Not all patients get the same treatment for pain because not all therapists have the same knowledge

“Exponential increases in magnetic resonance imaging (MRI) scanning to identify these damaged structures (believed to be causing low back pain) have led to escalating rates of spinal fusions and disc replacements.”

There is a trend towards increased surgery rates in the US for low back pain.  We see upwards of a 777% increase in spine surgery for low back pain.  The sad part is that the your chance of having surgery is more dependent on your geographic location than other variables.  It has been said that if you are trying to avoid a surgery that you should also avoid an MRI…which takes us to the next fact.

“…evidence that abnormal MRI findings are prevalent in asymptomatic populations and are poor predictors of future LBP (low back pain) and disability”

In other words, if you go looking for a problem…you’re likely to find one.  The “problem” on the MRI may not actually be causing your symptoms though, as we see “problems” with people that have no symptoms.  To put it another way, if a “herniated disc” was always a cause of pain, then everyone with a herniated disc will have pain.  We know that this isn’t true.  This indicates that the structure/tissue that is a “problem” on the MRI may not be causing any problems at all during your day.

“…providing a patient with a pathoanatomical diagnosis can result in increased fear and iatrogenic disability”

Lots of big words there, so let’s work through this together.

Patho: bad

Anatomical: body parts

Therefore: pathoanatomical = bad body parts

This is typically what you hear when you have imaging (MRI, X-ray, CT scan) performed.  Herniated disc, degenerative joint, arthritis, stenosis. All of these words mean that something abnormal was seen on the image.

Iatro: means relating to medical treatment

Genic: means coming from

This means that the “iatrogenic disability” could be disability coming from medical treatment.

I know what you’re asking: “How can the medical interaction with a doctor/therapist/medical professional be causing the disability?”

This is a great question that the authors of the article will go into in a short while. More to come.

“It is increasingly clear that persistent and disabling LBP is not an accurate measure of local tissue pathology or damage alone…it is best seen as a protective mechanism produced by the neuro-immune-endocrine systems in response to the individual’s perceived level of danger, threat or disruption to homeostasis.”

WHAAAT?!

This means that the tissue that was previously damaged may not be the culprit for prolonged pain.  For instance, your body can have a protective mechanism produced by the brain when it feels threatened.  The brain is powerful in creating change. For instance, watch this video to see how quickly it can start to change.

“…pain and behavioral responses may fluctuate based on a person’s perception of threat, levels of attention to pain, mood, contextual social stressors, sleep, and activity levels.”

If you feel threatened, your pain levels may increase.  Removing threat through distraction has been shown to be helpful in multiple studies.  Tetris seems to be one of the most studied games.  Also, math is more painful to some than others.  In the clinic, I have used math as a distraction and watched how pain rapidly resolves and some patients are able to perform movements that they wouldn’t consider performing if they weren’t distracted.  There is some thoughts that the more often we ask you about pain…the worse it actually gets because we force the patient to emphasize the feelings of pain compared to their current function.  Finally, we know that a lack of sleep can cause a myriad of problems from difficulty concentrating to an increase in pain due to increased nerve sensitivity.  These are all factors that play a role when a patient comes to the clinic experiencing pain.

“This contemporary understanding demands a shift away from providing a simplistic structural and/or biomechanical diagnosis and treatment for LBP…enables the patient to become a partner in a therapeutic journey”

For some patients, we can correlate a “problem” on the MRI with their symptoms, but in a subgroup of patients, we are unable to do this.  For that subgroup, we need to look past the pathoanatomical model and therapeutic alliance (the teamwork between the therapist and patient) becomes very important in order to empower the patient with regards to symptom response and education.

“Growing evidence suggests that current practice is discordant with contemporary evidence, and is in fact often exacerbating the problem.”

We may not need to abandon the patho model completely, but we as practitioners need to have more than just the patho model.  In order to prevent iatrogenic pain beliefs, we need to grow our skills in order to better help you…the patient.  If you are going to therapy and are not seeing relief within 6 visits and don’t feel that your therapist has a strong understanding of your pain…seek a second opinion. Not all Medical Doctors are the same, and the same can be said for physical therapists.

Excerpts taken from

O’Sullivan P, Caneiro JP, O’Keefe M, O’Sullivan K. Viewpoint: Unraveling the complexity of low back pain. J Orthop Sports Phys Ther. 2016;46(11):932-937.

 

 

Not knowing versus not learning

“Ignorance: a limited understanding of all the relevant physical laws and conditions that apply to any given problem or circumstance”

I don’t think that this is much of a problem in the physical therapy profession for the basic concepts of the profession.  The issue of ignorance comes into play when we start discussing current evidence.  A new graduate’s primary responsibility is to pass the boards ( a national test in order to determine basic competency in order to practice as a PT).  Unfortunately, the boards are based off the books used during the physical therapy program and the books are based from research that is at least 5 years old or older.  This means that the students are being tested on material that is greater than 5 years old.  Current published research may not make its way into an educational programs curriculum due to time constraints.  In this fashion, the students may be ignorant to current research or niche research.

“Ineptitude: meaning that knowledge exists, but an individual or group fails to apply that knowledge correctly in a particular circumstance. “

This is common.  We know that therapists are not staying current with published research.  Time and access are two barriers to staying up to date on the research.  Just a quick example.  I dedicate 10 minutes per day to reading.  Even 10 minutes per day is hard to fit in with all the other hats that I must wear such as: business partner (http://www.goodliferehab.com/) , father, husband, running a separate Facebook page that interviews influencers and performing community lectures.  There is only so much time in the day and I can understand how some therapists will have a difficult time fitting learning into their day.  Barriers to obtaining current research can be the cost of a subscription to get the journal articles.  For instance, I pay over $1,000/year just to have access to research.  This is a big chunk of money when you consider all the other life activities that aren’t free.  Pair this with the fact that the “average” salary for PT is 80,000 ish and that students have well over $100,000 in debt.

, that $1,000/year over the lifetime of a career becomes expensive!

“For instance, through numerous scientific breakthroughs, there has been a repudiation of ‘folk’ treatments in our profession-such as hot packs or ultrasound for heat therapy-in favor of treatments based on scientific evidence.”

Going to PT should not resemble going to a spa! If you are going to PT and getting electrodes placed on you…getting hot packs placed on you…getting rubbed with gel while someone is moving a wand on your skin…or getting a rubdown…THAT IS NOT PHYSICAL THERAPY! On the flip side, PT should not resemble personal training! Going to your therapist and getting a list of exercises for you to perform independently while your therapist is chatting with others…IS NOT PHYSICAL THERAPY! The closes profession that I can equate therapy to is that of a teacher-student (and not always is the therapist the teacher!).  This healthcare relationship should be a personal relationship that takes place in a private setting allowing for open communication between the therapist and patient.  The patient should walk out of each session with more knowledge than they walked in with. The patient should understand why interventions are performed…or better yet why some aren’t performed.  We need to get away from the tradition of PT and move towards what the evidence tells us.

“However, despite the excellent EBP (current evidence) resources now available, ineptitude remains a major 21st century challenge in medical and rehabilitation care”

I have a dare for all of you reading this.  When you go see your next healthcare practitioner I want you to ask a simple question: “How much education do you get every 2 years?” In PT, we are required to get a minimal amount of continuing education to maintain our license.  DO YOU WANT TO BE TREATED BY SOMEONE THAT IS ONLY GETTING THE MINIMAL AMOUNT OF EDUCATION OR SOMEONE THAT IS DEVOTING TIME TO FURTHER THEIR KNOWLEDGE OUTSIDE OF THE MINIMAL STANDARDS FROM EACH STATE!

“…3 types of influence that have been shown to relate to the rate of spread of an innovation: (1) perceptions of the innovation, (2) characteristics of those who adopt the innovation or fail to do so, and (3) contextual factors”

The following will discuss how these all relate.

“First, the perceived benefit of the proposed innovation relative to its cost is the most powerful influence.”

For instance, a hot pack may not give much benefit, but it is cheap and relatively safe.  You will see this frequently in a PT clinic that sees a high volume of patients because of its relative ease of use and safety…assuming the therapist is asking you how you’re doing and checking a few things before, during and after.

Cold laser treatment is slower to take off in our profession because it is an out of pocket intervention…which means that your insurance company won’t pay for it regardless of whether it works.  This intervention is slower to be used in the clinic because it may be cost prohibitive for some patients.

“Second, rapidity of change is directly related to how compatible the innovation is to values, beliefs, and history.”

There are some “treatments” that become popular during years of summer Olympics.  In 2012, a specific brand of tape was seen on many of the “big name” volleyball players.  The thought was that it “kept things more supported”.  There is no research that conclusively states anything near this type of statement…but there is a lot of research that says the opposite.  We still see it used in clinics today…which is okay, if the rationale for using it is what is intended from our current knowledge base.  For instance, we know that it reduces pain and allows for increased ROM…sometimes.  If the patients are educated in this regard and not that it “keeps things in place” …go for it.  It seems like 2016 was the year of the octopus.  If you looked at one of the “world’s most famous swimmers”, it looked like he wrestled with an octopus underwater.  This technique has been around for centuries.  Some therapists are starting to do it because patients are asking for it.

“Third, the complexity of an innovation affects the rate of its adoption, and, as expected, simple innovations spread faster than complicated ones.”

Ultrasound, electrical stimulation, and traction are all very easy to perform…since the machine does most, if not all, of the work.  These were quickly adopted into our profession and are hard to convince some clinicians to stop using…regardless of what the evidence states.

More complicated interventions such as “critical thinking” are harder to adopt.  For instance, when assessing a patient with back pain or vestibular issues, there is a plethora of research showing that if we can classify it that we have a better outcome.  Classifying the problem requires (1) knowledge, (2) assessment, (3) application, which is a lot harder than just pushing a button on a machine.

Some of the personality types are as follows: 1. Innovators, 2. Early adopters, 3. Early majority 4. Late majority, 5. Laggards

A lot of these are self-explanatory, but it trends from those that jump onto something quickly to those that just hate change.

“Organizations that foster social exchange among its members are likely to see faster adoption of innovations as compared with institutions and organizations that foster habits of isolation and tradition.”

Essentially, workplaces that allow for communication will allow for change faster than workplaces that keep everyone separate.  This has to do with changing a culture.  A business that has a fluid culture (one that is easily adjusted), is more apt to change than one that has a strict culture.

“Publishing our work in journals is essential-but publication of research is not, by itself, sufficient if our goal is to change clinical practice. People follow the lead of other people they know and trust when they decide whether to take up an innovation and change the way they practice!”

This is huge! Any profession is a small world and PT is no different.  To push the profession forward, we must depend on more than just published research.  There are many influencers in our sphere such as Dr. Ben Fung, Dr. Jarod Hall, the team from PT on ICE, the team from Evidence in Motion, Dr. Richard Severin, and myself (I’m always trying to sneak my way into this group of titans).  By seeing others lead the way, it is much easier to follow.  Only the innovators and early adopters will feel comfortable at the front of the pack.

As a patient and therapist, you may want to assess your therapists/mentor and determine which of the 5 personality types he/she has.

 

Thanks for reading.  Please leave a comment on my FB page letting me know what you think.

EXCERPTS TAKEN FROM:

Jette AM. Editorial: Overcoming Ignorance and Ineptitude in 21st Century Rehabilitation. Phys Ther. 2017;97:497-498.

 

link to abstract

 

Did therapy help your knee pain? If no…continue to read. 

Did therapy help your knee pain? 

“Knee osteoarthritis (OA) is one of the leading causes of pain and disability worldwide”

This is an indication of how prevalent this condition is in the world. Arthritis is seen as a byproduct of aging, but this doesn’t mean that it directly causes pain.

“…exercise intervention has been shown to be efficacious and is recommended in multiple guidelines; however, its treatment effect has been reported to be modest.”

Everyone can benefit from exercise, but the extent of the benefit for patients with knee pain may not be that “miracle” that people expect.  

“Although the statistical effectiveness of exercise for knee OA has been clearly demonstrated and may be equivalent or better than commonly prescribed medications, the effect on pain reduction and function remains modest.”

Exercise is a powerful tool or at least among the most powerful that we have now. In saying this though, it is not a magic elixir.  

“The MDT approach has been extensively used to classify and treat patients with spinal pain. Studies have shown the MDT approach to be valid, reliable, able to successfully predict outcomes and associated with decreased lumbar surgery rates, pain, and disability.”

If this doesn’t sound great, then I don’t know what does! MDT (Mechanical Diagnosis and Therapy) is a specific assessment and treatment style that Is not taught in school. One must go through advanced courses and take a test to say that they are competent at using the method. Ask your therapist if they have taken any courses in the method and if they have achieved the certification through the Institute. This is the only way to determine if the therapist that you are seeing is competent to utilize the principles of the system.  

“The most prevalent and well-studies MDT subgroup is the ‘derangement’ classification. This classification has been described in all joints and has been associated with a rapid response to specific end-range exericses…”

Would you like your symptoms to rapidly improve? Who wouldn’t? Roughly 40% of patients with knee pain may have symptoms that respond rapidly to a single exercise. Turning off pain doesn’t have to be difficult. In many patients, it only takes a single exercise to reduce or turn off the pain. This has to be followed-up with a constant assessment in order to determine which exercises the joint will tolerate at a specific point in time in order to ensure that the symptoms do not return when not in the clinic. There has been a lot of research in the medical world regarding Low Back Pain, but this article is the first that I have seen using the same principles for osteoarthritic knees.  

“…significant treatment main effects were present for all primary outcomes. The MDT derangement subgroup had improved scores at 2 weeks and 3 months compared to the MDT nonresponder subgroup for all primary outcomes”

This is huge! This sentence essentially states that doing one exercise is more beneficial than doing many for a small subset of patients. Now for a little more information on a derangement. If there is one exercise that can greatly improve your pain, then there will be multiple exercises that either have no effect or make the pain worse. If your therapist is not at least looking for and ruling out this preferential exercise or direction of movement, you may be in therapy for a longer period with a longer list of home exercises. These exercises may or may not have a positive or negative effect on patient’s whose symptoms are rapidly reducible.  

“The physical therapists were credentialed in the McKenzie system, and results may not be applicable to non-McKenzie-trained therapists.”

This sentence stands on its own. Anyone claiming to use a method should at least be trained and credentialed in using the method. In the Joliet area, there are only two of us endorsed by the McKenzie Institute to utilize this method.  

 

In short, this study was performed on patients waiting to receive a total knee replacement, which means that they were shown to have severe arthritis on an X-ray. The patients receiving McKenzie-based treatment outperformed those receiving traditional evidence based guideline therapy and those that received no therapy. Seek out an MDT trained clinician if you are experiencing knee pain.  

 

I can be found at:

Functional Therapy and Rehabilitation

903 N. 129th Infantry Dr

Suite 500

Joliet, IL

815-483-2440