To slouch or not to slouch?

“Epidemiologic studies have shown that individuals in occupations that involve prolonged periods of sitting experience a high incidence of low-back pain”

I don’t think that this surprises anyone, but as we continue to advance with technology, the jobs that require mostly standing are going away. Put the data into today’s terms. How many of us had cable t.v when we were kids? How many of us had tablets and laptops as kids? I didn’t and was more active because of it. My daughter would be extremely content to watch Curious George on the tablet all day instead of playing. This sedentary nature is hard to break and usually results in crying until she realizes that we are actually going to play. This research demonstrating sitting as a correlation to back pain needs to be looked at seriously, as our society is sitting more on average, at least in my opinion.

“When changing from a standing to a sitting posture…an increased load on the spine as measured by Intervertebral disc pressures.”

The study that this is from is the landmark study for measuring disc pressure. Alf Nacchemson’s study on disc pressures was the first of its kind and mostly likely will never be reproduced again. The subjects in the study allowed a needle inserted into the disc in order to read the pressure. Picture a pressure gauge for a tire and how it measures how much air pressure is in the tire. Now picture the same thing, but with a needle at the end, measuring the pressure in your disc. This is no good. In order to do this, the disc itself needs to be punctured. This is why the study will not be reproduced. No review board would ever approve a study in which the participants have an increased risk of injury…just for the sake of measuring.

“…anular failure and gradual disc prolapse following fatigue loading of lumbar discs wedged in flexion…sitting for 1 hour results in significant changes in the mechanical properties of the lumbar Intervertebral disc…Wilder et al propose that lumbar disc herniations can be a direct mechanical consequence of prolonged sitting.”

Anyone out there just adjust his/her sitting posture?

There is a lot of research demonstrating that sitting is bad for you. This can’t be argued. There is a newer article that states that sitting for one hour, while watching t.v., can take up to 22 minutes off of your life. In the phrase of the show that we are currently watching on Hulu…”YOU ARE THE BIGGEST LOSER!”

“…studies have shown that subjects with or without back pain are more comfortable sitting with a lumbar support in a LP (lordotic position) compared to a KP (kyphotic position).”

If you sit up really tall and elevate your chest, your low back will make a hollowed position…this is called lordosis. When you bend forward, your low back will make an arched position (think the overly slouched position) and this is called kyphosis. Previous studies demonstrated that the slouched position was less favorable than a more upright position…ARE YOU KIDDING ME?! Who doesn’t like holding a good slouched position for hours on end?

“McKenzie describes a ‘centralization’ phenomenon whereby certain lumbar movements and positions result in a change in the distribution of referred symptoms from a distal to a more central location”

OKAY…THIS IS HUGE. I have written about centralization in the past, here, here, here, here, and here, but I’ll cover it again…just for you. If you have pain that started in the back and then moved location, specifically into one of the legs…this is no good. If you have back and leg pain that moves from the leg into the back…this is good. This is the basics of centralization. It’s called a phenomenon because we don’t know exactly why it happens, but there is a high correlation between centralization and a disc lesion (such as a herniation), which can also be found here.

“…Donelson et al reported that 76 patients (87%) demonstrated centralization. Further, all individuals exhibiting this phenomenon did so following extension rather than flexion movements”

Let’s start with this study may be a little biased, but that doesn’t negate the information in the study…it just has to be looked at through a lens that takes this into account. This article is co-written by the man, the myth, and the legend Robin McKenzie. I hold this man in high regard, as do many therapists that practice in the orthopedic setting. He was voted the most influential PT of the last century and that is a title that takes a lifetime of hard work, educating others and helping the public at large. Here’s a quick video of the legend… watch Robin treat a patient.   With that said, it was still written by an author that has something to gain from a positive outcome by using lumbar rolls. He has his namesake rolls, so we can expect a good outcome from using the rolls prior to even reading the article. It’s still good information that a person can learn from though.

Ah yes…extension. This means bending backwards such as this video by Yoav Suprun a MDT instructor.

“Excluded from the study were patients with:

  1. Medically diagnosed stenosis, spondylolisthesis or recent fractures;
  2. Neurologic motor deficit:
  3. Surgical intervention for the present episode;
  4. Apophyseal joint or epidural injections administered within the previous 4 weeks;

6….

  1. Obvious deformity of acute list or lateral shift or lumbar kyphosis;
  2. Symptoms of hysteria or anxiety neurosis”

This is important to note that the authors are trying to subcategorize patients that are most likely to benefit from using a lumbar roll with sitting. Not all patients will respond well to extension. Patients with stenosis may not respond to extension. This is not true for all, but is the long standing myth taught in PT school. Patients that come in looking crooked or bent over probably shouldn’t be in this study either. I like the last one though…these authors were trying to think of every patient that may not benefit from a lumbar roll in order to rule out using the rolls on everyone.

“The first 70 patients to present within each of the categories were randomly assigned to either a KP or LP group. Whenever required to sit, the KP group were instructed to do so with their back in a supported but flexed posture. Conversely, the LP group were instructed to sit with their back in a supported but lordotic position.”

This is a decent amount of people in the group so it should give some valuable information. One group had to sit slouched and the other group has to sit upright.

“During their first visit to the clinic, patients were seated on the standard chair and immediately given the questionnaire to complete. They were then seated in their assigned posture for 10 minutes, and the questionnaire was readministered.”

This is actually a pretty good way to test the intervention or “treatment”. A test performed before the treatment and immediately after the intervention is the best way to minimize the number of variables looked at during the second testing. For instance, if I give you an anatomy test and tell you to take the same test after studying and watching t.v and sleeping, it’s hard to say which of the three changed the score on the second test. We can assume studying, but it’s not certain. If all you do is study or sleep or watch t.v., then we can narrow down what would’ve caused a change in score.

“Before leaving the clinic, patients were instructed as to the position they were to adopt, whenever seated, over the next 24-48 hours”

This is the part in which the “scientific rigor” of the study will break down. Over the course of 48 hours, there are so many possibilities of making a pain better or worse and the sitting posture is but one variable. Any outcomes taken after this point waters down the results.

Prior to the interventions, there were no differences between the groups with regards to pain location, leg pain or back pain intensity.

“…while there was a 21% decrease in BPI (back pain intensity) for the LP group, there was a corresponding 14.5% increase in pain for the KP group…reduction in leg pain for the LP group after only 10 minutes of sitting…the very marked reduction in leg pain (56%) for the LP group contrasts with no significant change in pain for the KP group”

There were a greater percentage of patients that responded well to sitting with a more upright posture than those that sat slouched and some of those that slouched actually got worse over time. The advice that out moms gave to stand up tall appears to hold true for some folks.

“…adoption of a LP resulted in 48% of these patients having pain that centralized above the knee after only 10 minutes of sitting…10% for the KP group…24% of the KP group’s pain peripheralized below the knee at POST-TEST 3 compared to 6% for the LP group.”

The first thing to take from this is that an upright posture is not for everyone, in that 6% of those that sat upright actually got worse. Getting worse means that the symptoms that you have from your back actually gets worse into the leg, calf or foot. Now, 48% got better in that the leg pain reduced within 10 minutes. What this means for the patient is that sitting taller is worth a shot if you have pain that radiates into your leg. If you get worse from sitting up tall…stop. It’s really that simple to start with. A lumbar roll could be a useful device to get you to sit more upright. This could be homemade such as a rolled up towel, a purse or a forearm by putting your arm behind your back at about the belly button area.

EXCERPTS TAKEN FROM:

 

Williams HM, Hawley JA, McKenzie RA, van Wijmen PM. A Comparison of the Effects of Two Sitting Postures on Back and Referred Pain. Spine. 1991;16(10):1185-1191.

 

Link to article

 

 

 

 

 

Barefoot influence on arch height

Barefoot influence on arch height

 

“Our aims were to establish the prevalence of flat foot in a population of schoolchildren in rural India and to determine whether this prevalence varied between shod and unshod children”

 

First, it is hard to translate this research over to an American population. Just because it is the prevalence in India, doesn’t mean that it will be the prevalence in other countries. Until I have other research though…this is all I have to work with.

 

Unshod means not wearing shoes. Therefore, shod means wearing shoes.

 

“…2300 children between the ages of four and 13…static footprints of both feet were obtained from all 2300 children”

 

This encompasses a large age span from the time prior to arch formation to post arch formation. I remember learning in school that the arch starts to take shape around the age of 8, but this may just be a tradition that has carried through the ages of PT students. Anyway, this is a large sample size to look at.

 

“The footprints were classified as normal, high-arched or flat. Some form of footwear was worn by 1555 children and 745 never used shoes.”

 

It’s still hard to believe that there were this many children that hadn’t used shoes. The children in the study were between the ages of 4 and 13. We sometimes take for granted all of the “needs” that we have here in the states. Anyway, here is a link to give an idea of what the arches would look like on a static footprint. One way to think of it is to get your foot wet and go walk on a wood floor or deck. You would have an imprint of your foot as follows: picture of arch height.

 

“…1551 were considered to have normal arches in both feet, 595 had a high arch in one or both feet and 154 had unilateral or bilateral flat foot. The prevalence of flat foot progressively decreased with increasing age.”

 

This last statement is what is taught in PT school. There are so many facts that are taught in PT school, but we don’t learn the research behind the facts. A majority of children go on to develop normal arch height. There needs to be a further breakdown of the children that go on to develop an “abnormal arch height”.

 

“There was a significantly higher prevalence in children who wore shoes (8.6%) than among the unshod (2.8%)”

 

There is a large difference between the two populations of children, but we also have to consider the small sample size of 154 children. I would love to see this study take it one step further and search for all children in a larger radius with flat feet and see if the same types of prevalence rates are present. If this is the case, then we can start to make some assumptions regarding footwear affecting arch height. There are so many other variables that are not accounted for that could also play a role in arch formation, so this study has to be taken with a grain of salt. It does though make a statement that kids wearing shoes may not develop a normal arch compared to those not wearing shoes. It literally states: “…shoe-wearing predisposes to flat foot”.

 

“It seems that closed-toe shoes inhibit the development of the arch of the foot more than do slippers or sandals. This may because intrinsic muscle activity is necessary to keep slippers from falling off.”

 

This is a good theory, but would have to be proven. As a PT, we tend to recommend against sandal or flip flops because of the same reason: we have to work differently to keep the shoes from falling off. There is something called the windlass mechanism that can be altered when wearing shoes that can easily fall off. Again, more research is needed in order to figure out which party is right.

 

Excerpts taken from:

 

Rao UD, Joseph B. The Influence of Footwear On the Prevalence Of Flat Foot. J Bone Joint Surg [Br]. 1992;74-B:525-527.

 

Link to article

 

 

 

 

OPEN MOUTH…INSERT (BARE)FOOT

Open mouth…insert (bare)foot

 

  1. “Around one in three older people falls each year with one third of over 65s and half of of over 80s falling each year.”

 

Falling sucks. People get hurt when they fall. Most older adults can’t withstand the impact of a fall and get seriously hurt. There is research demonstrating that people older than 80 that sustain a fractured hip have a higher prevalence of death. One way that we can keep people from dying is to keep people from hitting the floor. There are many ways to do this and the article below will emphasize how footwear plays a role.

 

  1. “The shoe features which have been shown to influence balance performance include heel height, heel collar height, and sole thickness and hardness.”

 

I am going to take the low hanging fruit first. The density of the foam that is on the bottom of the shoe will play a role in how a person balances. Think about standing on a bed and how unstable it is. Now, think about standing on a waterbed…a little more unstable. The less stable the bottom of the shoe the decreased stability you will have when on your feet. There were shoes at one time that were advertised to “improve your balance”, needless to say it didn’t work out so well. When we place more cushioning under our feet, we lose a little of our stability because we are decreasing the role that one of our three senses, proprioception, systems have in maintaining balance.

 

When we increase the height of the heel, a few things happen. First, we place more weight over the front of the foot and decrease the weight bearing over the back of the foot. This changes the base of support during walking, as the person will have an earlier heel off (when the heel leaves the ground) and a quicker heel strike. This is one reason, in my opinion, that a person wearing heels doesn’t take a large stride. Doing so would impair the balance because the base of support would be very narrow during portions of the gait cycle.

 

Another thing that happens when a person adds a heel is that the person becomes a little taller. There is a good t.v. episode about this on Seinfeld. Raising your height will make balancing a little more difficulty because the center of gravity has gone a little higher. Think of it this way, when you are on an unstable surface, what’s the easiest way to keep your balance…squat slightly to lower your base of support. This is why wrestlers are so well balanced during the match because the squat down when they are being pushed and pulled.

 

The heel collar height is a little harder for me to rationalize. The higher the collar, the less mobility the ankle will have. The lower the collar, the less external stability will be provided to the ankle. I could make a case for both.

 

“Lord and Bashford evaluated balance in 30 older women when barefoot, wearing low heeled walking shoes, wearing high-heeled shoes and wearing their own shoes. The worst balance performance was seen when subjects wore high heels.”

Is this surprising? I included the quote because the author’s name was Lord…just kidding. Story time:

 

I tell all of my patients that I would not have them do anything that I either haven’t done or am willing to try. I had a patient once whose main goal was to be able to walk in heels. Needless to say, she called me out on the carpet for trying to teach how to walk in high heels based on book knowledge and not on actual experience. She went out and bought me a pair of heels. I wore the heels the entire treatment session. I got some catcalls from coworkers during the session. The best part of the story is the following. After the session I through the heels in the back seat of the car. That night I gave my wife’s mom a ride in the car. She looked into the back seat and must have seen the heels. She didn’t mention anything in the car…possibly because she mostly speaks polish and didn’t want to start a conversation that she wouldn’t be able to understand, but she told my wife when I got home. BOY DID I GET AN EARFUL! After I explained myself and it is still a funny story that I get to live to tell.

 

“The aim of this study was to examine the effects of usual footwear (versus going barefoot) on balance in frail older women attending a geriatric day hospital”

 

Remember what I said about the different portions of the shoe? If a person is barefoot, the center of gravity is lower, there is no cushion and there is decreased ankle stability. Two of the three may favor barefoot walking. I thought for sure that barefoot would be the answer…Read more to see how wrong I was.

 

“Berg Balance Scale was used to assess balance…under two conditions in this study: shoes on and shoes off. The order of testing with shoes on and off was counterbalanced so that 50% of patients were tested ‘shoes on’ first and 50% ‘shoes off’ first so as to avoid an order effect when testing”

 

First, you can see my report on the Berg Balance Scale from many years ago. I’m sure that the research has changed slightly, but the basics will still hold true. It’s important that the authors of the study changed the order of performing the testing for different patients in order to get a good idea of how patients perform. For instance, in high school no one liked the dreaded POP QUIZ! But when the teacher did a review for a test and gave a “wink wink”, you knew that the question would show up on the test. This is the same concept. If the participant already knows what’s on the test (seeing as they do the test twice), we would expect the second score to be slightly, is not significantly, elevated from the first score.

 

“One hundred elderly females were assessed with a mean age of 82…most were living in the community, required a mobility aid and had had a fall in the previous year.”

 

This is good information. A study can only be generalized to the population that the study was performed. For instance, the results of this study can not be generalized to a barefoot running group or a military group. It sounds obvious, but you’d be surprised how many “professionals” read an abstract (summary) of an article and start applying the “research” immediately in practice.

 

“There was a significant improvement in the mean BBS score of 2.5 when shoes were on”

 

I was wrong. I expected barefoot to win hands-down. This is because I have read a lot of research on barefoot walking and running. I came in biased and was WRONG! There I said it…mark this date. Moving on. Come back next week when I have a better chance of being right again.

 

Horgan NF, Crehan F, Bartlett E. The effects of usual footwear on balance amongst elderly women attending a day hospital. Age and Ageing. 2009;38:62-67.

 

 

Link to article

 

 

The pain that doesn’t quit

 

 

“Peripheral neuropathic pain is the term used to describe situations where nerve roots or peripheral nerve trunks have been injured by mechanical and/or chemical stimuli that exceeded the physical capabilities of the nervous system”

 

Let’s start by saying that this paper is written by one of the gurus of the Physical Therapy profession and pain science theory. David Butler has done much to advance the profession in terms of understanding pain and how patients perceive pain.

 

When a tissue takes more stress than it can handle it gets injured. This also holds true for the nerves of the body. If they are compressed, stretched, inflamed, the person will experience a neuropathic (origninating from the nerve) pain that is caused by a peripheral (not coming from the brain or spinal cord) nerve.

 

“Hyperalgesia describes an exaggerated pain response produced by a normally painful stimulus, and allodynia characterizes a pain response created by a stimulus that would not usually be painful”

 

When a nerve gets injured, it can create an abnormal pain response. The pain response can be very elevated. For instance, I have treated patients that experience allodynia (non-painful stimuli creates a major pain response) and these patients experience intense pain with the stroking of a cotton swab. This abnormal response, although not common, is a sign of miscommunication between the nerve and brain regarding the stimulus.

 

“Movements or positions that expose sensitized neural tissues to compressive, friction, tensile or vibration stiulu can be symptomatic for patients experiencing a musculoskeletal presentation of peripheral neuropathic pain, and these phenomena would be described as mechanical hyperalgesia/allodynia”

 

Hyperalgesia: picture ice on your skin. Normally it is very cold and uncomfortable. For someone experiencing hyperalgesia, it may as well be a gunshot wound. Their brain can’t differentiate between something that should cause a little pain and something that should cause a lot of pain.

 

Allodynia: picture a butterfly landing on your knee. Now imagine that the butterfly has knives for feet and every time the wings beat it sounds like nails on a chalkboard…that’s allodynia. Something that should not be painful…sunshine and rainbows…now causes pain.

 

Anything that moves a nerve, compresses a nerve, vibrates or stimulates a nerve can cause this symptom. Good luck with life. Is there hope for this patient? Yes, but the road won’t be easy. These patients exist and I have had the badge of honor of treating some of these patients that do not present with a typical “mechanical” presentation.

 

“peripheral neuropathic pain associated with musculoskeletal disorders will generally exhibita a relatively consistent stimulus-response relationship”

 

What this means is that I would be able to create pain consistently with the same stimulus over and over again. This would be a good CIA interrogation technique (in the middle of watching Homeland as I type this). Unfortunately, the patients that are experiencing this sensitized nervous system have done nothing wrong, but the suffering will continue until the patient meets a therapist that has actually read the research on this condition. Pain neuroscience education is being taught in schools currently, but when I was in school there was no mention of this. I don’t think that I am that old, but apparetnaly I am.

 

“…neuronal injury near the Intervertebral foramen can affect nerve fibers associated with more than one spinal cord level. Central nervous system neurons become sensitized after peripheral nerve injury and expand their receptive fields”

 

This sucks. Picture a house of cards. What happens when you pull on of the bottom cards? It doesn’t go quietly…that’s for sure. When one nerve gets irritated or sensitized, it has the ability to sensitize surrounding nerves. Think domino effect. When other nerves get irritated, it expands the location that symptoms are felt. The spine is the roadmap for the body and each segment of the spine can create a negative sensation at other locations of the body. If there are more areas that are affected, then there is a greater effect on the segments further away from the spine’s typical referral pattern.

 

“Neurodynamic tests…challenge the physical capabilities of the nervous system by using multijoint movements of the limbs and/or trunk to alter the length and dimensions of the nerve bed surrounding corresponding neural structures…. ‘positive’ response to a neurodynamic test that would be considered suggestive of increased mechanosensitivity in neural tissues. First, the test reproduces the patient’s symptoms or associated symptoms, and movement of a body segment remote from the location of symptoms provoked in the neurodynamic test position alters the response. Second, there are difference in the test response between the involved and uninvolved sides or variations from what is known to be a normal response in asymptomatic subjects.”

 

This is a mouthful, but here we go. A test that assesses the sensitivity of the nervous system involves multiple components. For example, to test the knee one would look at the knee because it is local to the area that is being assessed. The nervous system is a system that starts at the brain and then descends throughout every segment of the body. To test this system, the entire system should be tested. If testing an area of the nervous system away from the area of complaint can alter the complaint, then the nervous system impairment is ruled in.

 

If you have a pain in the big toe and it gets worse when you bring your chin to your chest, the problem is not the toe. It is something between the toe and the chin that moves when you move your chin to chest. The nervous system is one of the possibilities. Not the only possibility, but probably the highest probability on the list of causes. This may indicate a sensitive nervous system.

 

“Alteration in resistance perceived by the examiner during neurodynamic testing is considered one of the most important signs of increased neural tissue mechanosensitivity…Similar activity from the hamstrings is associated with the resistance encountered ruing straight leg raise in asymptomatic and symptomatic subjects…changes in knee extension mobility secondary to releasing the neck flexion component of the slump test are not associated with changes in hamstring activity in asymptomatic subjects.”

 

Did I not state that the author is one of the top dogs of the PT profession. There is a saying that all professions should own their terminology. The best profession at this is probably lawyers, as they coined the term legalese. Dr(s) Nee and Butler have done a great job of owning the professional language in this article. I am a part of the profession and I have to read and re-read some of these statements.

 

Picture a rope that extends from your head and descends down the spine and into one butt cheek and down the leg to the bottom of the foot. If you bend your head forward, you pull on the rope. If you straighten your leg while seated, you pull on the rope. If you slouch, bring your chin to your chest, bring your knees to your chest and then try to straighten your knee you put a ton of pull on the rope. Now imagine that ever time that the rope is pulled that you experience pain at some location in your body. The final position would suck and your body will do every thing in its power to keep from straightening the leg because the rope just can’t pull any further. Now…if you were to look up you would provide some slack to the rope and open up some room to straighten the knee a little further. This is not indicative of hamstring “tightness”, but more of nerve “tightness” or sensitivity to being pulled on.

 

“ ‘positive’ neurodynamic test does not enable the clinican to identify the specific site of neural tissue injury…merely indicates…increased amount of mechanosensitivity.”

 

Any point of the rope could cause symptoms. We can’t say exactly which point of the rope is problematic…so we start to treat the entire rope. We can change the testing sequence (such as move the knee prior to moving the spine) in the hopes of biasing one portion of the rope over other portions, but it is not for certain. It doesn’t hurt to try to alter the sequence of movements in order to try to narrow down the location of sensitivity…oh wait…it does hurt to try it. Physiology funny.

 

“…neural structures will be subjected to different mechanical loads depending upon the order of joint movement durin gneurodynamic testing…the testing sequence has been shown to alter the mobility and/or symptom response during straight leg raise…and a median nerve biased ULNT”

 

This means that when your nerves are sensitive, we may be able to figure out where in the rope there is a problem by changing the position of your joints prior to testing the tension in the rope. For instance, if we move your toes towards your face prior to having your slouch and straighten your knee we are theoretically assessing the rope as it crosses the ankle joint, as this increases the load on the portion of the rope as it crosses that joint first prior to pulling on the rope with any other portion of the test.

 

“Provocation of symptomatic complaints during nerve palpation does not necessarily identify the site of neural tissue injury, because the entire neural tissue tract can become mechanically sensitive after injury to a particular nerve segment…Additionally, hyperalgesic/allodynic responses in uninjured neural tissues may be the result of alterations in central nervous system processing of afferent information.”

 

There are some tests that we use in PT in which we tap your nerve and if it provokes your pain then we believe that we have found the motherload. UREKA! X marks the spot and it must be the nerve that is directly under the location that I hit that caused the patient’s pain. This is one of the ways in which carpal tunnel is diagnosed. No good. An irritated nerve at any point in the chain can cause an irritation at any other point in the chain. You want to be seen by a therapist that understands this basic notion. If you are treated by a therapist for carpal tunnel, the therapists better be damn sure that the pain is coming from the carpal tunnel, though the symptoms may be coming from an irritation at the elbow, shoulder or neck…you will probably fail conservative care. You know what happens when you fail conservative care? The care becomes not so conservative anymore.

 

“Mechanical and chemical irritation can lead to musculoskeletal neural tissue injury. Repetitive compressive, tensile, friction, and vibration forces acting near anatomically narrow tissue spaces through which neural structures pass can cause mechanical irritation. Injured somatic tissues adjacent to nerve structures release inflammatory substances that can chemically irritate neural tissue.”

Essentially what this section is saying is that there are many things that can injure a nerve. Most people think of a traction injury such as a stinger in football or a significant spinal cord injury to injury nerve, but any load on the nerve that is greater than that nurse talents or a chemical around the nerve that the nerve cannot tolerate will also sensitizing nerve.

“Mechanical or chemical stimuli that exceed the physical capabilities of neural tissues induced venous congestion and therefore, impede intraneural circulation and axoplasmic flow. Subsequent hypoxia and alterations in microvascular permeability causing an inflammatory response in nerve trunks and dorsal root ganglia that leads to subperinurial edema and increased endoneurium fluid pressure.”
This is fancy talk for when the nerve gets injured, there is less circulation and leads to increased fluid pressure. Less circulation leads to decreased oxygen flow to that area, as oxygen is carried on the blood. When a nerve gets pressure placed on it from either a mechanical or chemical source, it could become sensitized.
“Emotional stress can exacerbate symptoms of nerve injury partly because the chemicals associated with stress are capable of stimulating a IGS. ”
When we stress there is a chemical change that happens in our body. We Edrene we release adrenaline that whole flight or fight sense. And because of this it can cause her nerves to fire inappropriately. This can also increase pain. For some patients who have this type of chronic pain that is to desensitize nervous tissue, meditation and calming of the nervous system can actually be a good intervention.
“… Pain is produced by the brain when it perceives that body tissues are in danger and the response is required. ”
This is extremely important. Without a brain there is no pain. This is a very common statement that is going on in the pain neuroscience education field. It is because of our brains output that we are experiencing pain. This output can occur in the absence of a painful stimulus. If our brain senses danger then it will elicit a pain response to prevent us from doing that action. For instance if your tissues are sensitized and you are thinking of going out parachuting, your brain may actually start to produce pain from both the adrenaline rush and from the perception of danger.
“The broad goals for managing musculoskeletal presentations of peripheral neuropathic pain are to reduce the mechanical sensitivity of the nervous system and restore its normal capabilities for movement.”

 

About 90% of patients attending therapy are doing so because they have pain that is affecting a portion of their daily activities. If this is the case, then we (as therapists) should be working to decrease your pain to return you (the patient) back to your activities without limitations. We have to not only reduce your nerves sensitivity, but then have to teach the nerves to tolerate varying movements that may provide tension or compressive forces without them screaming for mercy.

“… Therapist employs a system of reassessment to judge the impact that intervention strategies have on the non-neural and neural components of the problem.”
This is something that is overlooked by many patients. Many patients are unsure of what to expect from PT. I describe it to some as one big science experiment. There will be one patient and I will perform one intervention and determine how that one intervention affected the patient’s pain/function. If it worsened pain/function, then that is probably not the way that I should move the patient as an intervention. If the exact opposite movement also worsens the patient, then the patient may not have a directional preference. From here, the game begins. We have to assess the patient after each movement. When I say that patients overlook this, it’s because the patient’s may not understand this. Unfortunately, if the patient doesn’t understand that we need to perform interventions and recheck how that treatment affected the patient…the patient won’t ask any questions about treatments until their sessions are almost over. We as therapists have to make sure that the patient understands how the relationship between PT and patient can be optimized. Communication is the first way to optimize treatment.
“Appreciating the mechanical continuity of the nervous system may also assist patients in understanding why movement of body parts removed from the site of symptoms may be used as a treatment strategy to mobilize neural tissues. The impact movement has on the nervous system is not only mechanical; discussion should include explanations of how intraneural circulation, axonal plasmic flow, and nociceptors in neural connective tissues can be affected by mechanical loading.”

This statement is mind blowing because the authors are so thoroughly saying that one of the jobs of PT’s is to educate the patient on how the nervous system responds to exercises, manual therapy and movement in general. The problem with this is that I don’t think that I could do a thorough job of educating the patient on this topic. I can give a general explanation, but this topic is very complex in terms of how the body sends and receives signals.

“educating patients about the neurobiological mechanisms involved in the clinical behavior of the presentation of peripheral neuropathic pain can reduce the threat value associated with their pain experience and alter any unhelpful beliefs they may have about their problem. ”

 

This gets back to educating the patient how stress affects their system, by increasing neural output for the possibility of flight or fight. If a nerve is dysfunctional, then sending more messages through that nerve may lead to increased dysfunction. The patients have to understand this because if they can understand the difference between hurt vs harm the patient may have less pain with activities that they expect to hurt, but understand aren’t harmful.

“Gliding techniques, or ‘sliders’, are neurodynamic maneuvers that attempt to produce a sliding movement between neural structures and adjacent nonneural tissues”

 

I first saw these movements used way back in 2003. I am sure that they were used well before then, but I was given an education on them prior to entering PT school. I was volunteering with a great therapist, Bill White, and he was explaining the mechanics of how the nerve glides up and down the track. The mechanics of it made sense way back when, but the neurophysiological response wasn’t explaned to me at the time and I’m glad because I wouldn’t have understood it at the time.

 

“…purpose of neurodynamic tensile loading techniques is to restore the physical capabilities of neural tissues to tolerate movements that lengthen the corresponding nerve bed…tensile loading techniques are not stretches; these neurodynamic maneuvers are performed in an oscillatory fashion so as to gently engage resistance to movement that is usually associated with protective muscle activity.”

 

This goes back to what was described previously. When performing exercises to improve the nerve’s tolerance to movement, we have to move in such a way that systematically loads the nerve biasing one movement or another. In doing this, it is done in an oscillatory manner, meaning pressure on (from one end and off the other) and pressure off (from one end and on the other). This will build tolerance to movement in the nervous system, which theoretically will reduce sensitivity to movement over time and reduce pain.

 

In the end, it’s worth a shot if you have pain that has not responded well to a repeated movement or joint level approach, chemical or inflammatory approach or biopsychosocial approach.

 

EXCERPTS TAKEN FROM:

 

Nee RJ, Butler D. Management of peripheral neuropathic pain: integrating neurobiology, neurodynamics, and clinical evidence. Phys Ther in Sport. 2006;7:36-49.

 

The abstract can be found here

Post 88: The anatomy of the “pain in the ass”

“To better understand the medical enigma of low back pain (LBP) it is necessary to thoroughly understand all structures that could potentially refer pain to this region.”

 

This is an excellent start. Any researcher that can throw the word “enigma” into an article already has my respect. Back pain is a mystery because so many people have it and so many people have had it and yet we are no better at reducing the incidence of this problem…even with all of our modern conveniences. There are a few sources of low back pain that are spoken of in PT, the back and the sacroiliac joint (SIJ). Obviously there are other sources such as some of the vital organs, but this is for another topic.

 

TIME FOR A QUICK ANATOMY LESSON:

 

“The sacral articular (auricular area is c shaped and located on the lateral spect of this bone. During the fetal and prepubescent years, the sacral surface is flat, smooth and lines with hyaline cartilage. The articular surface of the ilium is also c shaped, but in contrast to the sacral articulating surface it is covered by firbrocartilage. The smooth and planar articular surfaces of the SIJ…permit movement in all directions…restraint by the strong inerosseous sacroiliac (SI) ligament.”

 

This is the part that we are taught in school. The SIJ can move in all directions and this could cause pain. It appears that this has changed over the years, because students are coming out of school biased that the SIJ doesn’t cause pain. I believe that the pendulum may have swung too far in the other direction. There are some therapists that believe that the SIJ causes a significant percentage of back pain (this is based on my experience and tends to be older therapists…based on what I was taught in school, I can understand their perspective). There are others that believe that the SIJ doesn’t cause back pain (I don’t believe this either, but will lean more towards it doesn’t cause pain than it causes all pain). There is some research that indicates SIJ dysfunction correlates with 7-13% of all patients with complaints of back pain.

 

Big picture from the above quote: when we are young, the SI joint is very smooth (picture two bars of wet soap on top of each other), covered in cartilage that makes it slippery (think the chewy stuff on the end of a chicken bone) and is very mobile aside from a ligament holding it in place. THIS IS ONLY WHEN WE ARE YOUNG! More on this later.

 

“As early as the third decade of life ridges and depressions begin to form, making the joint surfaces nonplaner…increases the frictional resistance to motion and imparts greater stability to the joint…taking on a coarser quality…limits movement by increasing the coefficient of frictional resistance between opposing articular sufaces”

 

Do this experiment for me. Go wash your hands. Get them very soapy and slide your palms together. How well do they slide over each other? They should slide very well. This is similar to how it is when we are younger. The SIJ slides back and forth with little resistance. Now…wash off most of the soap (this will increase the friction between the two surfaces) and then make a fist with each hand. Put your left and right knuckles together and try to rub them over each other. It’s not hard to rub back and forth, but you can feel more resistance from the knuckles making it a little harder to rub back and forth. This is what happens to the SIJ around the third decade of life. So as not to leave this example of washing the hands (I just created it, so if you don’t like it…it didn’t take much of my brainpower and I’m not offended). Now, I want you to lock your fingers together (left and right hand will be locked together (almost like when you see a child praying in the movies) and then try to move your hands left and right. They don’t move well right? Your wrists may move more than your hands if you are watching closely. SPOILER ALERT: This is what happens when we get around the 6th decade of life.

 

“The purpose of the study is to document and quantify the surface topography of the Interosseous region of the SIJ complex”

 

This article is very interesting for me to read. I typically don’t like to read cadaveric studies (studies on dead bodies), but the research for the SIJ is really limited and this one came across my desk at some point. Topographical maps: go way back to grade school for this one (As big as the word is, it was taught to most of us before high school). A map that has the contours of the earth built in is a topographical map. If you were to slide your hand over the map, you would feel the mountains, the valleys, hills etc. This same type of map can be made over a joint. It would be easier now than when this study was performed with the advent of the 3D printer.

 

“Moderate or extensive ridging of the Interosseous surfaces of the ilium and sacrum was identified in all 10 specimens with average age of 69 years. Ridging was extensive in 6 specimens (age range, 55-91 years), while moderate ridging was found in 4 specimens (age range, 58-80 years).”

 

Moderate or extensive ridging indicates that the joint has soft-fused together. This means that the joint has essentially joined together like two gears or a zipper would joint together. It would make movement of the joint, gear, zipper very difficult.

 

“In contrast, in the 20-year-old specimen only a slight ridging and depression pattern was observed on both the iliac and sacral surfaces”

 

This is more like sliding two hands together. The surfaces are relatively smooth and slide-able over each other.

 

“…there did appear to be a relationship with respect to age. Slight ridging was found in the 20-year-old specimen, while the median age of specimens with moderate ridging and extensive ridging was 58 years and 75 years, respectively”

 

This means that the older we become, the more ridges there are between the joints. These ridges serve to reduce the available movement between the two bones.

 

“…beyond their sixth decade, 6 were observed to have distinct regions within the SIJ complex where the Interosseous SI ligaments had become ossified …effectively fused the posterior aspect of the sacrum and ilium”

 

This is a big debate in PT. Does it move or doesn’t it move? The SI Joint that is. When we age, it appears based on this research study, that the SIJ loses motion over time. Any joint that can move can cause pain. If the joint is unable to move, then we hope that it is not in a painful position because the likelihood of moving it out of the painful position is unlikely. The good thing though is that it is a low prevalence of being the cause of pain, which means that if it didn’t cause pain when it moved, it may not cause pain when it doesn’t move. That’s logical, but there isn’t much research to prove or disprove it.

 

“60% of the specimens in or beyond the sixth decade of life had parial ossification…fused the ilium and sacrum posteriorly, which can be extrapolated to suggest that no movement through the SIJ complex was possible in these specimens.”

 

There you have it folks! In a majority of people over the age of 60, it doesn’t move. This means that it is still a possibility for causing pain. When a patient has pain that is in the buttock, it has to be ruled in as a cause until it is ruled out. It can be ruled out/in using Laslett’s rules. Laslett’s clinical prediction rules for the SIJ.

 

“…in all 10 specimens (100%) aged 55 years and over…more extensive ridging…reduced joint mobility”

 

The older we get, the less likely the SI joint is to move and the less likely we will find a problem that we can fix with movement of the specific joint.

 

“Mobility tests for the SIJ have been found to be unreliable and their regular use as diagnostic tools is questionable…hence the 1 to 2 mm of movement that may occur, it at all, is likely to be difficulty, if not impossible, for most clinicians to perceive.”

 

My manual skills are good, but I am not good enough to feel 1 mm of change. This is like feeling a change in position the distance of a tip of a pencil through layers of skin, adipose tissue (fat), muscle and ligaments. I readily admit that my skills suck for detecting this movement, but I think that I am in the majority on this one. With that said, in school we learned a bunch of tests to see how much movement happened in the SI joint. Needless to say, we didn’t learn much about this in school that still holds true today…aside from the anatomy.

 

I’ll finish this post with a quote that finished the article because it summarized my thoughts well.

 

“Assessing mobility in the SIJ in the older population is not likely to yield any meaningful information.”

 

Excerpts taken from:

 

Rosatelli AL, Agur AM, Chhava S. Anatomy of the Interosseous Region of the Sacroiliac Joint. JOSPT. 2006;36(4):200-208.

 

Post 87: Therapeutic Alliance

“Many common interventions for CLBP (chronic low back pain), based on the premise that structural or anatomical dysfunction underlies the pain experience, have failed to consistently produce significant long-term reductions in pain or improvements in function.”

 

This is where the chess match begins. Treating acute pain is relatively straight forward. Remove the aggravating factor, place the patient in the ideal position to heal based on patient response and let time take over. For patients with chronic pain, time has already taken place and they are still not better. For these patients, a mechanical assessment and treatment according to biomechanics may not be the best option. Obviously, all patients need to be assessed first in order to determine the possibility for a rapid reversal of the symptoms.

 

“Cognitive functional therapy (CFT)…focus is on reconceptualizing pain as a biopsychosocial problem, functionally retraining maladaptive and feared postures and movement patterns and addressing contributing lifestyle factors.”

 

This is very important. For some patients (read not all patients) they need to understand that pain may be a part of their life, but it shouldn’t be feared. There are multiple phrases thrown around in the PT world, or at least those that are much smarter than me throws them around. The first is “hurt doesn’t mean harm” and “no brain, no pain”.

 

I throw these phrases around more often now because if I mimic those smarter than I am, I may one day become more like them.

 

Some people fear pain because they feel that something bad is happening inside and they don’t want to be injured. Feeling pain doesn’t mean that there is an injury. https://www.youtube.com/watch?v=DphlhmtGRqI

 

This is a good video that educates patients and some therapists alike regarding pain perception.

 

A big portion of sessions with patients that “always” have pain is to teach them that avoiding an activity may be no better for the pain than performing the activity, but avoiding activity has many other consequences on the cardiovascular system, musculoskeletal system and neurophysiological system.

 

“…successful intervention, which included the formation of a supportive and motivating bond with the therapist, provision of accessible education, pain redefinition, fear deconstruction, and the restoration of hope and an acceptable sense of self”

 

BOUT TO GET REAL: My father is/was an alcoholic. I was raised in a bar until the age of 10 when he remarried my step-mom. Because of this, I was essentially raised around many adults (varying from construction workers, military veterans, laborers, and other every day Joe’s). I learned as a kid how to communicate with adults because that was my world. That skill has greatly helped me in this profession. Along with reading the works of Paul Ekman (You may know him from the show “Lie to Me”), I am good at finding a bond with the patient. Anectdotally, I find that if I can bond to the patient in any way that my outcomes are better than those that I can’t find that bond with the patient. I work really hard during the first visit to find that common interest, knowledge, experience in order to gain the patient’s trust. Once I have the patient’s trust, I spend a lot of energy trying to educate. This could be unlearning what they were taught from a previous practitioner or teaching them with a fresh slate. The most important part of the above quote is “restoration of hope and sense of self”. I do my best to empower the patient. There are some quotes that I use frequently in the clinic and the one that I use most often is when a patient thanks me for helping them. I almost always say: “you put in the work…I am just a cheerleader”. I don’t want to play the role of the hero. In my opinion, by playing the role of Tonto, I empower the patient to take control of his/her pain limitations. This has lead to many referrals from former patients, which is the greatest compliment that I can receive. As a healthcare professional, you place your life in my hands. I know that it sounds a little over the top, but if you can’t do what you want in life, it is my responsibility to return you back to those activities to the best of my abilities. When a patient refers a friend or family member, that tells me that I did a good job with the patient that they now trust me with their valued relationships. For me, there is more pressure to get the friend better than there was to get the first patient better, if I can’t help, then I let two people down instead of one.

 

“All aspects of the intervention were underpinned by a strong therapeutic alliance, with an emphasis on an open and motivational communication style.”

 

Therapeutic alliance https://en.wikipedia.org/wiki/Therapeutic_relationship has to do with the patient’s relationship with the therapist. This has to be a team relationship where each participant has an equal stake in the relationship. There is no paternal relationship, in which the PT is in charge and the patient has to do what the therapist says.

 

“…the codes that appeared important in achieving an optimal outcome were grouped into 2 themes: (1) changing pain beliefs and (2) achieving independece…Changing beliefs included the codes therapeutic alliance, body awareness, and pain control. Achieving independence included the codes, problem solving , self-efficacy, fear, stress coping and normality.”

 

Essentially, if we can teach a patient how to change their beliefs about pain and then take control over how they react to their situation, the patients tend to do better.

 

“Acceptance of a biopsychosocial model for their pain differentiated the large improvers and small improvers from the unchanged participants…Although the large improvers still acknowledged their biomedical diagnoses, these diagnoses appeared to be part of their pain history and no longer caused them distress.”

 

By changing a patient’s mindset, we can improve a patient’s perception on their situation. By changing a patient’s perception, we can then improve their ability to function in spite of their pain.

 

“Although small improvers also described their current pain predominantly in biopsychosoccial terms, they found the idea of an underlying sinister cause more difficult to relinquish”

 

When a patient believes that there is “something” causing the aptient’s pain, then it becomes much harder to accept that pain is okay. If there is something wrong, then the patient will place him/herself into a position in which they can’t get better until that “something” is fixed.

 

“Therapeutic alliance appeared to play a role in challenging pre-existing beliefs. The establishement of a trusting relationship with the therapist appeared to be important in facilitating effective communication in which individuals felt comfortable airing their concerns and doubts, with the underlying faith that the therapist had their best interests at heart.”

 

This is amazing. There is that old saying: “ I don’t care how much you know until you know how much I care”. If you are a patient and when you show up to therapy your therapists says “jump on a bike” and doesn’t acknowledge your situation or makes conversation about how you feel live with your issues, then the therapist is doing a disservice. We need to speak to the patient and ensure that the patient understands that we are here to help. That’s why we got into this profession right…at least it’s the answer that most students give when applying to PT school. If that’s the case, then how does a student go from caring about people and wanting to help to treating 3 patients at a time and simply commanding the circus of multiple patients at once. It’s hard to convince a patient that you really care when you are talking to so many other patient’s at the same time.

 

“On the contrary, those who were unchanged appeared less likely to describe a strong relationship with the therapist than large improvers”

 

Is it a wonder why so many patients believe that therapy doesn’t help. There has to be a bond with the patient. The patient has to understand that you are there for the patient’s good…not their money.

 

“Large improvers and small improvers described how the therapist assisted them to gain a new perspective of the self both physically and mentally…crucial in providing a rationale for their pain and increasing their faith in the new explanatory model”

 

Changing a patient’s perspective can allow the patient to improve his/her overall well being. Giving the patient the education about how the body moves and what is considered “normal” is important. I don’t know how many times I say “that is normal” to a patient that has been suffering with pain for a long period of time. There is a difference between hurt and harm. Unfortunately, some patients have the belief that all pain is bad. This is not the case and the patient has to be educated that some pain is normal…as long as it doesn’t linger.

 

The article goes on to say that changing a patient’s pain belief system should be a priority for treatment and striving to ensure that a patient is independent with pain management is important for returning the patient to meaningful activity. There was a lot of information in this article, but the above statement is the general point.

 

It amazes me as to how little people understand of how their body acts. I realize that I went to school for 7 years in total (undergraduate plus masters and then the doctorate degree), to learn this stuff, but I already had a strong interest in this prior to going into school. I at least wanted to know about what I was experiencing, be that Delayed Onset Muscle Soreness (DOMS) or general pain from powerlifting. I remember reading in the books “Mechanical diagnosis and therapy: lumbar spine” that the top intervention that patient’s want is education. I believe this to be more and more true the longer that I practice. It’s amazing that in the world of Dr. Google, there is so much bad information issued to the general population that when they come to therapy, I have to spend so much time unteaching false material and then try to change their belief system from being inundated with false material. This is not more true than in the treatment of back pain.

 

On a side note, I don’t typically look at the authors until I am completing the post. Peter O’Sullivan is one of the authors of the study. He is one of the greats that has pioneered motor control paradigms for physical therapy. Also, Wim Dankaerts was at the MDT conference in Austin in 2013. I was able to sit with him at the airport and discuss pain science and lumbar rolls. It is exciting when I get to actually talk to those that are mountaintop researchers. I always have to restrain myself from asking for an autograph.

 

Excerpts taken from: Bunzli S, McEvoy S, Dankaerts W, et al. Patient Perspectives on Participation in Cognitive Functional Therapy for Chronic Low Back Pain. Phys Ther. 2016;96:1397-1407.

 

 

 

 

A little bit of crazy.

If you choose not to read this article, I will understand. This is an older article, from a journal that is no longer in publication, and on top of that…it is full of statistics and math stuff! I was bored reading it, so I would think that you would be bored with me summarizing it. Anyway, some people may be interested so AWAY WE GO!

 

Dionee C, Bright B, Fisher K. Clinical Characteristics of lumbar disc disease: Retrospective database analysis. International Journal of Mechanical Diagnosis and Therapy. 2009;4(3):3-10.

 

  1. “Approximately 80% of the population experience spinal pain at some point in life.”

This statistic is repeated over and over again in the back pain research and has been mainstreamed by places like MSN health and a quick google search regarding back pain rates. Putting this into perspective, 4/5 people will experience back pain during the lifetime. That one lucky person may have a genetic predisposition to avoid back pain or maybe they just do everything right. I know what you are thinking-“Those bastards”. I too have had back pain and sciatica, so I am also just a statistic, don’t feel bad.

 

  1. “most episodes of back pain are considered mild in nature and usually resolve within one month without medical intervention”

This sentence reminds me of a story. It’ll be good, at least it makes me laugh. I had a job once in which a patient with back pain would call to schedule an appointment. The lead therapist would do her best to get the patient into the clinic on the same day. This would cause me to work during my lunch, so I was none too happy. At a later date (after I had established myself as a work horse), I asked the PT “What’s the rush? Why not just wait until tomorrow?” To this day, the answer gave me a major insight into not just the business aspect of therapy, but the overall ability to “sell” patients on therapy. She replied, “The patient may be better by tomorrow and if we are going to get them better, the patient should at least believe it was because of us.” Now, I get it…this sounds a little disgusting, but I can honestly say that it was the worst thing that ever happened in the clinic that I worked at, which is much better than the stories that I hear from other PT’s. Remember, this is a business, for better or worse, it is a business.

Moving on, most patients will get better over time. When this is the case and I truly don’t believe that I am the “game changer”, I will let the patient know my thoughts and have a discussion about additional appointments. I can typically say with certainty that I am not making the patient worse, but if it is the case, then there will be no additional appointments. If the patient likes attending therapy and believes that therapy will play a role in the recovery, then so it stands. Therapy continues. There is this buzz word that is thrown around “Evidence Based Medicine”, and a part of this ideology is that the patient’s beliefs also play a role in therapy.

 

  1. “in the United States, annual costs for back pain range from 20-50 BILLION US dollars.”

One way to put this into perspective is to try to write all of these zeroes on a check. It’s pretty darn hard! This number is huge and continues to grow decade after decade.

 

  1. “Twenty percent of all people with back pain actually seek medical intervention and up to 25% of those patients seek physical therapy services.”

If you thought that the first number was big, then multiply it by 4-5 and you would have the actual cost of back pain alone if everyone with pain went to a physician or therapist. You can start to understand the business of healthcare. We all want a piece of the pie…I mean we all want to help society of course.

 

  1. “despite the increase in costs over the past 10 years, there has been no significant measurable improvement seen in patient care”

Let’s start by saying this sucks. I have one gripe about this and then I’ll move on. You may not know this, but when you go to a medical practitioner, you pay for your time there. I know, I know…this is obvious. You pay me for what I do to you or for you. This means that the more that I do for you, the more we get paid. Now, start to connect the dots. If I keep you for 10 visits, instead of 5 visits, I just doubled my pay from the insurance company. Well, really I doubled the company’s pay from the insurance company and I get paid the same regardless. There is a concept that is coming down the pike called “pay for performance”. This essentially means that if we get you better we get paid more and if we don’t, then beans and rice for us. You play a role in this. You have to shop around and go to the therapist that 1. You trust 2. Has the heart of a teacher (I stole this from Dave Ramsey) and 3. Is looking out for your best interests. You don’t have to go to a place that your doctor recommends; you have the power of choice. That was a long gripe…sorry.

If you don’t believe that money dictates treatment, our professional organization, the American Physical Therapy Association, acknowledged as much with a recent article.

http://www.apta.org/PTinMotion/News/2016/3/14/SNFsRACs/

 

Again, our ability to treat back pain is not keeping up with the costs that we spend on it. We need to get better at treating this problem, and there are many ideas floating around in the profession with the hopes of either helping patients or learning which patients will not get better with PT. We can’t help everyone and if a medical professional is selling a “miracle”, “amazing”, “astounding”, etc cure for back pain…walk away (or run if your back will let you). You will spend more than the cost of reading a book on back pain from your local library.

 

  1. “Physiotherapists also agree that classification of back pain is necessary to group patients with similar characteristics to determine more specific standards of care with improved clinical outcomes”

We all classify our patients. I remember reading “Oh Great Guru Tony Delitto” write this in a previous research article. Some people have a very rudimentary way of classifying patients. For example, treating a patient with whiplash after a car accident is a pain in the A$$ to treat because not only do we have to try to help the patient, but we also have to play the legalese game of whether or not the patient is just out for a big payday. This patient would be in the “Pain in the A$$” category. For real though, expert therapists are classifying patients based on more than just personality and external aspects of the patient’s case. For instance, I don’t hide that I practice MDT. This system utilizes the scientific method by playing with variables in order to classify and then treat orthopedic conditions. It is a great classification system in the hands of those that have studied and passed the test to use the method. You know what they say…”With great power comes great responsibility”. This holds true both on a personal level and on a societal level in order to do what’s best for the patient and the healthcare system as a whole.

 

  1. “for example, characteristics of increased psychological distress, anxiety, and fear-avoidance have been associated with severity of back pain, resulting in poorer clinical outcomes in these patients.”

I won’t be politically correct with this one. If you have a little bit of crazy in you, then it may take a little longer to help you if I can get through the forest of crazy-trees. We all come with baggage, myself notwithstanding. This plays a role in how much pain a person experiences because pain is a personal thing. I hear frequently patients tell me that they have a “high tolerance for pain and someone else may report a higher level than I would”. Patient’s say this with a badge of honor, not realizing that when you are in front of me, I am not comparing your pain levels with another patient’s pain levels. In front of me, your pain level is the only one that matters, but I still chuckle when patients give me this tough guy persona. If you’re in healthcare, then you understand.

 

  1. “Investigators have found that the disc ages rapidly within the human body at the vertebral endplate by the second decade of life”

I’ll give you the good news first, then the bad news. Your first 19 years on earth are going to be great. After the first 19, your body will start breaking down. You will limp when getting up in the morning, you will need a hot shower to wake up and feel limber, you will have a yearly supply of ibuprofen in your cabinet. Sorry…I don’t feel that old, but all of the above describes me to a tee. One of the PT professors at GSU describes getting old like this “when you are young, you are a nice and juicy filet. As you age, you become more like beef jerky”. I have to give Dave Diers, PT credit for this analogy. If you like it though, he got it from me!JK.

 

  1. “Physiotherapists use the diagnostic imaging information and clinical presentation of signs and symptoms to formulate intervention guidelines. But, the individuals with seemingly pathologic changes observed on MRI can profess no symptoms of back pain while other with negative MRI results can describe significant back pain and disability”

That’s a knee slapper! GASP! What this means is that imaging may not tell the truth, the whole truth, or nothing but the truth. We place so much faith in these pictures. A patient that only has pain during bending forward, but then has imaging performed while lying down (a position that is pain-free), may not get the true picture or the real problem caught in the image. It’s like trying to find a ghost on camera. Sometimes you get lucky and there is the black figure in the background staring at you, but mostly you get orbs and are trying to determine if it is dust or an actual ghost. Point being-imaging doesn’t tell the whole story. If you really want to have surgery, go get an MRI and I’m sure someone will find a reason on the MRI to operate. Getting off track…When a tissue is pathologically stressed, it will cause pain. This is described by another researcher (Willaim Boisenault) when discussing red flags and cancer. If there is no pain, then the tissue is probably not being stressed. If you don’t feel pain during imaging, then it probably won’t show the problem, based on logic.

 

You know what, I am done with this article. The rest wasn’t very interesting and I don’t want to bore you with the details, but the end result is the following:

 

  1. If you were in a previous accident and the onset of symptoms prior to receiving therapy is greater than 21 days, then you have increased odds of having a disc dysfunction.

 

  1. If you have a little crazy in you and you waited longer than 21 days to seek care, then you have an increased risk of discogenic dysfunction.

 

Until next time. I am actually very surprised at all I had to say on this article because I thought that it was overall very boring to read.