If I care more about you than you do…we got a problem. If you live with chronic pain, you may not have to. Seek out a qualified healthcare practitioner, versed in research, and participate in your own health care.
- “…researchers and clinicians have come to understand patients as a heterogeneous group…One of the first classification schemes was created by McKenzie.”
Not all patients with back pain have the same back pain from the same source. Meaning one patient may have pain from the disc, one may have pain from the spine joints, one may have pain from pressure on the posterior longitudinal ligament and one may have a muscle sprain/spasm. That last one gets used a lot, but I have yet to see a true muscle sprain/spasm in the clinic. The point of this is that we first have to classify a patient when they come into the clinic. Another phrase for classifying is to make a “best guess” as to what is causing the problem. I worked with a well-respected physiatrist Dr. Ron Mochizuki and while we were presenting at a community event he stated, “When we know what fixes your problem, then we will know what caused it.” After hearing this, it made a lot of sense. Unfortunately, everyone wants an answer to the “WHY do I have pain?” question, but the answer is not that easy.
Mckenzie…where do I start? Robin was innovative and passionate. This guy, dearly departed, imparted more influence into our profession than any other practitioner in the previous century! For all of the PT’s that may actually read this, think about this. Readers of the Journal of Sports Physical Therapy voted the likes of Sahrmann, Paris, Mulligan, McMillan, Kendall, Maitland, and Robin as the most influential PT of the previous century. Robin bucked the trend in therapy at the time and was seen a cult leader. We now know that he was well ahead of his time. He was our House MD, both revered for his knowledge and sometimes mocked for his lack of servitude to the traditional treatment paradigm.
- “Centralization has been consistently associated with a good prognosis for both pain and function, and can direct appropriate treatment”
Centralization (Look it up! It’s that important if you have back pain) trumps depression, trumps yellow flags (You’ll hear more about these later) and again is the “TRUMP CARD” as previously stated in the literature to treating back pain.
- “This case study describes the assessment and treatment of a patient with a 20-plus year history of constant low back and bilateral leg pain, presenting with multiple yellow flags and verbalized fear avoidance…seen for a total of five visits over seven weeks”
A case study is a study with an “n” of 1. This means that this describes one patient. The “n” of one concept is being touted as very relevant in the popular podcasts such as the Tim Ferriss Show, Barbell Shrugged, The Paleo Solution Podcast, etc. What does this mean? In science, a case study is relegated near the bottom of the Totam pole. Why? If something works for one patient…So What?! It was only one patient. We think that a study should help thousands of people before we can claim it as helpful. This is horrible to think. It reminds me of a good story and then a personal story.
The first time that I heard this story was while I was in PT school. There was a guy, I apologize for not remembering his name. We were at Rush Hospital in Chicago and there was a recipient of a double lung transplant telling this story. He is the “n” of 1 and the transplant saved his life. The point of this is that a case study can be just as important as the big time studies if the person in the study gets a life saving treatment or intervention. His story inspired me to be a bone marrow donor. One of the hardest decisions that I ever had to make… and forever I will be a bone marrow donor. Forever I will have to have every other year interviews in order to educate me of the possible side effects that weren’t known at the time of my donation. My life is forever changed, but I am just an “N” of 1.
Back to the story…the patient had a 20-year history of back and both leg pain, with yellow flags. Any therapist reading this knows that we do not like seeing this patient in the waiting room prior to day one. They typically color in the entire body when asked to fill out the body diagram. They tend to color outside the lines on the body diagram. Really!? We know you have pain. Coloring outside the lines gets our attention, but not in a good way. A person with a 20 year history of pain is no good. I’ve seen many a therapist throw up their hands saying, “What am I going to do with this guy?” Needless to say, it still is a business and these patients tend to get put on a “shake and bake” “one-size-fits-all” program. Now on top of that, add in yellow flags and this has the makings of a disaster. Dave Ramsey has a saying that some people have “Eyeore” as a spirit animal. This is a quick summation of yellow flags.
- “Her score on the Modified Oswestry Low Back Disability Index was 56%”
This is a questionnaire that allows the patient to self describe how symptoms limit lifestyle. This score would correlate with severe disability.
- “Management following Initial Assessment: Self Management provided: repeated extension in lying; repeated extension in standing; slouch/overcorrect in sitting…educated about the excellent prognosis in the presence of centralization”
Remember what I said about the “Trump Card”? Even in someone that has experienced pain for > 20 years and shows up to the clinic looking like Eyeore, there is still hope! At least if the therapist is well versed in the research and doesn’t default to “shake and bake”.
Repeated extension in lying is similar to the cobra pose in Yoga. This exercise has been synonymous with McKenzie forever, but MDT is more than just this exercise. Postural correction? Wait…posture is important? For some people, changing postire can turn off pin and increase confidence.
- Visit Two (one week later)…Pain has reduced from 4/10 to 3/10. “She reported a consistent decrease in pain with the performance of her exercise…posterior-anterior mobilization of the lumbar spine (was added this session)”.
Not a huge change in pain intensity from visits one to visit two, but there was a huge change in perception. Once a patient understands that he/she has the power to change the pain, it’s over. The patient has to see that cause and effect. I don’t care if the pain has been there for 1 day or 20 years. I never tire of seeing the patient’s face when they start seeing the same patterns that I see. I love the look when they realize that the pain was within their control. That is awesome! P-A mobilizations are when the therapist puts his/her hands on the patient’s back, while the patient is lying face down. The therapist applies a downward force and the patient typically says “Ah…that feels good”. This may be no good (more to come later).
- Visit three (one week later): “initiating treatment with sustained extension in lying…head of the bed elevated for five minutes…performed to accommodate the patient’s reports of wrist pain with repeated extension in lying…symptoms were fully centralized”
Story Time: This is the famous story regarding Mr. Smith. Take yourself back to the 1950’s. Non-conformists weren’t looked upon in high regards. Robin was a non-conformist. Everyone at that time believed that if you bent a person backwards you would sever a person’s spine and cut the nerve roots in half! Seriously?! This is how they thought back then. Enter Mr. Smith…from here I will say go out and buy Robin’s book “Against the Tide”. It’s a great story from a great clinician and I can’t do this story justice because it is not my story.
- “Visit Four: pain level of 1/10…primarily centralized to the low back…avoiding passive treatment is consistent with promoting patient independence…hurt vs harm”
This patient is much better than previous visits at this time. A patient with 20 years of pain is starting to see the value of mechanical care. It’s funny I recently had a student that came into the clinic and said “I don’t plan on being a MDT based therapists when I graduate”. After this student left, I don’t think that he will be able to see treating a patient in any other way, as the results can be rapid…even in patients with 20 years of pain.
Passive treatments are any treatments in which the patient is not actively participating. This is the “Shake and Bake” described earlier. Passive treatments are as follows: massage, ultrasound, electrical stimulation, moist heat and some would say manipulation. Believe it or not, that is a strong statement. There are many therapists that built their careers on using passive treatments. These treatments require very little thought and the business gets reimbursed well for using these types of treatments. Our professional organization, the APTA, has come out strongly against the use of passive treatments and McKenzie was very much against passive treatments, as they foster dependence on the therapist instead of the patient taking ownership of the problem. I do physical therapy. I have a doctorate of PT. I can explain all of the same benefits that our profession uses to sell the continued use of these and then I can tell you that this research is old and there is little current research to show the benefit of the above list. We all want to help patients, but there is a huge chasm between traditional physical therapy and current therapy based on research.
Hurt vs. harm: If you have ever worked out, you understand soreness. Some coaches may have explained this as are you hurting or are you injured? Harm is no good, but hurt is normal. I have a two year old daughter and I am constantly stepping on small toys. It hurts…bad sometimes actually, but it doesn’t harm me. When a patient does something out of the ordinary, they will feel things out of the ordinary. This is not always harmful, but if that feeling lingers for a period of time (20 minutes based on research), then the hurt pain becomes harm pain. Stay out of harms way, but seek pain. This is the only way to become bigger, stronger, faster and the bigger, stronger, faster person tends to have a better quality of life than that of the smaller, weaker, slower person.
- “Visit Five: (one month later)…denied pain…patient scored 2% on her Modified Oswestry Disability Index…no longer fearful”
Twenty years of pain…GONE! This is a frequent occurrence in the clinic, but the therapist has to be trained in treating this type of patient. This a change of 10% is considered significant on the Oswestry, and this patient’s change was 5x significance! Of value, the patient’s belief system changed and was no longer afraid of movement!
- “several yellow flags…depression…inability to describe any relieving postures or activities besides rest; self-limiting…external locus of control”
This is Eyeore. Depressed, never excited, wants to rest and relax and believes that this is the best for symptoms, and external locus of control. This is the woe is me patient. Everything is out of the patient’s control and the world is against the patient. Think of the old joke about the country song…My dog died, my wife left me and the truck broke down. Never mind you didn’t feed the dog, love your wife or put gas in the truck. IT’S NOT MY FAULT! This is external locus of control.
MORAL: Don’t be Eyeore. Take control of your health. Go out and get bigger, faster, stronger.
Functional Therapy and Rehabilitation
903 N 129th Infantry Dr
Excerpts taken from:
Sheets C. Resolution of a 20-year history of chronic low back and leg pain with direction-specific exercise and focused pain education. IJMDT. 2009;4(3):30-36.