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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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On the road

Everyone that knows me knows that I listen to a lot a podcast during my commute. One of the things that I find more enjoyable than listening to a podcast, his actual interaction. Over the past month, I have spoken to about eight therapist from all over the country regarding clinical aspects of care and classification of symptoms. An excellent conversation this morning for about a half an hour, my commute is about 45 minutes to an hour, so I have plenty of time to chat. And we discussed research we discussed therapeutic alliance, we discussed patient’s expectations, we discussed chronic pain, We discussed classification of pain, and we just discussed clinical presentations that we commonly seen in the clinic.

I absolutely love dialogue!

Considering a nursing home after surgery

“Moreover, older adults who are hospitalized are 60 times more likely to develop a disability than those who are not. ”

This is HUGE!

We know some of the common statistics such as an adult over 80 years that falls and breaks a hip has a high likelihood of death within one year.

There is some research about reserve capacity and the body’s ability to withstand a major obstacle such as a fall or hospitalization. Reserve capacity is essentially the amount of ability that a person has that exceeds daily needs.

For instance, if you typically walk 2.5 mph, but have the ability to walk at 5 mph, the reserve capacity would be the difference between usual speed and RESERVE gait speed.

“… recovery of function during a SNF stay is inadequate under usual care”

I’ve worked in a SNF and will attest to this based on experience. I stuck out like a sore thumb during my time in the SNF.

I got many of my patients up and walking. I would stand next to the patient to motivate, encourage and correct any safety issues that I noted during a movement or exercise.

Many of my “peers” were sitting at computers about 20-30 feet away from patients barking out directions from across the gym. The atmosphere was more party like for the roles of professionals, in which many conversations revolves around personal lives of the therapists, instead of the patient.

“The 2017 Medicare payment advisory commission reported no change in functional outcomes as measured by a patient’s ability to perform bed mobility, transfers, and ambulation.”

This is crazy! A patient goes to a rehab unit in order to rehabilitate to a safer functional level. If there are no changes in outcomes…why bother!

I did some research on total knee replacements when creating the protocol for our outpatient facility and there was much research showing that patients that went home after surgery did better than those that went to a “SKILLED” nursing facility.

Again…why bother!

There may be some lower level patients that need the nursing care at a facility like this, but we really do need to do a better job of planning a patient’s discharge from the hospital.

“specifically in SNF’s, annual expenditures comprise 50% of the $60 billion US allotted to post acute care. The discrepancy between high levels of spending in SNF’s and sub optimal outcomes strongly suggest the need for innovative clinical research designed to advance models of care delivery and assert the value of SNF rehabilitation therapists”

☝️ 🤔🤑

Leaving this one to stand on its own.

“… hospital discharge patterns away from SNF towards less costly home health or outpatient services.”

This makes sense and we are seeing this happen for some orthopedic cases that would previously be sent to a SNF. It took incentivizing hospitals and physicians to get them to change the way they treat patients.

“Nursing home literature suggests patient motivation to participate in treatment, such as physical therapy is linearly correlated to patient perceptions of and satisfaction with support from peers, family, and staff.”

Wonder why some patients may not be motivated to work with staff?

Read this article.

Excerpts from:

Gustavson AM, Boxer RS, Nordon-Craft A et al. Advancing Innovation in Skilled Nursing Facilities through Academic Collaboration. PTJ-PAL. 2018;18(3): 5-16

A Penny saved is a penny earned

We’ve all been there! That place in which we are sinking instead of swimming. You ain’t alone.

Hear my story below.

Check out my episode “A penny saved is a penny earned” from Movementthinker: a physio’s perspective on Anchor: https://anchor.fm/vincent-gutierrez/episodes/A-penny-saved-is-a-penny-earned-e298p5