1. Mr John O’Dowd
MBBS, FRCS, FRCS Orth
Consultant Spinal Surgeon
Signposting For Combined
Psychological & Physical Care of
Spinal Injury & Pain Patients

3. Rehabilitation
Revive
Review
Repair
Rehabilitate
Optimise outcome
• Medical
• Function
• Psychological
• Work

4. Flags
• Red Serious underlying pathology
• Yellow Psychosocial barriers to
recovery
• Orange Serious psychiatric disease
• Blue Work environment
• Black Occupational policy and
systems

5. • 125 patients
• Subjective clinician categorization
• DRAM
– Experienced spine surgeon 26% sensitivity
– Predictive value
• Distressed 69%
• Nondistressed 77%

6. Waddell signs
Main CJ, Waddell G (1998) Behavioral responses to examination: a
reappraisal of the interpretation of “nonorganic signs”. Spine;
23(21):2367–2371.

7. STarT yellow flags
Dunn 2005 Keele
• Low risk
Low risk of future disabling LBP
• Medium risk
Physical and psychosocial indicators
for poor outcome, but without high
levels of psychological indicators
• High risk
High levels of psychological
prognostic indicators with or without
physical indicators

8. • Nine-fold reduction in sick leave in CBT group

9. Results
Mean 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

14. Mirza
2007 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
18 Conservative
16 Surgery
14
mean change in ODI 12
10
8
6
4
2
0
Sweden MRC Brox 2003 Brox 2006