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.

Post 86: back pain classification

“…it is often not possible to make a specific pathoanatomical diagnosis reliably for patients with low back pain (LBP)…85% to 95% of patients with LBP are diagnosed by their general practitioner as having nonspecific LBP”
 
This is very controversial. We know that back pain exists and exists as an epidemic in terms of how many people. At one point, (again I will try to find the study for a later blog) I read a study that reports at any one point in time there are 5 million Americans with back pain. Put into perspective, this is about the equivalent of the total population of 7 combined states. That’s a massive number of people.
 
RANT: Now for all of these people, we can give a reliable diagnosis to about 500,000 people. OKAY…follow me here. For 4.5 million people, we can not tell them why they are having pain based on population research and prevalence research. The reason why this is controversial is because there is one back specialist in specific, Stu McGill PhD that has said on record many times that there is no such thing as non-specific back pain…only a non-specific assessment. I agree with him partially, there are many patients with a diagnosis of back pain that can be subgrouped into a more specific diagnosis, but I am not willing to say that we can subgroup all patients with back pain into specific diagnoses. Americans should be pissed off. This is an epidemic! Research tells me that I can classify back pain, depending on which classification system I use, in about 75-80% of the cases.
 
Let’s do some math again.
 
Research states that I can classify (doesn’t always mean fixable) about 80% of back pain patients. This correlates to about 4 million of the 5 million people with back pain, we can at least start to give them some answers. This is assuming that they have made it into a clinic that has a physical therapist trained and using (this is another topic for another day) a classification method such as the Treatment-Based Classification System, Movement Impairment System, Mechanical Diagnosis and Therapy, Quebec Task Force system or another system that I may be forgetting off the top of my head, but these are the major systems in the research.
 
Now…research shows that only 7% of patient that have back pain get referred to physical therapy!!! ARE YOU F’NING KIDDING ME! This means that 350,000 patients are seeing a therapist. Continuing with the math that we can classify about 80% of the patients, we can classify 280,000 patients with back pain and 4.6 million are not being assessed by a physical therapist in order to be educated or classified into a syndrome that could be treated.
 
Physical therapists that are well trained can classify patients. This is assuming that there are no other conflicts of interest, such as treating the patient like a bank to simply supply the therapist (more likely the company that the therapist works for) with income. I say to patients many times… “you have the right to choose your therapists. Don’t let your physician tell you that you have to go to a certain therapist.” On the flip side, if you have chosen a physician and have not seen progress in 6 visits, you have to question whether or not that therapist is going to help you. You are not looking for someone that will string you along for 12-30 visits over the course of the year, but instead looking for someone that will give you the guidance and empower you in order to improve. This may or may not include manual therapy, modalities (this will rattle many of my previous students to hear me say that I am okay with using modalities), but will definitely include education and movement. I have heard from many people, including my own personal family, of the stories about going to therapy only to perform all of the exercises on their own and being followed by someone that looks like a high school student. If you are in this type of facility, go seek a therapist that will provide you with personalized care, because that is what you are paying for. I am taking a strong stance on this in this blog because I heard from multiple patients and family members this holiday week about the crappy therapy they are receiving. It upsets me because there are many therapists that are awesome at their job. Unfortunately, these people have only had the experience of the crappy ones, which formulates their opinions of all therapists. It hurts me to the core when I hear a patient say that therapy doesn’t work. It works very well if physical therapy is not seen as a treatment, but an assessment with recommendations either for therapy interventions/treatment or a referral to a specialist outside of therapy. Therapy can’t be seen as treatment, but assessment.
 
END RANT: it’s funny because I’ve already written 2 pages on the blog, but only covered one sentence of the research article.
 
“…most clinicians use pattern recognition and patient profiling in an attempt to optimize treatment outcomes.”
 
I don’t know if I would say that MOST clinicians use pattern recognition to treat patients. I’ve been assessing back pain for a long time now as a therapist and I still see many therapists that use one-size fits all attempt to treat back pain. For instance, as a clinical instructor there are many students that want to give a “shake and bake” style to treating back pain. This means that every patient gets massage, stretching, bridges, abdominal exercises, bird-dog, hollow-out maneuvers, stability ball work and finishes the session with either a hot pack alone or a hot pack with electrical stimulation. If every patient gets the same treatment, then we must believe that every patient has the same problem. If a thorough assessment is not performed, then every patient does have the same problem…low back pain. This needs to be subgrouped into patterns that will give us better outcomes than we have had in the past from just treating everyone the same way. I am by no means saying that this style of treatment won’t benefit some patients, as there is a category of patient that may benefit from this style of therapy. It won’t benefit ALL patients and at that point, we are no longer treating patients as individuals with individual needs.  
 
All of the above systems of categorizing patients stated in the rant are pattern recognition systems. This means that we take a thorough history and hear certain themes in the history that lead us into a specific subgrouping. We perform tests and measures that either rule in the initial theory or rule out opposing theories and then from that point initiate treatment.
 
The second type of treatment approach is called the HOAC (Hypothesis Oriented Approach for Clinicians: all students, at least my students, should know this approach also). This approach is commonly called the test-retest method of treatment. It is not specifically based on patterns and can be better utilized by novice therapists that have not seen thousands of spines from which to recognize patterns.
 
“One of the attempts is a classification-based treatment approach initially developed by Delitto et al and subsequently updated using more recent research”
 
Delitto…this is one of the “oh great gurus of physical therapy” and I say that seriously. As a therapist, I stand on the backs of the greats, and Tony is one of the greats in our profession. I read an article years ago in which he makes a statement that still holds true for me today. “All therapists classify their patients, but the classification system may not be very sophisticated”. For instance, if someone comes into the clinic and is unkempt, with a low level of education, and is looking to dictate treatment, we can make the assumption that this patient may not do well with therapy. This is great and all because we are at least trying to classify, but this type of patient can do excellent in therapy if a more sophisticated way of classifying is used.
 
“The aim of this study was to determine whether the effectiveness of this classification-based approach was generalized to another health care system, other clinicians, and another population. In this study, we compared classfication-based treatment with usual physical therapy care in patients with subacute (6-12 wk) and chronic (>12 wk) LBP.”
 
FOR THE THOUSANDS IN ATTENDANCE AND THE MILLIONS WATCHING AT HOME…LET’S GET READY TO RUMBLE!!!
 
This is huge. Very rarely are two types of therapy facing off against each other to see which type of therapy is more effective. Typically, the research compares a type of therapy to either no therapy or a placebo type of therapy. Another aspect that is important is this: if I treat a group of patients and they all do well, does that mean that my style of treatment is good for all patients and all other therapists to use? Maybe or maybe not, but the only way to know is to test it.
 
“Participants were recruited by physical therapists from 21 private physical therapy clinics in the city of Amsterdam and the surrounding (rural) areas”
 
This is a large number of clinics that are participating in the research. There is more room for error based on the total number of clinics and difficulty in oversight, but having a large number of clinics allows for better generalization of the results. For instance, a study that demonstrates excellent results with patients in a rural area may not translate well to doing the same type of treatment with patients in an urban area.
 
“On the basis of their clinical presentation, patients could fit 1, more than 1, or none of the classification categories, that is, direction specific exercises, manipulation, or stabilization exercises”
 
Direction specific exercises: when categorizing patients with back pain, there is a high number of patients that respond to one specific exercise in order to either reduce or abolish back pain. This is found through both a thorough history and movement assessment. Typically, the direction is extension, but it is not always the case. Previous research on MDT indicates that of those that are classified into the derangement category.
 
Manipulation: This is a thrust manipulation. Means that the therapist will twist the patient in such a way that a small movement will create a change in the joint position and cause the brain to interpret sensations differently. This may or may not be accompanied with an audible “pop” or cavitation.
 
Stabilization exercises: everyone that has been to a physical therapist is familiar with the term core stabilization. This indicates that the patient will be performing exercises in order to activate the muscles from the mid-thigh to the armpit.
 
One category that is left out of this study is the traction category. I am unsure if it is left out because there are so few patients that would benefit from traction that the authors decided not to use this category.
 
“Baseline characteristics…they were largely similar in both groups”
 
This means that before starting treatment that there were no major differences in the patient population. For instance, if one group has all younger patients and another group has all older patients, this study would not be very telling. The younger patients are expected to respond/heal better than older patients.
 
“The classification procedure classified 54% as direction-specific exercises, 27% as manipulation, and 19% as stabilization exercises…The percentage of patients meeting the criteria of a “clear classification” was 74.4%”
 
Let’s break this down. Using the McKenzie method, we can classify about 80% of the patients. Of these patients, about 70-80% are classified as a derangement, indicating that they may have a directional preference. This would be about 56-64% of the patients that may respond to a directional preference exercise. The statistics from the McKenzie method are very similar to those of this study, so I am not too surprised that about half of the patients that in a study or in the general population would be classified according to a single direction.
About 25% of the patients were classified as manipulation and less than 1/5th were classified according to core stability. Although core stability is traditionally offered in PT, and throughout my career has been the largest intervention issued by many of my colleagues, only 1/5th were categorized into this category.
 
“We hypothesized that patients would benefit most from classification-based treatment; however, we found no support for this hypothesis.”
 
Both the control group and the treatment based classification group improved. This is not to say that the classification group is incorrect, but that it is no better than another system…at least in this study.
 
“We did not include the subgroup traction because the Dutch LBP guidelines discourage traction in patients with LBP”
 
A lot of the studies that I am blogging on I have read over the course of 7 years. I forgot the reason that traction wasn’t included, but having read much research reporting that traction is slowly falling out of favor, it makes sense to take it out of the intervention approach.
 
“Ideally, a classification algorithm should classify patients into 1 subgroup only. In this study, using only the first part of the algorithm, 24% of all patients did not meet any of the subgroups and 16% met more than one subgroup”
 
This is concerning in that this system can’t precisely classify 40% of the patients. This is better than no classification system at all, but it needs to be improved. The authors do a good job of providing ways to improve the system. One way is to change directional specific exercises to centralization.
 
“We attempted to provide optimal training and guidance for our treating physical therapists in the classification-based group; however, this support may have been insufficient for optimal competence and may therefore have caused an underestimation of the effectiveness of the direction-specific exercises and consequently also of the classification-based treatment approach”
 
This is the strongest statement of the entire article. Training a therapist is important and I am glad that the authors make the statement that maybe the therapists weren’t trained well enough to utilize this method, which would then make this method unreliable. Not all researchers are trained in the methods to the highest extend in the subject that they are researching. I can tell you that I treat patients in such a different manner than I did 7 years ago, using the same McKenzie method. I still use the same techniques and principles, but my critical thinking skills and pattern recognition skills have advanced over the years to such an extent that I am faster to make decisions and move on from an intervention that is not giving me the desired effect.
 
This brings forth a previous comment that I read from Tony Delitto in an article regarding physical therapists. It is paraphrased, so don’t judge me. Are you a therapist practicing for 20 years with 20 years of experience or are you a therapist that has been practicing for 20 years with one year of experience repeated 20 times?
I’d like to think that I am the former.
 
As I said, I go back and write these blogs long after having actually read the study. This study has some of the heavy hitters of spine care as the authors. I had the privilege to hear Hans van Helvoirt and Maurits W van Tulder speak at varying conferences and these people are among the greats. Julie Fritz has written many of the articles that I blog on. Essentially, this research was done by the “who’s who” of back pain.
 
Excerpts taken from: Apeldoorn AT, Ostelo RW, Helvoirt H et al. A Randomized Controlled Trial on the Effectiveness of a Classification-Based Syste for Subacute and Chronic Low Back Pain. Spine. 2012;37(16):1347-1356.

Post 83: running mechanics

“Footwear such as sandals or moccasins were invented less than 50,000 yr ago, but the modern running shoe with a cushioned elevated heel, arch supports, and a stiffened midsole was created only in the 1970’s”
 
http://news.nationalgeographic.com/news/2010/06/100609-worlds-oldest-leather-shoe-armenia-science/
 
This is an article that I read a while back talking about the oldest shoe was built about 6,000 years ago. It is not too different from what we know to be a shoe. It covers the foot, has an ability to tighten to the foot and protects the foot from elements on the ground.
 
The standard shoes that we know today were created in the 1970’s. Prior to this, most shoes looked like the typical Keds shoes.
 
“More than 75% of today’s shod runners typically rearfoot strike (RFS, in which the heel first contacts the ground, but barefoot or minimally shod runners more often forefoot strike (FFS), with the ball of the foot landing before the heel, or they sometimes midfoot strike (MFS), with the heel and ball of the foot landing simultaneously”
 
When you run, something has to hit the ground first. This could be the heel, the ball of the foot or both could hit at the same time. This seems like a small point, but what if the type of shoe that you are wearing dictates your running pattern. There’s the old saying that form follows function, but what if the shoes form dictates our function?
 
“…FFS landing, unlike RFS landings, generate no impact peak…Elevated heels also encourage a runner to RFS, even when the foot is slightly plantar flexed, facilitating an longer stride and eliminating controlled dorsiflexion by the plantar flexors during landing”
 
A lot is said here. There is more impact to your body when you heel strike. There is less impact to your body when you forefoot strike. The next jump that is made by some is that an increased impact may lead to increased injury rate. We are not there yet.
 
Also, one loses the ability to control ankle motion when wearing heels. For instance, if you strike the ground with your toes first, the large muscles of the calf control your heel down to the ground. If you strike with your heel first, the smaller muscles on the front of the shin control your toes back to the ground. This is one of the hypotheses behind shin splints, in that the repeated lowering the toes to the ground causes the muscle to be overworked.
 
“…runners switched from an RFS gait in shoes to an MFS or FFS gait when barefoot or minimally shod”
This may be the smoking gun. When you wear standard shoes, you are more likely to strike your heel on the ground first and when you run barefoot, you are more likely to strike the ball of your foot. This is the concept behind people wearing the toe shoes for running (see vibram 5 fingers), as there is less impact on the body when wearing a minimalist shoe.
 
“At a given speed, the cost of transport during running increases approximately 1% for every 100g of added shoe mass”
 
This makes sense right? If the shoes are heavier, then it will require more energy in order to move your foot. This is another reason for lighter shoes during distance running. The lighter shoe will have less padding though. This will cause a change in the runner’s stride patterns. So far a lighter/minimalist shoe takes less energy to run and reduces impact on the body. Not seeing the negatives yet…they exist and will be covered at a later post.
 
“Although higher external dorsiflexion moments in FFS gaits cause higher triceps surae contractile costs, more controlled dorsiflexion during an FFS could perfmit more elastic energy storage and return because the heel descends substantially under controlled dorsiflexion, stretching the Achilles tendon while the triceps surae contracts eccentrically or isometrically”
 
First, the authors are from Harvard. This should explain all of the smartsy language used above. What this means is that when a person lands on the ball of the foot, the calf muscle has to take more of the work than the muscles on the front of the shin. When this happens, this could lead to a problem such as Achilles tendonitis. Also, by loading up the Achilles there could be more energy output from the stretching of the Achilles during the running cycle. Think of a spring. When you pull the spring apart, and then let go…what happens? Assuming you didn’t deform the spring, it bounced right back to its shortened position. Well, assuming your don’t tear the Achilles, it will bounce back to its shortened position, which when running will help to propel the runner forward (depending on the amount of forward lean of course, but this is a topic for another post or discussion).
 
“Another biomechanical difference between FFS an RFS running is knee flexion. RFS runners typically land with the foot in front of the knee, which is more extended and less complaint at strike but then flexes more during stance; in contrast, FFS runners land with an initially more flexed knee and have more knee flexion during impact but flex the knee less thereafter”.
 
I recommend watching videos by Brian Mackenzie or google Dr. Nicholas Romanov to learn more about the FFS style of running. In essence, when you land with a straight knee and a heel strike, you are effectively placing a braking force on your running, meaning that it is slowing you down slightly and you have to overcome the breaking force in order to propel yourself forward again. When you land with a flexed knee and the foot underneath you or better yet, slightly behind you, you are allowing for a propelling force instead of a breaking force. Also, landing on a less compliant knee is no good. If you jump and land on a locked out knee compared to landing on a slightly bent knee, which one will feel better? Please…go try it and come back.
 
“…running in minimal shoes is slightly less costly (on average, 2.41%-3.32%) than running in standard shoes after accounting for the effects of shoe mass, strike type, habitual footwear, and stride frequency.”
 
Essentially running in a minimalist shoe, which in this study was the Vibram 5 Fingers, requires less energy to run the same distance compared to wearing a standard shoe. Although this number seems small, over a long duration race or better yet, over the course of a running career, this could have a great impact.
 
This is a smaller study, so the results will need to be replicated in a larger group, but it is one of the first studies to directly assess the difference between running in a minimalist shoe compared to a standard shoe.
 
Excerpts taken from:
 
Perl DP, Daoud AI, Lieberman DE. Effects of Footwear and Strike Type on Running Economy. Med. Sci. Sports Exerc.2012;44(7):1335-1343.
 
 

Post 85: Can we predict what your MRI will show…before the MRI

“Patients who have lumbar discectomy with predominant leg pain at initial presentation are known to have a better result than patients with primarily low back pain without radiation”
WHAAT!? You mean to tell me that patients with back pain only, don’t do well with a surgical approach? Yougottobekiddingme!
Obviously I joke. We can predict that a certain portion of the population may actually respond better to a surgical approach or other invasive interventions compared to therapy. Patients that have more leg pain than back pain may do better with a surgical approach than those with more back pain than leg pain.

“Of 27 patients who had only leg pain at initial examination, 26 (96%) were found subsequently to have an extruded fragment.”
Leg pain, in the absence of back pain, has a high rate of being an extruded disc fragment. What’s this mean? Picture a half-filled tube of toothpaste. Let’s start with the lid on. If you squeeze the back of the tube, the paste moves towards the front of the tube. This is similar to how a spinal disc reacts to movement. When you compress the back portion, in most healthy discs, the toothpaste consistency portion of the disc moves forward. Now, take the lid off. When you squeeze the tube, the paste comes out. Try to put it back into the tube…good luck. It doesn’t work. When the paste material in the disc comes out through an opening in the disc, this is called an extrusion.
“…33 of 39 (85%) patients with predominantly leg pain had an extruded fragment.”

The statistic to pay attention to is the high percentage of patients that either have all leg pain or mostly leg pain present with an extrusion. This information is learned simply by talking to the patient and paying attention to what the patient is saying. If you hear this pattern, think that there may be a discogenic lesion in the lumbar spine.

“Only 2 of 12 patients presenting with more back pain than leg pain were subsequently found to harbor an extruded fragment”

This sentence sounds ominous. “Harbor an extruded fragment”, sounds like harboring a fugitive. Funny thing…the way a therapist words the education portion with the patient can either be helpful or harmful. Harboring is a negative connotation and may actually increase the patient’s pain if described in this manner. The portion that is most important though is that only 12% of patients with more back pain than leg pain present (harbor) with an extrusion. An extrusion may be less likely found in a patient with more back pain than leg pain. This plays a role in the patient’s rate of improvement over time, so it is very important for all therapists to know this information. Unfortunately, if a PT is not reading the research, this information may never be learned. I only took one course in the previous 10 years that even mentioned this information.

“No difference was observed in the pain severity of patients with an extruded fragment, compared with those with a disc protrusion. Patients with an extruded fragment were more likely to experience a resolution of back pain at the onset of leg pain, than patients with a disc protrusion”

There are some theories about this. Let’s start again with some education. A protrusion is what happens when the toothpaste pushes against the tube, but the lid is still on. This means that the hydrostatic properties (big words) of the disc is still intact. Hydrostatic mechanism is simply stated that when you push on the back of the toothpaste tube, the paste moves to the front and when you push on the front of the tube, it moves to the back (in most cases, but not all cases this happens. There is another study that I may discuss if I can find it at a later date that discusses how older looking discs may respond differently).

One theory for the resolution of back pain is that the posterior longitudinal ligament (posterior = back of spine, longitudinal = up and down, ligament = ligament) no longer has pressure against the ligament when the disc loses the hydrostatic mechanism. The ligament, when irritated under experimental situations, is known to cause back pain to the side of ligament irritation (another study that I will have to find for a later blog). If there is no pressure against the ligament, it may be a factor in not experiencing back pain.

“Pain fibers are present in the outer layers of the annulus and posterior longitudinal ligament and produce severe central low back pain, when stimulated directly or stretched by injection of saline”
Over the years I have read so many studies. I also have a decent memory, so all of the stuff that I typed above I didn’t realize came from this study that I am writing about. I typically read an article and then come back and blog on it at a much later date. This quote says in more sciency terms what I said in the previous paragraph.

“The ability to predict the presence of an extruded fragment is clinically important because these patients have been reported to achieve a better result from discectomy and therefore case selection could be improved by a simple assessment of pain distribution on presentation”

WAIT!!! Not all patients with an extrusion need surgery!!! This is simply a starting point. If the patient presents with this pattern, but also demonstrates centralization of symptoms, the patient is expected for a good outcome.

Moral of the story: you are not your symptoms, but they can assist us in determining how to proceed with care.

Excerpts from:

Pople IK, Griffith HB. Prediction of an Extruded Fragment in Lumbar Disc Patients from Clinical Presentations. Spine. 1994;19(2):156-158.