The relationship between the tampa scale of kinesiophobia and low back pain rehabilitation outcomes

Thanks to Gregg et al for

The relationship between the tampa scale of kinesiophobia and low back pain rehabilitation outcomes.

For those of you who are terribly ignorant about such things, “The Tampa Scale for Kinesiophobia (TSK) is commonly used in clinical practice to quantify levels of pain related fear of activity or re-injury in patients presenting with back pain. Patients with high levels of kinesiophobia are often considered at greater risk of developing long term activity limitation and chronicity. There is, however, little evidence to support this assumption”

Gregg et al used a questionnaire on 313 patients of a back clinic.

The study concluded that “The Tampa Scale for Kinesiophobia (TSK) provides no benefit as a screening tool to predict pain, functional and work outcomes following rehabilitation. Measured changes in TSK scores following rehabilitation do not correlate strongly with similar, concordant changes in pain scores, functional levels or return to work outcomes”.

Well, who knew

classification of back pian:

Thanks to Norton et al for “Classification of patients with incident nonspecific low back pain: implications for research” that appears in “spine”

Four distinct groups of patients were identified and validated. One group (53.4%) of patients recovered immediately. One third of patients (31.7%) may appear to recover over six months, but maintain a 37-48% likelihood of receiving care for low back pain in every subsequent quarter, implying frequent relapse. Two remaining groups of patients each maintain very high probabilities of receiving care in every quarter (65-78% and 84-90%), predominantly utilizing therapeutic services and pain medication, respectively. Probabilistic grouping relative to alternatives was very high (89.6-99.3%). Grouping was not related to demographic or clinical characteristics.

Conclusions
The four distinct sets of patient experiences have clear implications for research. Inclusion criteria should specify incident or recurrent cases. A six-month clean period may not be sufficiently long to assess incidence. Reporting should specify the proportion recovering immediately to prevent mean recovery rates from masking between-group differences. Continuous measurement of pain or disability may be more reliable than measuring outcomes at distinct endpoints.

References used

Deyo, R.A., et al., Report of the NIH task force on research standards for chronic low back pain. Spine J, 2014. 39(14): p. 1128-43.
Stanton, T.R., et al., A modified Delphi approach to standardize low back pain recurrence terminology. Eur Spine J, 2011. 20(5): p. 744-52.
Kamper, S.J., et al., How is recovery from low back pain measured? A systematic review of the literature. Eur Spine J, 2011. 20(1): p. 9-18.
de Vet, H.C., et al., Episodes of low back pain: a proposal for uniform definitions to be used in research. Spine, 2002. 27(21): p. 2409-2416.
Hoy, D., et al., The Epidemiology of low back pain. Best Pract Res Clin Rheumatol, 2010. 24(6): p. 769-81.
Tosteson, A.N.A., et al., Comparative effectiveness evidence from the spine patient outcomes research trial: surgical versus nonoperative care for spinal stenosis, degenerative spondylolisthesis, and intervertebral disc herniation. Spine, 2011. 36(24): p. 2061-8.
Radcliff, K., et al., The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation: a subgroup analysis of the SPORT trial. J Bone Joint Surg Am, 2012. 94(15): p. 1353-8.
Lurie, J.D., et al., Magnetic Resonance Imaging Predictors of Surgical Outcome in Patients With Lumbar Intervertebral Disc Herniation. Spine, 2013. 38(14): p. 1216–1225.
Indrakanti, S.S., Value-based Care in the Management of Spinal Disorders: A Systematic Review of Cost-utility Analysis. Clin Orthop Relat Res, 2012. 470(4): p. 1106-1123.
Freburger, J.K., et al., The rising prevalence of chronic low back pain. Arch Intern Med, 2009. 169(3): p. 251-8.
Costa, L.d.C.M., et al., The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ, 2012. 184(11): p. E613-E624.
Heuch, I. and I.S. Foss, Acute low back usually resolves quickly but persistent low back pain often persists. [12 mo]. J Physiother, 2013. 59(2): p. 127.
Tamcan, O., et al., The course of chronic and recurrent low back pain in the general population. Pain, 2010. 150(3): p. 451-7.
Foster, N.E., Barriers and progress in the treatment of low back pain. BMC Med, 2011. 9: p. 108.
Axen, I., et al., Clustering patients on the basis of their individual course of low back pain over a six month period. BMC Musculoskelet Disord, 2011. 12: p. 99.
Dunn, K.M., K. Jordan, and P.R. Croft, Characterizing the course of low back pain: a latent class analysis. Am J Epidemiol, 2006. 163(8): p. 754-61.
Von Korff, M.-. Studying the natural history of back pain. Spine, 1994. 19(18 Suppl): p. 2041S-2046S.
Ivo, R., et al., Brain structural and psychometric alterations in chronic low back pain. Eur Spine J, 2013. 22(9): p. 1958-1964.
Bushnell, M.C., M. Ceko, and L.A. Low, Cognitive and emotional control of pain and its disruption in chronic pain. Nat Rev Neurosci, 2013. 14(7): p. 502-11.
Cassidy, J.D., et al., Incidence and course of low back pain episodes in the general population. Spine, 2005. 30(24): p. 2817-23.
Carragee, E., et al., Are first-time episodes of serious LBP associated with new MRI findings? Spine J, 2006. 6(6): p. 624-35.
Sinnott, P.L., et al., Identifying neck and back pain in administrative data: defining the right cohort. Spine, 2012. 37(10): p. 860-74.
Vogt, M.T., et al., Analgesic usage for low back pain: impact on health care costs and service use. Spine, 2005. 30(9): p. 1075-1081.
Kominski, G.F., et al., Economic evaluation of four treatments for low-back pain: results from a randomized controlled trial. Med Care, 2005. 43(5): p. 428-35.
Martin, B.I., et al., Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine, 2007. 32(3): p. 382-387.
Hoogendoorn, W., et al., High physical work load and low job satisfaction increase the risk of sickness absence due to low back pain: results of a prospective cohort study. Occup. Environ. Med, 2002. 59(5): p. 323-328.
Skouen, J.S., et al., Relative cost-effectiveness of extensive and light multidisciplinary treatment programs versus treatment as usual for patients with chronic low back pain on long-term sick leave: randomized controlled study. Spine, 2002. 27(9): p. 901-909.
Cherkin, D.C., R.A. Deyo, and J.D. Loeser, Use of the International Classification of Diseases (ICD-9-CM) to identify hospitalizations for mechanical low back problems in administrative databases. Spine, 1992. 17(7): p. 817-825.
Mental Health: A Report of the Surgeon General, 1999, Substance Abuse and Mental Health Services Administration and the National Institute of Mental Health, U.S. Department of Health and Human Services: Rockville, MD.
Adams, J.R. and R.E. Drake, Shared decision-making and evidence-based practice. Community Ment Health J, 2006. 42: p. 87-105.
Lanza, S.T., et al., PROC LCA: A SAS Procedure for Latent Class Analysis. Struct. Equ. Modeling, 2007. 14(4): p. 671-694.
Mafi, J.N., et al., Worsening Trends in the Management and Treatment of Back Pain. JAMA Internal Medicine, 2013. 173(17): p. 1573-1581.
Landon, B.E., et al., The relationship between physician compensation strategies and the intensity of care delivered to Medicare beneficiaries. HSR, 2011. 46(6pt1): p. 1863-82.
Hughes, D.R., M. Bhargavan, and J.H. Sunshine, Imaging Self-Referral Associated With Higher Costs And Limited Impact On Duration Of Illness. Health Affair, 2010. 29(12): p. 2244-2250.
Lanza, S.T., et al., Proc LCA & Proc LTA user’s guide (Version 1.3.0), 2013, The Pennsylvania State University: University Park: The Methodology Center.
Buchbinder, R. and M. Underwood, Prognosis in people with back pain (Commentary). CMAJ, 2013. 185(4): p. 325.
Ritzwoller, D.P., et al., The association of comorbidities, utilization and costs for patients identified with low back pain. BMC Musculoskelet Disorders, 2006. 7: p. 72-81.
Wasiak, R., et al., Back Pain Recurrence: An Evaluation of Existing Indicators and Direction for Future Research. Spine, 2009. 34(9): p. 970-977.
Lemeunier, N., A. Kongsted, and I. Axen, Prevalence of pain-free weeks in chiropractic subjects with low back pain – a longitudinal study using data gathered with text messages. Chiropr Man Therap, 2011. 19: p. 28.
Tyree, P.T., B.K. Lind, and W.E. Lafferty, Challenges of Using Medical Insurance Claims Data for Utilization Analysis. Am J Med Qual, 2006. 21(6): p. 269-275.
Croft, P.R., et al., Outcome of low back pain in general practice: a prospective study. BMJ, 1998. 316: p. 1356-1360.
Riley, G.F., Administrative and claims records as sources of health care cost data. Med Care, 2009. 47(7 Suppl 1): p. S51-5.
Wingert, T.D., et al., Constructing episodes of care from encounter and claims data: some methodological issues. Inquiry, 1995. 32(4): p. 430-43.
van Hooff, M.L., et al., Predictive factors for successful clinical outcome 1 year after an intensive combined physical and psychological programme for chronic low back pain. Eur Spine J, 2013. 23(1): p. 102-112.

Meniscoid Entrapment theory

If a therapist, like me,  jumps on your back to give it a crack, it may be that they are acting out a  “meniscoid entrapment theory” moment. This  means, they are speculating that vertebral joints have small menisci  (synovial folds) that gets trapped within the joint. This entrapment causes  guarding  and preventing movements ( that group of facet joints lock).

The idea of using a manipulative techniques  is, so some think, is to  change the pressure within the joint , pushing the synovial  folds back out.

Originally proposed by Kos and Wolf. elaborated by Bogdvk And Jull.

Frankly, I think my theory that your back is invaded by evil demons, makes far more sense!

My achilles

Three elements helped my achilles

1) effective stretch and strengthening regime for my achilles tendon.

2) An understanding of the POSE running technique

3) Going barefoot.

This article is how to sort your Tendinosis in 8 weeks

I began  using ice and , stretching,

Here are my two favourite stretches

but I  also employed  “eccentric loading exercises” ( the lowering part of  a calf raise, for you body building type)

  • Get the balls of your foot on a block or a step
  • and use  both feet  (handsupport) to get you above the block.
  • then lower down with the weight on the injured side.
  • I found being on a staircase with a handrail helped me control the load.

Here is a handy “You Tube” clip

After that, it was  3 sets of 10 reps . How awful the pain is suggests the amount of load you can work with in the early stages.

This was inspired by some ideas from crossfitter Philip Holbrook ( and his physio) and this report….

Eccentric calf muscle training for the treatment of chronic achilles tendinosis

by Toros Tsermakian, Ioannis Mitsakis, Christos Lyrtzis, Ioannis Tsartsapakis,  Menelaos Mitsakis, Christos Papadopoulos,  and Georgios Nousios,  who sort of observed/discovered the following

  • Overuse injuries involving the Achilles tendon are common, especially among runners.
  • The majority of Achilles tendon overuse injuries occur in men,
  • higher rate in middle-aged athletes than do most other overuse injuries.

So,  they studied the effect of eccentric calf muscle training in 18 athletes with chronic Achilles Tendinosis with a long duration of symptoms despite conventional nonsurgical treatment. Calf strength and the amount of pain during running was  measured before and after the study.

At the start of the trail,  all patients had Achilles tendon pain so sever that they could  not run. There was also   significantly lower  calf muscle strength on the injured side.

At the end of the study. Almost everyone was cured. It bloody well worked for me.

for a fuller report visit here http://www.jssm.org/suppls/11/posterpresentations.pdf

  • In the early stages i used ice after the exercise to help with the swelling.

Achilles pain

Whilst my research focus is mainly on back pain, I have  a lot of clients with  Achilles tendinopathy, i though i might as well add a few  articles with advice on remedial treatment for sore achilles.

If you are going to a party and want to show off, you simply must drop the name  Silbernagel into the conversation. He is quite famous in coming up a type of training to help with Achilles Pain. He was part of the team  who researched “A Randomized Controlled Study Continued Sports Activity, Using a Pain-Monitoring Model, During Rehabilitation in Patients With achillies tendonosis” published in Am. J. Sports Med. 2007

That team tried this protocol:

Phase 1: Weeks 1-2 Patient status: Pain and difficulty with all activities, difficulty performing ten 1-legged toe raises

Goal: Start to exercise, gain understanding of their injury and of pain-monitoring model Treatment program: Perform exercises every day

  • Pain-monitoring model information and advice on exercise activity
  • Circulation exercises (moving foot up/down)
  • 2-legged toe raises standing on the floor (3 sets × 10-15 repetitions/set)
  •  1-legged toe raises standing on the floor (3 × 10)
  • Sitting toe raises (3 × 10)
  • Eccentric toe raises standing on the floor (3 × 10)

Phase 2: Weeks 2-5 Patient status: Pain with exercise, morning stiffness, pain when performing toe raises

Goal: Start strengthening Treatment program: Perform exercises every day

  • 2-legged toe raises standing on edge of stair (3 × 15)
  • 1-legged toe raises standing on edge of stair (3 × 15)
  • Sitting toe raises (3 × 15)
  • Eccentric toe raises standing on edge of stair (3 × 15)
  • Quick-rebounding toe raises (3 × 20)

Phase 3: Weeks 3–12 (longer if needed) Patient status: Handled the phase 2 exercise program, no pain distally in tendon insertion, possibly decreased or increased morning stiffness

Goal: Heavier strength training, increase or start running and/or jumping activity Treatment program:

Perform exercises every day and with heavier load 2-3 times/week

  • 1-legged toe raises standing on edge of stair with added weight (3 × 15) • Sitting toe raises (3 × 15)
  • Eccentric toe raises standing on edge of stair with added weight (3 × 15) • Quick-rebounding toe raises (3 × 20)
  • Plyometric training :Phase 4 Week 12–6 months (longer if needed)

Patient status: Minimal symptoms, morning stiffness not every day, can participate in sports without difficulty

Goal: Maintenance exercise, no symptoms Treatment program: Perform exercises 2-3 times/week

Guess what: you practice pain!!!

Its the same with anything, the more you practice, the better you become: perfect practice makes perfect performance.

But, this great secret of super performers (practice, practice, practice,) is the same for those with chronic pain. The better you get at sending pain messages, the more it hurts.

This is great if you are  a masochist, but sucks  a bit  for the rest of us.

“Simply put, pain that persists can become chronic because your neurons become more efficient at transmitting pain signals. The strengthening of connections between neurons through repeated use is called Long Term Potentiation, (LTP).

Dr. Darnall said “The results also underscore the importance of non-pharmacologic psycho-behavioral treatments for chronic pain and also for anxiety,” she added. “When people learn skills to decrease the physiological markers of anxiety or stress, they are simultaneously treating pain.”

Anxiety amplifies pain, so it seems there is  a lot in that tree hugging hippy crap of relaxing and thinking happy thoughts: certainly being negative and depressed does not help your pain

Read another review here