Multidimensional Reasoning PDF

MPTY03.1 Prof. Dr. Firas MOURAD CLINICAL REASONING 2: ADVANCED MULTIDIMENSIONAL AND DISPOSITIONAL REASONING 1 MUSCULOSKELETAL PHYSIOTHERAPY ORTHOPAEDIC MANUAL PHYSICAL THERAPY (OMPT) DEFINITION ORTHOPAEDIC MANUAL P...

MPTY03.1 Prof. Dr. Firas MOURAD CLINICAL REASONING 2: ADVANCED MULTIDIMENSIONAL AND DISPOSITIONAL REASONING 1 MUSCULOSKELETAL PHYSIOTHERAPY ORTHOPAEDIC MANUAL PHYSICAL THERAPY (OMPT) DEFINITION ORTHOPAEDIC MANUAL PHYSICAL THERAPY IS A SPECIALISED AREA OF PHYSIOTHERAPY / PHYSICAL THERAPY FOR THE MANAGEMENT OF NEURO-MUSCULOSKELETAL CONDITIONS, BASED ON CLINICAL REASONING, USING HIGHLY SPECIFIC TREATMENT APPROACHES INCLUDING MANUAL TECHNIQUES AND THERAPEUTIC EXERCISES. ORTHOPAEDIC MANUAL PHYSICAL THERAPY ALSO ENCOMPASSES, AND IS DRIVEN BY, THE AVAILABLE SCIENTIFIC AND CLINICAL EVIDENCE AND THE BIOPSYCHOSOCIAL FRAMEWORK OF EACH INDIVIDUAL PATIENT. Voted in at General Meeting in Cape Town, March 2004 IS THE BIOPSYCHOSOCIAL MODEL IN MUSCULOSKELETAL PHYSIOTHERAPY ADEQUATE? WITHIN THE PRACTICAL MANAGEMENT OF HEALTH, REDUCTIONISM IS INADEQUATE AS IT RELIES HEAVILY ON THE PHILOSOPHY OF THE INTERPRETER TO BUILD THE BRIDGES BETWEEN THE CHARACTERISTICS, AND MELD THE BIOMEDICAL, PSYCHOLOGICAL, COGNITIVE, BEHAVIORAL, SOCIAL AND OCCUPATIONAL THREADS BACK TOGETHER TO MAKE A WHOLE. REMOVE THE BOUNDARIES BETWEEN THE THEMES AND THEIR OVERLAP TO EMBRACE THE DISPOSITIONAL QUALITY. Daluiso-King & Hebron, 2020 IS THE BIOPSYCHOSOCIAL MODEL IN MUSCULOSKELETAL PHYSIOTHERAPY ADEQUATE? DISPOSITIONALISM: NON-LINEAR INTERACTION AND MUTUAL MANIFESTATIONS. A HELIX BETTER SYMBOLIZE THE UNIQUE SEQUENCING OF THE THEMES OF AN INDIVIDUAL’S HEALTH, AND THE ‘EXPRESSIONS’ OR INDIVIDUALIZED PHENOMENA THAT ARISE FROM THE COMPLEX INTERACTIONS BETWEEN THESE INTEGRAL CHARACTERISTICS. COMMUNICATION AND THERAPEUTIC ALLIANCE ARE THE SCAFFOLD OF THE HELIX, THE STRUCTURE THAT ENABLES THE INGREDIENTS OF COMPLEX, UNIQUE HUMAN EXPERIENCE TO BE EXPLORED. Daluiso-King & Hebron, 2020 THERAPEUTIC ALLIANCE THERAPEUTIC ALLIANCE IS A DYNAMIC CONSTRUCT WITHIN THE CLINICAL ENCOUNTER AND IS INFLUENCED RECIPROCALLY BETWEEN THE PERSON SEEKING CARE AND THE PHYSIOTHERAPIST BY BIOLOGICAL, SOCIAL AND PSYCHOLOGICAL CONTRIBUTING FACTORS. ‘COMMUNICATION’ MAY ACT AS A CATALYST IN OPERATIONALISING THE THERAPEUTIC ALLIANCE IN A PHYSIOTHERAPY CONTEXT. Søndenå et al., 2020 IDEAS, CONCERNS AND EXPECTATIONS IN CLINICAL COMMUNICATION THIS COMMUNICATION TECHNIQUE SHOULD BE PART OF A NORMAL CONVERSATION (NO TICK-BOX), BY QUESTION SOMETHING THE PATIENT HAS ALREADY TOLD AND ASKING OPEN QUESTION. ICE HELPS ACQUIRE THE PATIENT’S PERSPECTIVES WITHIN THE HEALTHCARE ASSESSMENT. ICE PROMOTES PATIENT-CENTERED CARE. ICE CAN REDUCES PRESCRIPTIONS, WHILIST IMPROVING SHARED DECISION MAKING AND PATIENT SATISFACTION. Murtagh et al., 2022 ICE IN CLINICAL COMMUNICATION IDEAS, TO ACQUIRE KNOWLEDGE ABOUT THE “What are your thoughts about this?” SITUATION, HELP CLARIFY MISCONCEPTIONS, IMPROVING UNDERSTANDING, AND GAIN RAPPORT “Many people read about their symptoms online, have you found anything out?” “What do your friend or family think about it? CONCERNS, TO ADDRESS FEARS AND ANXIETIES “What worries you about these symptoms?” ABOUT THE SITUATION “Is there anything specific concerning you?” EXPECTATIONS, TO ESTABLISH PATIENTS' “What did you expect from today’s appointment?” AGENDA, ALSO HELPING SHARED DECISION- MAKING “Moving forward, what do you think might be helpful for you following this session?” Murtagh et al., 2022; Whitaker, 2021 PATIENT VALUES IN PHYSIOTHERAPY PRACTICE 1. VALUES OF ONE-SELF UNIQUENESS: PERSONAL RECOGNITION AND THE WISH TO BE SEEN AS A UNIQUE INDIVIDUAL AUTONOMY: BEING WELL INFORMED IN ORDER TO MAKE A RIGHT DECISION BY THEMSELVES 2. VALUES OF THE PROFESSIONAL TECHNICALLY SKILLED: COMPETENT, INCLUDING COMUNICATION SKILL CONSCIENTIOUS: MORAL IN THE CLINICAL DECISION-MAKING PROCESS COMPASSIONATE: EMPATHISE WITH THE PERSON AND HIS/HER UNIQUE HISTORY RESPONSIVE: ABLE TO ADAPT TO THE PATIENT’S NEED 3. VALUES OF INTERACTION PROVIDE COPERATION AND OPEN SPACE FOR QUESTIONS EMPOWERING THE PATIENT AND PROVIDE TIPS/TOOLS TO SUPPORT SELF-CARE Bastemeijer et al., 2020 PATIENT VALUES IN PHYSIOTHERAPY PRACTICE  MAIEUTIC THE CRITERION OF THE SEARCH FOR TRUTH WITHIN THE PERSON AND TO DRAW IT OUT BY ELICITING KNOWLEDGE IN THE MIND OF A PERSON, INTERROGATING AND INSISTENCING ON CLOSE AND LOGICAL REASONING. PEDAGOGICAL METHOD BASED ON THE ACTIVE PARTICIPATION OF THE SUBJECT. PAIN: A MULTIDIMENSIONAL PERSONAL EXPERIENCE THE MULTIFACTORIAL AND HIGHLY PERSONAL NATURE OF THE PAIN EXPERIENCE CONTRIBUTES TO THE CHALLENGES OF ADEQUATE DESIGN AND INTERPRETATION OF RCTs TREATING EVERY PATIENT ONLY AS SUPPORTED BY EVIDENCE DRAWN FROM A ‘ONE SIZE FITS ALL’ STYLE COMPARING GROUP MEANS RISKS UNDER- OR OVER-TREATMENT OF THE INDIVIDUAL PERSON MORE LOGICAL AND ACHIEVABLE APPROACH WOULD BE: 1. IMPLEMENT A CLINICALLY RIGOROUS YET FEASIBLE AND PERSONALIZED MULTIDIMENSIONAL ASSESSMENT 2. IDENTIFY MULTISYSTEM PATTERNS IN THE PATIENT PROFILE THAT MAY BE DRIVING THE PAIN EXPERIENCE 3. INTERVENE IN A TARGETED FASHION BASED ON THE RESULTS OF THAT ASSESSMENT Walton & Elliot, 2018 PROGNOSTIC PROFILING - DEFINITIONS A SERIOUS CONDITION Serious MSD MIMICKING A MUSCKULOSKELETAL DISORDER WHICHIncluding REQUIRERoS URGENT MEDICAL EVALUATION OR INTERVENTION SPECIFIC MUSCKULOSKELETAL PAIN DISORDER WHERE PAIN AND SYMPTOMS CAN Determine BE DIRECTLY ATTRIBUTED (AT LIST the condition IN PART) TO A Specific MSD Specific MSD and prognosis BIOLOGICAL (PATHOLOGY OR DISEASE) PROCESS ASSOCIATED WITH THE Management pathway MUSCULOSKELETAL SYSTEM Determine Address modifiable Prognostic NON-SPECIFIC CONDITION prognostic factors Profile - NO UNDERLYING PATHOLOGY - IF A PATHOLOGY PRESENT THERE IS NO ROBUST CORRELATION BETWEEN THE CLINICAL PRESENTATION AND UNDERLYING PATHOLOGY Non–specific Guideline informed MSD + or - Management NON-SPECIFIC SPINAL PAIN THE BIOMEDICAL DIAGNOSIS IS CONTESTED ON THE ONE HAND, HAVING A DIAGNOSIS OF EXCLUSION (e.g., CANCER) IS REASSURING BUT, ON THE OTHER, DIAGNOSTIC UNCERTAINTY REMAINS WHERE THE CAUSE OF THE PAIN IS UNKNOWN, WHICH APPEARS TO LEAD TO PAIN-RELATED GUILT, DISABILITY, AND DEPRESSION DIAGNOSING CONDITIONS IS REGARDED AS AN ESSENTIAL ELEMENT OF MEDICAL PRACTICE, AND CORRESPONDINGLY ACQUIRING AN ACCEPTABLE DIAGNOSIS IS A SIGNIFICANT FEATURE WITHIN THE PATIENT’S ILLNESS EXPERIENCE Low, 2017 DIAGNOSIS DIAGNOSIS IS OF EXCEPTIONAL IMPORTANCE: DIAGNOSIS ASCRIBES A CAUSAL CLAIM, WHICH SUGGESTS A BIOMEDICAL EXPLANATION OF ILLNESS, WHEREBY THE ILLNESS CAN BE CONTROLLED AND TREATED WITH THE POTENTIAL FOR SUBSEQUENT OPTIMISM AND HOPE ABOUT THE FUTURE DIAGNOSIS HAS LEGAL AND POLITICAL IMPLICATIONS GIVING INDIVIDUALS THE OPPORTUNITY TO ACCESS WELFARE BENEFITS DIAGNOSIS PROVIDES PSYCHOLOGICAL REASSURANCE AND SOCIAL ACCEPTANCE BY VALIDATING ILLNESS Low, 2017; Mishler, 1982; Nettleton, 2006; Lyng, 1990; Telles & Pollack, 1981 BIOPSYCHOSOCIAL MODEL BPS MODEL MAY HAVE BEEN MISUNDERSTOOD AND THEREFORE INEFFECTIVELY APPLIED, BOTH IN RESEARCH AND CLINICAL PRACTICE. IT FAILS TO EXPLAIN THE BODY/MIND PROBLEM WITH NO CLEAR THEORETICAL LINK BETWEEN THEM FROM A PATIENT’S VIEWPOINT, THEIR BODY IS AT THE CENTRE AT A PREREFLECTIVE LEVEL AND MAY NOT CORRESPOND TO THE HEALTHCARE PRACTITIONERS’ CATEGORICAL UNDERSTANDING Low, 2017; Pincus et al., 2013; Billis et al., 2007; Davidsen et al., 2016; Davidsen et al., 2009 PAIN ‘AN UNPLEASANT SENSORY AND EMOTIONAL EXPERIENCE ASSOCIATED WITH, OR RESEMBLING THAT ASSOCIATED WITH, ACTUAL OR POTENTIAL TISSUE DAMAGE’ PAIN IS AN INDIVIDUAL EXPERIENCE AND THE RELATIONSHIP BETWEEN BIOLOGICAL, LIFESTYLE, PSYCHOLOGICAL, AND SOCIAL DOMAINS ON EACH INDIVIDUAL IS HIGHLY VARIABLE CONSISTENT WITH THIS VARIABILITY, A MULTITUDE OF POTENTIAL FACTORS CAN INTERACT TO PRODUCE AND MAINTAIN A PAIN EXPERIENCE Mitchell et al., 2018; IASP Taxonomy, 2020; William et al., 2016  CAUSAL COMPLEXITY ALL CAUSAL FACTORS MAY COEXIST, ARE SITUATIONAL, CONTEXT DEPENDENT, INTERACT IN A NON-LINEAR FASHION, AND CAN ONLY BE SEEN AS CORRELATIONS CAUSE AS A CLUSTER OF POWERS, OR DISPOSITIONS, ORIENTATED TOWARD AN EFFECT THE EFFECT IS REACHED WHEN A SINGLE OR COMBINATION OF DISPOSITIONS EXCEED A THRESHOLD Mitchell et al., 2018; IASP Taxonomy, 2020; William et al., 2016 VECTOR MODEL CAUSAL FACTORS CONVEY THE RELATIVE STRENGTHS OF POWER INDICATED BY A VECTOR’S LENGTH IN Increase the level of concern Decrease the level of concern RELATION TO EACH OTHER AND DIRECTION TOWARDS OR HISTORY OF CGH AWAY FROM THE MANIFESTATION OF AN EFFECT OR NOT NECK PAIN SUDDEN ONSET NEURO THE OVERALL TENDENCY IS A COMPOSITION OF ALL THE PATTERN CHANGED POWERS THAT MUTUALLY MANIFEST TOWARD SYMPTOM VALSALVA ATYPICAL GENERATION IN A GIVEN CONTEXT PRESENTATION THIS FAVOURS UNIQUENESS, CONTEXT SENSITIVITY, AND HOLISM, IN CONTRAST WITH THE TRADITIONAL REDUCTIONIST MEDICAL APPROACH Low, 2017 IMPLICATIONS PEOPLE WHO SUFFER WITH PAINFUL CONDITIONS WISH TO KNOW AND UNDERSTAND THE CAUSE (DIAGNOSIS) OF THEIR SYMPTOMS BIOMEDICAL LINEAR MODELS ARE INSUFFICIENT TO PROVIDE AN ADEQUATE EXPLANATION AS CONDITIONS AND CONTEXTUAL FACTORS VARY WITH TIME BPS MODEL HAS BEEN CRITICISED FOR IGNORING THE PATIENT’S EXPERIENCE AS COMPARTMENTALISES THE CONDITION INTO BIOLOGICAL, PSYCHOLOGICAL, AND SOCIAL PHENOMENA THE UTILITY OF DISPOSITIONS IN CLINICAL PRACTICE MAY AVOID THE TENSION THAT CLASSIFICATION SYSTEMS CREATE BY BEING NONCATEGORICAL IN SO MUCH THAT MULTIDIMENSIONAL CAUSAL MECHANISMS REPLACE SIMPLISTIC LINEAR ONES Low, 2017; Butler et al., 2004 MULTIDIMENSIONAL PROFILING INDIVIDUAL PROFILE IS ESTABLISHED BY INCLUDING A DIAGNOSIS TOGETHER WITH THE CONTRIBUTING FACTORS WEIGHTED ACCORDING TO RELATIVE IMPORTANCE TO GUIDE AND PRIORITISE TARGETED MANAGEMENT Mitchell et al., 2018 Mitchell et al., 2018 1. PATIENT CENTERED PATIENT OFTEN REPORT FRUSTRATION IN RELATION TO THE PERCEIVED LACK OF LISTENING, OR ‘HEARING OF WHAT IS SAID’ BY HEALTHCARE PROFESSIONALS NUMEROUS BENEFITS OF COMPETENT LISTENING SKILLS: INDIVIDUAL’S PERSPECTIVE ON THE PROBLEM PROBLEM IMPACT GOAL & EXPECTATION Kenny, 2004; Jagosh et al., 2011; Mitchell et al., 2018 1. PROGNOSTIC PROFILING - DEFINITIONS Serious MSD Including RoS Determine the condition Specific MSD Specific MSD and prognosis Management pathway Determine Address modifiable Prognostic prognostic factors Profile Non–specific Guideline informed MSD + or - Management 2. STAGE OF THE DISORDER RECENT: ACUTE OR FLAIRE-UP SUB-ACUTE: NATURAL PROGRESSION OF TISSUE HEALING RECURRENT: NEW EPISODE AFTER A SYMPTOMS FREE PERIOD PERSISTENT: 3-6 MONTHS AFTER THE EXPECTES RESOLUTION *Relevant to inform management from clinical practice guidelines Mitchell et al., 2018 3. PAIN FEATURES_MECHANISMS Mitchell et al., 2018; Chimenti et al., 2018 4. PAIN FEATURES_CHARACTERISTICS Mitchell et al., 2018 5. PAIN FEATURES_SENSITISATION Mitchell et al., 2018; Jagosh et al., 2011 6. PSYCHOSOCIAL CONSIDERATION [YELLOW FLAGs] CONTRIBUTION OF PSYCHOSOCIAL FACTORS TO PAIN AND ASSOCIATED BEHAVIOURS MAY BE PRE-MORBID OR CO-MORBID TO THE PRESENTING DISORDER CONSIDERATION OF PSYCHOSOCIAL FACTORS AT AN INDIVIDUAL LEVEL IS REQUIRED TO INFORM THE RELATIVE ‘WEIGHTING’ AND CONTRIBUTION OF THESE FACTORS TO THE OVERALL PRESENTATION USE OF VALIDATED SCREENING TOOLS AND SCREENING ALLOWS FOR MULTI-DIMENSIONAL PROFILING TO INFORM TARGETED CARE PATHWAYS Mitchell et al., 2018; Vlaeyen et al., 2012; Lang et al., 2012; Hill & Fritz, 2011; Nicholas et al., 2011; Vargas-Prada & Coggon, 2015; Linton et al., 2011; Hill et al., 2010; Sattelmayer et al., 2012 6. COGNITIVE [THOUGHTs & BELIEFs] ATTENTION ATTITUDES & BELIEFS INACCURATE OR IRRATIONAL BELIEFS, THOUGHTS, BEHAVIORS, EXAGGERATED NEGATIVE ORIENTATION ABOUT, OR RESULTING EXPECTATION FROM, THE EXPERIENCE OF PAIN SELF-EFFICACY INFLUENCE BEHAVIOUR RELATED TO PAIN, CARE SEEKING, COMPLIANCE, ACCEPTANCE, AND EXPECTATION CATASTROPHING DIRECTLY INFLUENCE PAIN INTENSITY AND DISABILITY LEVEL COPING George and Hirsh, 2009; Sullivan et al., 2002; Crombez et al., 1999; Bennell et al., 2016 6. AFFECTIVE [EMOTIONAL] DEPRESSION DIAGNOSABLE PSYCHOPATHOLOGY OR AFFECTIVE ANXIETY DYSREGULATION THAT INCLUDE DEPRESSION, ANXIETY, OR OTHER MOOD OR PERSONALITY DISORDERS STRESS CAUSAL MECHANISMS ARE YET UNCLEAR IT APPEARS LIKELY THAT PAIN MAGNIFIES NEGATIVE MOOD WHILE NEGATIVE MOOD FEAR AMPLIFIES PAIN WORRY INCREASE PAIN FOCUS, TISSUE SENSITIVITY, MUSCLE TESNION|GUARDING, AUTONOMIC AROUSAL, ALTERED PAIN FRUSTRATION | ANGER BEHAVIOUR, IMPACT CON LIFE-STYLE AND SOCIAL FACTORS Blozik et al., 2009; Dimitriadis et al., 2015 6. SOCIAL FACTORs SOCIOECONOMICs EDUCATION|LITERACY RELATIONSHIP WIDE-RANGING AND AMORPHOUS CONTEXTUAL FACTORS THAT AFFECT NOT ONLY ONE'S EXPERIENCE OF PAIN BUT ALSO ACCESS HEALTH LITERACY TO APPROPRIATE CARE, WILLINGNESS TO REPORT, AND THE WAY IN WHICH PAIN IS DESCRIBED CULTURE HEALTH CARE Raichle et al., 2011; Mitchell et al., 2018 6. MENTAL HEALTH & PSYCOLOGICAL WELLBEING Raichle et al., 2011; Mitchell et al., 2018 6. WORK RELATED MAJORITY OF SERIOUS WORKERS’ COMPENSATION CLAIMS (REQUIRING AT LEAST ONE WEEK OFF WORK) ARE DUE TO MUSCKULOSKELETAL DISORDERS WORK ABSENCE OF MORE THAN NINE WEEKS IS ASSOCIATED WITH A 50% CHANCE OF NOT SUCCESSFULLY RETURNING TO WORK THERE IS STRONG EVIDENCE SUPPORTING THE HEALTH BENEFITS OF WORK AND CONVERSELY THE DETRIMENTAL EFFECTS ON HEALTH OF PROLONGED WORKLESSNESS. Beales et al., 2016; Mitchell et al., 2018 6. PERCEPTION OF WORK [BLUE FLAGs] Mitchell et al., 2018 6. WORKPLACE FACTORS [BLACK FLAGs] Mitchell et al., 2018 7. LIFESTYLE Heneweer et al., 2009; Lin et al., 2011; Finan et al., 2013; Davies et al., 2008; Dean & Soderlund, 2015; Wintermeyer et al., 2016; Ditre et al., 2011 8. GENERAL HEALTH Blozik et al., 2009; Dimitriadis et al., 2015 8. GENERAL HEALTH POORER GENERAL HEALTH AND CO-MORBIDITIES NEGATIVELY INFLUENCE OUTCOMES IN MUSCKULOSKELETAL DISORDERS COMORBIDITIES MAY BE CUMULATIVE AND LINKED BY COMMON UNDERLYING PATHOLOGICAL AND NEUROPHYSIOLOGICAL PROCESSES MULTI-MORBIDITIES ALONG WITH A MUSCKULOSKELETAL DISORDERS HAS INCREASED RISK OF A POORER PROGNOSIS ROLE OF GENETIC AND EPI-GENETIC Steenstra et al., 2005; Hestbaek et al., 2003; Mannion et al., 2006; Nimgade et al., 2010; Dominick et al., 2012; Edwards, 2006; Kim & Schwartz, 2010; Caldji et al., 2011; Sibille et al., 2012 9. FUNCTIONAL BEHAVIOUR Cane et al., 2013; Mitchell et al., 2018 9. FUNCTIONAL BEHAVIOUR + PHYSICAL IMPAIRMENTS Cane et al., 2013; Mitchell et al., 2018 CASE STUDY: ACUTE BACK PAIN Background A 28-year-old bricklayer developed back pain at the end of a workday two days ago. His workday involved heavier than usual lifting. He could hardly move when getting out of bed the following morning. He reported feeling slightly better, but he was still unable to straighten up properly when standing. His symptoms were mainly localised to his lumbosacral region, but he also had a mild ache in his right posterior thigh region. He reported pain with bending forward and when straightening up after prolonged sitting on the couch. There was some aching in his back at night and he felt much stiffer in his back on waking in the morning. Slowly walking around for a few minutes and applying heat helped to make his back feel considerably better. He had not had any prior treatment at the time of consultation, other than using a heat pack and taking some paracetamol. He had not worked for the past two days. He had not had any investigations of his back. Other than an occasional backache after a day of physical work, he had not had any previous back problems. CASE STUDY: ACUTE BACK PAIN Individual’s Perspective Individual’s problem(s): He described his back pain as his main problem and this was affecting his capacity to work as a bricklayer. Functional capacity: Limited with sitting for more than 15 minutes, putting shoes and sock on, and getting in and out of a chair or car. He was avoiding any forward bending or lifting. As an objective measure of functional limitations, his Patient Specific Functional Scale for working his usual job as a bricklayer was 1/10. Goals/Expectations: To this individual, recovery meant he would be able to get back to work as quickly as possible. He wanted his back ‘fixed’. Diagnosis Serious Pathology: There were no red flags identified during the patient interview or physical examination. Specific diagnosis: There was no indication of a specific diagnosis to explain his symptoms. Specific clinical screening tests for cauda equina syndrome and lower limb neurological deficit were normal. No spinal investigations had been undertaken, and were not indicated in this instance (based on clinical practice guidelines). On that basis, the ‘non-specific’ diagnosis of Acute Back Sprain was warranted. *Informing the individual that he had an ‘acute back sprain’ rather than ‘non-specific back pain’ is considered important. For some individuals, labeling their problem as ‘non-specific’ might be unhelpful- it may impress upon the patient that either there is nothing wrong with them or that the HCP doesn’t know what is wrong with them and can’t provide a diagnosis. This perception could give rise to a negative HCP-patient relationship or a sub-optimal outcome. Stage Acute Pain Features Types: His presentation was suggestive of dominant peripheral nociceptive pain including some contribution of inflammatory processes (pain at night and increased back stiffness with prolonged sitting and waking in the morning). Characteristics: He presented with dominantly mechanically patterned pain. There were clear postures (sitting on the couch) and movements (forward bending) that aggravated his pain, as well as movements that relieved his pain (walking around). Further, the ‘response’ and ‘stimulus’ were proportionate in that his symptoms were moderately relieved after a short period of walking around. Sensitisation: The contribution of sensitisation to his back pain was considered low, on the basis that he had fairly localised back pain, with moderate sensitivity to movement, and the loading and palpation stimuli were consistent with the clinical course and stage of the disorder. For example, forward bending, slouch sitting and localised palpation (mechanical hyperalgesia) of his lower lumbar spinal tissues reproduced his back pain to a degree consistent with his clinical presentation (symptoms were also relieved immediately on cessation of these stimuli). Psychosocial Considerations Cognitive factors: There were no cognitive factors (in relation to his thoughts and beliefs) that were considered to be strongly contributing to his clinical presentation. However, his mindset of having his problem ‘fixed’ for him should be addressed in the education component of his management. Educating and encouraging him to take an active role in his rehabilitation, rather than expecting a passive ‘cure’, would be an important component of his overall management. Contribution was considered low-moderate. Affective factors: These were not identified as significantly contributing to his clinical presentation, based on answers from his Orebro Musculoskeletal Pain Screening Questionnaire and discussion with the individual. Contribution was considered low. Social factors: He lived with his partner and young daughter. As his partner was not working and they had recently purchased a new house, he felt some pressure to return to work as quickly as possible. These social factors were not considered to be significant, but it would be important to address the time frames for return to work as part of management planning. Contribution was considered low-moderate. Work Considerations Black Flags (workplace factors) were considered to be a significant contributing factor for his back pain, as his symptom onset appeared directly related to his work. He was likely eligible to lodge a claim under the workers’ compensation system. Following his assessment, he was recommended to see his general practitioner to complete the necessary paperwork and was referred to the relevant regulatory body website for information about workers’ compensation injuries. Consideration of whether any workplace factors contributed to his back pain could be important in terms of the prevention of future back pain recurrence. Communication with the treating medical practitioner and employer around his current capacity for work, treatment plans and expected time frames for recovery are key elements of effective management of individuals with work related pain. Contribution was considered moderate. Lifestyle Considerations He was active with his job and played recreational touch rugby twice per week. His sleep was only mildly disturbed due to his back pain. Lifestyle factors were not considered to be a significant contributing factor at this point (low). General Health There were no contributing whole person considerations identified (low). Functional Behaviours Helpful vs Unhelpful: He demonstrated some helpful (protective) functional behaviours. His avoidance of forward bending / lifting was considered ‘protective’ as on physical examination, repeated forward bending clearly increased his back pain. Conversely, his habitual sitting posture involved flexion of the lower lumbar spine. Adjustment of this posture via anterior pelvic tilting resulted in an immediate improvement in pain during sitting. Therefore, his sitting posture was considered unhelpful (provocative) in this context, as it was clearly contributing to increased back pain when sitting. Functional Behaviours Impairment of movement: Forward bending was painfully limited to fingertips reaching mid-thigh level. Lumbar extension was mildly painful and stiff, but repeated lumbar extension in standing resulted in improved mobility and reduced pain. Impairment of control: His habitual sitting posture involved slumped (flexed) lower lumbar spinal posture. Correction of this posture improved his symptoms as described above. He adopted a similar flexed posture with squatting and moving from sit to stand. This lack of postural variability was deemed to be a likely contribution to his initial symptom onset, based on the repetitive bending nature of his work tasks. Hence, it was considered to be important to address this for initial symptom management, as well as prevention of future episodes of low back pain. Functional Behaviours Pain Behaviours: There were no signs of unhelpful pain behaviours influencing his clinical presentation. Deconditioning: Poor leg muscle endurance (sustained squat) and poor lumbar extensor muscle endurance were identified on clinical testing. This reduced muscle performance influenced his lumbar posture in functional tasks such as picking up bricks, and as such it was considered important to address for prevention of future episodes of low back pain. Physical impairment Reduced ROM during lumbar flexion. Spring testing revealed familiar pain reproduction at L4 and L5. Summary 56 Clinical Decision Making Diagnosis: This individual presented with a typical acute low back sprain, most likely related to repetitive bending and lifting of a heavier nature than usual in his job. There were no contributing factors identified that would suggest that he would not respond well to a standard evidence-informed management approach. Prioritised list of Contributing Factors: Symptom onset related to repetitive bending and lifting of a heavier nature than usual in his job Habitual postures and movement patterns that involved a bias towards flexion of his lower lumbar spine Expectation that his back needed ‘fixing’ Physically demanding work Deconditioning of lower limbs and lumbar extensor muscles Prioritised List of Management Considerations Evidence informed management: education regarding a positive prognosis, keeping active and simple analgesics Communication with his employer Physical conditioning to address the physical contributing factors Physiotherapy Management Pain management modalities including heat, manual therapy and gentle mobility exercises Education to reduce excessive bending for a few days, and advice to increase postural variability Training of sitting and functional postures to enhance postural variability during bending, lifting and sitting. Consider use of proprioceptive taping in the first session. Conditioning program to address lower limb and back extensor muscle endurance Longer term ergonomic review of work tasks directly associated with his symptom aggravation Communication with the treating medical practitioner, employer, insurer and other stakeholders as required