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PHYS THER
Vol. 89, No. 1, January 2009, pp. 82-90
DOI: 10.2522/ptj.20080113
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Case Reports

Physical Therapist Management of Acute and Chronic Low Back Pain Using the World Health Organization's International Classification of Functioning, Disability and Health

Sean D Rundell, Todd E Davenport and Tracey Wagner

SD Rundell, PT, DPT, OCS, is Physical Therapist, Portland Sports Medicine and Spine Physical Therapy, 1610 SE Glenwood St, Portland, OR 97202 (USA)
TE Davenport, PT, DPT, OCS, is Assistant Professor, Department of Physical Therapy, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, California, and Clinical Specialist, Department of Physical Medicine and Rehabilitation, Kaiser Permanente Woodland Hills Medical Center, Woodland Hills, California
T Wagner, PT, MPT, OCS, is Clinical Specialist, Department of Physical Medicine and Rehabilitation, Kaiser Permanente Woodland Hills Medical Center, and Clinical Mentor, Residency in Orthopaedic Physical Therapy, Kaiser Permanente Southern California

Address all correspondence to Dr Rundell at: sean{at}pdxspine.com


Submitted April 16, 2008; Accepted October 3, 2008


   Abstract
 
Background and Purpose: The World Health Organization's Classification of Functioning, Disability and Health (WHO-ICF) model was developed to describe, classify, and measure function in health care practice and research. Recently, this model has been promoted as a successor to the Nagi model by some authors in the physical therapy literature. However, conceptual work in demonstrating use of the WHO-ICF model in physical therapist management of individual patients remains sparse. The purpose of this case report series is to demonstrate the application of the WHO-ICF model in clinical reasoning and physical therapist management of acute and chronic low back pain.

Case Description: Two patients, 1 with acute low back pain and 1 with chronic low back pain, were treated pragmatically using the WHO-ICF model and other applicable models of clinical reasoning.

Intervention: Manual therapy, exercise, and education interventions were directed toward relevant body structure and function impairments, activity limitations, and contextual factors based on their hypothesized contribution to functioning and disability.

Outcome: Both patients demonstrated clinically significant improvements in measures of pain, disability, and psychosocial factors after 3 weeks and 10 weeks of intervention, respectively.

Discussion: The WHO-ICF model appears to provide an effective framework for physical therapists to better understand each person's experience with his or her disablement and assists in prioritizing treatment selection. The explicit acknowledgment of personal and environmental factors aids in addressing potential barriers. The WHO-ICF model integrates well with other models of practice such as Sackett's principles of evidence-based practice, the rehabilitation cycle, and Edwards and colleagues’ clinical reasoning model. Future research should examine outcomes associated with the use of the WHO-ICF model using adequately designed clinical trials.


   Introduction
Top
 Abstract
 Introduction
Patient 1 (Chronic LBP)
 Patient 2 (Acute LBP)
 Discussion
 References
 
Low back pain (LBP) is among the most ubiquitous and expensive health conditions affecting the developed world.1–4 Low back pain also is among the most common musculoskeletal conditions treated by physical therapists.5 As a complex biopsychosocial phenomenon, the application of the medical model to describe LBP has challenged the identification of optimal treatments. Disability models provide useful patient-centered schema that assist clinicians in understanding the influences and relationships among LBP, its hypothetical contributing factors, and its resultant disability. Disablement models such as the Nagi model can help a clinician evaluate and prioritize the components that may be most responsive to interventions to reduce disability,6,7 and they can be helpful in determining needs, matching interventions to health states, and evaluating outcomes.8,9

The World Health Organization's International Classification of Functioning, Disability and Health (WHO-ICF) model was developed to simplify the process of describing, classifying, and measuring function and health. It provides a method that considers biological, individual, and social contributions that can be used across clinical practice and research. The WHO-ICF model has 2 main components (Fig. 1). The first part is functioning and disability, which is further divided into body functions and structures, activities, and participation. Body functions and structures are assessed in terms of change in physiological function and anatomical structure. Activity is the execution of a task or action, and participation is defined as involvement in life affairs. Functioning is the positive aspect of these components, and disability is the negative aspect. Each component can be broken down into categories relating to functioning and disability. The second main component of the WHO-ICF model includes a classification system to further describe environmental and personal contextual factors that can influence functioning and disability.10


Figure 1
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  		Figure 1. World Health Organization's International Classification of Functioning, Disability and Health model.

 
The WHO-ICF model is thought to retain certain advantages over the Nagi model. First, the WHO-ICF model explicitly acknowledges bidirectional relationships among domains of function and contextual factors. In addition, the WHO-ICF model's description of contextual factors would appear to reinforce physical therapists’ consideration of patients’ affective, social, and environmental factors that contribute to the physical therapist's prognosis. These advantages have contributed to the WHO-ICF model being advocated in the physical therapy literature11,12 as a potential successor to the Nagi model. The WHO-ICF model already has been applied to describe certain chronic conditions, such as LBP, in order to derive "core sets" and "brief core sets" that use consistent language.8,13 However, the WHO-ICF model's usefulness to clinical reasoning in individual patient cases remains unclear. The purpose of this case report series is to demonstrate the use of the WHO-ICF framework in the management of acute and chronic LBP.


   Patient 1 (Chronic LBP)
Top
 Abstract
 Introduction
 Patient 1 (Chronic LBP)
Patient 2 (Acute LBP)
 Discussion
 References
 
History

The patient was a 53-year-old woman with a chief concern of a 28-year history of LBP. She reported an insidious onset of symptoms that had progressively worsened and had become constant during the last 3 years. Pain intensity, as measured with a numeric pain rating scale,14–16 was 5/10 at intake, 10/10 at worst, and 3/10 at best. Lifting, bending forward, and sitting for 15 to 20 minutes aggravated symptoms. The patient described the symptoms as variable from day to day, but typically worse at the end of the day. She estimated her sleep was interrupted by 50% because of her LBP. Symptoms eased with heat, massage, and over-the-counter ibuprofen. Associated symptoms included an intermittent ache along the paraspinal musculature and an intermittent ache to throbbing pain radiating from the lateral hips to the anterior thighs. She also reported occasional bilateral numbness of the entire foot at night and upon waking. The patient reported having no saddle paresthesia, change in bowel and bladder function, or generalized weakness or incoordination of her lower extremities.

Other medical history included an appendectomy, tonsillectomy, hysterectomy, hypertension, hypercholesterolemia, and depression. Her depressive symptoms were being treated with bupropion hydrochloride (150 mg twice daily). Other current medications included lisinopril (10 mg once daily) and hydrochlorothiazide (25 mg once daily) for hypertension, metoclopramide (10 mg once daily) for gastroesophageal reflux, and lamotrigine (200 mg once daily) for stabilizing mood. The patient's work activities included lifting and carrying boxes of files and sitting at a computer. Her hobbies included gardening. The patient's goals were to garden and perform all work duties with a pain level of ≤4/10.

Examination

At intake, the patient's Oswestry Low Back Disability Questionnaire (ODQ)15,17,18 score was 18/50, her Beck Depression Index (BDI)19,20 was 8/63, indicating minimal depressive symptoms; and her Fear-Avoidance Belief Questionnaire (FABQ)21,22 work subscale score was 2/42, suggesting minimal fear-avoidance behavior concerning work activities. However, her FABQ physical activity subscale score was 20/24, indicating high fear-avoidance behavior concerning physical activity outside of work. The Lower Back Activity Confidence Scale (LoBACS)23,24 revealed scores of 49%, 90%, and 100% for the perceived ability to function in activities of daily living and work activities, self-regulate symptoms, and perform therapeutic exercises, respectively.

The patient was observed to have decreased lumbar lordosis, posterior pelvic tilt, and forward head in a standing position. Decreased hip extension during terminal stance bilaterally and increased frontal-plane motion of the pelvis during mid-stance were noted during observational gait assessment. Patellar reflexes were 1+ bilaterally, and Achilles reflexes could not be elicited. Myotomal and dermatomal function were normal. Standing lumbar active range of motion (AROM)25 revealed increased left-sided pain with flexion but normal excursion. Extension, right side bending, and left side bending did not reproduce symptoms, although excursion was decreased. Passive range of motion (PROM) during a right straight leg raise (SLR), as measured with bubble inclinometry, was 52 degrees, with reproduction of right gluteal pain, but sensitizing using dorsiflexion was negative. Left SLR was positive at 60 degrees for familiar back pain, and sensitizing with dorsiflexion was positive.

Hip extension PROM during a Thomas test, as measured using bubble inclinometry with the knee flexed,26 revealed right hip extension lacking 15 degrees and left hip extension lacking 18 degrees. Manual muscle tests of the hip revealed bilateral gluteus medius muscle strength (force-generating capacity) was 3/5 and gluteus maximus muscle strength was <3/5.27 Abdominal performance testing, which was conducted as described by Sahrmann,28 showed level 0.3 was the highest level performed correctly, where level 2 indicates adequate strength and control. Hypomobility and reproduction of greater left-sided pain than right-sided pain were noted with posterior-anterior pressures at L4-L5 and L5-S1.29,30

Evaluation

Based on the initial examination data, the mediators influencing the patient's chronic LBP were categorized using the WHO-ICF model (Tab. 1). We hypothesized that hip muscle performance and length impairments observed resulted in poor segmental stabilization and consequent LBP, causing limitations in the activities of lifting and carrying and maintaining body positions. Difficulties with these activities were hypothesized to negatively affect her participation in employment duties and leisure activities. They also were thought to be involved in a cycle that promoted further impaired muscle power functions and reduced joint mobility.


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  		Table 1. The World Health Organization's International Classification of Functioning, Disability and Health (WHO-ICF) Model Applied to the Evaluation of Patient 1 (Chronic Low Back Pain)a

 
Another important hypothesized bidirectional relationship was between the personal factor of her high FABQ physical activity score and her activity limitations. We hypothesized that fear-avoidance beliefs acted as a potential barrier to her physical activities. Conversely, we thought that the pain experienced during these activities reinforced her avoidance beliefs concerning them. The personal factor of low self-efficacy concerning daily living and work activities was thought to be another factor contributing to her activity limitations. Going in the other direction, the pain and limitation with physical activities likely reduced her perceived ability to perform them. Her work environment, involving low shelves and filing cabinets, and the distance required to transport files were environmental factors that may have negatively influenced her participation in work duties.

Intervention

The patient was educated on her physical therapist's diagnosis, prognosis, and plan of care. She was seen for 4 visits over 10 weeks. Patient education and graded exercise were used to address her avoidance of physical activity. Specifically, she was educated during the initial visit that pain did not signal harm, to maintain a consistent activity pace, and to stay as active as tolerable. This was reinforced during discussions in subsequent visits. Graded exercise consisted of beginning a daily program of walking for 15 minutes and progressing the duration every couple days. To address decreased abdominal muscle power function, she was instructed in supine abdominal drawing-in.28 Quarter squats without allowing knee valgus were prescribed for muscle performance impairments of her hip lateral rotators and abductors, and a hip flexor stretch was prescribed to address her impairment of hip extension. On follow-up visits, interventions focused on contract-relax procedures to the rectus femoris and iliopsoas muscles. Abdominal bracing in a supine position was progressed in intensity to bracing with alternate marching.28 Prone hip extension AROM with knee flexion was added to strengthen the hip extensors, and squatting was progressed in depth and resistance provided.

Outcome

At 10 weeks, the patient reported that she was able to bend and carry charts at work for a full day without increased pain. She regularly sat at work for 30 minutes without pain. Her worst pain was reported as 3/10. Her ODQ score was 6/50. Hip flexion with the Thomas test was 6 degrees on the left and 10 degrees on the right. Abdominal strength was graded as level 0.4.28 The patient canceled a follow-up appointment at 14 weeks and subsequently was contacted by telephone. Final questionnaires revealed an ODQ score of 2/50, a BDI of 4/63, an FABQ work subscale score of 0/42, and an FABQ physical activity subscale score of 6/24. The patient's LoBACS scores were 87%, 100%, and 100% for the functional, self-regulatory, and exercise subscales, respectively. Pain intensity, as measured with a numeric pain rating scale, was 2/10 at worst. The patient global rating of change scale31 revealed a perception of "much improved."


   Patient 2 (Acute LBP)
Top
 Abstract
 Introduction
 Patient 1 (Chronic LBP)
 Patient 2 (Acute LBP)
Discussion
 References
 
History

The patient was a 38-year-old female computer programmer. Her chief concern was a 14-day history of intermittent right lumbar "burning and pressure." The patient's symptoms were characterized by a sudden onset when standing after sitting for 3 hours at her computer. She rated her symptoms as 8/10 at worst, 0/10 at best, and 5/10 at the time of her examination. Aggravating activities included sitting 2 hours or longer, sleeping supine for 1 hour or longer, jogging longer than 45 minutes, and weight bearing on her right lower extremity. She usually awakened without pain in the morning and experienced her symptoms after sitting at work. Her symptoms continued to worsen throughout the day. She also reported a secondary concern of burning right lateral leg pain that she experienced intermittently during the last year. This pain began insidiously 1 year previously, concurrently with multiple brief episodes of LBP. Her episodic LBP resolved, but the leg pain remained aggravated with jogging, driving or prolonged sitting.

At the time of intake, she reported that her leg pain increased as her right LBP increased. Her symptoms eased with changing positions from sitting or supine, using her elliptical machine, and using her abdominal exercise equipment. She slept without disturbance in a side-lying position. The patient stated that her pain intensity had diminished since initial onset. She reported having no numbness or paresthesias in her lower extremities, change in bowel or bladder function, saddle paresthesia, or weakness or incoordination in the lower extremities. Significant medical history included anxiety disorder and depression. Medications included ibuprofen (600 mg 3 times daily, as needed) for pain and inflammation, nortriptyline (600 mg 3 times daily) for depressive symptoms, methylprednisolone (4 mg once daily) for inflammation, fexofenadine (60 mg once daily) for allergies, and norethindrone (35 mg once daily) for contraception. Her work activities were sitting at a computer 8 hours a day, and she had a 1-hour commute to and from work. Her exercise program included jogging, using the elliptical machine, and abdominal curls with a floor-exercise apparatus. The patient's goal was to sit 5 hours at work unlimited by pain.

Examination

The patient's initial Roland-Morris Disability Questionnaire (RMQ)15,18,32 score was 5/24. The RMQ was selected prior to the case due to its sensitivity to change in people with acute LBP.18 The patient's FABQ scores were 18/42 for the work subscale and 9/24 for the physical activity subscale, indicating low fear-avoidance beliefs. Her LoBACS scores were 86%, 100%, and 90% for the function, self-regulatory, and exercise subscales, respectively.

The patient displayed decreased thoracic kyphosis, increased lumbar lordosis, and greater prominence of the right lumbar paraspinal musculature with visual postural assessment. Initial pain in a standing position was 1/10 located at the right lumbar spine and lateral leg. During right single-leg stance, the patient had increased lumbar pain and increased pelvic drop with trunk rotation. Left single-leg stance was pain-free with a level pelvis. Myotomal lower-quarter strength screening revealed the L1-L5 innervated muscles were graded as 5/5 and equal bilaterally. The S1 myotome testing demonstrated 8 unilateral heel-raises on the left and 6 unilateral heel-raises on the right, with right heel-raise performance limited by leg pain rather than weakness. Dermatomal light touch was normal. Patellar and Achilles tendon deep tendon reflex tests were 2+ bilaterally. Lumbar AROM revealed flexion was normal and status quo. Extension was limited with increased right lumbar pain at end-range. Left side bending was limited, and her right lumbar pain was worse at end-range. Right side bending was normal and status quo. Prone hip medial (internal) rotation PROM was 56 degrees on the left and 54 degrees on the right, and lateral (external) rotation was 46 degrees on the left and 48 degrees on the right. Straight leg raise was negative with 96 degrees of PROM on the left. Straight leg raise on the right was positive for reproduction of LBP at 88 degrees, and it was unchanged with dorsiflexion sensitizers. Tenderness and restrictions were noted with palpation of the right lumbar paraspinals. The right L5-S1 segment was hypomobile and reproduced her lumbar pain. The left L5-S1 segment was hypomobile and pain-free. The L1–2 through L4–5 segments had normal mobility, which was painful on the right and pain-free on the left.

Evaluation

Based on the initial examination data, the mediators influencing the patient's acute LBP were categorized and ranked above using the ICF model (Tab. 2). The patient met 4 of the 5 criteria that predict success with manipulation in patients with LBP, and she did not have any signs of nerve root compression. Research suggesting she had a 92% chance of a successful outcome with lumbopelvic manipulation prioritized her reduced mobility of joint functions as the primary body function limitation.33 We hypothesized that the reduced mobility of joint function at L5–S1 on the right and the resulting sensations of pain were contributing to her limitations with maintaining body positions and movement. Her limited movement and sensation of pain contributed to her restrictions in regular recreation activities. The contextual factor of the health care professional's awareness and application of research evidence was thought to positively mediate her rehabilitation. A significant bidirectional relationship in this case was between the requirement of sitting at a computer for 8 hours for employment and her sensation of pain. Pain limited her ability to maintain this body position, but the duration of sitting required for her work led to increased pain intensity. The patient was given an excellent prognosis due to the strong research evidence for her improvement with manipulation.


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  		Table 2. The World Health Organization's International Classification of Functioning, Disability and Health (WHO-ICF) Model Applied to the Evaluation of Patient 2 (Acute Low Back Pain)a

 
Intervention

The patient received 3 treatment sessions over 23 days. She was educated on her physical therapist's diagnosis, prognosis, and plan of care. The initial intervention involved a left side-lying manipulation technique directed at L5–S1 on the right to improve mobility of joint function and reduce sensation of pain.34 Subsequently, the patient was instructed in a home exercise program of left side lying with right trunk rotation AROM. She was educated on sitting posture and ergonomics for computer use to address the potential environmental barrier of prolonged sitting at a computer for work. During the second visit, the side-lying manipulation was repeated. Further examination revealed a negative SLR, but slump testing was positive for LBP and increased right leg pain. The patient was instructed in a self-administered AROM exercise in the test position to address the associated reduced nerve mobility and sensation of pain. She was instructed to take a standing break from sitting every hour at work to minimize the environmental barrier of sitting for work. During visit 2, testing of prone hip extension with knee extended on the right revealed anterior pelvic rotation and right ilium anterior rotation in the transverse plane, indicating a lack of lumbopelvic neuromuscular control. This was the only remaining impaired body function at visit 3. The patient was prescribed prone hip extension stabilization exercise to address this impairment.

Outcome

Immediate improvement was demonstrated after the initial manipulation, with 0/10 lumbar and leg pain in standing, no pain with lumbar extension AROM, decreased pain with left side-bending AROM, and no pain with right single-leg stance. At the second visit, her right LBP and leg pain were less intense (ie, 2/10 at worst). Extension created right lumbar pain at end-range, and right L5–S1 accessory motion was still painful and hypomobile. She was able to sit 5 hours at work without LBP, and her RMQ score was 1/24. During the final visit, the patient reported no pain since the day of the last treatment. She was working a full day and returned to jogging without pain. Her final RMQ score was 0/24. Her LoBACS scores were 91%, 100%, and 100% for the function, self-regulatory, and exercise subscales, respectively. Her FABQ scores were 5/42 for the work subscale and 4/24 for the physical activity subscale. Re-examination demonstrated normal lumbar AROM, normal and pain-free accessory motion testing, and a negative slump test. The patient was discharged from physical therapy with all goals met.


   Discussion
Top
 Abstract
 Introduction
 Patient 1 (Chronic LBP)
 Patient 2 (Acute LBP)
 Discussion
References
 
The WHO-ICF model is characterized by a bidirectional flow of information rather than hierarchical organization of its domains. This was demonstrated with several hypothesized bidirectional relationships in the 2 cases. The WHO-ICF model appears to provide an effective framework for physical therapists to better understand each person's experience with his or her disablement and assist in prioritizing treatment selection. It is notable that the health condition identified in this case series was LBP, which is a symptom-based condition rather than a specific, tissue-based pathology.35 The WHO-ICF model assisted in identifying body structure and function deficits and activity limitations. Interventions directed at these impairments, contextual factors, and limitations addressed the health condition and appeared to affect activity and participation. For example, the hip muscle performance and length deficits observed in the patient with chronic LBP were hypothesized to result in poor segmental stabilization and consequent LBP. The WHO-ICF model may predict the potential success of physical therapy interventions for other symptom-based health conditions in which a specific, tissue-based pathology is unclear.

Patients in this case report series benefited from the WHO-ICF model's explicit acknowledgment of personal and environmental factors as important contributors to disablement through their interaction with the physical domains. For the patient with chronic LBP, a belief related to avoidance of physical activity was a negative personal factor. Recognizing this negative personal factor allowed the therapist to direct specific educational interventions designed to reduce her fear-avoidance behavior and secondarily her participation restrictions. Environmental factors also played a large role in both cases. In the patient with chronic LBP, the structural setup of her workspace, the use of a computer for work, and the requirements that she transport files contributed to her participation at work. The requirement that the woman with acute LBP sit and work at a computer 8 hours a day for her job greatly played a part in her disability.

Existing clinical reasoning models were used concurrently with the organization of function provided by the WHO-ICF model (Fig. 2). For example, Edwards and colleagues’ clinical reasoning model36 was used to organize the appropriate performance of the functions of the physical therapist. A hypothesis was developed from history and physical examination data, the therapist's knowledge, and the patient's experience. After the evaluation, the therapist selected the best possible interventions based on research, clinical experience, and patient preference that matched the previously selected components. Reassessment occurred by monitoring the effectiveness of the interventions using various outcome assessments from the examination to measure change in activities and participation. Questionnaires with acceptable psychometrics allowed accurate measurement of patient perceptions in order to evaluate and modify the hypotheses developed within the WHO-ICF framework as the rehabilitation cycles continued. In addition to the concept of the rehabilitation cycle, evidence-based practice principles were used to identify the best possible examination, evaluation, and intervention strategies.37 Classifying acute LBP into treatment-based categories based on clinical presentation has been associated with superior outcomes compared with nonmatched treatments.33,38 Clearly, although the WHO-ICF provides a powerful new tool for physical therapists, existing clinical reasoning models may be expected to retain complementary roles in the clinical reasoning process by physical therapists.


Figure 2
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  		Figure 2. Integrated model of physical therapist clinical reasoning incorporating the World Health Organization's International Classification of Functioning, Disability and Health (WHO-ICF) model, with important concepts from Sackett's principles of evidence-based practice,37 the rehabilitation cycle, and Edwards and colleagues’ clinical reasoning model of physical therapists.36

 
This case report provided 2 examples of the application of the WHO-ICF model in patients with LBP. It provides preliminary evidence for the clinical utility of the bidirectional relationships among the WHO-ICF model's domains, explicit acknowledgment of personal and environmental factors that affect disablement, and potential complementary clinical reasoning models. Future research is necessary to apply the WHO-ICF model to other body regions and health conditions common in physical therapist practice. This research should establish the clinical effectiveness of its application and derive core sets that may be useful for optimal education, research, and reimbursement.


   Footnotes
 
Dr Rundell and Dr Davenport provided concept/idea/project design, writing, and data analysis. Ms Wagner assisted in the project design. Dr Rundell provided data collection, project management, and patients. Dr Davenport and Ms Wagner provided consultation (including review of manuscript before submission).

Dr Rundell completed this case report series in partial fulfillment of the requirements of the Kaiser Permanente Southern California Orthopaedic Physical Therapy Residency. The authors thank Joe Godges, PT, DPT, OCS, for his insightful comments regarding an early version of the manuscript. The authors also gratefully recognize Kris M Keller, PT, Department Administrator, and Justin W Hamilton, PT, MPT, OCS, for their administrative support of this project. The authors affirm that they have no financial affiliation or involvement with any commercial organization that has a direct financial interest in any matter included in the article.


   References
Top
 Abstract
 Introduction
 Patient 1 (Chronic LBP)
 Patient 2 (Acute LBP)
 Discussion
 References
 

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