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Re: LBP Treatment Approaches
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Re: LBP Treatment Approaches - June 29, 2005 7:34:00 AM
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JLS_PT_OCS
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Alex-
I see what you mean there. But I must say one advantage of a high volume practice is that it forces you to determine early on who will get better quickly with minimal intervention and who will need more time. It's your ability to do that, and the manner in which you do that, that is up to you.
If you have a separate Lumbar Stabilization (local approach) class, then the concept of setting aside time for those who need it really isn't that different. Signing someone up for some regular manual therapy time, or lumbar stabilization, or sports-level rehab, things which our clinic already has separate classes and group settings for, is no more difficult than getting a chronic pain group going. But the knowledge and desire have to be there (and the patient population). I think for a lot of therapists, that is the part that is lacking. Certainly, with me it is very recent that I have developed the desire/knowledge to do this sort of thing.
I have come to the opinion that more acute people with straightforward biomechanical dysfunction or acute tissue injuries are really very easy to treat. So easy that anyone could do it well. I used to really like these patients and have a sense of frustration or "here we go again" when I sensed a chronic pain patient start to get going. All I could do was throw some obligatory exercise or manual therapy thing at them, and couldn't wait till they got out of the office so I could see the next one, hopefully an ankle sprain or knee arthroscopy so I could get caught up with my schedule and see someone who wasn't emotionally draining and frustrating to treat.
The strange thing is, as I go along, I am less interested in treating a lot of this easy sports type stuff, and more interested in seeing the harder stuff, the more chronic things. They can hire any ankle taper, oops I mean athletic trainer, to do such easy reconditioning stuff, that doesn't engage my therapeutic abilities much at all. I don't learn anything or truly feel I have done much, at the end of the day.
That's not to say I don't like variety, and I do enjoy treating chronic sports type injuries and pain states, but my emphasis is just shifting.
I think if you are at a place in the Army where you have a population of those in chronic pain (and this varies based on location...certainly we don't see as much of it as our civilian counterparts do, and I see a lot more than you do right now, probably) you just have to set up a separate program for them.
Just as you would any other subgroup that could benefit from a specific intervention. Just matching classifications to treatments most likely to work. Sound familiar?
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 8:59:00 AM
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Jon Newman
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[QUOTE]It is unfortunate but is the way we do business in the Army [/QUOTE]Hi Alex,
I think it is how buisness is done most places and is one of those classic conflicts like man vs. machine, man vs. man. When one combines the two, compromises are often made and I think we all know which one budges first.
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 4:16:00 PM
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Shill
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From: Madison WI USA
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Jason,
Thanks for the references. Im not really surprised by any of the conclusions, but need to see the full text to get further info. Its funny how searching a few words off topic can get you a useless bunch of articles, and then changing a few words gets you the good ones.
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Steve Hill PT
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Re: LBP Treatment Approaches - June 29, 2005 4:43:00 PM
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nari
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Jason
You are right, in that other people (trainers, football coaches etc etc) can do a lot of the basic small injury stuff; we should be using our grey matter to persue what they can't do.
I am sure you will find that the challenge to treat chronic/persistent pain becomes addictive.
No recipes, no protocols, new ground to cover (CBT sort of approaches).
Someone fiercely said: "But that is NOT physiotherapy".....
My argument is this: When we have someone in pain from nonpathological conditions, and their functional mobility is affected, along with ADLs, with stiffness and loss of natural movment...we can change that without losing the focus, and without touching a joint or muscle group...then that is still physiotherapy, from outside the box, rather than going around in circles inside the box.
pardon the rant....
Nari
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Re: LBP Treatment Approaches - June 29, 2005 4:49:00 PM
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UTDC
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Hi Alex,
Dr. Fritz published that in the Annals of internal medicine- the full text can be found at: http://www.annals.org/cgi/reprint/141/12/920.pdf
Jeff
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Re: LBP Treatment Approaches - June 29, 2005 5:46:00 PM
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karmzack
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Nari, I would say that chronic pain treatment as described is still physiotherapy - just specialized similar to vestibular rehab. It certainly isn't mainstream orthopedic PT.
Does anyone have a patient education or exercise sheet that I could look at to see an example of a chronic pain treatment program. I'm interested, but it seems so voodoo to me.
What type of chronic pain patient are you talking about here? I had a patient yesterday that has had LBP on and off for 15 years, is he a canidate for treatment under your theory? Or are you talking about the RSD type patient?
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Zack Solomon MPT, OCS, CSCS
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Re: LBP Treatment Approaches - June 29, 2005 7:45:00 PM
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steve
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Zack,
Certainly a fellow with 15 years of low back pain would very likely have some chronic pain issues. I cant speak for Nari but I look for prognostic signs of chronic pain syndrome with day one patients - ie. History of chronic pain, fear avoidance (Fabq score), catastropizing, litigation etc. I like the voodoo comment, and would suggest a great starting point would be to order David Butler's explain pain book - as Jason stated earlier it is very easy to read and is a great starting point with respect to treating and understanding pain.
Do you really think that it isn't one of the mainstays of physiotherapy treatment? We treat acute conditions for sure but a vast number of patients that come to see most orthopaedic therapists (Although potentially you see patients earlier in your neck of the woods) would fall atleast partially into having a central pain mechanism. Some of the research has identified as many as 50% of individuals with pain for greater than 7 weeks will develop some form of chronic pain syndrome. Even if the number is much less I would wager that a great number of our patient failures clinically would fall into the chronic pain category. If we treat them with a biomechanical or pathoanatomic model not only have we wasted their time and ours, we have likely made their perception of their condition worse by reinforcing that there is something significantly wrong with them and it is failing to get better despite treatment.
Any others thoughts?
Steve
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Re: LBP Treatment Approaches - June 29, 2005 9:28:00 PM
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Alex Brenner PT MPT OCS
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Jon and Jeff,
Sorry, too many typos and errors in my above post. I meant to say "predictors for those who do NOT respond to manipulation". The article is actually "factors" not predictors. Anyway, here is the reference below. It seems I only had the authors and the journal correct.
Physical Therapy Volume 84 · Number 2 · February 2004
Factors Related to the Inability of Individuals With Low Back Pain to Improve With a Spinal Manipulation. Julie M Fritz, Julie M Whitman, Timothy W Flynn, Robert S Wainner, and John D Childs
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Alex Brenner, PT, MPT, OCS
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Re: LBP Treatment Approaches - June 29, 2005 9:46:00 PM
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Alex Brenner PT MPT OCS
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[QUOTE]You are right, in that other people (trainers, football coaches etc etc) can do a lot of the basic small injury stuff;[/QUOTE]I would have to disagree. I worked as a high school trainer at Fort Knox for 3 seasons and would have to say that the coaches had no clue what injuries they were dealing with. The side line trainers were not much better and certainly were way too basic on rehab and intervention. Sure, anyone can ice an ankle sprain but what do you do after that. That is where we come in.
As a student I did one of my clinical rotations at West Point Military Academy, the Mecca of sports medicine and home to one of the only APTA credentialed Physical Therapy Sports Medicine residency programs. I worked along side the athletic trainers there and even as a student recognized that their skills were not equal to ours. And this is probably one of the premier collegic levels for athletic training and sports medicine. To say that they are the best or equal to a PT performing injury assessment and rehab intervention for orthpaedic and sports medicine is not accurate. Zack (on this forum) can attest to this because he was with me during that affiliation. We talked about that a lot.
[QUOTE] I have come to the opinion that more acute people with straightforward biomechanical dysfunction or acute tissue injuries are really very easy to treat. So easy that anyone could do it well.[/QUOTE]Again, I disagree somewhat. Any ortho/sports medicine therapist could easily treat. Maybe a well trained ATC, but certainly not anyone. You just posted something last week about an ER physician placing an acute ankle in a posterior splint. I used to see this all the time too, and they are physicians!
I don’t know J, maybe it is less challenging, but I certainly enjoy it more and find it more gratifying when I see soldiers get better and returned to duty. This is why we wear the uniform, to get soldiers healthy and get them back to the fight. I see less chronic pain in soldiers, more with the family members and retirees. This is not my emphasis, I feel I am here to get the active duty guys better. Maybe in a civilian clinic I would go the route you are taking, but for me, not now.
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Alex Brenner, PT, MPT, OCS
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Re: LBP Treatment Approaches - June 30, 2005 12:45:00 AM
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Diane
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As Steve is pointing out lots of patients have layers of chronicity under whatever "acute" thing they might walk in with. A big trick in treatment is to avoid inadvertantly turning anything acute into anything chronic through provocation testing. Katherine Harmon, a Canadian pain researcher, says that PTs should treat ALL patients (including the fresh sprained ankle patients) as if they were potentially chronic pain patients, with an eye to prevention of same. In other words, with care and good handling and attention to the nervous system. So I agree with Alex, that excellent care is necessary with all injury; would stress that very thick multiply layered reasoning is important including attention to all the anatomy, not just bones&joints, and some radar about people and whether their flags are yellowish.
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Re: LBP Treatment Approaches - June 30, 2005 1:58:00 AM
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JLS_PT_OCS
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I think Diane and Steve are making good points, in that any patient can have some of the S/S of chronic pain pattern, and we should be on the lookout for this shift so that we can begin to modify treatment appropriately.
Alex-
I think you have a point there about competency in orthopedic rehab, perhaps many of us find it so mundane that we take for granted that not many others can do it competently. I have the same experience firsthand with ATCs as you report.
However, I have found recently (since being forced to restrict our access to active duty soldiers only and not any family members or retirees - for those unfamiliar with the military that means generally fit and healthy people from 18-50) that this "chronic pain" thing I am describing is happening a lot more often and to more people than I previously thought.
Zack asked a good question about who I think fits in this category, and I have recently broadened the net somewhat. I used to think that only the CRPS/RSD and Fibromyalgia type folks fit in. You know, the kind that make you groan: Fibromyalgia, Migraines, Chronic Fatigue, multiple bouts of treatment with no improvement, etc. Well, not only am I looking at these patients in a new way (and with somewhat of a guilty feeling about how I used to regard them) but I am seeing that this chronic pain and/or central sensitization thing is happening to LOTS of people that don't fit that category.
Zack, try to think of the last patient you had that sounds like this, and regardless of your current work environment, I'm sure you can think of one quickly: painful problem for over 2 mos, unsuccessful rehab attempts, diagnostic imaging essentially NL or WNL, workups by several health professionals with unsuccessful treatment, pain or problem attributed to a tissue which we know is long past it's healing/repair time.
Now whether it's PFPS or LBP or "failed back surgery" or spine pain, I know I've got several of these folks right now. Continuing to direct treatments soley at their tissue in a pathoanatomic model of care is not likely to bring further improvement. Also, many of them may be having neurodynamic problems that right I now I do not know how to evaluate or manage. I'm not saying we should abandon physical measures and send them to counseling, but that we should be doing a little bit of both.
Just as our tissue rehabilitation skills as PTs are greater in rehab than those of ATCs, also our abilities to recognize this chronic pain thing should be better, and we should be able to competently approach it. BECAUSE THIS HAPPENS TO YOUNG, ACTIVE, SPORTS PEOPLE, TOO. We shouldn't have this division of "I'm an ortho/sports PT" OR "I'm a chronic pain PT".
You wouldn't do that for knee pain and back pain, right?
Waddell has consistently said that the reductionist approach to LBP using the pathoanatomic model has failed miserably. While I always agreed with him, I wasn't sure what to do about it. I have a much better idea now.
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 30, 2005 2:02:00 AM
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karmzack
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Alex, or should I call you Luke, of course I’m going to agree with you, we appear to be the last Jedis in this thread.
Alex and I work with a nearly identical patient population, with one exception, I only see active duty military (I think he sees family members also) which means my typical patient is 22 years old, male, and spends his day either marching with a fifty pound rucksack on his back, bending over a truck engine all day, or manually pulling a helicopter across the tarmac in a forward bent position. And they run nearly everyday, sometimes twice a day. My job is to evaluate their injuries and return them as quickly as possible back to their job. Is it easy?, maybe some cases, but that’s my job, I am the musculoskeletal expert. There is no one else as qualified as I am to treat most, even basic, musculoskeletal injuries. I have seen some PTs get bored with it and start taking the “cookie cutter” approach with every patient. They want more and they go to med school, hense my questioning earlier that got shot down.
If my patient has chronic pain, I first look at the biomechanical requirements of their job because that is where their chronic pain originates. They don’t want to go see the doctor because their back hurts, they think they are invincible, their wives usually make them come into our clinic because they are tired of the months of whining at home. I provide education and address any functional limitations and their pain improves. Easy? Hell no! I’ve got to be the best salesman in town to get a 22 year old to change his movement and positioning habits. Does an ortho surgeon think a meniscus debridement is easy, probably, but he’s not going to have the nurse step in for him!
With that said, I do occasionally get a patient that has a grade I/II ankle sprain that was placed in a CAM walker for 2 months because that’s what his PCM though would be the best treatment. He then ends up in my office with terrible pain, most likely RSD. Too bad he didn’t come to PT earlier for that “easy” treatment. I now have to manage this patient that has pain so bad that it has consumed his life. Now I am out of my league and this is why I take interest in this thread, so I can learn more. Not to abandon my current beliefs.
I’ve been given a great reference for a starting point to learn about chronic pain, but when I find 743 books on chronic pain it can be a little overwhelming. I guess I should look at the research and see whose theory has the most evidence, but my desk is still piled high with article to read to further improve those “easy” evaluations and treatments.
As far as my patient with a 15 year history of LBP is concerned, I don’t have the energy right now to discuss my opinion. All I can say is I think the problem is deeper than the Deep Model of Neurogenic Pain.
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Zack Solomon MPT, OCS, CSCS
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Re: LBP Treatment Approaches - June 30, 2005 2:11:00 AM
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karmzack
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Jason, our posts crossed. I do agree with most of your comments. I guess I got hung up on the implication that my job was easy and anyone can do it. It's 1 AM in Hawaii, I'm going to bed.
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Zack Solomon MPT, OCS, CSCS
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Re: LBP Treatment Approaches - June 30, 2005 2:49:00 AM
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JLS_PT_OCS
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You shouldn't take it personally, Zack. I was not implying that anyone's job is easy. It's unfortunate you interpreted it that way.
Also, I didn't mean to "shoot down" your suggestion, just to make my own...that you might be surprised at the depth and breadth of the replies, so you might like it better if it had it's own thread.
I didn't mean anything more than that.
I have found the pressures of the military lifestyle nicely parallel job stress/pressures found in the civilian world of work related injuries and worker's compensation, and is therefore rife with the same factors that help create chronic pain states in the first place.
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 30, 2005 3:39:00 AM
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Shill
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I think that some folks feel that some of this CBT crosses the line from manipulation of the physical realm to manipulation of the mind through psychotherapy. I certainly can see the argument towards that, but also that it is part of what we do daily. My question is.. do we have the training to psychoanalyze, and if so, to what depth, or are we being armchair psychologists?
Where is THAT line drawn?
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Steve Hill PT
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Re: LBP Treatment Approaches - June 30, 2005 4:36:00 AM
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JLS_PT_OCS
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Good question.
I think anyone can do some of that sort of thing. You needn't be a nurse to apply a bandaid, or a physician to hand someone a Tylenol, or a PT to show someone how to use a cane.
I think that given some of our current research, we are in good position to do a lot of this. Meaning, some of the studies I cited are less about about analyzing someone's psyche and really about providing education about pain physiology and life/activity management skills. That seems firmly in the domain of "education" rather than "psychoanalyzing", but I can certainly see how that line may be blurry.
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 30, 2005 5:20:00 AM
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Diane
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This is for Zack:
http://www.noigroup.com/products.html
You can buy the book directly from here.
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Re: LBP Treatment Approaches - June 30, 2005 6:51:00 AM
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Jon Newman
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Hi Shill,
That is a good question. I try to help people deal with problems with movement and disability. Some of the techniques used in psychotherapy are useful here. However, that is different than psychoanalyzing. I don't see that as part of our professional scope.
It would be useful to help clarify that thought, perhaps in another thread, with the concept of psychoanalyzing you had in mind. For instance, if you have someone who will only participate in passive forms of therapy and you think to yourself, "This person is using some passive coping strategies in this instance of their problem they are seeing me for"--is that psychoanalyzing?
Or maybe you have someone who feels they need to run more so they don't decondition instead of giving their plantar fasciitis a rest and you see this behavior as a problem and address it, is that psychoanalyzing?
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 30, 2005 8:56:00 AM
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karmzack
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From: Hawaii
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[QUOTE]painful problem for over 2 mos, unsuccessful rehab attempts, diagnostic imaging essentially NL or WNL, workups by several health professionals with unsuccessful treatment, pain or problem attributed to a tissue which we know is long past it's healing/repair time. [/QUOTE]I always assumed there was a large psychological component to their pain. They wake up every morning expecting to be in pain, and if you help them decrease their level of pain, they expect their previous level of pain to return. I work hard to try and break this expectation. Maybe my approach to "psychotherapy" is incomplete and I need to include more education on chronic pain. I'm still not fully convinced that this "chronic pain theory" applies to non-RSD patients, but I guess that will come with time behind Explain Pain, thanks Diane.
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Zack Solomon MPT, OCS, CSCS
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Re: LBP Treatment Approaches - July 2, 2005 10:26:00 AM
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jbeneciuk
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From: Jacksonville, FL
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Just ordered my copy of "Clinical Neurodynamics"; too many posts regarding it...have to see what all the buzzz is about !!
Thanks for the replies everyone.
JBeneciuk
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