Directional Preference and Functional Outcomes Among Subjects Classified at High Psychosocial Risk

  • For patients with NSLBP who are classified at high psychosocial risk during the initial evaluation, clinical practice guidelines recommend managing these patients according to the biopsychosocial model, which endorses interdisciplinary treatments combining medical, physiotherapy, and mental health care services to improve patient outcomes and decrease health care. costs. The recommended treatment is formal cognitive‐behavioural approaches (CBA) augmented by evidence‐based physiotherapy intervention.
  • The authors hypothesize that patients classified at high STarT risk whose symptoms show a first‐visit DP and whose treatment was matched to their DP will achieve better functional outcomes at discharge from physiotherapy services compared to those high STarT risk patients who do not demonstrate a directional preference
  • 138 patients older than 17 years of age experiencing NSLBP complaints, classified into a high STarT risk category at baseline, and referred to a participating outpatient physiotherapy clinic were included. Patients were excluded due to pregnancy or suspicion of serious spinal pathology such as fracture, cancer, or visceral diseases. Eight PTs, credentialed in McKenzie methods participated in data collection. 
  • Patients completed the STarT and FOTO's FS Lumbar Computer AdaptiveTest (LCAT) measures at intake The LCAT is a psychometrically strong outcome measure to assess the patient's FS and change in FS at discharge. Other variables assessed included age, gender, symptom duration, payer, use of medication at intake, exercise history, lumbar surgical history, prior treatment, condition complexity determined 29 possible comorbid conditions, McKenzie credentialing level of therapist, and treatment duration
  • 65% of 109 pts were classified as having a directional preference with 35% having no DP. 29 pts were lost to follow up. Pts who dropped out were more likely to not have a DP, have more chronic symptoms, more use of medication, and had longer treatment duration
  • Pts who demonstrated a DP exhibited a change in functional status by >30 points compared to 21 points by pts who did not have a DP. After adjusting for confounding factors, the analyses indicated a significant and clinically important difference in the change of functional status b/w pts who demonstrate a directional preference and those who do not.
  • Despite recommendations for targeting patients classified at high STarT risk for formal CBA interventions, the majority of high STarT risk patients in this study not only demonstrated DP during the initial evaluation but also responded well with significant and clinically important increases in function scores at discharge compared to the No‐DP subgroup.
  • The data suggest that physiotherapists credentialed in McKenzie methods can consider DP‐matched exercises as a potential alternative method to STarT stratification treatments to improve functional outcomes when managing high STarT risk patients with NSLBP.