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Re: LBP Treatment Approaches
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Re: LBP Treatment Approaches - June 27, 2005 1:23:00 PM
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Barrett
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I presume we'll never see here a similar thread regarding "Treatment Approaches for Foot Pain."
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: LBP Treatment Approaches - June 27, 2005 3:03:00 PM
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jbeneciuk
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From: Jacksonville, FL
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Barrett:
Could you elaborate on your last response ?
JBeneciuk
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Re: LBP Treatment Approaches - June 27, 2005 3:48:00 PM
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Barrett
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Would we ever consider naming a body part (aside from the spine), adding the word "pain" and assume sufficient information had been provided for a discussion about treatment approaches?
Perhaps I'm wrong, but I don't think so.
What does this say about our ability to test, assess, clinically reason about (terrible phrasing there, I know) and measure spinal function and its relation to the very pain we chase around?
Some reasonable questions: Does this LBP have a chemical or mechanical origin or both?
Is there a relevant pathology?
Can the use of movement-strengthening or otherwise-in an effort to alter symptoms be justified with a strong and uncontested theory of dysfunction?
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: LBP Treatment Approaches - June 27, 2005 4:18:00 PM
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PTupdate.com
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Sorry it took a few days to get back with you Sarah and Lizz. Those with obvious signs of nerve root pathology/irritation/encroachment, be it disc, bone compression almost alwasys can be given some type of relief on their first visit. Either they will show you the positon that helps ease their pain, or you can experiment and find it for them.
Even the cases of severe pain with a strong chemical component can be give relief, even with modalities such as ice or ES. Even when I had my own HNP (2 levels..one sneeze), I was able to relieve physical compression via positioning/exercise during the day. Chemical irritation, usually hitting me in the middle of the night, was relieved with strong ES and the gut-killing indomethacin.
Barrett..not sure what you are asking. If someone comes in with pain, and I believe it is some dysfunction based on classifications (which I don't use that much), and some movement or strengthening helps them, why not be justified?
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
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www.PTupdate.com
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Re: LBP Treatment Approaches - June 27, 2005 5:27:00 PM
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karmzack
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I'd agree with John, When I have a patient come to my clinic in noticeable pain I like to give them a little "candy" with the ES and ice or heat. 95% of the time they feel better after the treatment (even if it's temporary) and I like to think they are more confident that I can help them. I always tell them the ES is the temporary solution and the exercises are the permanent solution. Many patients come to my clinic wanting immediate change I can provide that sometimes with manipulation and posture training and most times with IFC and MHP. My preferred permanent solution in a good spinal stab. program, but it takes a strong commitment from the patient.
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Zack Solomon MPT, OCS, CSCS
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Re: LBP Treatment Approaches - June 27, 2005 6:16:00 PM
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jbeneciuk
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"Can the use of movement-strengthening or otherwise-in an effort to alter symptoms be justified with a strong and uncontested theory of dysfunction?"
Barrett:
Maybe I'm just ignorant, however I still do not understand the point you are trying to get to.
I realize that our clinical testing has its flaws, as the importance of ruling out a serious pathology (ex: cauda equina), however I also believe that after a serious pathology is ruled out...the stage of LBP has to be considered (acute, subacute, chronic)...this may assist us in the origin of pain and help guide our treatment approach..
(ex; Chronic LBP may be associated with some psychosocial factors, deconditioning, depression, etc...these pts may have their pain originating from more complex processes involving the nervous system, as opposed to a mechanical dysfunction of the spine.)
This is why I decided to start this topic, because I wanted to strike a discussion as to what leads others in deciding to change an approach if one is not working and what factors lead us to believe a given approach is not working (time, functional questionaires, etc)...
I feel you may be questioning why we feel that movement is even an option?
Maybe my feeling is wrong ? Is it?
JBeneciuk
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Re: LBP Treatment Approaches - June 27, 2005 8:53:00 PM
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nari
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JBeneciuk..
ALL pain originates from the brain/CNS, regardless of injury or dysfunction 'sites'.
No such thing as pain receptors or pain input..and if this considered as a 100% fact - Barrett's reasoning makes more sense??
nari
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Re: LBP Treatment Approaches - June 28, 2005 2:12:00 AM
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Sebastian Asselbergs
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nari, your post from June 25 is exactly how I wanted to answer - uncanny how close your approach is....And your last post is bang-on too.
I have yet see two patients with the same complaint-complex. In 23 years of practice.
Outcomes are very useful and I use them. But the treatment is dictated by the patient's history, complaint, needs and goals, my evaluation (which is short!) and personal EDUCATION. I have been teaching patients about physiology and pain, and motion and health - more and more in the last few years. It is by FAR the most important aspect in the early stages of recovery. And I do believe there is elegant evidence to support that notion...Funny enough, "strengthening" is not found in any of my education or treatment sessions.
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Mundi vult decipi
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Re: LBP Treatment Approaches - June 28, 2005 2:45:00 AM
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PTupdate.com
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I will add one more thing on to my treatment routine...while I certainly wish to relieve pain (usually the reason they are in my office in the first place), I also want to address WHY it might have occurred in the first place.
It has always been my treatment approach, and many tell me quite simplistic....if tight, stretch it..if weak, strengthen it, if abnormally moving, restore normal biomechanics.
Usually, if I can resolve these matters, the pain/irritation disappears, and I did the person the extra favor of addressing the original cause, therefore limiting the liklihood of a return. This is often the downfall of approach for some PT's and chiros. I alwasy use the example of improperly worn car tires. Anybody can slap you on a new set, but if alignment, tire pressure, balance are not restored, you'll trash that new set of tires too, and be right back in the shop (clinic)
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: LBP Treatment Approaches - June 28, 2005 3:20:00 AM
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jbeneciuk
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Nari:
I realize that al pain originates in the brain, however what I was referring to ..I believe john may have said in a more clear way...why might the pain have originated in the first place ? (ex; sit of injury..perceived as painful..yet tissue injured is what we aim to treat...my earlier point is with chronic patients, there may not be a mechanical dysfunction (ex: muscle strain)..where in fact there may be more of a change in the central processing of the CNS..I do not claim to be an expert in the processing of pain, although others may feel they are, what I am saying is that when dealing with patients sx, and there reports of pain, surely what is the culprit of the pain would vary based on acute vs chronic complaints...I'm not denying that pain originates in the brain, what I was speaking of was the tissue at fault (does this sound as if I'm coming across more clear??) anyone?
JBeneciuk
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Re: LBP Treatment Approaches - June 28, 2005 3:41:00 AM
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Barrett
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But Sebastian, if a strengthening program resulted in functional gains and and an improved score on a few written tests wouldn't you be obligated to use it even if it didn't make any sense?
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Barrett L. Dorko P.T.
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Re: LBP Treatment Approaches - June 28, 2005 4:22:00 AM
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PTupdate.com
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He might need to feel obligated if his current program with a patinet is not working. But, if he is having success with his methods, and is addressing both their current situation and possible causes without strengthening, he won't have a necessary obligation to change.
But, if performing a strengthening exercise will improve a patients function and test scores (most are validated products measuring pain and quality of life) why not perform?
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: LBP Treatment Approaches - June 28, 2005 4:43:00 AM
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jbeneciuk
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Nari:
"no such thing as pain receptors or pain input"
can you ellaborate ?
Barretts' reasoning makes more sense regarding what?
that movement in an attempt to alter pt sx isn't justified...
Barrett: what is your response Re: my last reply?
JBeneciuk
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Re: LBP Treatment Approaches - June 28, 2005 5:44:00 AM
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Sebastian Asselbergs
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Well Barrett. Since you ask :-)
Stimulating/allowing the system to recruit these possibly "inhibited" muscles better needs to be done. If some want to use "strengthening exercises" OK. But don't call them that - maybe they are helping the body recruit the function more appropriately. There is just not enough evidence for me to say that there is much "weakness" associated with low back pain. Or that those muscles are in any way a core issue to the patient's pain.
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Re: LBP Treatment Approaches - June 28, 2005 6:10:00 AM
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JLS_PT_OCS
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Well, I don't know how to post next, but...
I must say that I am in the middle now of a complete rethink of the way I practice.
Some things Jon, Barrett, Nari, and others have been saying sort of stuck with me, and I am definitely in the middle of some type of transition. I can't say for sure what it is.
Right now, I have one foot clearly in the room with the "strengthening" group, and at least part of one foot in another room entirely. I suspect it's a movie theater, actually. Where Barrett has been for some time, and I'm just now arriving.
Even 6 weeks ago, I would agree to Barrett's point, that if the strengthening exercises improved the outcomes and the patient's function, I WOULD be obligated to use them. Now I'm not so sure. Now I just finished reading "Explain Pain" last night, and I don't believe anymore in a lot of things that I do and was taught to do, especially for people with chronic pain.
I don't quite know how to explain it.
I used to see my job as a Neuromuscular Reeducator, and that the manipulation, modalities, and "strengthening" exercises were means to that end. I didn't think that usually "strength" was the problem, the exercises were used as a vehicle to modulate pain input, reduce disuse and fear of use, and reeducate the neuromuscular system. Then when people could function better, but still had pain, I would declare victory, and tell them all about how much better their function was. Even if their pain had not resolved.
I'm not sure if I still fully believe in that, though. In fact, I'm sure I don't. I just don't know what to do from here.
For now, I will continue to use the old tools that I elaborated on above for acute people, but for the chronic ones....I need a whole new approach. I'll post more when I find one.
Sorry for the ramble...
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: LBP Treatment Approaches - June 28, 2005 6:17:00 AM
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KAK
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On this end it was an enjoyable ramble.
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Re: LBP Treatment Approaches - June 28, 2005 7:06:00 AM
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Barrett
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I hope that everyone understands that my question of Sebastian was posted in an effort to get others to see that the issue of improvement, even if measured reliably, cannot mitigate the significance of theory.
In short, I'm asking "How does that work? and expecting the one promoting an intervention to tell me in the form of defendable theory. If you can't do that or don't concern yourself with such things I'll ask, "What did you go to school for?"
I was not making the point that if something worked that we would be obligated to use it-but the opposite; that if something worked and we didn't know how or couldn't explain it reasonably we had returned to the first age of medicine, also known as "pre-Hippocratic supernaturalism." (Followed by theory. original research and, today, science and advanced technology) Why would a PT want to go back there? Isn't that where most of "alternative" therapy now resides?
I see in Duffy's and others replies occasional specific references to the origins of pain, and when they do that I continue to listen because this is where we must go if we are to progress. Abandoning that search when something unrelated to those origins seems to "work" is, I feel, an unacceptable detour. I know it's easy to go there.
A typical exchange while I'm teaching:
Student: I had the patient with a backache do some strengthening and he got better.
Me: What was weak?
Student: The (insert the muscle of the week).
Me: Why would that hurt?
Student: Because it led to dysfunction, bad posture, imbalance, tendonitis from overuse blah, blah blah...
Me: Can you show me any sort of actual study demonstrating that this is a consequence of muscular weakness-that they are related in any way?
Student:Well, no. But the patient got better, and (return now to the first comment by the student and repeat infinitely)
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: LBP Treatment Approaches - June 28, 2005 9:01:00 AM
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karmzack
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Jason, Does this mean that you are going to stop treating patients that have been in pain greater than 4-6 weeks because of a disconnect with traditional PT theory?
I guess I should go back and read Richardson's book again on stabilization, I believe there is research cited comparing neuromuscular function and pain and supporting the view for strengthening. In my mind it makes sense. Maybe I should start reading more about chronic pain, but I'll have to wait until I'm done reading my functional training books.
I went to a course taught by Michelle Cameron (the modality "guru")2 weeks ago. She spent many years working as a PT until she decided she needed more and went to medical school. She starts her residency in Neurology this summer. I see some bright minds in this forum that could easily follow in that direction and be successful. Has anyone pondered that idea?
Sorry for the change in direction, a simple yes or no would satisfy my curiosity.
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Zack Solomon MPT, OCS, CSCS
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Re: LBP Treatment Approaches - June 28, 2005 11:42:00 AM
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JLS_PT_OCS
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Zack-
Yes it does. I think I have been using interventions aimed at joint biomechanics, muscle/joint tissue, and other connective tissue when people really had/have a neural component to their symptoms that I am/was not seeing/treating. I think a lot of my "chronic pain" patients now continue to get a lot of interventions aimed at their non-neural body tissues, when a significant chunk of evidence says that I should be doing more/better pain education/CBT and graded activity increases, along with appropriate exercise interventions.
Once again, I have been caught behind the wave of new evidence in a particular area, in this case neurobiology of pain and chronic pain states. I have been chasing people's pain around with modalities, manipulation/mob, and strength exercises without understanding what central sensitization of pain is and how to treat it. No wonder they never got better. I stood proudly atop the modest functional gains these people were able to achieve, never worrying for a second that I was not able to address their pain. I rather proudly proclaimed that I was addressing function, not pain, as if pain was something the patient was just making up. Funny, but every one of those patients said something like "Sure, let's try the therapy, anything to help the pain", and I KNEW I was not expecting to make a significant change in their pain experience, just to help them bend forward a little better or carry the groceries farther. How silly of me to initial the box under patient goals if I never thought I could change the one thing they were looking for me to: the pain experience.
After reading Explain Pain (and Shacklock's Clinical Neurodynamics is on it's way), I think I am much better able to develop a patient education class on pain physiology and dealing with chronic pain, as a CBT intervention.
Something I should have done a long time ago...it's embarassing and nearly disgraceful how much I didn't know about pain before reading that book.
Well, at least it's a start...
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: LBP Treatment Approaches - June 28, 2005 11:43:00 AM
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JLS_PT_OCS
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Zack, I think your Med school question is a whole new thread, buddy...
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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