Psychosocial Management of Patients with Low Back Pain

Low back pain occurs at epidemic proportions in the United States, affecting 60-90% of individuals during their lifetime. It is second only to headache for the most common reason for experiencing lost work productivity, accounting for a loss of 5.2 hours per worker per week for each episode. Total healthcare expenditures in the United States incurred by individuals with low back pain are alarmingly at 90 billion dollars annually.

Research has shown that relatively few patients with low back pain experience prolonged disability due to an episode of low back pain, but those who do account for a disproportionate amount of the related costs. Further research has demonstrated that psychosocial factors such as fear avoidance beliefs, catastrophizing, and depressive symptoms, are more predictive of which patients will experience prolonged disability than factors such as physical impairments, age, sex, type of injury, or the nature of the patient's employment.
Dr. Julie M. Fritz, PhD, PT, ATC  has been a member of a collaborative team whose previous work has examined assessment methods for quantifying psychosocial factors, in particular fear-avoidance beliefs. This team has also studied the outcomes of physical therapy management that utilizes cognitive-behavioral principles accounting for the important role of psychosocial factors.

Current research interests are focused on determining optimal screening procedures for identifying patients with an acute episode of low back pain who are at increased risk for prolonged disability, and developing effective strategies to reduce this risk.

Current Projects

Overcoming obstacles to recovery: Comparing usual care to a screening-based approach for patients with low back pain in primary care

This project will be a multi-center pragmatic randomized clinical trial that will be a collaborative effort between the  University of Pittsburgh, Intermountain Health Care, and  Wilford Hall Medical Center in San Antonio, Texas.

The purpose of this project is to compare the effectiveness of two approaches to the management of individuals visiting their primary care provider with a chief complaint of acute/subacute low back pain. Patient-completed screening questionnaires will be used at baseline to screen all patients for two key psychosocial risk factors for delayed recovery: fear-avoidance beliefs, and depression.

All patients will be treated with an active management approach consisting of information on the favorable prognosis of low back pain and advice to remain active based on current recommendations in clinical practice guidelines for the primary care management of acute low back pain. One group will be managed with a usual care approach consistent with practice guidelines recommending active management alone during the initial course of care, with referral to physical therapy and consideration of psychological factors occurring only in those patients who fail to recover after 4-6 weeks.

The other group will receive a screening-based approach that includes the active management intervention plus patient-specific interventions matched to the level of fear-avoidance beliefs and depressive symptoms identified during the screening examination.

Outcome data will be collected at 6 weeks and at 6, 12, and 24 months and will include clinical outcomes of care (pain, disability, general health status, quality of life, fear-avoidance beliefs, depressive symptoms, and patient and provider satisfaction), direct and indirect healthcare costs, and subsequent healthcare utilization.

Collaborators

• • Gerard Brennan, PT, PhD
  • Director of Clinical Quality and Outcomes
  • Intermountain Health Care
  • Salt Lake City, Utah
• • John Childs, PT, PhD, MBA, OCS, FAAOMPT
  • Assistant Professor and Director of Research
  • US Army-Baylor University Doctoral Program in Physical Therapy
  • San Antonio, Texas
• • Anthony Delitto, PT, PhD, FAPTA
  • Associate Professor and Chair, Department of Physical Therapy
  • University of Pittsburgh
  •  
• • Steven Z. George, PT, PhD
  • Assistant Professor
  • University of Florida
  • Gainesville, Florida
• • Brenda Reiss-Brennan, MS, APRN
  • Mental Health Integration Director
  • Intermountain Health Care
  • Salt Lake City, Utah

Key Publications

1. George SZ, Fritz JM, McNeil DW. Responsiveness of pain-related fear and avoidance measures for patients with acute low back pain. The Clinical Journal of Pain. In press
2. George SZ, Bialosky JE, Fritz JM. Physical therapy management of a patient with acute low back pain and elevated fear avoidance beliefs - a case report. Phys Ther. 2004;84:538-549.
3. George SZ, Fritz JM, Bialosky, JA, Donald DE. The effect of a fear-avoidance based physical therapy intervention for patients with acute low back pain: results of a randomized clinical trial. Spine. 2003;28:2551-2560.
4. Fritz JM, George SZ. Identifying specific psychosocial factors in patients with acute, work-related low back pain: the importance of fear-avoidance beliefs. Phys Ther. 2002;82:973-983.
5. Fritz JM, George SZ, Delitto A. The role of fear avoidance beliefs in acute low back pain: relationships with current and future disability and work status. Pain. 2001;94:7-15.
6. George SZ, Fritz JM, Erhard RE. The comparison of fear avoidance beliefs in patients with lumbar and cervical spine pain. Spine. 2001;26:2139-2145.
7. Fritz JM, Wainner RM, Hicks GE. The use of nonorganic signs and symptoms as a screening tool for return to work in patients with acute low back pain. Spine. 2000;25:1925-1931.