical professor D’Youville College
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“The only purpose of the
physician is to amuse the patient
while nature cures the disease”
Voltaire
Learn to be Comfortable with Uncertainty
“Discomfort with
uncertainty…result(s) in a tendency
to seek quick answers and dogmatic
clinical approaches”
Slade SC, et al. The dilemma of diagnostic uncertainty when treating people with
chronic low back pain: a qualitative study. Clin Rehabil 2012;26(6):558-69.
Timmermans S, Angell A. Evidence-based medicine, clinical uncertainty and learning to
doctor. J Health Soc Behav 2001; 42: 342–359.
Much of Primary Spine Care Occurs
in the Gray Areas!
The Diagnostic Balance
Patient wants a
clear
explanation
SRDs are a clinical
diagnosis but no
definite diagnostic test
What are the best treatment for
spine related disorders??
What about the scientific literature?
Doesn’t that provide the answers??
100’s of Randomized Controlled Trials
 Many meta-analyses
 Many systematic reviews of RCTs
 Systematic reviews of systematic reviews
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What does the research tell us?
“nothing really helps
very much”
Traditional Approach to Research on Spinal Pain
Based on the treatment-outcome model
Outcomes
Treatment
“Statistical Relevance”
K. Spratt, Ph.D.
Outcomes
Treatment
Diagnosis
Assessment
The ADTO Model
Courtesy Ron Donelson, MD
O
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Cardiac
Esophageal
Chest Pain
Pain
Pain
NTG
Anti-acids
Nothing
Outcome Measures
10% Improved 25%
80% Improved 20%
80%
25%
10%
10% Improved
Are the small benefits worth the additional costs?
Courtesy Ron Donelson, MD
What about “subgrouping” for spine?
Pain, disability and suffering experience of each individual
patient
There are 7,125,000,000 subgroups!
So What’s a Doc to Do?
Somatic
Psychological
Neurophysiological
Social
CRISP® : Applying the BPS Model
and
CRISP® : Applying the ADTO Model
O
T
D
A
The Challenge of Spinal Diagnosis
1.
Spinal pain is multifactorial
2.
Factors relate to various dimensions (somatic,
neurophysiological, psychological, social)
3.
Most factors have no objective test
General Considerations in Spine Care
Basic statistics
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Reliability
◦ Kappa (K): based upon paired observations
◦ Intraclass correlation (ICC): based upon
groups
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Validity
◦ Sensitivity
◦ specificity
Interpretation of Kappa: Measure of Reliability
reliability after chance has been removed
Kappa Agreement
< 0 Less than chance agreement
0.01–0.20 Slight agreement
0.21– 0.40 Fair agreement
0.41–0.60 Moderate agreement
0.61–0.80 Substantial agreement
0.81–0.99 Almost perfect agreement
Sensitivity and Specificity: validity
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Sensitivity
◦ SnNout
◦ True Positives
◦ Eg. ESR for inflammation
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Specificity
◦ SpPin
◦ True Negatives
◦ Well Leg Raise for radiculopathy in L.E.
SENSITIVE TEST
SPECIFIC TEST
Is the change clinically
meaningful?
30%
MCID
Minimally Clinically Important
Difference
Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials
Dworkin RH,, et al. Core outcome measures for chronic pain clinical trials: IMMPACT
recommendations. Pain 2005;113:9–19.
Gatchel RJ, et al. Validation of a consensus-based minimal clinically important difference
(MCID) threshold using an objective functional external anchor. Spine J 2013;13(8):88993.
What is meaningful to the patient?
 What
do you most want to return to
that you are unable to because of
your condition?
 Cost (direct and indirect)
 Does the provider care?
“doctors are from mars
patients are from venus”
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3 most important attributes of DR:
- caring attitude, explains things so easy to
understand, takes the time to listen
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3 most important attributes of DR:
- diagnostic ability, years in practice,
attended a well known college
and
‘Patients don’t care how much
you know, until they know how
much you care’
Anti-inflammatory Diet
General Principles
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Inadequate sleep
Stress
Sugar, white flour
Refined oils(corn, seed, soy)-linoleic acid
Farm raised fish, cattle, poultry
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pro-inflammatory, insulin resistance
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Metabolic Syndrome
Abdominal obesity, high BP, high TG, low HDL, high fasting glucose
?Inflammatory triggers NSS
Metabolic Syndrome
marker
 Fasting BG:
 TG:
 HDL:
 BP:
 Waist:
abnormal finding
>100mg/dL
>150mg/dL
<40(m) <50(w)
>130/85
>40”(m) >35”(w)
Anti-inflammatory Diet
(www.deflame.com)
Eliminate ALL grains, esp those with gluten (wheat, rye,
couscous spelt, barley oats) (avoid legumes)
 Eliminate ALL refined sugar
 Eliminate hydrogenated oils
 Limit soy and dairy (except cream)
 Don’t smoke (duhhh!)
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Anti-Inflammatory Diet (cont)
(www.deflame.com)
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Fruits and vegetables
Nuts and certain seeds
Dark Chocolate (75% or more cocoa)
Cold water fish (salmon, mackerel, sardines)
Meat, chicken – grass fed and free range
Spices (ginger and tumeric)
Red wine and stout (assuming no trigger or
alcoholism)
Heavy cream
Omega-3 eggs
Olive oil, coconut oil, butter
Spreading the Good
News!
Good News: Injuries Do Not Lead to Long Term
Problems!
Individuals who have had minor trauma (lift inj, minor fall,
MVC) are at no increased risk of long term problems
Carragee, et al. Spine 2006; 6(6):624-35
Good News: Pre-existing Degenerative
Changes Not a Risk Factor
Individuals with degenerative changes on MRI
are at no increased risk of long term problems
Carragee, et al. Spine 2006; 6(6):624-35
Good News: Heavy Lifting Jobs and LBP
Persistent, minor LBP likely to occur in workers w/ a heavy
job
BUT
No increased risk of significant LBP or disability – especially
with low fear beliefs!
Carragee, et al. Spine J 2005
Good News: MRI Findings After LB
Injury Not Likely Related to Injury
The vast majority of patients have no
change in MRI after LB injury.
Carragee, et al. Spine 2006; 6(6):624-35
Good News: Chronic Neck
Problems After Whiplash about
same as general population
50% of people with WAD continue to
have pain at 1 year; however 20-40% of
general population report pain in
previous month
 NP attributed to MVC for longer
periods; but not much longer than the
general population
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Essential Messages for Everyone
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Overcoming vs getting rid of: self efficacy
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Activity is good
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Avoiding activity detrimental
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LBP is a very painful inconvenience that nearly
everyone can overcome (biopsychosocial)
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Initial visit therapy is an active therapy so that pt’s
first experience of relief is something that they do
Essential Messages for Everyone
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RTW is therapy
◦ “You don’t get better in order to go back to work. You go back
to work in order to get better”
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Some pain on returning to activity is normal
Essential Messages for Everyone
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Imaging findings are deceiving and usually
not reflective of severity of problem
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Pain severity is not necessarily reflective of
severity of the problem
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Pay attention to how you lift
PAIN IS INEVITABLE
SUFFERING IS OPTIONAL
Imaging/ Special Tests for spine pain
3 - 15% of spine pts should require further
investigation
Indications for Advanced Imaging:
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Severe or progressive neurologic deficit
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Serious underlying conditions suspected
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If findings would change course of treatment
Chou R, et al. Diagnosis and treatment of low back pain: a joint clinical practice
guideline from the American College of Physicians and the American Pain Society. Ann
Intern Med 2007;147(7):478-91.
Indications for Advanced Imaging in
Radiculopathy Patients:
• ESI considered
• Surgery considered
Chou R, et al. Diagnosis and treatment of low back pain: a joint clinical practice
guideline from the American College of Physicians and the American Pain Society. Ann
Intern Med 2007;147(7):478-91.
Unnecessary imaging is not only
wasteful, it can be harmful!
Early MRI leads to higher costs, poorer
outcomes, longer disability
Early MRI groups - $12, 948 to $13, 816
higher medical costs!
Webster BS, et al. Iatrogenic
consequences of early magnetic
resonance imaging in acute, workrelated, disabling low back pain. Spine
(Phila Pa 1976) 2013;38(22):1939-46.
Imaging: MRI reports and outcomes
237 cases of uncomplicated DDD seen on MRI
seen in imaging facility
 30% of cases received Epidemiological Info (EI)
sheet with the MRI results (“DDD is normal
variant”)
 70% of cases did not receive E.I. sheet
Results
 E.I. group less likely to receive opiates**
 E.I. group less like to receive repeat imaging
 E.I. group less like to receive referral
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McCullough RADIOLOGY 2012
MRI and Spine Surgery
Direct correlation between rates of MRI and rates
of spine surgery in the US
Lurie J, et al. 2003;28(6):616-620
“Iatrogenic Imaging Disability”
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“Spondylosis”
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“Disc bulge”
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“Degenerative disc disease”
C.R.I.S.P.
(clinical reasoning in spine pain)
The Three Essential Questions
1. Do the presenting symptoms reflect a
visceral disorder, or a serious or
potentially life-threatening illness?
2. Where is the pain coming from?
3. What is happening with this person as a
whole that would cause the pain
experience to develop and persist?
Question #1:
Do the presenting symptoms
reflect a visceral disorder, or a
serious or potentially lifethreatening illness?
Red Flags noteworthy in spine pain
Perineal numbness
Loss control bowel/bladder
History of cancer **** (B, L, P, K)
neck pain/HA with 5Ds And 3Ns
Abdominal bruit (AAA)
Signs/symptoms infection
Unable to reduce symptoms
mechanically
• Hx of significant trauma
(mild+osteopenia)
• Family hx inflammatory arthropathy
• Unexplained weight loss
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Disorder
Detected by
Cancer
Hx CA, no positional relief,
fever, unexplained wt loss,
blood in stool
Benign tumor
Local severe pain, no
positional relief, relief w/
NSAID, pain percussion
Infection
Hx fever, chills, febrile, pt
tender, red, heat
Fracture
Hx trauma, hx
osteoporosis, pain
percussion
Disorder
Detected by
GI disease
GI complaints, pain w/
food, abdominal exam
GU Disease
GU complaints, bleed,
spot, discharge, GU exam
Myelopathy
Gait, bowel/ bladder, UMN,
spasticity
Cauda Equina Syndrome
Bowel/ bladder, saddle
anesthesia, anal sphincter
tone
Cardiac
ischemia
(common)
Dissecting
abdominal aortic
aneurysm, visceral
injury
Pyelonephritis,
renal stones
Deep-seated
pelvic pain
Pelvic
inflammatory
disease Ectopic
pregnancy
Fibroids
Endometriosis
Prostatitis
Cardiac
ischemia
(atypical)
Cholelithiasis,
peptic ulcer
disease,
pancreatitis
“Mechanical” low
back pain
Activityrelated,
persistent
Severe,
tearing
Colicky
Cramping,
spasmotic,
abdominal
For diagnosis Cancer
sensitivity
1.Age>50
.77
2.Prior CA
.31
3.Weight loss unexplained
.15
4.No relief bed rest
.90
5.Not better 1 mo tx
.31
6. If 1+2 or 3 or 5
1.0
specificity
.71
.98
.94
.46
.90
.60
Bigos, Acute LBP in adults, AHCPR, 1994
Systemic Inflammatory Arthritide
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Most common polymyalgia rheumatica
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A.M. stiffness (35 -40 minute rule)
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Generalized joint pain, especially shoulders
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Older age (50-65+)
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Flu like symptoms, giant cell arteritis
Spondyloarthropathy
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Pain often SI
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Family Hx
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Worse in AM
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Good response to
NSAIDs
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AM stiffness
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SI – itis on imaging
Hx of Chrohn’s/
colitis
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Sed rate/ CRP elevated
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< age 40-45
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Negative RA factor
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Uveitis
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HLA-B27 present
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Ehrenfeld M. Spondyloarthropathies. Best Pract Res Clin Rheumatol 2012;26(1):135-45.
Suspect Seronegative
Spondyloarthropathy if:
Berlin criteria:
1. Morning stiffness >30 min
2. Improvement with exercise but not with rest
3. Awakening during the second half of the night
only
4. Alternating buttock pain
If at least 2 of 4 are present:
Se 70%; Sp 81%; +LR 3.7
Rudwaleit M, et al. Inflammatory back pain in ankylosing spondylitis: a reassessment of
the clinical history for application as classification and diagnostic criteria. Arthritis
Rheum 2006;54(2):569-78.
Ankylosing Spondylitis (AS) - Radiographs
AS - Radiographs
Cauda Equina Syndrome
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Bowel/ bladder dysfunction
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Sexual dysfunction
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Saddle anesthesia
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Decreased anal sphincter tone
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Bilateral multisegmental neurological deficit
Modic I change and p. acnes
infection?
Albert HB, et al. Does nuclear tissue infected with bacteria following disc herniations
lead to Modic changes in the adjacent vertebrae? Eur Spine J. 2013 Feb 10.
Question #2:
Where is the pain coming from?
Identify the Primary Pain
Generator(s)
Disc
derangement
 Joint dysfunction
 Radiculopathy
 Myofascial
trigger points
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Disc Derangement
Historical Factors Suggestive of
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Acute episode(s)
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Antalgia
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Pain with sitting
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Pain with sit-to-stand
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Pain with flexion
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Worse in AM
Disc Pain
McKenzie Technique
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Generally low Inter Examiner Reliability (IER)
for classifying patients with LBP (includes
trained and untrained practitioners)
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But good IER (k = .60) for fully trained
practitioners to identify key characteristics of
derangement (lateral shift, centralization,
directional preference/ direction of benefit)
Werneke MW, et al. McKenzie lumbar classification: inter-rater agreement by
physical therapists with different levels of formal McKenzie postgraduate training.
Spine 2014 Feb 1;39(3):E182-90.
Validity of Centralization Signs - Lumbar
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Low sensitivity (0.47) and high specificity (1.00) in the
lumbar Spine
Young S, et al. Correlation of clinical examination characteristics with three sources of
chronic low back pain. Spine J 2003;3(6):460-465.
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74% correlation between centralization on exam and
positive discogram
Donelson, et al. Spine 1997; 22(10):1115-1122
Distribution of symptoms
Historical Factors Joint Dysfunction
(? Reliability/validity/LR)
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Localized pain
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Often unilateral
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Often HA
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Pain with rotation/ extension
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Hx trauma (sudden or repetitive)
Scientific evidence: neck
No systematic reviews were identified which
examined the diagnostic accuracy of history-taking
in patients with neck pain. Rubenstein Clin Rheum 2008
SI Provocation Tests - Reliability
Moderate to high reliability of various SI provocations
tests.
Laslett & Williams Spine 1994;19(11)
Identifying SI Joint Pain
(Laslett criteria)
Distraction/Compression
 Thigh thrust
 Gaenslen's test
 FABERE
 Sacral thrust
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SI Provocation Tests - Validity
Three or more positive SI tests:
SE = 0.94
SP = 0.78
Laslett, et al. Man Ther 2005; 10:207-218.
Radiculopathy
Historical Factors Suggestive of
Pain
Severe LE pain
 Pain below knee
 Claudication (stenosis)
 Neuro symptoms
 Severe LBP (herniation)
 Worse with extension (stenosis)
 Worse with flexion (herniation)
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Nerve Root
Myofascial Pain
Muscle Palpation Signs
(Trigger Points)
Carol et al J Man Manip Ther 2007
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Referred pain – good interexaminer reliability
Jump sign – good reliability
Nodule palpation – poor reliability
Twitch response – poor reliability
Question #3:
What is happening with this
person as a whole that would
cause the pain experience to
develop and persist?
Perpetuating Factors Believed to Be
Important in Spine Related Disorders
 Dynamic instability
(impaired motor
control)
 Nociceptive system
sensitization
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Fear
Catastrophizing
Passive coping
Poor self-efficacy
Depression
etc
Hip Extension Test
Dynamic Instability
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Pt prone, extend leg lifting up, keeping
knee straight, as high as possible
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(+) = if see lateral shift of pelvis or
hyperextension of trunk
for
Hip Extension
Test - Reliability
Substantial (k=0.72 – 0.76) inter-examiner
reliability of the hip extension test.
Murphy, et al. J Manipulative Physiol Ther
2006;29(5):374-377
Hip Extension Test - Validity
Co-contraction of Transverse Abdominis
and Multifidus increases trunk activity
and decreases trunk movement during
hip extension
Oh JS, et al. Effects of performing an abdominal drawing-in maneuver during prone hip
extension exercises on hip and back extensor muscle activity and amount of anterior
pelvic tilt. J Orthop Sports Phys Ther. 2007;37(6):320-4.
Nervous System Sensitization –
Smart Criteria
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Pain disproportionate to injury or pathology
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Strong association with psychological factors
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Disproportionate, non-mechanical and unpredictable
exacerbating/ remitting factors on history
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Diffuse, nonanatomic areas of pain/ tenderness
Good discriminative validity, classification accuracy using these
criteria
Smart KM, et al. The Discriminative Validity of "Nociceptive," "Peripheral Neuropathic," and "Central
Sensitization" as Mechanisms-based Classifications of Musculoskeletal Pain. Clin J Pain 2011, 27(8):655-663
Smart KM, et al. Mechanisms-based classifications of musculoskeletal pain: Part 1 of 3: Symptoms and signs of
central sensitization in patients with low back (+ leg) pain. Man Ther 2012 17:336-344.
CRISP Protocol
Management**
**The majority are managed at the
primary spine care level without
need for referral
Three Components
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In response to ques. #1: Further investigation
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In response to ques #2: Addressing pain generators
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In response to question #3: Addressing perpetuating
factors
Treatment Decisions
Question 2
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Disc derangement – end range loading, distraction
manipulation
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Joint dysfunction – joint manipulation
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Radiculopathy –
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Acute: NSAID, oral steroid, ESI
Chronic: neural mobilization
Trigger points – myofascial treatments
Treatment Decisions
Question 3
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Instability – stabilization training
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Nociceptive system sensitization – education and graded exposure
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Psych factors – relationship-centered care, education, graded exposure, psych
intervention (what is threshold???)
CRISP = Multi-Dimensional Diagnosis
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Serious underlying disease
Pain generators
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Disc derangement
Joint dysfunction
Radiculopathy
Myofascial pain
Perpetuating factors
◦ Dynamic Instability
◦ Nervous system sensitization
◦ Psychological factors
CRISP = Multi-Dimensional Treatment
Teaching CRISP
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University of Pittsburgh
Pittsburgh, PA USA
◦ Developing full 100 hr program
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Southern California University of Health Sciences
Angeles, CA USA
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University of Johannesburg Johannesburg, SA
Los
Thank You
“When you work you are a flute through
whose heart the whispering of the hours turns
to music.”
K Gibran The Prophet