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Response to Gifford 2002

I was given this article to read by a Physical Therapist that I respect. This article was meant to educate me on the concept of centralization. For those that have spent time with me know that I am all for being educated.

I struggled with this article because it was full of opinion and anecdotal evidence. Also, the article was written 17 years ago. Much has been published since this piece was written. I will write this one exactly how I have written previous blog posts, but will go a little more into depth utilizing evidence instead of my experience, which I typically do in my other posts.

“For patients with back pain fear of movement, and bending in particular, could well be generated by clinicians whose own beliefs and fears about bending being “dangerous” are passed to patients.”

I completely agree with this. There is no reason to fear a movement, for most people. In all my years as a therapist, there has only been one patient that I was hesitant to move. After her history, I just had her slouch and sit up tall. Both positions created sharp sensations into her legs and she noted that when this happens her legs go weak. I had her lie on her belly and on her back and any movement again caused that sharp pain into the legs. After that, I asked her daughter (patient was non-English speaking) if there was any imaging that was done. Of course there was!

The daughter said that she didn’t want to start with the images because every doctor that her mom has been to said that she needed surgery.

I looked at the images and here’s what I want you to imagine:

Imagine playing Jenga with a 5 year old. You are doing your best not to let the tower fall, but it’s all over the place. Some pieces are half put into place, others have been slightly knocked out before moving onto another piece…You get the picture!

The patient eventually had a fusion…and her pain was completely resolved!

After the fusion, she was able to perform ½ Turkish get ups, chair squats, floor transfers, and speed walking without symptoms! Fusions aren’t for everyone, but then again conservative care doesn’t help everyone either.

With that said, there is never reason to be afraid of movement, but it has to be honored.

“However, management strategies, like the McKenzie system or approach, whose traditions predominantly seek to avoid bending may be part of creating a greater problem than is necessary”

This is a half-truth. With Mechanical Diagnosis and Therapy, there are some movements that are temporarily minimized. Patients are classified into one of three categories with this method, assuming the presentation matches a classification.


 

If you would like to read more about the system from my previous posts, click here https://movementthinker.org/?s=mckenzie.

The system does not try to avoid bending. This is a misunderstanding of the system. A patient can be classified into one of the three subgroups: derangement, dysfunction, and postural syndrome. They could also be classified into a category called: other, but to simplify things, we will only speak of the derangement syndrome.

With the derangement syndrome, a patient is issued movements, postures and positions that have proven, in the clinic, to reduce the patient’s symptoms or to improve their mechanical baselines (range of motion, reflexes, strength, dermatomal sensation, or special test). The patient is then issued this movement for the home program, with the instructions to minimize activities that increase stiffness, reduce strength or increase symptoms (pain, numbness, or tingling) further away from the spine.

If this means that the patient should minimize forward bending…so be it. It may also mean that the patient should minimize backward bending (think painting ceilings or other overhead type movements). The goal is to minimize the movements that aggravate symptoms and introduce movements that improve symptoms…TEMPORARILY!

I haven’t read too much research to contradict this last sentence, meaning there isn’t anything that I have read in 12 years that states we should continue to perform movements, postures or positions in the presence of worsening symptoms. I’d love to read it if it’s actually out there. You can email it to me a vincegutierrezpt@icloud.com.

“It is my belief that around 20 years of propaganda based on the disc derangement model and the concept of centralization of pain relating to dubious biomechanical models for back pain has led to an unprecedented therapist fear of flexion that is passed on to patients.”

I won’t completely disagree with the premise of the statement. A therapist that is poorly trained in the method, meaning one that hasn’t completed the credentialing process, should not be the basis of one’s opinion regarding the method. https://www.jospt.org/doi/abs/10.2519/jospt.2018.7876 A therapist that is properly trained no longer utilizes the disc model to educate the patient. The disc model has fallen out of favor, quite possibly for the reason stated above.

Also, we know that the disc model is not 100% accurate, as demonstrated by https://www.ncbi.nlm.nih.gov/pubmed/19841611 Zou et al.

“In other words, flexion, way back in Williams’ time (50’s and 60’s), was not a feared movement and patients still got better.”

I would challenge this with more research that has come out since publication of Gifford’s blog post.

 

INTERVENTIONS – FLEXION EXERCISES: Clinicians can consider flexion exercises, combined with other interventions such as manual therapy, strengthening exercises, nerve mobilization procedures, and progressive walking, for reducing pain and disability in older patients with chronic low back pain with radiating pain. (Recommendation based on weak evidence.)

This is straight from the Clinical Practice Guidelines for Low Back pain, which can be found at https://www.jospt.org/doi/pdf/10.2519/jospt.2012.42.4.A1. 

I put this first, but another summary statement in the same guideline shows: 

INTERVENTIONS – CENTRALIZATION AND DIRECTIONAL PREFER­ENCE EXERCISES AND PROCEDURES: Clinicians should consider utilizing repeated movements, exercises, or procedures to promote centralization to reduce symptoms in patients with acute low back pain with related (referred) lower extremity pain. Clinicians should consider using repeated exercises in a specific direction determined by treatment response to im­prove mobility and reduce symptoms in patients with acute, subacute, or chronic low back pain with mobility deficits. (Recommendation based on strong evidence.)

I’m just saying. 

This isn’t to say that using flexion based exercises won’t help patients, but based on research by Stephen May, it may only help a small percentage of patients, as seen in this article: https://www.sciencedirect.com/science/article/pii/S016147540600217X

“Clearly restoration of flexion is part of the McKenzie approach, but it is usually after some form of extension and introduced with caution.”

As therapists, we should know that words mater and I take offense to the portion that states “introduced with caution”, but I digress. 

A return to function is one of the steps in a recover, when classified into the derangement syndrome, but also for all patients that present to the clinic with symptoms. What is different about MDT is that return to function occurs after the patient has reduced symptoms and is able to maintain that reduction independently. Those that practice MDT do not start with return to function before the other two categories, although this is common to see in clinics with non-credentialed PT’s. 

A therapist will return a patient to extension, flexion and lateral motions over time. This is expected. When discussing with patients, I will typically say “we would like to return to pain-free movement through all planes that you can move through and then progress confidence with movement over time and utilizing different loads”. 

FLEXION IS NOT SPECIAL! Unfortunately, other therapists (including those that say they utilize MDT) believe flexion to be a dangerous movement, which would then make Mr. Gifford’s comments true. 

“When are physical therapists going to stop forcibly extending patients”

This comment was said to be made by an anesthesiogist. Surprisingly, I would agree with this because the wording is very specific. Therapists that are credentialed in MDT rarely “forcibly extend” anyone. There is a progression of forces built into MDT, which adds a layer of patient empowerment to the system. Before a PT performs manual therapy, the patient must perform the movement independently. This article specifically measures the fluid movement when performing extension based movements, both independently and with PT assistance. https://www.jospt.org/doi/full/10.2519/jospt.2010.3284

Utilizing MDT, a patient must first perform a movement (flexion, extension or lateral movement) independently for many repetitions (usually 10-15 every 2-3 hours at home) without a worsening of symptoms in order to ensure that the correct exercise was given. If the patient’s symptoms stop improving with the movement, then a version of force progression is pursued. Force progression takes many forms, such as increased repetitions, increased ROM, decreased time between sets, AND PT assistance utilizing manual therapy. Ideally, there is no “forcible extension” beyond patient’s own abilities unless the patient absolutely requires it to reduce symptoms. 

“Having to face patients who one moment have simple back pain and then later rapidly develop leg pain and a neuropathy is not nice and something I would preferred to avoid”

This is a fear tactic to besmirch MDT. If a PT is credentialed in the method, then this is not expected to happen. Having used this method as my base for 12 years, I have never personally seen this happen. 

Again, the research consistently supports utilizing a specific direction (key) to unlock the patient’s pain. Please, if you are interested in these topics, read the following two studies: https://www.ncbi.nlm.nih.gov/pubmed/15564907and https://www.researchgate.net/publication/41420157_Specific_Directional_Exercises_for_Patients_with_Low_Back_Pain_A_Case_Series

These articles are very informative to read, in that the first article is a randomized controlled trial (supposedly a strong design) and the second is a case series utilizing the patients that worsened from the first article. It was a novel series of studies. 

“My clinical observation is that it is very rare for common back pains to want to only move in one direction-except when they are fearful of a particular movement”

I would agree with this. Not all patients require a structured program and many can improve without physical therapy. This is not news based on the previous publications of the STartBack Screening Tool https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208163/

Many patients improve just from moving and returning to normal activities…but some do not. 

“My stance is that it is always best to start easy, comfortable and relaxed, pain free if possible, build confidence slowly and then gradually move into range and greater repetitions over time”

Again, just speaking of the derangement syndrome, I would say that MDT is not much different from his views. A patient that benefits from extension, which seems to be the movement most related to MDT although there are many other options that a patient may benefit utilizing, will start by simply lying on his/her stomach. I am not sure what could be more comfortable or relaxed than just lying down. If this is tolerated and there is no worsening of symptoms, then the patient is progressed to lying on the stomach, but propped up on elbows. This actually satisfies Mr. Giffords stance. The only aspect that opposes Mr. Gifford’s stance is that this is done over one or a couple of visits. Mr. Gifford would apparently prefer that this progression from lying on your belly to actually propping yourself up on your elbows should take “a few days, occasionally many weeks”. That is an area of disagreement from my clinical experience. 

“Using pain response (lessening/increasing, shifting location) with movements as the main guide to treatment ‘direction’ needs a note of caution.”

A common misconception is that pain response is the only aspect that is reassessed during a treatment with a credentialed MDT professional (could be either a physician, chiropractic physician or physical therapist). 

Pain location and response are important aspects to pain attention to after movements. For instance, patients that do not experience centralization are more likely to require an invasive procedure as noted by Skytte https://www.researchgate.net/publication/7812658_Centralization_Its_Prognostic_Value_in_Patients_With_Referred_Symptoms_and_Sciatica

Patients that demonstrate centralization within 7 visits are more likely to have a favorable outcome based on work by Werneke https://journals.lww.com/spinejournal/Abstract/1999/04010/A_Descriptive_Study_of_the_Centralization.12.aspx

“No, for me (Gifford), the more you tangle with a stirred up pain, whatever the direction you gor for, the most common outcome is ‘pain worse and worse’”

I don’t necessarily disagree with this, but this patient would not be classified utilizing MDT. About 5 pages ago, I mentioned that there was another category called: other. This patient would be classified as “other” and most likely would be classified better utilizing another method, such as the Pain Mechanism Classification System as follows: https://www.scholars.northwestern.edu/en/publications/validation-of-a-pain-mechanism-classification-system-pmcs-in-phys

“Repeated movements may e injuring neural tissue that nly starts to generate nociceptive activity and become sensitized much later on”

I agree with the statement, although he again is using a fear tactic to prove a point. When this happens, something was missed. This is an error by the PT, because this patient is no longer classified as a derangement syndrome and again is better off with the PMCS and treated accordingly. 

There is nothing wrong with having a patient not utilize MDT principles if they are not appropriate. The issues occur when a PT utilizes the treatment principles with a patient that was classified incorrectly. This again stresses the point of seeing a therapist that is credentialed or Diplomaed. 

I hope that this comes across as respectful as there is no ill intent in the writing. I only hope to expand the discussion. 

In the end, the professional has to choose what courses to take in order to feel comfortable treating patients with symptoms originating from the spine. I included personal experiences with research in order to give the reader more than just an anecdotal reports. 

I would appreciate it if you could share this with friends.

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Part I: TBCS revision

“In order to optimize the treatment effect, patients with LBP should be classified into homogeneous subgroups and matched to a specific treatment. Subgroup-matched treatment approaches have ben shown to result in improved outcomes compared with nonmatched alternative methods.”

There is more information coming out over time that demonstrates certain patients do well with specific treatments related to that particular patient.

Looking at the broad scale, there are many people with LBP across the world.  Not everyone with LBP has similar symptoms or will respond to the same treatment.

For instance, if your pain gets worse with repeated or prolonged bending, prolonged sitting an standing slouched, your treatment will look differently than someone that gets better with the aforementioned activities.

This is what is meant by subgrouping patients into groups.  We take the patient’s presentation and history and match that to an intervention that tends to work well for that group.

One such method of subgrouping can be found here.

This article will highlight a different approach to subgrouping, the Treatment-Based Classification System. This is a post that I previously wrote on this system.

“There are 4 primary LBP classification systems that attempt to match treatments to subgroups of patients using a clinically driven decision-making process: 1. the mechanical diagnosis and therapy classification model described by McKenzie, 2. the movement system impairment syndromes model described by Sahrmann, 3. the mechanism-based classification system described by O’Sullivan and 4. the treatment-based classification system described by Delitto et al.”

I won’t hide from my deficiencies.  I am well versed in the MDT system and fairly well versed in the treatment based classification system.  I am not well versed in the MIS or the MBC.  I will limit my advice to that which I am knowledgeable.

Yet, these systems-without exceptions- have 4 main shortcomings:

  1. No single system is comprehensive enough in considering the various clinical presentations of patients with LBP or how to account for changes in the patient’s status during an episode of care.
  2. Each system has some elements that are difficult to implement clinically because they require expert understanding in order to be utilizied efficiently.
  3. None of these classification systems consider the possibility that some patients with LBP do not require any medical or rehabilitation intervention and are amendable for self-care management.
  4. The degree to which the psychosocial factors are considered varies greatly among these systems, which runs contrary to the clinical practice guidelines established by the American Physical Therapy Association (APTA) that advocate using the biopsychosocial model as a basis for classification.”

I will address these points regarding my knowledge of MDT and TBC.  I will not address the MIS or the MBC due to my lack of knowledge regarding these systems.

1. No single system is comprehensive enough or accounts for changes in status during an episode of care.

First, I can’t fully agree with this statement.  Yes, there is no system to date that can account for every patient that walks through the door.  This is true.  This is why a therapist must be well versed in multiple systems.  For instance, MDT is a system that doesn’t take into account non-movement based pain presentations.  When paired with an approach that takes this patient presentation into account, it makes for a great pairing.

The TBC does not account for change during the patient’s episode of care.  Once a patient is classified and the intervention is applied, there is no algorithm for further improvement or progression.

This is not true though for MDT.  For instance, a patient can be classified into one of three categories.  The first two categories have built in progressions, regressions and modifications to movement.  The third category is a category that doesn’t require much intervention aside from advice.

With the first category, derangement (another way to say this would be rapidly changing) there is a clear progression.  Let’s start with the term derangement.  No one likes this term to be used for patients.  It’s a long running joke that we should never tell patients that they have a derangement. Words do matter and the patient’s perception of this term may be just as important as our expectations for the patient.

Now, moving on to the important part of the post.  When a person is classified as a der…I mean a rapidly changing presentation, here is what the progression looks like in the clinic:

  1. Reduce the der…Dangit! I almost did it again.  Make the symptoms better quickly.
  2. Make sure that the patient can maintain the reduction in symptoms.
  3. Return to the functional activities that the patient would normally do during the day without reproducing symptoms
  4. Teach how to prevent the symptoms from returning

That seems like a fairly simple strategy when bringing patients through a program in PT, but unfortunately this simple construct is lost on a lot of professionals.

 

Why you ask?

 

Thanks for asking.

 

Because unfortunately, there is no profit in getting people better.  Shhhh….You didn’t hear it from me.

 

Regarding the second category of Mechanical Diagnosis and Therapy: Dysfunctional tissues, it also comes with a game plan that is easier to follow than the first, but not as fun to implement.

Also, the name dysfunction is another term that I have gotten away from in the clinic.  Again, patients don’t want to be deranged or dysfunctional, although if given the choice, I would much rather have a derangement.  They want to know is it going to improve and if yes, what’s the timeline.

These issues are like hamstring or achilles problems…they tend to get better if left alone until….WHAM! You goin for a quick sprint to keep your child from running out of the door at the grocery store.  OR you run down the stairs because you are feeling froggy.

It let’s you know….DUFUS! YOU NEVER CORRECTED THIS PROBLEM!

This tissue issue (say that 5 times fast!) needs to be loaded to the point of pain and then allowed to recover before it is loaded again.

Like one of my mentors Annie O’Connor says in her courses “No pain… No gain…No guts…No glory”

This example is rarely used in therapy, but this is one case in which this example is fitting.  Ideally, this tissue is loaded consistently.  I have seen research that states the achilles tendon should be loaded about 1200X/week.  That’s a whole hell of a lot of repetitions.

As a matter of fact, if you would like to read more about this, you can find a previous article that I commented at this link.

  1. “Each system has some elements that are difficult to implement clinically because they require expert understanding in order to be utilized efficiently.”

I would wholeheartedly agree with this statement.  There is research that demonstrates good reliability when MDT is applied by those that have taken, and passed, the credentialing exam.  It has been shown multiple times, but here is one of the more current articles.

The systems are not easy to use, nor should they be easy to utilize.  It irritates me to no end when I hear about a therapist “using the McKenzie exercises” even though he/she has no idea regarding the wrongness of the statement.  Open mouth…insert foot.

There has to be something sacrificed in order to learn a method or system.  Time, money, life…these are all things that I sacrificed in order to get to where I am at in my career, which much to learn remaining.

 

“None of these classification systems consider the possibility that some patients with LBP do not require any medical or rehabilitation intervention and are amendable for self-care management.”

Again, can I disagree with these statements.  At one of the MDT conferences (they blend together), Nadine Foster presented on the STarTBack screening tool.  MDT is advancing to keep up with the research.

Those that keep up with the research or attend MDT-based conference, understands that not all patients require follow-up, or even an evaluation!  Some patients do get better with time.

To follow-up with this, there is still one classification that I didn’t describe yet. This is the postural syndrome. In this syndrome, the patient has no signs or symptoms of a problem…unless he/she maintains one position for too long.  Once the patient moves from that position…the symptoms disappear.  It’s like Wizzo (it’s a Chicago thing).  I bet you didn’t know that you were going to get a history lesson.

“The degree to which the psychosocial factors are considered varies greatly among these systems, which runs contrary to the clinical practice guidelines established by the American Physical Therapy Association (APTA) that advocate using the biopsychosocial model as a basis for classification.”

I agree with this, in that MDT or the TBCS doesn’t appear to utilize psychosocial factors in classifying patients.  There is another classification that appears to be paired well with MDT.  Check out this podcast with Annie describing this system.

This will be continued in the next article that goes more into depth on TBCS.

If you would like to read the article highlighted above, you can find it at this link.

Thanks for reading.  For those that gained a little knowledge from this article…please share so others can learn about classification of low back pain.