The Importance of the Functional Examination in Patient-Centered Care for Back Patients
By Craig Liebenson DC

Introduction
The management of back and neck disorders has been revolutionized by recent scientific evidence. International guidelines recommend a shift from the medicalization of spine problems (medication, imaging, and surgery) to a self-management strategy. The clinical framework for how to promote this includes an emphasis on a patient-centered, biopsychosocial approach.

Optimal clinical management depends on accurate diagnosis. Unfortunately, only a minority of back pain patients can be given a clear diagnosis of their pain generator or relevant pathoanatomy (1). The conundrum of the back problem is that while most patients do well in spite of this diagnostic failure, that the vast majority of the costs arise from the minority of sufferers who become chronically disabled (17).

Modern care focuses on the patient’s functional goals. According to the World Health Organization’s International Classification of Function (ICF) document functional status should be defined in terms of (2,36,37) disability - limitations at a personal level (activity intolerances); impairments - limitations at a physical level (e.g. endurance/mobility/coordination); and participation restrictions - limitations at the societal level (work absence).

Disability
Health promotion should begin with goals, not means (3). Goal setting should be mutual and related to activities deemed important to the patient. It works best when patient is in pain and the goal is to reduce pain. Patients seeking care for back pain apparently have two major goals: to receive information about how to manage their symptoms, and to receive advice about how to resume normal activities (35). Pioneering guidelines for back pain state that “the main goal for treatment of back pain has shifted from treatment of pain to treatment of activity intolerances related to pain” (1). Activity intolerances or patient disability can be measured in reliable and responsive ways and become markers of the patient’s progress over time (5,15,31-33,38).

Impairment
International guidelines recommend performing a diagnostic triage to classify patients with low back problems into three distinct groups (12,14). First, due to “red flags” of serious disease – e.g. tumor, infection, fracture, serious medical disease (<2%); second, due to nerve root compression (<10%); or third, due to “non-specific” mechanical factors (85-90%).

This “state of the art” will hopefully evolve since the most crucial of all “stake holders” - the patient - is dissatisfied with the diagnosis “non-specific” back pain (6). A report from the 2^nd International Forum of Primary Care Researchers on LBP concluded that achieving a validated classification system for “non-specific” LBP was their top research priority (7).

When “red flags” are present imaging or laboratory investigations are indicated. However, if imaging tests are ordered in the absence of “red flags” they can be misleading due to their high false positive rates for clinically insignificant age-related degenerative findings (8,9,39).

In order to better assess the 90% of patients with non-specific mechanical back pain there are two basic approaches. The first is to assess the patient’s mechanical sensitivity (MS). This involves testing of ranges of motion to determine which movements are pain-free or painful to find the patient’s directional preference. The second is to assess the patients abnormal motor control (AMC). This involves performing functional or performance tests to identify coordination, balance, or endurance deficits.

A recent study demonstrated that individualized care guided by identification of the patients MS was preferable to evidence-based care (26). This McKenzie style approach resulted in a 95% success rate whereas evidence based care was only 56% successful. A related study found that treatment which is guided by within-session reassessment of MS was able to predict between-session improvement (16). The patient’s whose care resulted in within-session reduction of MS were at least 3.5 times more likely to have between session improvement than those that did not experience within-session improvement.

Enthoven et al found that tests of AMC (e.g. strength, endurance, coordination) are influenced by pain, and thus not predictive of recovery in acute patients, however they are in subacutes (13). The most important dysfunctions to be screened for that are related to future back problems are single leg standing balance ability and trunk extensor endurance (4,23,27,34).

There is good evidence that a motor control signature distinguishes back pain sufferers from asymptomatic individuals (28). In particular delayed activation, overactivation, and delayed relaxation of stabilizers during unexpected perturbations of the trunk (30). One muscle that has been the subject of extensive study is the transverse abdominus (TrA). A delayed activation of the TrA during arm or leg movements has been found to distinguish back pain patients from asymptomatic individuals (21,22). A rehabilitation program designed to improve this dysfunction has been shown to be effective for chronic LBP patients (29).

Another muscle that has received a great deal of attention is the multifidus. Atrophy – demonstrated as a decreased cross sectional analysis – of the multifidus in the low back has been shown to occur in patients with acute LBP (18). Recovery from acute pain did not automatically result in restoration of the normal girth of the muscle (19). However, spinal stabilization exercises successfully restored the muscle’s size in one study (19) while in another various exercise strategies did not (24). In the study which showed that the exercise did restore the muscle’s girth follow-up data demonstrated a decreased recurrence rate in those who did the exercises vs. those who did not (20).

Participation
Most people cope with pain without seeking health care. Patients usually seek care if they are getting worse, not getting better, or have severe pain. Patients are often fearful that the wrong movement will make it much worse (11). While a precise pathoanatomic diagnosis of the pain generator remains elusive emerging evidence shows a strong association between psycho-social factors and chronic LBP. These psycho-social illness traits (i.e. fear-avoidance behavior, anxiety) have been termed “yellow flags” to distinguish their relative importance from “red flags” of potentially serious disease processes. Individuals with a preponderance of “yellow flags” are at heightened risk for developing chronic symptoms and disability (25).

Participation is dependent on the physical ability to perform an activity, but it also encompasses social and attitudinal factors many of which are instilled in the patient from the health care provider! (10).

Conclusion
Focusing on functional issues rather than structural problems is a key to reactivating the patient. Patients are normally apprehensive about the safety of normal activities for their painful back. Reactivation advice about the safety of resuming normal activities is the single most important key both emotionally and physically to a successful recovery. A thorough functional evaluation which identifies a patients functional goals (e.g. activity intolerances), and functional means (e.g. mechanical sensitivities and abnormal motor control) is a key to a patient-centered approach of self-care management.

Acknowledgement
This article has been reprinted with kind permission from Kiropractoren 9 (2005).

References:

1. Agency for Health Care Policy and Research (AHCPR). Acute low-back problems in adults. Clinical Practice Guideline Number 14. Washington DC, US Government Printing, 1994.
2. Australian Institute of Health and Welfare. Disability Data Briefing. The International Classification of Functioning, Disability and Health, ICF, ICIDH, Canberra 2002; (http://www.aihw.gov.au/publications/dis/ddb20/ddb20.pdf) accessed 20 February 2004].
3. Bandura A. Health promotion by social cognitive means. Health Education & Behavior 2004; 31:143-164.
4. Biering-Sorensen F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine 1984; 9:106-119.
5. Binkley JM, Stratford POW, Lott SA, Riddle DL. The lower extremity functional scale (LEFS): Scale development, measurement properties, and clinical application. Physical Therapy 1999; 79:371-383.
6. Borkan J, Reis S, Hermoni D, et al. Talking about the pain:a patient-centered study of low back pain in primary care. Soc Sci Med 1995; 40:977–88.
7. Borkan JM, Koes B, Reis S, Cherkin DC. Report From the Second International Forum for Primary Care Research on Low Back Pain: Reexamining Priorities. Spine. 23(18):1992-1996. 1998.
8. Borenstein DG, O’Mara JW, Boden SD, Laurman WC, Jacobson A, et al. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects. J of Bone and Joint Surgery 2001; 83-A:1306-1311.
9. Brandt-Zawadzki MN, Jensen MC, Obuchowski N, et al. Interobserver and intraobserver variability in intrepretation of lumbar disc abnomralities: a comparison of two nomenclatures. Spine 1995;20:1257-1263.
10. Buchbinder R, Jolley D. Population based intervention to change back pain beliefs: three year follow-up population survey. British Medical Journal 2004;328:321–323.
11. Buer N, Linton SJ. Fear-avoidance beliefs and catastrophizing: occurrence and risk factor in back pain and ADL in the general population. Pain 2002; 99:485-491.
12. Danish Health Technology Assessment (DIHTA). Manniche C et al. Low back pain: Frequency Management and Prevention from an HAD Perspective, 1999.
13. Enthoven P, Skargren E, Kjellman G, Oberg B. Course of back pain in primary care: a prospective study of physical measures. J Rehabil Med 2003; 35:168-173.
14. European Guidelines for the management of acute nonspecific low back pain in primary care – preliminary draft - http://www.backpaineurope.org)
15. Fairbank JCT, Pynsent PB. The Oswestry Disability Index. Spine 2000; 25: 2940-2953.
16. Hahne A, Keating JL, Wilson S. Do within-session changes in pain intensity and range of motion predict between-session changes in patients with low back pain. Australian Journal of Physiotherapy 2004; 50:17-23.
17. Hashemi L, Webster BS, Clancy EA, Volinn E. Length of disability and cost of workers’ compensation low back pain claims. J Occup Environ Med 1998; 40:261-269.
18. Hides JA, Stokes MJ, Saide M, Jull Ga, Cooper DH. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine 1994; 19(2):165-172
19. Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of acute, first-episode of low back pain. Spine 1996; 21(23):2763-2769.
20. Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine 2001; 26:e243-e248.
21. Hodges PW, Richardson CA. Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds. Arch Phys Med Rehabil 1999; 80(9):1005-12.
22. Hodges PW, Richardson CA. Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb. J Spinal Disord 1998; 11(1):46-56.
23. Holm SM, Dickenson AL. A comparison of two isometric back endurance tests and their predictability of first-time back pain: A pilot study. Journal of the Neuromusculoskeletal System, 2001; 9(2):46-53.
24. Käser L, Mannion AF, Rhyner A, Weber E, Dvorak J, Müntener M. Active therapy for chronic low back pain. Part 2. Effects on Paraspinal Muscle Cross-Sectional Area, Fiber Type Size, and Distribution. Spine 2001; 26:909-919.
25. Linton SJ. A review of psychological risk factors in back and neck pain. Spine 2000; 9:1148-1156.
26. Long A, Donelson R, Fung T. Does it matter which exercise? Spine 2004; 29:2593-2602.
27. Luoto S, Heliovaara M, Hurri H, Alaranta H. Static back endurance and the risk of low-back pain. Clin Biomech 1995; 10:323-324.
28. McGill S, Grenier S, Bluhm M, Preuss R, Brown S, Russell C. Previous history of LBP with work loss is related to lingering deficits in biomechanical, physiological, personal, psychosocial and motor control characteristics. Ergonomics 2003; 46:731-746.
29. O’Sullivan P, Twomey L, Allison G. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolysthesis. Spine 1997; 24:2959-2967
30. Radebold A, Cholewicki J, Polzhofer BA, Greene HS. Impaired postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic idiopathic low back pain. Spine 2001; 26:724-730.
31. Stratford P, Gill C, Westaway M and Binkley J. Assessing disability and change on individual patients: a report of a patient specific measure. Physiother Can. 1995; 47:258-263.
32. Stratford PW, Binkley J, Solomon P, et al. Defining the minimum level of detectable change for the Roland-Morris questionnaire. Phys Ther 1996; 76:359-65.
33. Stratford P, Binkley JM, Stratford POW. Development and initial validation of the upper extremity functional index. Physiotherapy Canada Fall 2001; 259-266, 281.
34. Takala EP, Vikari-Juntura E. Do functional tests predict low back pain. Spine 2000; 25(16):2126-2132.
35. Turner JA. Educational and behavioral interventions for back pain in primary care. Spine 1996; 21:2851-9.
36. United Nations. World programme of action concerning disabled persons. Division for Social and Policy Development, United Nations; 2003 [http://www.un.org/esa/socdev/enable/diswpa01.htm, accessed 16 February 2004].
37. World Health Organization. International Classification of Functioning, Disability and Health: ICF, World Health Organization, Geneva (2001).
38. Vernon HT, Mior S. The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther 1991; 14:409-415.
39. Wiesel SE, Tsourmans N, Feffer HL, et al. A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine 1984; 9:549.