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FOTO Rehab Outcomes Blog

Persistent Low Back Pain: Case Study 6 visits over 3 months

The beauty of a case study lies in the description of the story.

Although case studies fall low on the evidence scale, there is so much value to be had in the description of the story. We've learned that there is a risk of glaring bias in a case study. Granted, this is a factor to keep in the back of our minds while at the same time appreciating the story and the thought processes shared.

Rehabilitation professionals are going to be challenged about the frequency of patient visits. How is the frequency determined? Because it's just that way or because certain aspects of the individual patient dictates the provided frequency of care.

What I immediately found interesting about this case study was frequency of care. Providing 6 sessions over a 3 month duration is not something typical here in the States. What I find missing is knowing the patient's ability to function prior to initiating services compared to the 3 month. Did the patient's function change?

The study highlights how fear level reduced. The Orebro Musculoskeletal Pain Questionnaire is a tool designed to predict disability and return to work.  I will presume the study used the short form Orebro.  A score of 1-50 indicates a lower risk for work disability where as 51-100 indicates a higher risk.

The take home in this study is in the methods used to address the psychosocial factors and beliefs to reduce fear level and change the risk category for work disability. Based on this case study, it doesn't appear many visits are required for the cognitive changes. Although few visits are required, the patient needs time for change to happen.  It would have been nice to see if function changed. 

Below you will find a quick view of the abstract.


Process of Change in Pain-Related Fear: Clinical Insights From a Single-Case of Persistent Back Pain Managed With Cognitive Functional Therapy.



Study Design: Single-case report with repeated measures over 18 months.

Background: Management of persistent low back pain (PLBP) associated with high pain-related fear is complex. This single-case report aims to provide clinicians with an insight to the process of change in a person with PLBP and high bending-related fear, managed with an individualized behavioral approach - Cognitive Functional Therapy (CFT).

Case Description: A retired manual worker with PLBP believed that his spine was degenerating, that bending would hurt him and avoidance was the only form of pain control. At baseline, he presented high levels of pain-related fear on the Tampa Scale of Kinesiophobia (TSK: 47/68) and a high-risk profile on the Orebro Musculoskeletal Pain Questionnaire (OMPQ score: 61/100). Unhelpful beliefs and behaviors led to a vicious cycle of fear and disengagement of life-valued activities. Guided behavioral experiments were used to challenge his thoughts and protective responses, indicating his behavior was modifiable and the pain controllable. Using a multidimensional clinical reasoning framework (MDCRF), CFT management was tailored to target key drivers of PLBP, and delivered over six sessions in a three-month period.

Outcomes: Over an 18-month clinical journey he demonstrated improvements in bending-related fear, pain expectancy and pain experience; and substantial changes in pain-related fear (TSK: -14 points to 33/68) and risk profile (OMPQ: -25 points to 36/100). Clinical interviews at 6 and 18 months revealed positive changes in mindset, understanding of pain, perceived pain control, and behavioral responses to pain.

Discussion: This report provides clinicians with an insight to using a MDCRF to identify and target the key drivers of the disorder, and using CFT to address unhelpful psychological and behavioral responses to pain in a person with PLBP and high pain-related fear. Level of Evidence Therapy, Level 5. J Orthop Sports Phys Ther, Epub 13 Jul 2017. doi:10.2519/jospt.2017.7371.

 2017 Jul 13:1-38. doi: 10.2519/jospt.2017.7371. [Epub ahead of print]