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Re: LBP Treatment Approaches
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Re: LBP Treatment Approaches - June 28, 2005 12:04:00 PM
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chiroortho
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[QUOTE]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.[/QUOTE]I have to agree with Zack here, if I understand him correctly.
I think the CPR for tx of LBP that Childs put together is seminal, helpful and commendable. But I don't think it's cast in stone, nor do I think it should reasonably be expected to be a hard limitation on manip for LBP.
I'm as much an adherent to EBM as the next guy, but I also recognize that (1) the research on tx of LBP is still in it's infancy relative to manipulation, and (2) things like 'pain for less than 16 days' is really questionable. Does that mean that if the pain is 3 weeks old that manip should be considered 'unreasonable'?
This is NOT to say that anything goes of course. But even patients with a 10 year history of LBP, for example, even with pain that extends into a leg (non-HNP) deserve a trial of SMT if no other untoward history/findings are noted. I've got 23 years of experience with folks like that, that improve with nothing but SMT - it's hard for me to think that patients that don't meet the 16 day/no pain below the knee parameters should just be told 'Nope, sorry, you don't meet the manipulation CPR - no manip for you'.
Bottom line: I firmly believe that EBM is a useful tool and a GUIDELINE, not an absolute. The clinician on the scene is the final arbiter of what should be done. Experience, clinical skill, even empirical reasoning, is a HUGE part of the equation when it comes to treating people.
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Greg Priest, DC, DABCO
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Re: LBP Treatment Approaches - June 28, 2005 3:03:00 PM
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karmzack
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Greg, you agree with Jason. I can't say that I do. Overall I'm a little confused.
Jason. When you talk about a neural component to the patient's symptoms. Are you talking about a neural control component?
Spine stab theory addresses a cause and effect of intermittent LBP. When the spine is injured the multifidus quickly shrinks by 25% and fails to activate correctly. This has been shown to occur within 24 hrs following injury and lasts indefinitely even when the pain has disappeared. The patient is set up for reinjury and further pain.
Or are you talking about the actual neural development and sensation of pain?
You can't discount the psychosomatic component to pain either, is this related to the "neural component"?
I find this all stimulating even if I'm having difficulty following Barrett's theory. I am after all a manipulator-strengthener-function-is-all-important therapist. I tried to find the Explain Pain book at Amazon and B&N but no luck. There were about 70 other books on pain though.
I refer patients to the Pain Clinic every once in a while. The patient's usually return high on drugs, shot up on steriods, and buzzing from TENS. I think I may have to get in touch with my neurodynamic side for the sake of my patients.
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Zack Solomon MPT, OCS, CSCS
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Re: LBP Treatment Approaches - June 28, 2005 3:24:00 PM
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chiroortho
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I think I misunderstood you both. Sorry.
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Greg Priest, DC, DABCO
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Re: LBP Treatment Approaches - June 28, 2005 3:27:00 PM
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Ender
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From: VA
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Zack,
You can get the book from [URL=http://www.optp.com.]www.optp.com[/URL]
Under the shop online section, click on David Butler.
OaksPT
Take oUt the period after com for the link to work.
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Re: LBP Treatment Approaches - June 28, 2005 3:31:00 PM
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jbeneciuk
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Considering that this seems to involve a majority of chronic pain scenarios, I have come across an interesting reading from the "evidence in motion" website...it is a chapter in "Best Practice & Research Clinical Rheumatology"...the chapter is entitled "What is the value of physical therapies for back pain?" (it breaks down LBP into stages: acute, subacute and chronic)...the section regarding chronic LBP emphasizes the importance of graded exercise programs and cognitive-behavioral approaches ("seems to be moderately effective")..where all other forms of treatment do not have enough evidence to deem suitable.
If anyone gets the chance to read this, I would like to hear any comments.
evidenceinmotion.com
under research section
Best Practice for LBP (June 16)
download the "Moffett" article
"What is the value of physical therapies for back pain"
I also must admit that sometimes I have difficulty following the theories of Barrett, possibly because of my lack of experience dealing with neurogenic pain...I am making an attempt to learn more regarding it, especially in an attempt to assist my chronic patients.
JBeneciuk
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Re: LBP Treatment Approaches - June 28, 2005 4:04:00 PM
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SJBird55
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Jason, I know exactly how you feel. I've been kind of feeling as you described for quite awhile. What I need to help me would be more evidence so to speak in peer-reviewed literature to help guide my decision making process and to help me to have a less vague picture in my mind of anticipated responses to interventions, a bit more detail on the actual interventions and in what kind of time frame responses occur.
Anyone who has been in pain for >6 months kind of has me feeling very humble and inexperienced.
As Sebastian has alluded to regarding "strengthening"... in some cases, I know I'm definitely strengthening. In a lot of cases, I really don't think "strengthening" is what is actually occurring. We've been so programmed to think with the stupid CPT codes that those CPT codes have really limited our thought processes, in a way. I don't know if that makes sense, but it many times feels like I'm in a box with third party reimbursement because I have to know that fee for service schedule and I have to know all the stupid rules regarding documentation.
I have really changed my way of approaching patients in pain - in particular the acute and subacute stages - thanks to Diane, Nari and Barrett. I've even put together a couple of little educational "brochures" about pain for patients. I really haven't historically had a large population of chronic pain patients and hardly any sympathetically maintained pain patients. Maybe I'm lucky? Or unlucky in the sense that I don't get to experiment or play around with what I have kind of learned through reading.
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Re: LBP Treatment Approaches - June 28, 2005 4:22:00 PM
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PTupdate.com
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I can see the point that SJ is making, and others as well. Perhaps placing somebody on the Nautilus back extensor machine is routinely called "strengthening", but the effects seen, almost always positive, are due to other reasons. But, we still just say we are "strengthening".
It goes back to a thread a few years ago, where "hamstring stretches" were discussed. Years ago I figured I was just stretching the hamstrings, but soon realized that I was performing a neural mobilization instead. The technique was the same, the beneficial results the same, and for the ease of use, continue to say "hamstring stretches".
The same goes for the back "strengthening". However, research by Dr. Vert Mooney and others have shown very good results with back "strengthening" exercises on chronic pain patients who have failed multiple other treatments.
And Barrett, I was very able to read the sarcasm in your earlier statement to Sebastian and how you were phrasing it.
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: LBP Treatment Approaches - June 28, 2005 4:42:00 PM
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karmzack
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[QUOTE] What I need to help me would be more evidence so to speak in peer-reviewed literature to help guide my decision making process and to help me to have a less vague picture in my mind of anticipated responses to interventions, a bit more detail on the actual interventions and in what kind of time frame responses occur.
[/QUOTE]SJ- I'm with you on this. It appears to me that one approach (manipulation/strengthening) lacks theory but has specific interventions. Whereas the other approach (deep model of pain) has a theory but vague interventions.
Duffy- I think one of the reasons we use the term strengthening is because the concept is well understood by patients. If we said we were modifying their neural control of movement or modulating pain, we'd probably get a blank stare. I teach a spine stab class and try to drive home the importance of CNS control of the trunk stabilizers, after about 15 minutes I notice some level of understanding, it takes some effort though.
_____________________________
Zack Solomon MPT, OCS, CSCS
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Re: LBP Treatment Approaches - June 28, 2005 5:39:00 PM
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nari
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Jason
It is possible to have a foot in both camps - Cartesian and nonCartesian (poor old fellow Descartes, his legacy will always haunt him).
What I think is so important about treating neural issues is the results are likely to be more permanent. Note I said likely - many patients are uneducatable; for me, anyway, despite Lorimer Moseley's strong convictions, I feel that there are quite a few how are not amenable to education...
jbeneciuk
That is too lengthy to answer in a post. I can only refer you to the texts of Butler, Shacklock et al....
Nari
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Re: LBP Treatment Approaches - June 28, 2005 5:44:00 PM
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SJBird55
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You know... a patient I am currently treating had a complaint about the previous physical therapist he had. Yes, he had back pain. Yes, it was chronic. But, what he verbalized, which I think does put it nicely in regard to a patient's perceptions, is that he needed "confidence." The last therapist was nice and gave him a bunch of stretches which were "somewhat helpful," but no one had really listened to him. He's in his 50's, not desiring to retire and is a police officer. His role is training both with weapons and hand to hand combat. He has to pass his physical performance test. He hasn't really said exactly what he does, but he mentioned two of his buddies were shot up a few weeks ago (but lived) and that he's frequently called to go in or something, so I got the impression that he isn't just doing a beat in a car. His biggest beef with all the medical providers so far is that no one really listened to him and everyone seemed happy that his pain was reduced with a very low level of function. No one had pushed him to let him feel what he can perform. He reported that every time he attempted to perform at a higher level of function, all his symptoms would return. But when I watch him and point out my observations, quite a few of his movement patterns have some unusual subtle substutions or what I'd call poor feedforward/preparatory stabilization. His body was basically anticipating pain and preparing for pain and almost like automatically protecting him from pain. But... when I pointed out what I observed, offered suggestions and discussed it with him, cognitively and consciously he could alter his movement patterns to normalize them (and he didn't have pain). His statement about needing "confidence" really hit home to me.
"Confidence" has more of a mental image in my mind. So, as he gains "confidence" and self-efficacy, what I'm wondering is if what I'm observing as motor programming errors (I have no idea what else to call them) will potentially go away and he'll be just fine? So, in other words, the activities that I did that were billed as "strengthening," were actually like a restoring of the hard wiring and the connections in movement? I can't explain it, but I'm seeing changes, he's functioning better at work... and you know, this guy was already decently fit when he walked in my doors, so in my heart, I really don't truly believe that the activities really just "strenthening" in nature. Something else is going on... I just don't know what. Which just brings me back to a nagging question I have had for months... what the heck do I do? What am I doing?
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Re: LBP Treatment Approaches - June 28, 2005 7:13:00 PM
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Bournephysio
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Nari, Wasn't Descartes know (at least partially) for stating that the mind and body were separate? Under that thinking both someone who thought the only dysfunction was in the CNS and someone who thought that the only dysfunction occured in the tissues are BOTH guilty of cartesian thinking. I would think that noncartesian would be someone who understands that you can't isolate the mind from the body. Dysfunction in the body will necessarily impact the cns and vice versa. I don't think that there is much of a need for cartesian thinking. Even a simple ankle sprain causes motor control and proprioception changes. In chronic pain there is still likely tissue dysfunction.
Doug
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Re: LBP Treatment Approaches - June 29, 2005 2:11:00 AM
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JLS_PT_OCS
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Greg - I think you are over-interpreting the CPR for manipulation. Remember one factor is just as important as another. The time isn't the salient issue, it's just one of the five. And I agree about a trial of manipulative care also, it's difficult to beat the cost/benefit ratio there.
Doug - Good point about cartesian thinking.
Chris- yes, I enjoyed that article, and it helped lead me to my current thoughts.
Zack- well, for right now, I'm talking about people with central sensitization of pain. I'll have to leave the neurodynamic stuff for another day (Shacklock's book arrived yesterday)
I guess I realized yesterday, after talking for 45 min with a chronic pain patient (neck and shoulders) that 99.9% of the interventions I have are aimed at tissues, and most if not all of my chronic pain patients have very little tissue dysfunction in relation to their central sensitization/sympathetically maintained pain problem.
They go from health professional 1 to health professional 2 to ....#40. No one really listens to them, everyone only is offering them more tissue-based solutions, and in the meantime, they get worse and worse. And what small improvements they get in function, we in the medical system celebrate (much to the patient's chagrin, they're still in pain).
I do still plan to use many of the tools I currently use (manip/mob and Lx stabilization - both local and global approach are examples) but now I am starting to think that those are MUCH less important than a good CBT program of instruction. In fact, a big part of why I think the supervised Lx stability program was so successful in many of my patients has NOTHING to do with the multifidus and TrAbd, and everything to do with the CBT interaction between therapist and patient. It's the little pain and life management discussions I have with patients during those sessions, and the graded activity I sort of provide, that is making the difference. This reminds me of the manual therapy discussions we have all had -- I'm sure stabilization training works for chronic pain patients to some degree, but I don't think it works only for the reasons we think it does. Though I'm sure neural movement control and Mult/TrAbd is part of the picture, I think those other CBT types of stuff are probably more important for the chronic pain person.
Reading Explain Pain and see why chronic pain patients complain of the things they do, it really opened my eyes in a new way. After having read a lot about CBT interventions, I have been interested in doing something like that, but didn't know where to start. In fact, at CSM, a famous PT researcher was even presenting about CBT, and when I asked him where I could find some resources or sample programs, he told me they were widely available in the literature. Gee, thanks for nothing, pal. Yet another researcher-clinician disconnect.
Anyway, you should have seen the look on this guy's face yesterday when I showed some honest empathy, and explained why he felt the way he did. He was floored that someone actually understood. I mean, he almost fell out of his chair, he couldn't believe it. Of course, I did give him the obligatory exercise program, but I really don't think that will be very helpful. I think it's the pain education that is the missing link for most of these people.
I think that once I get this CBT intervention going, it will become an integral part of the clinic, and I will be better at recognizing when someone is experiencing diminishing returns from a tissue-based program and showing signs of chronicity, and therefore needs to be transitioned to an aggressive CBT and graded activity format.
Now, making up the power point presentations will be the killer...
:)
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 29, 2005 3:15:00 AM
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Diane
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Jason,
Brilliant post.
:) ,
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Re: LBP Treatment Approaches - June 29, 2005 3:32:00 AM
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Shill
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Jason,
Could you cite the "wave of new evidence" to which you refer? You are quite good at doing this. Aside from the books, what are the studies that have caused your reevaluation of your practice?
Thanks,
Steve
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Steve Hill PT
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Re: LBP Treatment Approaches - June 29, 2005 5:15:00 AM
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Bournephysio
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Almost there Jason. Release your old misconceptions and your journey to the dark side will be complete.
Look at your techniques that are aimed at the "tissues." Dissect them. Are they actually effecting the tissues? How does manipulation affect the tissues? Not likely. Its most likely a neurophys effect (Steve, do you still have that long list of references I sent you). Same with almost everything we do. There is still no strong link with TA and mechanics. Outcomes yes, mechanics no. If you've seen Hodges talk you will have probably seen the slide where he talks about all the possible mechanisms. He stresses the mechanical but look at what else is there.
Take a look at CBT and see if you can dissocociate it from mechanics. Maras has shown that stress and anxiety change loading in the spine. Many others have shown activity changes. Do you think that chronic pain patients show stress and anxiety when doing activities? Think at the molecular tissue level. How do you think the tissues themselves are going to respond to constant bombardment with cytokines and chemokines and neurotransmitters? How do you think they will respond to loading in such a situation (which incidentally is where I want my research to go)?
Shaklock, Butler and Moseley keep coming up on this forum. Why not Watson?
One thing I have noticed in physio is that we have a hard time finding balance. Its all one thing or another. I think that having a strong theoretical framework helps. With a strong theoretical framework, new evidence tends to fill in space or slightly modify your framework rather than outright challenge it. This prevents some of the huge paradigm shifts we see. Its all about balance.
Doug
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Re: LBP Treatment Approaches - June 29, 2005 5:26:00 AM
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Jon Newman
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[QUOTE] I think you are over-interpreting the CPR for manipulation. Remember one factor is just as important as another. The time isn't the salient issue, it's just one of the five. [/QUOTE]I don't know if this has actually been adequately addressed. It would be interesting to perform an experiment in which different groups (each consisting of different qualifying criteria) are compared. Would a group with 6 months of back pain but having the presence of the other conditions still achieve that 95% success rate? Or would a group whose FABQ are all high (and those FABQ issues are NOT addressed per the experiment) achieve the 95% success rate?
We don't know, but I'm sure that taken as a whole population, it should wash out that way. At least when the CPR experiment is repeated in an RCT, that's what we should see.
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: LBP Treatment Approaches - June 29, 2005 5:44:00 AM
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JLS_PT_OCS
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Steve-
Here's a start:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15722803&query_hl=2
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15599128&query_hl=2
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15599127&query_hl=2
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15502689&query_hl=2
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15322439&query_hl=2
Doug-
I think you're right about balance, and I'm ready to leave the Jedi order, by the way. You, Barrett and any other Sith lords want to take a new apprentice?
I think my main problem now is that everything I know how to do is tissue based and biomechanical in nature. So when I see another side of the issue, I'm blown away. I don't want to so much abandon the biomechanical models in which I was educated, but to better see them in a larger context of what their strengths and weaknesses may be, and have a larger array of treatments to use on my patients as their classification changes.
I want to be able to competently provide manipulation, stabilization, graded exercise, CBT and pain education, etc, etc so there will be a larger group of patients that can benefit. It's just that right now, I am completely out of balance. I'm trying to change that.
Jon-
I think the factors are addressed pretty well in the validation study, and Alex did also in his case study. There was a guy who was WAY out of the 16 day time period, but had other predictive factors and did great with a few manips from Alex. I've had several similar patients.
You have some good points there about group comparisons, but I lack enough statistical knowledge to adequately answer them from a theory standpoint. From a practice standpoint, I go ahead and give them their manip, and see what happens. If nothing, then move on to the next thing.
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 29, 2005 6:14:00 AM
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steve
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Jason,
Very impressive postings. This mirrors the way my clinical practice has turned over the last couple of years. I would very much agree that the obligatory exercise program simply serves as an adjunct to the pain education treatment you are giving these patients It likely addresses some kinesiophobia issues for many of these patients which is why functional exercise is likely a better choice than standard strengthening exercises.
Steve
Unfortunately I dont have the reference list Doug mentions but I think he is referring to the physiological effects of manipulation and the research that has been done in this area.
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Re: LBP Treatment Approaches - June 29, 2005 6:23:00 AM
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Alex Brenner PT MPT OCS
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Jon,
I think Julie Fritz and Childs published a study in Physical Therapy about a year ago on the predictors for those who do not respond with manipulation and a high FABQ was one of them. If I have a patient with high fear avoidance manipulation is not my first line treatment and I believe this Fritz study shows that.
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Alex Brenner, PT, MPT, OCS
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Re: LBP Treatment Approaches - June 29, 2005 6:27:00 AM
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Alex Brenner PT MPT OCS
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J,
I commend you on your new knowledge of the force, I mean pain. I am not there yet.
One problem that I foresee in our line of work is time. I for one simply do not have the time to commit to these types of patients (chronic pain). I think they do require lots more attention, holding their hand if you will. I would prefer to see 10 soldiers with musculoskeletal complaints that that I know I can treat and get better in a few visits than 1 chronic pain patient that bogs my schedule down. It is unfortunate but is the way we do business in the Army. At least at the places I have been stationed.
_____________________________
Alex Brenner, PT, MPT, OCS
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