STarT Back Screening Tool

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Training 5 or more? Get your team access to ALL courses plus exercise prescription & telehealth. Try Plus for teams Introduction With physical activity levels decreasing and developmental disabilities increasing, it is important that therapists and teachers understand how to screen children for developmental difficulties. Children who are identified as needing more input during this screening process can then be encouraged to exercise in a safe and meaningful way. This course, the second in a series on the physical, cognitive and psychosocial development in early and middle childhood, explores some key assessment and intervention ideas for children aged three to seven years. Aims The aim of this course is to provide you with appropriate assessment tools for children aged three to seven years and to discuss ways to safely implement a physical activity programme for children. Outline This course is made up of videos, reading, forum posts and a final quiz. The course content is split into the following sections: Video Reading activity Quiz Target audience This course is aimed at rehabilitation professionals, students and assistants including but not limited to Physiotherapists, Occupational Therapists, Speech and Language Therapists, Rehabilitation Doctors, Rehabilitation Nurses, Prosthetists, Orthotists, Psychologists, Audiologists, Dietetics, Social Workers. Community Health Workers, Nurses or Medical Doctors interested in this subject are also invited to participate. More info Practicalities Hours of Learning - No deadlines are applied to this course and it can be started and completed in your own time according to your personal schedule. We expect the required elements to take around 1-1.5 hours depending on your schedule and learning style. Additionally there are many optional resources provided and if you choose to review these the course could take longer to complete. 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Learning outcomes At the end of this course you will be able to: discuss specific tests that can be used to assess a child’s development interpret the results of screening tests in children select an appropriate tool to monitor the effectiveness of an intervention in children summarise the World Health Organisation’s physical activity guidelines for children describe key components of a physical activity intervention for children Featured reviews I highly recommend this course for physiotherapists who practice CBR (community-based rehabilitation) and whose entry point of practice is education in a formal school setting! Shella Marie Tugonon Physiotherapist Philippines After attending this course, I wanted to know which tools exactly- if any - are used in Dutch schools. I never really thought about that before. It is a very giving course with immediately useful information and links to exercise and testing tools. Janne van Student Netherlands It is a great course to learn about developmental coordination disorder, various assessment tools and interventions for different age groups! Shilpika Dhuri Physiotherapist India Brilliant course! Thank you for breaking it down so simply. Tracy's clinical experience comes through how she explains concepts and principles! It is especially true for physios like myself who are not highly specialised in childhood/paediatric physio. Profession not set United Kingdom Related courses You might be interested in More info. Academic Readiness and Developmental Disabilities in Early and Middle Childhood Development 2-2.5 hours 138 Presented by Tracy Prowse & ReLAB-HS More info. Assessment and Exercise Interventions in Early and Middle Childhood Development 1-1.5 hours 294 Presented by Tracy Prowse & ReLAB-HS More info. Benign Joint Hypermobility Syndrome 1-1.5 hours 383 Presented by Tracy Prowse & Paediatrics Physiotherapy Group of the SASP More info. Developing Physically Active and Sporty Kids – Benefits and Barriers 1-1.5 hours 116 Presented by Tracy Prowse & ReLAB-HS More info. Developing Physically Active and Sporty Kids – Injuries Specific to Children and Teenagers 1-1.5 hours 116 Presented by Tracy Prowse & ReLAB-HS More info. Developing Physically Active and Sporty Kids – Overuse Injuries and Burnout 1-1.5 hours 137 Presented by Tracy Prowse & ReLAB-HS More info. General Assessment Considerations for Children with Pain 1.5-2 hours 142 Presented by Tracy Prowse & ReLAB-HS More info. General Management of Paediatric Pain Problems 1.5-2 hours 123 Presented by Tracy Prowse & ReLAB-HS More info. Holistic Healthcare Interventions for Children 1.5-2 hours 106 Presented by Tracy Prowse & ReLAB-HS View all courses Try Plus today Get started for free, and continue building your career. 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Images (9-item tool)[edit | edit source]

STarT Back Screening Tool

Objective (9-item tool)[edit | edit source]

The Keele STarT Back Screening Tool (SBST) (9-item version) is a brief validated tool, designed to screen primary care patients with low back pain for prognostic indicators that are relevant to initial decision making [1].

Intended Population (9-item tool)[edit | edit source]

Primary care patients with low back pain [1].

Method of Use (9-item tool)[edit | edit source]

The STarT Back Screening Tool helps primary care clinicians (GPs, physiotherapists etc) to group patients into three categories of risk of poor outcome (persistent disabling symptoms) - low, medium, and high-risk. By being able to categorise patients into these 3 groups, clinicians are then able to target interventions to each sub-group of patients to help outcome [1].

The STarT Back Screening Tool is available in a number of languages including: English, Dutch, French, Spanish, Danish and Welsh (Keele University n.d). The tool produces two scores: overall scores and distress subscale scores [2].

  • The distress subscale score is used to identify the high-risk subgroup. To score this subscale add the last 5 items; fear, anxiety, catastrophising, depression and bothersomeness (bothersomeness responses are positive for 'very much' or 'extremely' bothersome back pain). Subscale scores range from 0 to 5 with patients scoring 4 or 5 being classified into the high-risk subgroup [1].
  • The overall score is used to separate the low risk patients from the medium-risk subgroups. Scores range from 0-9 and are produced by adding all positive items; patients who achieve a score of 0-3 are classified into the low-risk subgroup and those with scores of 4-9 into the medium-risk subgroup [1].

Evidence (9-item tool)[edit | edit source]

The STarT Back trial [3] compared the clinical and cost effectiveness of stratified management approach; allocating patients to different treatment pathways based on their prognosis (low, medium, or high risk of poor outcome); with that of current best practice. The trial demonstrated that this new model results in greater health benefits, achieved at a lower average health-care cost, with an average saving to health services of £34.39 per patient and societal savings of £675 per patient [1].

The Keele SBST 6-Item Version[edit | edit source]

The Keele SBST 6-item version includes 6 of the same items as the original 9-item version, with 3 items excluded (fear, anxiety and pain elsewhere), making it quicker it use. However, [1] have reported that their research (unpublished) shows that the 6-item version is only able to allocate patients to one of two subgroups (low risk or high risk). Patients who score 3 or more items positively have a high-risk of persistent disabling low back pain.

The Keele SBST 9-Item Clinical Measurement Tool[edit | edit source]

The Keele SBST 9-item clinical measurement version has been designed to help physiotherapists objectively measure the severity of the domains screened by the original 9-item version. When repeated measures are used this enables an objective marker of change over time to be made for individual items; essentially this version can be used as an outcome measure in addition to being used to subgroup patients in the same way as the original 9-item version. In order to be able to use this version to subgroup patients in the same way as the original 9-item version, cut-offs have been established for each item. The cut-off points that equate to an agree/positive score on this version for subgrouping are:

  • Leg pain - 'moderately' or more
  • Shoulder/neck - slightly or more
  • Dressing - 5 or more
  • Walking - 5 or more
  • Fear - 7 or more
  • Worry - 3 or more
  • Catastrophising - 6 or more
  • Mood - 7 or more
  • Bothersomeness - 'very' or more [1]

The authors[1] suggest it is very easy to produce an acetate using these cut-off that you place over the questionnaire to quickly enable you to score the clinical measurement tool for subgrouping purposes.

The Keele SBST 5-Item Generic Condition Tool[edit | edit source]

The Keele SBST 5-item generic condition version is the 9-item psychosocial subscale adapted to screen/identify distress in other conditions. Scores range from 0-5 with patients scoring 4 or 5 being classified as a high psychosocial risk [1].

[1] have stated that for now they are unable to recommend the use of a modified version of the SBST (including the 5-item generic condition version) for conditions other than low back pain.

Links[edit | edit source]

Keele STarT Back Screening Tool website: http://www.keele.ac.uk/sbst/

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STarT Back Approach - Physiopedia Introduction The STarT Back approach uses a simple tool to match patients to treatment packages appropriate for them based on prognosis. This has been shown to: Significantly decrease disability from back pain Reduce time off work Save money by making better use of health resources Taking the concept further it has been shown in the IMPaCT study that this approach can be successfully embedded into normal primary care[1]. The STarT Back approach is used widely in the UK and and continues to be adopted internationally. The STarT Back Screening Tool[edit | edit source] The Keele STarT Back Screening Tool (SBST) is a simple prognostic questionnaire that helps clinicians identify modifiable risk factors (biomedical, psychological and social) for back pain disability.  The resulting score stratifies patients into low, medium or high risk categories.  For each category there is a matched treatment package. There are now several different versions of the Keele STarT Back screening tool: 9-item tool: for all clinicians including GPs[edit | edit source] The SBST 9 item tool has 9 questions about predictors for persistent disabling back pain. They include radiating leg pain, pain elsewhere, disability (2 items), fear, anxiety, pessimistic patient expectations, and low mood and how much the patient is bothered by their pain. All 9-items use a response format of ‘agree' or ‘disagree', with exception to the bothersomeness item, which uses a Likert scale. The Keele SBST produces two scores: overall and distress (psych) subscale. These are used to stratify patients into low, medium and high risk groups which have their respective matched treatment packages. The patient is asked to think about the last 2 weeks and tick "disagree" or "agree" for questions 1-8 and then give a scale for question 9. Back pain spread down the leg(s) Pain in the shoulder or neck at some time Only walked short distances due to back pain Dressed more slowly due to back pain "It is not safe for a person with a condition like mine to be physically active" "Worrying thoughts have been going through my mind a lot of the time" "I feel that my back pain is terrible and it's never going to get any better" "In general I have not enjoyed all the things I used to enjoy" How bothersome has your back pain been? Clinical measurement tool: monitor change[edit | edit source] The 9-item SBST Clinical Measurement Tool is designed to help clinicians objectively measure the severity of the domains screened by the 9-item tool. When repeated measures are used this enables an objective marker of change over time to be made for individual items. Cut-offs have been established for each item - to enable those using this tool to subgroup patients in the same way as the 9-item screening tool. The cut-off points that equate to an agree/positive score on the clinical measurement tool for subgrouping are: Leg pain - 'moderately' or more Shoulder/neck - slightly or more Dressing - 5 or more Walking - 5 or more Fear - 7 or more Worry - 3 or more Catastrophising - 6 or more Mood - 7 or more Bothersomeness - 'very' or more Its very easy to produce an acetate using these cut-offs that you place over the questionnaire to quickly enable you to score the clinical measurement tool for subgrouping purposes. Matched Treatments[edit | edit source] The STarT Back approach uses the STarT Back tool to stratify patients with back pain into low, medium and high risk groups for ongoing disability. For each group there is a different treatment package matched to their level of risk. Low Risk[edit | edit source] The patients in the low risk category are very likely to improve. The aims of this package are to support and enable self-management. The key factors are to address patient concerns and to provide information. One-off consultation with clinician (doctor, physiotherapist or nurse) sufficient for most patients Assessment to include medical issues but also patient worries, concerns and social impact Brief physical assessment as appropriate. Examination helps with patient confidence Medication review and advice Address specific patient issues from the assessment Seek to encourage activity and self-management Avoid unhelpful labels and medicalisation Provide oral and written information Explain outlook is good but can re-consult if necessary Medium Risk[edit | edit source] This builds on the assessment from the low risk package. The main aims are to restore function (including work), minimise disability even if pain is unchanged and to support appropriate self-management.  This is the risk group that we are most likely to use usual physiotherapy treatments with as directed by guidelines. Similar to low risk, elicit concerns and adequate physical examination Tailored treatment according to physical findings and specific needs / worries of the individual patient Course of physiotherapy, which for some patients may only be brief Specific physiotherapy interventions when clear specific findings from physical assessment (i.e. manual therapy, specific exercises). General functional activities when no strong relationship between physical findings and back pain complaint Treatment objectives should be specific and have an end time point. All specific treatment effects should ‘translate’ into functional improvements and reduced disability Some patients will need onward referral to specialist services (i.e. secondary care spinal services, ortho, pain clinic) High Risk[edit | edit source] This again builds on the low and medium risk packages. The aims are to reduce pain, reduce disability and improve psychological functioning. The physiotherapists delivering the high risk package have additional training, mentorship and ongoing professional support to enable them to elicit and address more complex issues in patients who often have additional psycho-social barriers to recovery. It is important to emphasis that the physiotherapists also provided physical treatments to these patients as required. 6 individual (45-60 min) physiotherapy appointments over 3 months using a combined physical & cognitive-behavioural approach Enable patients to manage on-going and/or future episodes of low back pain Specific focus on cognitive, emotional and behavioural responses to pain and their impact on function Identification of potential obstacles to rehabilitation (e.g. Yellow & Blue Flags) Identification of possible targets for intervention Recommendations for Practice[edit | edit source] Examination[edit | edit source] A brief examination of patients with back pain has two basic purposes.  Firstly it will help screen patients for possible serious spinal pathology even though taking a good history is much more important. Secondly it will improve patient satisfaction and effectiveness of the consultation. It is suggested that the following be performed as a bare minimum: Inspect – general appearance, gross structural deformities Active movements – flexion (significant limitation often pathological), extension, side flexion Myotomes– rise from a knee squat (L3/4), walk on heels (L4/5) and walk on toes (S1/2). SLR (if leg pain or if you feel is needed for reassurance) +/- slump test Obviously if the history raises concerns that there may be non-spinal pain, structural deformity, widespread neurological disorder or serious spinal pathology it is appropriate to examine the patient more fully as per normal clinical practice Screen for Red Flags[edit | edit source] Red flags in spinal conditions Explanation and management[edit | edit source] Language and labels Use functional explanations for pain (sprained back, non-serious back pain). Example: “Many people have back pain from time to time but it is rare for this to be caused by a specific problem. Mostly all that is needed is to get your back moving again and things will settle down. ”Avoid “spondylitis, degeneration, crumbling” etc. Can be more specific sometimes, for example sciatica, if this leads to specific management. Avoid investigating in the first place unless it is specifically indicated (link CKS). However if you do so be aware that the technical terms used in reports often alarm patients. Translate appropriately, examples: “normal for your age ”, “ the changes seen on your scan are like getting grey hair or wrinkles as you get older” Prognosis: low risk – excellent, medium risk – good but guarded, high risk – suggest hope for improved function but don’t promise cure pain. Dealing with distress Suspend pre-judgment Listen carefully / summarize points Plan to address points Care with language and labels Be honest and realistic Do not criticize the opinions of other clinicians who have seen the patient. Provide information Activity promotion Activity promotion: beneficial, hurt doesn’t equal harm, minimise bed rest Pacing: short, frequent bouts of activity rather than overdoing things and then regretting it the next day, rests between activity, do less than maximal capabilities and increase as tolerated. Return to work as soon as possible, prolonged absence likely to lead to loss of employment. Use fit notes to support return to work and communicate suggestions to the employer. Help the patient negotiate an early return to work if at all possible. Medication usage to aid recovery link to Clinical Knowledge Summaries Key Resources[edit | edit source] STarT Back Trial[edit | edit source] Hill J, D Whitehurst, Lewis M, Bryan S, Dunn K, Foster N, Konstantinou, Main C, Mason E, Somerville S, Sowden G, Vohora K, Hay E. A randomised controlled trial and economic evaluation of stratified primary care management for low back pain compared with current best practice: The STarT Back trial.The Lancet, Volume 378, Issue 9802, Pages 1560 - 1571, 29 October 2011 link E Hay, K Dunn, J Hill, M Lewis, E Mason, K Konstantinou, G Sowden, S Somerville, K Vohora, D Whitehurst and C Main. A randomised clinical trial of subgrouping and targeted treatment for low back pain compared with best current care. The STarT Back Trial Study Protocol . BMC Musculoskeletal Disorders April 2008, 9:58 link Whitehurst DG, Bryan S, Lewis M, Hill J, Hay EM. Exploring the cost-utility of stratified primary care management for low back pain compared with current best practice within risk-defined subgroups. Ann Rheum Dis 2012; 71(11): 1796-802. link Main C, Hill J, Sowden G and Watson P. Integrating physical and psychosocial approaches to treatment in low back pain. The development and content of the Keele STarT Back trial's "high risk" intervention (StarTBack; ISRCTN 37113406). Physiotherapy 2011 link IMPaCT study[edit | edit source] Foster N, Mullis R, Hill J, Lewis M, Whitehurst D, Doyle C, Konstantinou K, Main C, Somerville S, Sowden G, Wathall S, Young J, Hay E. Effect of Stratified Care for Low Back Pain in Family Practice (IMPaCT Back): A Prospective Population-Based Sequential Comparison. Ann Fam Med March/April 2014 vol. 12 no. 2 102-111 link Sowden G, Hill JC, Konstantinou K, Khanna M, Main C, Salmon P, Somerville S, Wathall S, Foster N. Subgrouping for targeted treatment in primary care for low back pain: the treatment system and clinical training programmes used in the IMPaCT Back study (ISRCTN 55174281) Family Practice 2011 link Foster NE, Mullis R, Young J, Doyle C, Lewis M, Whitehurst D, Hay EM; IMPaCT Back Study team. IMPaCT Back study protocol. Implementation of subgrouping for targeted treatment systems for low back pain patients in primary care: a prospective population-based sequential comparison. BMC Musculoskelet Disord 2010; 20(11): 186. link STarT Back Tool[edit | edit source] Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum 2008;59(5):632–41  Jonathan C. Hill *, Kate M. Dunn, Chris J. Main, Elaine M. Hay. Subgrouping low back pain: A comparison of the STarT Back Tool with the Örebro Musculoskeletal Pain Screening Questionnaire. Eur J. Pain 2009; doi:10.1016/j.ejpain.2009.01.003  Gusi N, Del Pozo-Cruz B, Olivares PR, Hernandez-Mocholi M, Hill JC. The Spanish version of the “STarT Back Screening Tool” (SBST) in different subgroups. Aten Primaria 2010  Hill et al. Comparing the STarT Back Screening Tool's Subgroup Allocation of Individual Patients With That of Independent Clinical Experts.Clinical Journal of Pain: 2010 - Volume 26 - Issue 9 - pp 783-787  Morsø L, Albert H, Kent P, Manniche C, Hill J. Translation and discriminative validation of the STarT Back Screening Tool into Danish. Eur Spine J. 2011 Dec;20(12):2166-73. Epub 2011 Jul 19.  Olivier Bruyere, Maryline Demoulin, Clara Brereton, Fabienne Humblet, Daniel Flynn, Jonathan C Hill, Didier Maquet, Julien Van Beveren, Jean-Yves Reginster, Jean-Michel Crielaard and Christophe Demoulin.Translation validation of a new back pain screening questionnaire (the STarT Back Screening Tool) in French Archives of Public Health, 70:12 (07 Jun 2012)  Stratified Care[edit | edit source] Hill JC. The early identification of patients with complex back pain problems. The Back Care Journal. Spring 2010.  Hill JC, Fritz JM. Psychosocial influences on low back pain, disability, and response to treatment. Phys Ther. 2011;91:712–721  Fritz JM, Beneciuk JM, George SZ. Relationship between categorization with the STarT Back Screening Tool and prognosis for people receiving physical therapy for low back pain. Phys Ther. 2011;91:722–732 Alice Kongsted, Else Johannesen and Charlotte Leboeuf-Yde. Feasibility of the STarT back screening tool in chiropractic clinics: a cross-sectional study of patients with low back pain. Chiropractic & Manual Therapies 2011, 19:10 doi:10.1186/2045-709X-19-10  Fritz JM, Beneciuk JM, George SZ. Relationship between categorization with the STarT Back Screening Tool and prognosis for people receiving physical therapy for low back pain. Phys Ther 2011;91:722–732.  del Pozo-Cruz B, Parraca JA, del Pozo-Cruz J, Adsuar JC, Hill JC, Gusi N. 2012. An occupational, internet-based intervention to prevent chronicity in sub-acute lower back pain: A randomized controlled trial. Journal of Rehabilitation Medicine. vol. 44(7), 581-587. Hill JC, Foster NE, Hay EM. 2010. Cognitive behavioural therapy shown to be an effective and low cost treatment for subacute and chronic low-back pain, improving pain and disability scores in a pragmatic RCT. Evid Based Med, vol. 15(4), 118-119. l Field J, Newell D. Relationship between STarT Back Screening Tool and prognosis for low back pain patients receiving spinal manipulative therapy. Chiropr Man Therap. 2012 Jun 12;20(1):17.  Beneciuk JM, Bishop MD, Fritz JM, Robinson ME, Asal NR, Nisenzon AN, George SZ. The STarT Back Screening Tool and Individual Psychological Measures: Evaluation of Prognostic Capabilities for Low Back Pain Clinical Outcomes in Outpatient Physical Therapy Settings. Phys Ther. 2012 Nov 2. Wideman TH, Hill JC, Main CJ, Lewis M, Sullivan MJ, Hay EM. Comparing the responsiveness of a brief, multidimensional risk screening tool for back pain to its unidimensional reference standards: The whole is greater than the sum of its parts. Pain. 2012 Nov;153(11):2182-91.  N Foster & A Delitto. Embedding Psychosocial Perspectives Within Clinical Management of Low Back Pain: Integration of Psychosocial Informed Management Principles into Physical Therapist Practice - Challenges and Opportunities. Physical Therapy 2011.  The Inclusion of CBT in Physiotherapy Education - Physiopedia The History of Cognitive Behavioural Therapy In the early 1960s, psychoanalyst professor Aaron Beck developed cognitive therapy after investigating the psychoanalytic concepts of depression. During his studies, he discovered that depressed patients spontaneously experienced automatic negative thoughts. These negative thoughts fell into three categories: negative thoughts about themselves, the world, and the future. After spending some time with these patients, Beck recognised that these automatic negative thoughts were highly related to the individual’s emotions. Beck started to notice rapid improvements amongst these individuals after helping them identify, evaluate and respond to their maladaptive thinking and behavioural patterns. In order to see the effects of this form of cognitive therapy, a randomised controlled study was conducted looking at the impact of cognitive therapy in depressed patients. Results showed cognitive therapy to be as effective as imipramine, an antidepressant. These findings were a huge milestone as a form of talk therapy had been compared to a pharmacological medication. Today CBT has been scientifically proven to be effective in numerous clinical trials for varying disorders[1]. What is CBT?[edit | edit source] CBT stems from the cognitive model of psychopathology. This theory looks at how individuals' perceptions and thoughts about situations influence their emotional, behavioural and physiological reactions[2]. For example, when individuals are stressed, their thoughts tend to be distorted and dysfunctional. If individuals learn to identify, address and correct these thoughts, their stress levels tend to decrease leading to more functional behaviour. CBT teaches individuals to confront their irrational thoughts, in a more realistic and adaptive manner so that they experience improvements in their emotional state and behaviour. CBT can include a number of cognitive and behavioural techniques including self-instructions and adaptive coping strategies[3]. CBT involves six overlapping phases that can be adapted to a diverse set of populations with various disorders. The phases represent the different theoretical components of the multidimensional treatment. Even though CBT follows a logical sequence, the treatment should be flexible and individualised to the patient’s needs. The Six Phases of CBT[4] [edit | edit source] Phase 1: Assessment[edit | edit source] Figure 1: 6 Phases of CBT   This phase involves assessing information given from the patient and family through a series of self-reported measures and observational procedures to identify the degree of psychosocial impairment. Information provided determines the most appropriate course of action. Establish baseline measures.  Phase 2: Reconceptualisation[edit | edit source] Cognitive part of CBT Patients are often asked to maintain a self-report diary. Seeks to help patients challenge and question their maladaptive thoughts (e.g. “I am a failure in life because I am in pain”). Collaboratively set goals with the patient. Phase 3: Skills Acquisition and Consolidation[edit | edit source] Therapist uses various cognitive and behavioural strategies to teach patients how to deal with obstacles in their day to day lives. Collaboratively focus on problem solving strategies i.e. relaxation techniques/pacing/graded exposure/coping strategies. Phase 4: Skills Consolidation and Application[edit | edit source] Patients are given homework to help reinforce the skills that they have learned. Phase 5: Generalisation and Maintenance[edit | edit source] Patients review homework and practice skills that have been taught and considers potential problematic situations that may arise. Patients evaluate their progress and attribute success to their own coping efforts. Phase 6: Post-Treatment and Follow-Up[edit | edit source] All aspects of therapy are reviewed. Therapist monitors and evaluates patient's application of CBT to their life. How and Why Does CBT Fit Into Physiotherapy Practice?[edit | edit source] Current physiotherapy education stems from the International Classification of Function, Disability and Health (ICF) Model[5]. The incorporation of CBT into physiotherapy practice will enhance the delivery of the bio-psychosocial model providing a more holistic approach towards patient-centred care. This will ensure a more comprehensive and successful journey for both patient and practitioner. The correct implementation of CBT by physiotherapists within their scope of practice will increase the success of treatment and overall outcome for patients. The fundamental principles of both CBT and physiotherapy are comparable and integrate cohesively as shown in Table 1.  Table 1: Relatable principles between CBT and physiotherapy    Cognitive Behavioural Therapy    Physiotherapy Identification of current and specific problems The synthesis of a problem list The use of goal setting The use of SMART goals The treatment is individualised and collaborative between therapist and patient Patient centred care Aims to uncover and change behaviours Correcting bad habits and uncovering why the bad habits have occurred in the first place Aims to build CBT skills to prevent relapse Focus is on self management   The addition of CBT in a physiotherapist's skill set can help enable patients to identifiy and change negative thought patterns which are detrimental for successful rehabilitation. This allows patients to regain internal locus of control which can positively influence the patient’s specific problems[2]. Physiotherapists are in a prime position to help manage and modify a patient's maladaptive thoughts. The start of a physiotherapy assessment begins with a subjective examination. This provides the opportunity for physiotherapists to gauge if CBT would be an appropriate tool for the patient. Appropriate tools to identify psychosocial risk factors i.e. yellow flags, would enable the collaboration of the physiotherapist and patient to target these patient problems when setting SMART goals[6]. A treatment plan can then be seamlessly adapted with both the physical and psychosocial conditions in mind. This may also help to reduce the impact of any negative stigma patients may have with regards to requesting and obtaining psychological support. In some cases, physiotherapists will be the first point of health care contact for many patients. This places physiotherapists in a prime position to help treat the patient holistically. In scenarios containing complex patients with psychosocial issues at the stem of the problem list, the aim of treatment can be directed appropriately with collaboration between the physiotherapist and patient. This is likely to reduce rates of relapse due to previous maladaptive behaviours and reduce re-admission rates. The amalgamation of CBT into the current physiotherapy curriculum would equip physiotherapy students with the skills to identify and manage patients indicative of yellow flags early, thus reducing the need for a referral to a clinical psychologist. Ultimately, physiotherapists tackling subtle psychosocial issues at the start may decrease contact time amongst the multidisciplinary team and decrease health costs.  This would have the potential to increase the success rate of treatment and reduce readmissions as the patient would learn to self manage their behaviours. Missing Links in Current Physiotherapy Training [edit | edit source] In addition to the principles of physiotherapy and CBT integrating seamlessly, there exist some gaps in current physiotherapy training.[7] The current curriculum: Emphasises anatomical, neuro-musculoskeletal, biomechanical, biomedical knowledge over the biopsychosocial model Treating disease and injury Outcome measures focusing on strength, movement, modalities, function, balance Provides limited interprofessional education Provides some education within the biopsychosocial realm of physiotherapeutic management Lacks depth and focus on how to assess and manage psychosocial factors More time spent on biomedical assessment and treatment of physical conditions At times provides education into modalities that are lacking evidence base and underpinning Lacks application and practice to fully reinforce psychosocial principles Difficult to consolidate psychosocial education in practice Additionally, the focus of continuing professional development (CPD) continues to enforce the biomedical model of assessment and treatment, with minimal CPD workshops that address the psychosocial approach. A CBT module within the physiotherapy curriculum can help further develop a physiotherapy student to become a more well-rounded and competent clinician. Current Literature to Support CBT [edit | edit source] There is empirical evidence that suggests CBT is effective in improving conditions such as anxiety, depression, post-traumatic stress disorder, eating disorders and chronic pain. In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) recommends CBT as the treatment of choice for a number of mental health illnesses previously mentioned. In addition there is a growing body of evidence behind the effectiveness of CBT for physiotherapy, producing significant improvements for patients with back pain[8], chronic pain[9] and fibromyalgia[10] with regards to function, pain experience and coping strategies. Table 2: Cases in which CBT has been shown to benefit Psychiatric disorders Medical problems Psychological Problems Depression Anxiety Personality Disorder Panic disorders Obsessive-compulsive disorder Substance abuse ADHD Eating disorders Sex offenders Bipolar disorder Schizophrenia Chronic back pain Sickle cell disease pain Migraine headaches Tinnitus Cancer pain Irritable bowel syndrome Chronic fatigue Syndrome Rheumatic disease pain Insomnia Obesity Hypertension Couple problems Family problems Complicated grief Anger and hostility Pathological Gambling [11] Evidence For The Use of CBT [edit | edit source] There has been an increase in the demand for interventions that may prevent the development of persistent pain problems. In 1997, a review of 10 trials of early interventions for acute back pain based in primary care settings was carried out. These programmes dealt with fear and anxiety which is often associated with acute pain, leading to positive results over various control conditions[12]. A study conducted in 1998 also found that a cognitive-behavioural programme for patients with acute back pain significantly reduced worry and disability at follow-up – therefore preventative measures may be viable. In 2001, a randomised controlled trial was published which aimed to investigate the preventative effects of a CBT group intervention for people reporting neck or back pain[13]. The participants had experienced four or more episodes of relatively intense spinal pain during the past year but had not been out of work for more than 30 days. As a result the aim was to prevent a non-patient population developing a more serious pain problem and entering a chronic stage. The experimental group participated in a six-session structured programme where the individuals met in groups of 6-10 once a week for two hours. The CBT group showed more stable improvements over the control group with reduced sick days. The CBT group also reported a decrease in fear avoidance and an increase in the number of pain-free days concluding early preventative measures may be helpful.  With regard to the issue of absenteeism, musculoskeletal disorders (MSDs) are one of the most commonly reported work-related illnesses. There is now general agreement among the various occupational health guidelines for management of MSDs. This encompasses the identification of psychosocial obstacles to recovery, provision of advice that MSDs are self-limiting conditions and that remaining at work or an early return to work (RTW) should be encouraged and supported[14]. A study was conducted in 2006 in a large pharmaceutical company in the UK. Occupational health nurses (OHN) were trained to deliver an intervention to workers taking absence due to various MSDs including low back pain (LBP) and upper limb disorders[15]. This training package included education about pain and pain mechanisms, tackling negative beliefs and attitudes and reinforcing the importance of keeping active and early RTW . Results showed a decrease in absent days in one particular site compared to the control site where workers were seen by the OHN on RTW. In summary, this study adds to emerging evidence that absence from work can also be reduced by providing information and support to employees. CBT has also been used successfully with angina patients[16]. The Heart Manual is a six-week cognitive behavioural rehabilitation tool  designed to correct misconceptions about the cause of Myocardial Infarction (MI). In addition it helps patients develop strategies for dealing with stress in order to neutralise enduring misunderstandings. The Heart Manual is one way of providing educational and psychological support for post MI patients, although it will not meet the needs of a minority who require additional help[17]. An initial randomised controlled trial evaluating the Heart Manual found that those receiving the manual had improved emotional states, fewer GP contacts and hospital readmissions at six months post MI. Subsequent studies have found significantly fewer readmissions in the 77 treated patients and improvement in emotional state and sense of control at six months[18]. As previously mentioned, CBT can also play a role in the treatment of various mental health conditions. A study was published in 2002 which aimed to test the effectiveness of added CBT in accelerating remission from acute psychotic symptoms in early schizophrenia[19]. A 5-week CBT programme plus routine care was compared with supportive counselling plus routine care and routine care alone in a multi-centre trial randomising 315 people with DSM-IV schizophrenia and related disorders in their first (83%) or second acute admission. Linear regression over 70 days showed predicted trends towards faster improvement in the CBT group. Concluding that CBT shows transient advantages over routine care alone or supportive counselling in speeding remission from acute symptoms in early Schizophrenia. Does CBT Work For All Patient Populations?[edit | edit source] As mentioned previously, CBT is applicable in a wide range of situations and beyond the initial problem for which the patient may seek treatment. Although it has been specialised and adapted for use within a number of specific disorders ranging from depression to psychosis, CBT has also become increasingly popular for a wide variety of chronic pain conditions, particularly for chronic LBP[20]. Despite this, there exists a patient population that is less likely to respond to CBT as a treatment[21]. In addition, some research has shown that a CBT approach is equally as effective at reducing pain levels as traditional interventions[22]. Perhaps a more systematic approach to matching CBT to certain patient populations and filtering it to those who are more likely to respond positively to treatment is the approach required for CBT. Figure 2: STarT Tool Scoring System The Keele STarT Back Screening Tool (SBST) is designed to address the mismatch. A sample musculoskeletal (MSK) screening tool can be downloaded here. The SBST categorises patients with LBP into three subgroups based on their prognosis (low risk of chronicity, medium risk with physical obstacles to recovery, and high risk with psychological obstacles to recovery)[23]. The practice of physiotherapy revolves around patient centered care. The choice for a physiotherapist to utilise CBT as an intervention stems from prior CBT training and therapist intuition/clinical reasoning. Moreover, a tool such as the SBST can determine if any discrepencies exist between patients. The SBST is valid and repeatable, and consists of 9 items which include: referred pain, co-morbid pain, disability, bothersomeness, catastrophising, fear avoidance, anxiety and depression. The latter 5 items combine to form a subscore relating to psychosocial factors that indicates appropriateness for CBT as an intervention[24]. The SBST is currently being adapted to MSK conditions, with trials occurring in NHS 24 in Scotland. Figure 3: Subgrouping and Care Plan Targeting patient subgroups that are most likely to be receptive to CBT can help improve outcomes and reduce costs. A trial of the SBST conducted by Hill et al. 2011[25] demonstrated increased health benefits along with reduced cost of health care. The trial revealed that with the SBST and trained therapists to deliver targeted interventions for each of the three subgroups of patients, there was a direct mean savings of £34.39 per patient and an indirect productivity saving of £675 per patient when compared with patients receiving current care. Pain-related productivity and societal losses can manifest through sick days and repeat health care visits. A randomised control trial conducted in 2005[26] found that CBT in addition to physiotherapy reduced the mean number of health care visits due to pain from 6 to 1, and reduced the percentage of sick days from 9-14% to 2-5% when comparing groups that received minimal treatment and CBT. This type of evidence suggests that with therapeutic interventions that take into account the biopsychosocial model of patient care, there is a possibility to reduce disability and reduce the cost of care. The evidence suggests the effectiveness of CBT is improved when directed at the correct patient populations. Tools like the SBST need to be used in conjunction with sound clinical reasoning in a patient centered approach to target those who are likely to benefit from it. With adapted versions of the SBST to encompass other MSK conditions being trialed with NHS 24 currently, newly trained physiotherapists would benefit from CBT training to effectively utilise this new information gained from patients in practice. Physiotherapists are evidenced-based practitioners and there exists not only a need for further training to incorporate CBT principles, but a desire from practicing physiotherapists to expand knowledge on CBT principles[27]. The Role of CBT in the Multidisciplinary Team and Family [edit | edit source] CBT can also be used away from the therapist-patient relationship. Some areas where CBT can be applied by an Allied Health Professional (AHP) include: Supporting families of those with both chronic and acute conditions: Reassurance to family members of those affected by chronic and acute conditions is essential in the treatment and recovery of the patient[28]. Programmes designed to include families in the care of relatives with chronic conditions can be implemented, particularly in the terminal setting. These programmes can guide family members with goal setting, supportive communication techniques and provide them with the tools to assist in monitoring clinical symptoms and medications[29]. For those with career threatening injuries (e.g. professional athletes or manual workers), coping with potential loss of income can be extremely stressful for both themselves and their families.   In order to get families to adopt a supportive role there often needs to be a change in cognition. Unrealistic and irrational thoughts regarding their loved ones prognosis may be detrimental to the treatment process. Therefore, where possible, such beliefs should be addressed to reduce the potential of any maladaptive behaviours[30]. For those with acute conditions that may result in loss of earnings or concept of self, CBT may help to prevent anxiety and cognitive distortion (e.g. catastrophising), as well as increased adherence to the rehabilitation protocol[31]. To work effectively with other members of the MDT, particularly in challenging settings e.g. palliative care, oncology: When those working in palliative care settings have been interviewed with regards to work place stressors, more stressors were related to difficulty with colleagues, work environment, and occupational roles than with the interaction with patients and their families[32]. Seeking support from colleagues is often preferred and more accessible then official support models in place for those working in health provision areas with high stress[33]. With an insight into the cognitive and behavioural components of our own actions we can develop higher self-monitoring traits along with increased empathy. This in turn may lead to further understanding of fellow professionals within the MDT thus enabling us to defuse any potentially volatile situations. Furthermore, many of the environments in which physiotherapy skills are required tend to be highly stressful and emotional. As a result we may be required to engage in supportive behaviour and cognitive reasoning with colleagues. To ensure optimal personal mental health for AHP’s: The Health and Safety Executive recognises that there are many factors in the workplace that contribute to strains on NHS professional’s mental health. These include: excessive demands, lack of control, lack of support, poor working relationships, role ambiguity and organisational change[34]. The 2009 Boorman Review reported that the NHS loses 10 million working days annually due to sickness costing the NHS an estimated £555million, with mental health along with MSDs being the primary cause. Combined they are the leading cause of health-related early retirement in the NHS[35]. The Work Foundation estimates that presenteeism due to poor mental health leads to a loss of working time nearly 1.5 times that caused by sickness absence due to mental health in the United Kingdom[36]. By having an understanding of ones own cognitive state, AHPs may be able to overcome the inherent stressors in their jobs. It has been documented that self-directed CBT can reduce an individual’s own stress, anxiety, depression and cognitive dissonance[37][38]. As CBT incorporates the introspection of thought process from Cognitive Therapy and the goal of behavioural change from Behavioural Therapy, CBT can be a useful tool for physiotherapists in their own development as a competent and holistic professional. Enhanced insight into maladaptive thoughts may lead to a reduction in mental health issues, likely resulting in a decrease in work days lost in the NHS[39]. Applying CBT to Physiotherapy Practice[edit | edit source] CBT principles can be applied in conjunction with current physiotherapy practice. CBT also involves taking the following into consideration[1]:  Therapeutic Alliance It is essential that the patient views therapy as teamwork It is important for the therapist to provide empathy, warmth and genuine regard through listening and understanding the patients' true feelings.  Providing a realistic outlook Ensure the patient understands and agrees with modes of therapy utilised. Encourage the patient to take an active role in their recovery by providing therapy homework.  Goal setting Elicit SMART goals from the start to ensure the patient understands what they are working towards.  Education The therapist should aim to teach the patient skills and techniques of how to be their own therapist.  Time Limited Patients are usually treated for 6-14 sessions during which the therapist aims to provide relief, resolve patients' most pressing problems and teach them skills to avoid relapse.  Structured therapy In order to maximise efficiency and effectiveness each session should be structured.  Various techniques CBT uses various techniques in order to cater to the individuals' needs.  Identify, evaluate and respond Patients can have hundreds of automatic thoughts everyday but it is important that the therapist teaches the patient to identify the key cognitions and how to respond. Conclusion[edit | edit source] The evidence demonstrates that CBT can benefit all aspects of the patient journey which incorporates not only the patient but family members and the MDT as well. Current physiotherapy education attempts to emphasize and root its practice based on the ICF model. The integration of a CBT module in the current curriculum would highlight the importance of combining both the biomedical and psychosocial models of healthcare. Numerous benefits of CBT have been demonstrated throughout this proposal. These include enhancing the patient journey, facilitating a more efficient practice and ultimately minimising health care costs. The sample module this page presents demonstrates the simplicity and feasibility of implementing a CBT module. Merging stratification approaches in physical therapy management of a case of subacute low back pain - Physiopedia Abstract This report outlines the application of an amalgamation of two systems of stratification for patients with Low Back Pain (LBP) applied to a case of subacute back pain with a history of recurrence. The STarT Back Screening Tool (SBST) was used to assist with stratifying the patient along the lines of prognosis and to interventional resource allocation. She was found to fall within the Moderate risk stratification group who would benefit from specific Physiotherapy intervention. The Treatment Based Classification (TBC) was used to guide further stratification along the lines of best matched treatment to clinical findings. After three weeks of matched, evidence based intervention, the patient has demonstrated a clear positive response with the abolition of pain and reduction in her self rated disability, using the Oswestry Disability Index (ODI) and has been reclassified by the SBST as Low risk. This case represents the potential utility of this amalgamated approach. Client Characteristics[edit | edit source] This patient is a 37 year old registered nurse who is known to be Asthmatic but well controlled, and has a history of migraines and uterine fibroids with painful menses. She is an avid exerciser and is a member of a cross-fit exercise group that meets and exercises four times weekly. She gives a 2 year history of recurring episodes of LBP aggravated usually by increased work loads during her shift and which generally responds well to her exercise routine and settles within 2-3 days. About 7 weeks prior to her evaluation, she developed back pains after an unusually challenging work shift but noted on that occasion that she now had intermittent pains in the anterior of her left thigh. She was concerned about the new symptoms and sought medical attention at the staff clinic and had an MRI done which revealed a small central disc herniation at the L5 S1 level with no other bony or soft tissue anomaly. She was prescribed Norgesic with minimal relief and at her physician follow-up was referred to PT with a diagnosis of Mild L5 S1 Disc Prolapse. Examination findings[edit | edit source] Subjective Findings She gave no history of trauma, or other symptoms or signs of serious spinal pathology including bowel or bladder disturbance, unexplained weight loss, saddle anaesthesia or widespread neurological symptoms. Her chief complaint was of intermittent central back pain, which was cramping in nature and rated at 4/10 on the Numerical Rating Scale (NRS) with occasional radiation into the mid-anterior aspect of the left thigh. Pain is aggravated by static forward flexed postures such as during patient dressings and pains are reduced by raising the arms overhead and leaning backwards. She noted that sitting is more comfortable than standing. Her symptoms had generally decreased in frequency and intensity from onset but appeared to have plateaued at current levels. Despite her discomfort she had not stopped from work but was uncertain about resuming her exercise routine. Her self-rated disability, using the Oswestry Disability Index (ODI) was 6% and the patient reported her principal objective was to eliminate her current pains so she can resume her cross-fit workouts with her group. The STarT Back Screening Tool scored at a 4 (medium risk) with 3 points coming from the subscore (Question 5 -9). Physical Findings Static testing: Impaired back extensor muscular endurance (could not clear the sternum off the plinth and hold for more than 20 seconds). Abdominal endurance tests were normal. Dynamic testing: Nil temporal or spatial gait deviations noted Full painfree ROM in flexion, extension, sideflexion and rotation. Aberrant movement on return from flexion, which was associated with pain. Repeated movements did not increase or decrease symptoms Nil impairment in motor control of the lumbar spine musculature during sit to stand transitions or ascending/descending stairs. However there was abnormal timing of the activation of the paravertebral muscles on return from flexion. bending Palpation Hypermobile L3 on PAIVM with reflex muscle spasm in the left sided paravertebral muscles at that level. Tenderness over the L3 and L4 spinous processes Neurological testing Normal reflexes Intact sensation Normal myotomal muscle power in lower limbs and trunk Special tests - ve SLR  -ve SLUMP -ve Femoral Nerve Traction +ve Prone Instability test Clinical Hypothesis[edit | edit source] The patient presents with subacute back pain with motor control impairments in the lumbar spine, within an overall background of recurrence. It can be reasoned that the disc protrusion identified on MRI likely represents the end result of the patient’s work habits, but given the lack of provocation signs with the dural mobility tests (Slump/SLR) and the disparate location of the extremity symptoms (L2/3 dermatome versus L5 S1) it seemed unlikely to be the cause of the patients symptoms. A more likely aetiologic factor is the tender, hypermobile vertebral segment at L3. The SBST also identified a yellow flag in the form of fear –driven pain beliefs. This also needed to be addressed to limit the risk of future disability. Intervention[edit | edit source] Patient education. She was educated on the fact that a protruded disc on MRI does not constitute proof of cause with LBP and that the prognosis was good highlighting the positive elements of her case including her premorbid exercise habits, and the fact that she remained at work through the episode. Back care advice: given the nature of her work and the MRI confirmation of a disc protrusion, the patient was also taken through a 1 on 1 session of biomechanical strategies to reduce the rate of progression of the lumbar disc degeneration, including the safe execution of exercises in her cross-fit program and ADLs. Progressive core muscle activation with emphasis on correct form. Staged reactivation: As part of the strategy to combat her fear of pain, a deliberate attempt is made to equip the patient to succeed on attempts to master new skills. Once she had progressed to the point where she was activating her spinal stabilizers effectively, we incorporated that activation into various postures and then movement including standing, reaching and walking. She has completed 3 treatments in as many weeks Outcomes[edit | edit source] Over the course of three weeks (3 visits) the patient’s pain has completely abolished with a commensurate reduction in her ODI score, currently at 2%. On re-pass of the SBST the patient’s overall score had declined to a 1, moving her into the low risk category. The next step in her rehabilitation is to translate her stabilization strategies into more dynamic functional tasks such as brisk walking. This is part of staged approach to returning to running and other exercises over the next 3-5 weeks. Discussion[edit | edit source] Hancock (2015)[1] alluded to the value of merging aspects of the various stratified care models in an effort to increase clinical utility. He proposed a hybrid model merging the STarT Back and Treatment Based Classification systems. Hodges and colleagues also propose a hybrid model, finding that it could simplify the selection of treatments.[2] Hancock's hybrid approach was applied to this case with the patient being stratified to the Medium risk category initially. The matched treatment approach to such a categorization involves Physiotherapy interventions based on clinical findings[3]. The clinical findings satisfied 4 of 7 named criteria for the ‘Stabilization’ treatment sub-group of the TBC and consequently the patient’s management included exercises to activate the spinal stabilizers, including the Tranversus Abdominis and Multifidi muscles. Smith, Littlewood and May (2015)[4] concluded from their systematic review, that specific core stabilization exercises as prescribed in this case, offer no distinct advantage over general conditioning exercises. However in their review the authors did not specifically examine stabilization exercises when prescribed after sub-grouping patients. While the patient’s rehabilitation is currently on-going, initial response to three weeks of stratified care demonstrate elimination of pain with reduced disability, measured with the Oswestry Disability Index and an improvement in the patient’s overall risk stratification on the SBST. It has been noted that the TBC is the only model that demonstrates no significant difference in intertester reliability between novice and experienced clinicians[5]. Additionally, its ease of implementation relative to the significant training and time investment of other stratification models, such as the MDI[6] gives it notable advantages in clinics where Physiotherapists of varying experience manage LBP patients. The merger of the SBST and the TBC also allows for consideration of the role of cognitive behavioural approaches to managing patients with yellow flags and chronic LBP, which the TBC does not explicitly address on its own. As such this hybrid approach offers clinicians an evidence based and pragmatic approach to stratification of patients and allocation of existing physiotherapy resources in patients with LBP. Tampa Scale of Kinesiophobia - Physiopedia Introduction The Tampa Scale of Kinesiophobia (TSK) was first developed in 1991 by R. Miller, S. Kopri, and D. Todd. A year before, the developers had introduced the term kinesiophobia at the Ninth Annual Scientific Meeting of the American Pain Society to describe patient circumstances characterised by an "excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or reinjury".[1][2] You can learn more about kinesiophobia and its clinical relevance here. Objective[edit | edit source] TSK is a self-reported questionnaire that quantifies fear of movement, or (re)injury. Intended Population[edit | edit source] The TSK was initially used to distinguish between non-excessive fear and phobia in patients with chronic musculoskeletal pain, i.e. the fear of movement in older people with chronic low back pain. [2] Later, its use expanded to other conditions and parts of the body, such as the neck, [2][3] the lower extremity, [4] temporomandibular disorders, [5] cardiac conditions, [6] fibromyalgia.[7] Some factors of the scale have been recommended for use in adolescents with idiopathic scoliosis undergoing spinal surgery.[8] Items, Categories and Versions[edit | edit source] In its original form, the TSK is a 17 item assessment checklist. [1] It uses a 4-point Likert scale (Strongly Disagree-Disagree-Agree-Strongly Agree) with statements that have been later linked to the model of fear-avoidance, fear of work-related activities, fear of movement, and fear of re-injury.[9] Shorter and modified forms of this instrument varying from 4 to 14 items were also developed for routine assessments, specialised patient care and research.[10][11] So far, the TSK scale, originally written in English, has been translated into multiple languages such as Dutch, [12] Italian, [13] Japanese, [14] Finnish, [15] Swedish, [16] Turkish, [6] Greek, [17] Chinese, [18] Norwegian, [19]and Spanish.[20] Most factor-analytic studies of the TSK favour 2 generally accepted areas of assessment (subscales) across various pain conditions:[21][22][23] Activity Avoidance – the belief that activity may result in (re)injury or increased pain. (TSK-AA) Somatic Focus – the belief that pain is a sign of underlying and serious medical issues (TSK-SF) Scoring[edit | edit source] Individual item scores range from 1-4, with the negatively worded items (4,8,12,16) having a reverse scoring (4-1). The 17 item TSK total scores range from 17 to 68 where the lowest 17 means no or negligible kinesiophobia, and the higher scores indicate an increasing degree of kinesiophobia. [3] The shortened version TSK-11 which is the most common, [24] dismisses items with poor psychometric performance, and its score ranges from 11-44.[25] Scores above 37 (17-item) are generally considered to indicate kinesiophobia. [24] However, gender and pain diagnosis seem to correlate with TSK scoring, thus affecting the norming of this scale. [23] Roelofs et al. [23] provide norms for scoring across different populations and versions of the TSK. Psychometric properties[edit | edit source] Psychometric properties of the TSK are provided below. For more information on psychometric properties for tools used in health-related research and care, click here. Reliability[edit | edit source] The TSK shows a high level of internal consistency across all items and is positively associated with related measures of fear-avoidance, pain catastrophizing, pain-related disability .[26] In the Finnish version of TSK, the test-retest reliability (ICC) = 0.887. [27] Validity[edit | edit source] Construct validity: moderate correlation coefficient with measures of pain-related fear, pain catastrophising, and disability in patients with CLBP. Predictive validity: moderate correlation coefficient with physical performance tests. [21] In whiplash patients, higher scores on the TSK (Dutch version) were associated with a longer duration of neck symptoms, without reaching statistical significance for improving the ability to predict the duration of neck symptoms after motor vehicle collisions.[28] However, it must be noted that the sample follow-up and available for analysis was small. Concurrent validity is moderate, ranging from r(s) =0.33 to 0.59. [29] [30][31] There is also another valid, and reliable abbreviated version of the scale that consists of 11 items. [32] Responsiveness[edit | edit source] For patients with chronic low back pain, TSK was sensitive to detect clinical changes [33], it was also sensitive to detect changes after spinal fusion. [34] Unlike in patients with ACL injury, it isn't the best way to assess psychological factors according to the Japanese version. [35] Links[edit | edit source] Tampa scale of kinesiophobia (TSK) (modified version, NovoPsych, TSK.) MDApp, TSK. Free online TSK calculator Hypertonia Assessment Tool - Physiopedia Objective The Hypertonia Assessment Tool (HAT) is a standardized clinical tool used to identify different forms of hypertonia in the paediatric population. These subtypes include: Spasticity Dystonia Rigidity There are several scales that measure the severity of hypertonia, but up until the HAT, none differentiated between the forms of hypertonia. This is important to identify as different forms of hypertonia are managed differently, including medically (in terms of drug prescription) and surgically. With regards to research, being able to identify subtypes of hypertonia enables better specificity with patient recruitment and outcome reporting.[1] Intended Population[edit | edit source] The HAT is administered to children between 4 to 19 years of age. These children should demonstrate hypertonia in at least one limb.[2] Hypertonia is defined as “abnormally increased resistance to externally imposed movement about a joint”[1] In the HAT user manual it puts it as “increased resistance to passive stretch of a muscle”. Tool description[edit | edit source] The HAT is a seven-item scoring tool. These 7 items comprise of 2 spasticity items, 2 rigidity items and 3 dystonia items. These 7 items are recorded for each of the affected limbs. Equipment required[edit | edit source] HAT scoring chart (one sheet for each limb being tested) Pen/ pencil to record scoring Examination table for child/youth to lie down on. Set-up[edit | edit source] The child or youth should lie supine on the examination table/ support surface. The child should be wearing unrestrictive clothing and the hand or foot of the limb being tested bare. If possible, hands should be placed gently on their upper abdomen. A roll should be placed under the knees and a pillow under the head. Method of Use[edit | edit source] Before commencing administration of the HAT it is recommended to review the HAT user manual. During the assessment, the evaluator moves a child’s limb in a series of purposeful stretches and movements. The movement itself is observed, as well as increased tone and/or resistance. These 7 items include: Increased involuntary movements or postures of the designated limb with tactile stimulus of another body part. Increased involuntary movements or postures with purposeful movement of another body part. Velocity dependent resistance to stretch. Presence of a spastic catch. Equal resistance to passive stretch during bi-directional movement of a joint. Increased tone with movement of another body part. Maintenance of limb position after passive movement. The test takes approximately 5 minutes per limb tested. Scoring and interpretation[edit | edit source] The presence of at least one HAT item per hypertonia subgroup (Spasticity, dystonia or rigidity) confirms the presence of the specific hypertonia. If a child scores in more than 1 hypertonia subgroup, mixed tone is present. Scoring is divided into 0 or 1. With 0 designated as an absence of the movement abnormality and 1 to a positive identification of the movement abnormality. [3] Evidence[edit | edit source] Individual item validation, Inter-Rater reliability, Test-Retest Reliability and Criterion Validity was performed during the initial formation and testing of the HAT.[1] 25 children (diagnosed with cerebral palsy) were recruited for the study. They were examined by three independent physicians (blinded to each other’s scores). Two administered the HAT, while the third administered a paediatric neurological examination. After 2 weeks the same children were re-examined using the HAT. A study performed by Knights et al. (2013) found that videotaping the test being performed did not significantly change the outcome of the scoring. Dystonia, item 1 however, did not change the HAT hypertonia diagnosis and was removed from the HAT.[4] Reliability[edit | edit source] In the initial formation of the HAT test test-retest reliability was reported as excellent for spasticity (1.0), for dystonia only moderate (0.43) and for the absence of rigidity excellent (0.91-1.0). Interrater reliability was substantial (0.65) for spasticityy, fair for dystonia (0.3) and excellent for the absence of rigidity (0.91-1.0) .[1] In a study performed in 2016 - using 2 physicians and 45 children - interrater reliability (n=45 ) of the HAT subtypes was moderate to substantial. Intrarater reliability (n=42) was almost perfect.[5]It must be noted that this study took participants diagnosed with neuromotor disorders and not strictly cerebral palsy. Validity[edit | edit source] When looking at validity, the initial study reported moderate to good (0.57-0.74) validity for spasticity, mixed readings for dystonia (ranging from fair to substantial) (0.3-0.65) and for the absence of rigidity, all readings were excellent (0.91-1.0).[1] In the 2016 study, validity for the HAT in testing spasticity was confirmed, whereas it was advised that further studies were needed to ascertain validity for dystonia and rigidity.[5] Links[edit | edit source] To access the free downloadable scoring sheet click here. To access the free user manual you need to register on the Holland Bloorview Kids Rehabilitation Hospital site here.

References[edit | edit source]

  1. ↑ Jump up to: 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Keele University. STarT Back Screening Tool Website. http://www.keele.ac.uk/sbst/ (accessed 23 July 2013).
  2. ↑ Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, Hay EM. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Care & Research 2008;59:632-41. fckLRhttp://onlinelibrary.wiley.com/doi/10.1002/art.23563/full (accessed 29 July 2013).
  3. ↑ Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM. Comparison of stratified primary care management for low back pain with current best bractice (STarT Back): a randomised controlled trial. Lancet 2011;378:1560-71. fckLRhttp://www.ncbi.nlm.nih.gov/pubmed/21963002 (accessed 29 July 2013).


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