signposting for spinal injury & pain john odowd,
TRANSCRIPT
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Mr John O’Dowd MBBS, FRCS, FRCS Orth
Consultant Spinal Surgeon
Signposting For Combined Psychological & Physical Care of
Spinal Injury & Pain Patients
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Rehabilitation
ReviveReviewRepairRehabilitate
Optimise outcome• Medical• Function• Psychological• Work
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Flags
• Red Serious underlying pathology
• Yellow Psychosocial barriers to recovery
• Orange Serious psychiatric disease
• Blue Work environment• Black Occupational policy and
systems
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• 125 patients• Subjective clinician categorization• DRAM
– Experienced spine surgeon 26% sensitivity– Predictive value
• Distressed 69%• Nondistressed 77%
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Main CJ, Waddell G (1998) Behavioral responses to examination: a reappraisal of the interpretation of “nonorganic signs”. Spine; 23(21):2367–2371.
Waddell signs
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• Low riskLow risk of future disabling LBP
• Medium riskPhysical and psychosocial indicators for poor outcome, but without high levels of psychological indicators
• High riskHigh levels of psychological prognostic indicators with or without physical indicators
Dunn 2005 KeeleSTarT yellow flags
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• Nine-fold reduction in sick leave in CBT group
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ResultsMean change in RMDQ higher in intervention groupAt 12 months stratified care associated with mean in crease in generic health benefit (0.039QALY)Stratified care cost £240.01 v £274.40
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Mirza2007 systematic review
•Four studies–Fritzell & al–Fairbank et al–Brox 2003 & 2006
•Methodological concerns•Surgery
–May be better than unstructured non operative care–May not be more effective than structured rehabilitation programme, including CBT
0
24
68
1012
1416
18
Sweden MRC Brox 2003 Brox 2006
Conservative
Surgery
mean change in ODI