Mr John O’DowdMBBS, FRCS, FRCS Orth

Consultant Spinal Surgeon

Signposting For Combined

Psychological & Physical Care of

Spinal Injury & Pain Patients

Rehabilitation

Revive

Review

Repair

Rehabilitate

Optimise outcome

• Medical

• Function

• Psychological

• Work

Flags

• Red Serious underlying pathology

• Yellow Psychosocial barriers to

recovery

• Orange Serious psychiatric disease

• Blue Work environment

• Black Occupational policy and

systems

• 125 patients

• Subjective clinician categorization

• DRAM

– Experienced spine surgeon 26% sensitivity

– Predictive value

• Distressed 69%

• Nondistressed 77%

Main CJ, Waddell G (1998) Behavioral responses to examination: a

reappraisal of the interpretation of “nonorganic signs”. Spine;

23(21):2367–2371.

Waddell signs

• 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

• Nine-fold reduction in sick leave in CBT group

ResultsMean change in RMDQ higher in intervention group

At 12 months stratified care associated with mean in crease in generic health benefit (0.039QALY)

Stratified care cost £240.01 v £274.40

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

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Sweden MRC Brox 2003 Brox 2006

Conservative

Surgery

mean change in ODI