HOW PT CAN HELP WITH FMS

HOW CAN PT HELP WITH FIBROMYALGIA?

I was recently asked in an open forum how PT can help fibromyalgia.  I hope the summary of this article sheds light on how important of a role PT’s play in this ailment.

“…Fibromyalgia syndrome (FMS) as a syndrome characterized by chronic widespread pain and tenderness in at least 11 of 18 predefined tender points”

First, when something is characterized as a “syndrome” it means that there is a cluster of symptoms that are common amongst people, but there is no definite test in order to prove that it is the cause of symptoms.

This makes FMS difficult to treat and understand because we don’t have a specific test in which to try to “fix” the underlying cause.

This article will go into what we know about FMS and what is hypothesized about FMS to further the patient’s knowledge of how PT can help.

“…prevalence rates between 0.5% to 6%”

This means that in the general population we will see this diagnosis between 5 in 1,000 and 6 in 100.  Depending on the setting that a PT works in, the prevalence rate may be much higher.  I can say personally that this is either the primary diagnosis or a secondary diagnosis in about 25% of my current caseload.

“…high comorbidity with other disorders, particularly chronic fatigue syndrome and mental disorders, including depression and anxiety disorder”

FMS is not frequently a diagnosis on its own. The patient with FMS may also have other issues such as chronic fatigue, which is not the same as FMS.  The person may also have a psychological issue, which may play a role in FMS.

“FMS is not only a chronic pain syndrome but also consists of a whole range of symptoms referring to effort intolerance and stress intolerance, as well as hypersensitivity for pain and other sensory stimuli”

Fibromyalgia goes well beyond pain only.  The patient with FMS is not frequently able to tolerate a great deal of activity without worsening of symptoms.  This is a major role for the PT to educate the patient regarding when it is safe to push harder and when the patient may need to back off activity in order to allow the system (read that as body as a whole) to calm down. A good book for this topic is “A World of Hurt” by Annie O’Connor and Melissa Kolski.

Hypersensitivity is a key finding in FMS and this will be spoken about later in the article.

“The precise etiology and pathogenesis of FMS remain undefined, and there is no definite cure”

When I read this, it sounds doom and gloom, but if you read it more like a science person instead of as a layperson it makes sense.  If we don’t know the cause of a specific action, then we can’t possibly know how to stop the action or prevent it in the first place.

“It is not our intention to advocate that physical therapists are able to manage a complex disorder such as fibromyalgia on their own”

Because there are multiple components to the syndrome (remember the psychological issues spoken of earlier), this is not a problem that can be handled by one professional without help from others.  As PT’s, we can play a role in managing this process, but that’s it…we play a role.

“Fibromyalgia syndrome is characterized by sensitization of the central nervous system, which explains the majority of, if not all, symptoms…Once central sensitization is established, little nociceptive input is required to maintain it…an increased responsiveness to a variety of peripheral stimuli, including mechanical pressure, chemical substances, light, sound, cold, heat, and electrical stimuli…results in a large decreased load tolerance of the senses and the neuromuscular system.”

When your nerves are more sensitive, then the sensations that you feel such as pain, heat, pressure, etc may be felt quicker and more intense than those without this syndrome.  This is the concept of little nociceptive input (pain input) is required to maintain sensitivity.  For instance, when someone has a lower threshold for pain (not an ego thing) then smaller deviations will cause pain.  I have treated patients that claimed to have increased pain from being touched by a feather! It is real and the patient’s experience of pain cannot be denied.

“…pain facilitation and pain inhibition is influenced by cognitions, emotions, and behaviors such as catastrophizing, hypervigilance, avoidance behavior and somatization”

This is a great article because the authors did a great job of attempting to summarize FMS in a concise manner. Pain is an experience.  It doesn’t mean that a tissue is injured, as pain can be felt in the absence of injury.  A person can also have a severe injury and not have pain.  A person’s emotional state can override the pain response. For instance, I experienced a major injury to my face in which my nose was pulled from my face during a weightlifting movement.  I had no pain until I actually saw the injury in a mirror.  The injury was unchanged from the minutes of standing at the bar until I went into the locker room and saw the injury.  What changed was my mental state.  I started worrying about severe damage, financial concerns, loss of work etc.  All of these are the same worries that everyone else has when they experience a pain that is not explained (this is the definition of catastrophizing).

Avoidance behavior means that a person will stop performing activities because of fear of making symptoms worse. Finally, somatization indicates that a person experiences symptoms in the absence of a test that can show anything is actually causing the pain.

Avoiding activity and catastrophizing actually causes a change in the nervous system in that it may sensitize the spinal cord.

“…abnormal functioning of the stress system seems to occur mostly in the aftermath of a long period of overburdening by physical and emotional stressors and to be precipitated by an additional trigger in the form of an acute physical or emotional event.”

Now you, as the reader, can see why PT’s can’t solve this puzzle alone.  There are so many variables that play a role in this syndrome that more than one professional needs to be involved in the care.

“…many patients with FMS have maladaptive illness beliefs, cognition, and behaviors that preclude successful rehabilitation.”

The primary intervention that takes place in therapy, almost regardless of the diagnosis, is education.  When a patient understands their own beliefs and how they may play a role in hindering progress, we have actually reached a milestone.  This is very much based in education.  If we can educate the patient enough regarding pain and more importantly how to respond to pain and its meaning, then we can progress towards other interventions.  If we can’t teach the patient or come to a mutual understanding regarding pain and how it is thought to work, then progress will be difficult.  As stated in the following portion of the article; “Poor understanding of pain may lead to the acquisition of maladaptive attitudes and behavior in relation to pain”. This means that the number one treatment that PT’s can offer to patients with FMS, and any other pain disorder for that matter, is education.

“…more adequate pain beliefs lead to increased confidence, which, in turn, leads to increased activity levels. An education course directed at improving self-efficacy for the management of the pain disorder ameliorated symptom severity and improved physical function”

We have to break the cycle of pain.  This may be achieved by breaking any part of the cycle.  The thought is that if we can increase a person’s activity level, or tolerance, that we could improve or decrease how sensitive the nerves are to outside stimuli.  This would allow a person to slowly tolerate more and more activity with less pain over time.  This is considered graded exposure.

“Evidence in support of activity management alone for those with FMS is currently unavailable. However, it is generally included in cognitive behavioral therapy.”

The thought is that if we can reduce the stress (think physical, emotional and otherwise) that a person is experiencing, that we would be able to reduce flare-ups.  This is a good thought, but hasn’t been proven.  What we know is that we need to increase activity levels because there are many good benefits from an active lifestyle such as decreased risk of mortality, increased lifespan, and improved quality of life.

“Limited evidence supports that use of spinal manipulation and moderate evidence supports the use of massage therapy in patients with FMS”

There are many in the field of PT, including the American Physical Therapy Association, has stated that the passive use of physical therapy should be questioned if it is the primary treatment.  Passive therapy is treatment done TO the patient instead of done BY the patient.  This “passive therapy” also fosters the dependence of the patient on the therapist.

When a patient is dependent on a therapist for improvement, the winner is always the therapist and his/her bank account.  In the end, we want to empower the patient to take control of his/her pain status and start to experiment with activity in order to establish a baseline activity that can be performed without flare-ups.

“Strong evidence supports aerobic exercise, and moderate evidence supports muscle strength training for the management of FMS”

This is an easy statement to make, but many patients tell me that “they couldn’t tolerate any exercise”. This is where the therapist-patient team (therapeutic alliance) really comes into play.  It is the therapist’s job to listen to the patient in order to provide treatment strategies that will improve the patient’s fitness levels, WITHOUT flaring-up symptoms.

“Physical exercise is troublesome for many patients with FMS due to activity-induced pain, especially for patients with severe disabilities”

This statement sums up the challenge of physical therapy and the challenge for the physical therapist.  A patient with FMS cannot be issued a check-list of exercises to perform in the clinic.  There has to be a relationship of trust between the therapist and the patient.  When a patient comes into the clinic, he/she trusts that the therapist is issuing interventions with the patient’s end-goal in mind.  If, at any time, the patient feels that the therapist is not providing GREAT care, then the patient needs to leave and find a therapist that treats them as a person and not a number! This is important and will come up again towards the end of the article.

“Nonspecific factors such as the patient’s emotional processing of the encounter with the health care professional, the quality of the therapeutic alliance, and the patient’s treatment preferences may be important in predicting therapeutic outcomes.”

THIS IS HUGE! The emotional processing of the encounter….Read that again….How the patient perceives being treated during the session plays a role in the outcomes. When we know that there is an emotional component to FMS, it is our responsibility to ensure that we accommodate this by trying to provide the best experience as possible. This starts from the initial phone call and progresses through the initial visit.  This perception starts prior to the patient coming into the clinic.  The patient needs to be heard and feel important in order to get the best results. I would say that this should hold true to all patients and not just for those with chronic pain or FMS.

Thanks for reading and I hope it was helpful.

Excerpts taken from:

Nijs J, Mannerkorpi K, Descheemaeker F, et al. Primary Care Physical Therapy in People with Fibromyalgia: Opportunities and Boundaries Within a Monodisciplinary Setting. Phys Ther. 2010;90(12):1815-1822.

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.

 

 

Get PT 2nd

“out of 137 patients, 100 had been recommended for spinal fusion. After evaluation, the group advised 58 of those patients to pursue a non operative plan of care”
There’s a slogan going around social media saying “GETPT1ST” I don’t know if I completely agree with the saying, but I can’t disagree with that either. The saying could just as well be get PT second. At some point a second opinion has to come in to play for a patient’s dysfunctions or pain. That second opinion, in my belief, has to come from someone without a financial stake in the surgery. This could be a physiatrist, PT, or a separate surgeon, which was done in the study cited. 
The take home point is that 58% of those recommended for spinal fusion were recommended to seek a separate form of care, thus advised to avoid the surgery initially. What this means for the patients is that a second opinion should always be sought out, because the person advising a plan of care is advising it from their perspective. I’d love to say that everyone has the patient’s best interest in mind, but I can’t. In that case, the patient must become more educated and advocate for him/herself. For instance, a surgeon does surgery, a physical therapist does physical therapy and a physiatrist does physiatry. We see problems from different lenses and therefore will advise different plans of care for varying presentations. Some patients need surgery and some don’t. Some patients need physical therapy and some don’t. We can’t say PT first because PT is not magic and can’t fix everyone’s issues. 
“As clinicians, we bring our own biases into the treatment plan for patients”
Want to decrease unnecessary surgeries? Have a multidisciplinary team do evaluations, researchers say. PT in Motion. April 2017:46. 

Wait…PT’s perform manipulations?!

Wait…PT’s perform manipulations?!

 

“Without the ability to match patients to specific interventions, clinicians are left without evidence or guidance for their decision-making”

 

This couldn’t be truer. If we believe that all patients with back pain are the same, then we will give all patients the same treatment. If not all patients respond to the same treatment, then we can say that not all back pain is the same. We have to be able to classify which patients are most likely to respond to a specific treatment; otherwise we are just throwing spaghetti at a wall and hoping that some sticks. When a patient walks into the clinic, I am forming hypotheses as soon as I see the patient get out of the chair in the waiting room. By watching a patient move from the chair to walking and from walking to sitting, we can start to assess pain response (facial expressions) and movement quality (upright versus bent forward or sideways in addition to stride length of the legs and how much rotation is happening with arm swing). We can also have a short chat with the patient to determine how the patient describes their symptoms. Some patients are okay with waiting until we get to the private area before telling their story and others just want to start unloading their story before I have pen to paper to write things down. These are all of the actions that I take into consideration before we even get to the room to assess the patient.

 

“Identifying methods for classifying patients with LBP has been identified as an important research priority”

 

Why do most things matter…MONEY! We as a country lose almost $100 billion per year on back pain. This is a lot of money. If we were to put in a dollar every second to pay for this, it would take 31 years to equal $1 billion! As you can see, LBP is an ailment that we have to figure out in order to keep healthcare solvent.

 

“The purpose of this study was to develop a clinical prediction rule for identifying patients with LBP likely to respond favorably to a specific manipulation technique.”

 

This is a derivation study, the first step of trying to come up with a clinical prediction rule. One must understand CPR’s prior to reading and implementing the research. Here is a quick link that has to do with the types of CPR (clinical prediction rules). Also, there is much controversy surrounding CPR’s from people such as Dr. Chad Cook, who I highly respect. I don’t know if I would go as far as he does in saying that Clinical Prediction Rules are dead, but they do have to be read thoroughly and criticized. They also have to be validated and placed into an environment in which they can be utilized in order to have an environmental impact. This has been done with diagnostic CPR’s such as the ankle or knee rules.

 

Me personally, I don’t believe that we should give up on a quest to determine which intervention works best for a specific set of the population. We can provide value to our customers by providing the best evidence based treatments that we have available. To kill off a method of prescribing treatment limits a therapist’s ability to confidently provide treatment.

“…patients with LBP at two outpatient facilities: Brooke Army Medical Center and Wilford Hall Air Force Medical Center…between the ages of 18 and 60 years…baseline Oswestry disability score had to be at least 30%”

 

This study is highly specific to a military crowd, with an average age of younger than 40. Now if this is not the patient that is being treated in my clinic, it is difficult for me to make the correlation from one population to another. The only thing that we can say for certain about the results of this study is that is pertains to the population that was involved in the study. The baseline Oswestry disability score (for more on the Oswestry see this link.

 

“After the manipulation, the therapist noted whether a cavitation was heard or felt by the therapist or patient.”

 

The cavitation is the audible pop that people think of when getting a fast manipulation. This is similar to popping your knuckles. This pop is not needed for a manipulation to occur, as the movement and speed instead of by the noise that occurs define the manipulation.

 

“A maximum of two attempts per side was permitted.”

 

This doesn’t make sense to me to perform multiple manipulations directed at the same region. The authors noted that if no cavitation was produced that another manipulation would be performed up to four maximum manipulations. We just covered that an audible pop is not needed, so I am unsure why two were allowed for the patient. Let’s just assume that a patient gets better from the manipulation, was it one manipulation or two manipulations that improved the patient? Is it possible that a patient could get better with one, but then get worse with the second…even though a cavitation is heard? There are too many variables that start to play into this study.   This is the landmark study for giving the prediction recommendations for spinal manipulation in PT. Which brings us to the next point.

 

“Two additional treatment components were included: 1) instruction in a supine pelvic tilt range of motion exercise…and 2)instruction to maintain usual activity level within the limits of pain.”
Now we have 3 possible variables introduced into this science experiment. Any scientist would look at this and say that there are too many independent variables, which can affect the outcome. The first is obviously the manipulation. The second is the pelvic tilt. The third is time.

 

“The mean OSW (Oswestry Disability Index) score at baseline was 42.4+/-11.7, and at study conclusion was 25.1 +/- 13.9.”

 

This means that the scores initially ranged from 31-53 and the final scores ranged from 11-39. A change of 10 can be considered significant, so there was a significant change overall for the better.

 

“Thirty-two patients (45%) were classified as treatment successes, and 39 (55%) were nonsuccesses”

 

A majority of patients didn’t respond to the intervention(s), but it was close to a coin flip. This indicates that if we manipulated everyone that came through the door, we would have a success (about 50% improvement in ability) in about half of the patients. This isn’t a bad ratio if it is only done in one visit.

 

“…duration of symptoms < 16 days, at least one hip with >35 degrees of internal rotation, hypomobility with lumbar spring testing, FABQ work subscale score <19, and no symptoms distal to the knee…were used to form the clinical prediction rule.”

 

Here it is! All students are expected to memorize this by the time that they graduate from PT school. All PT’s (at least those that work on backs) are expected to know these criteria for manipulation. There are of course some that will state that CPR’s aren’t very effective in practice, but this rule seems to have stood the test of time over many studies.

 

“…a subject with four or more variables present at baseline increases his or her probability of success with manipulation from 45% to 95%. If the criteria were changed to three of more variables present, the probability of success was only increased to 68%”

 

WHAAAT!? If someone has 4 of the 5 guidelines from above, the success was 95%! This is yuge. I’ll take those odds of success to the tables any day of the week. Now with this said, I have manipulated very few patients. Those that I have manipulated had immediate positive results and the pain was abolished…didn’t return upon follow-up over the course of 2 weeks. I may not be manipulating as many patients as I could, but I also give the patient the opportunity to independently manage and abolish before attempting to perform a manipulation. It’s a theory from another spine management system.

 

“In the present study, only one manipulation technique was used, and it is unknown whether other techniques would provide similar results.”

 

This is also very important to state. There was little research regarding manipulations in the physical therapy research. It must be said that not all manipulations are created equal and that performing a different technique may not have the same result. It may be better or worse. We can only extrapolate this study’s results to those that would match the type of patient treated in this study and the manipulation performed in this study.

 

 

 

 

EXCERPT FROM:

Flynn T, Fritz J, Whitman J et al. A Clinical Prediction Rule for Classifying Patients with Low Back Pain Who Demonstrate Short-Term Improvement With Spinal Manipulation. Spine. 2002;27(24):2835-2843.

To slouch or not to slouch?

“Epidemiologic studies have shown that individuals in occupations that involve prolonged periods of sitting experience a high incidence of low-back pain”

I don’t think that this surprises anyone, but as we continue to advance with technology, the jobs that require mostly standing are going away. Put the data into today’s terms. How many of us had cable t.v when we were kids? How many of us had tablets and laptops as kids? I didn’t and was more active because of it. My daughter would be extremely content to watch Curious George on the tablet all day instead of playing. This sedentary nature is hard to break and usually results in crying until she realizes that we are actually going to play. This research demonstrating sitting as a correlation to back pain needs to be looked at seriously, as our society is sitting more on average, at least in my opinion.

“When changing from a standing to a sitting posture…an increased load on the spine as measured by Intervertebral disc pressures.”

The study that this is from is the landmark study for measuring disc pressure. Alf Nacchemson’s study on disc pressures was the first of its kind and mostly likely will never be reproduced again. The subjects in the study allowed a needle inserted into the disc in order to read the pressure. Picture a pressure gauge for a tire and how it measures how much air pressure is in the tire. Now picture the same thing, but with a needle at the end, measuring the pressure in your disc. This is no good. In order to do this, the disc itself needs to be punctured. This is why the study will not be reproduced. No review board would ever approve a study in which the participants have an increased risk of injury…just for the sake of measuring.

“…anular failure and gradual disc prolapse following fatigue loading of lumbar discs wedged in flexion…sitting for 1 hour results in significant changes in the mechanical properties of the lumbar Intervertebral disc…Wilder et al propose that lumbar disc herniations can be a direct mechanical consequence of prolonged sitting.”

Anyone out there just adjust his/her sitting posture?

There is a lot of research demonstrating that sitting is bad for you. This can’t be argued. There is a newer article that states that sitting for one hour, while watching t.v., can take up to 22 minutes off of your life. In the phrase of the show that we are currently watching on Hulu…”YOU ARE THE BIGGEST LOSER!”

“…studies have shown that subjects with or without back pain are more comfortable sitting with a lumbar support in a LP (lordotic position) compared to a KP (kyphotic position).”

If you sit up really tall and elevate your chest, your low back will make a hollowed position…this is called lordosis. When you bend forward, your low back will make an arched position (think the overly slouched position) and this is called kyphosis. Previous studies demonstrated that the slouched position was less favorable than a more upright position…ARE YOU KIDDING ME?! Who doesn’t like holding a good slouched position for hours on end?

“McKenzie describes a ‘centralization’ phenomenon whereby certain lumbar movements and positions result in a change in the distribution of referred symptoms from a distal to a more central location”

OKAY…THIS IS HUGE. I have written about centralization in the past, here, here, here, here, and here, but I’ll cover it again…just for you. If you have pain that started in the back and then moved location, specifically into one of the legs…this is no good. If you have back and leg pain that moves from the leg into the back…this is good. This is the basics of centralization. It’s called a phenomenon because we don’t know exactly why it happens, but there is a high correlation between centralization and a disc lesion (such as a herniation), which can also be found here.

“…Donelson et al reported that 76 patients (87%) demonstrated centralization. Further, all individuals exhibiting this phenomenon did so following extension rather than flexion movements”

Let’s start with this study may be a little biased, but that doesn’t negate the information in the study…it just has to be looked at through a lens that takes this into account. This article is co-written by the man, the myth, and the legend Robin McKenzie. I hold this man in high regard, as do many therapists that practice in the orthopedic setting. He was voted the most influential PT of the last century and that is a title that takes a lifetime of hard work, educating others and helping the public at large. Here’s a quick video of the legend… watch Robin treat a patient.   With that said, it was still written by an author that has something to gain from a positive outcome by using lumbar rolls. He has his namesake rolls, so we can expect a good outcome from using the rolls prior to even reading the article. It’s still good information that a person can learn from though.

Ah yes…extension. This means bending backwards such as this video by Yoav Suprun a MDT instructor.

“Excluded from the study were patients with:

  1. Medically diagnosed stenosis, spondylolisthesis or recent fractures;
  2. Neurologic motor deficit:
  3. Surgical intervention for the present episode;
  4. Apophyseal joint or epidural injections administered within the previous 4 weeks;

6….

  1. Obvious deformity of acute list or lateral shift or lumbar kyphosis;
  2. Symptoms of hysteria or anxiety neurosis”

This is important to note that the authors are trying to subcategorize patients that are most likely to benefit from using a lumbar roll with sitting. Not all patients will respond well to extension. Patients with stenosis may not respond to extension. This is not true for all, but is the long standing myth taught in PT school. Patients that come in looking crooked or bent over probably shouldn’t be in this study either. I like the last one though…these authors were trying to think of every patient that may not benefit from a lumbar roll in order to rule out using the rolls on everyone.

“The first 70 patients to present within each of the categories were randomly assigned to either a KP or LP group. Whenever required to sit, the KP group were instructed to do so with their back in a supported but flexed posture. Conversely, the LP group were instructed to sit with their back in a supported but lordotic position.”

This is a decent amount of people in the group so it should give some valuable information. One group had to sit slouched and the other group has to sit upright.

“During their first visit to the clinic, patients were seated on the standard chair and immediately given the questionnaire to complete. They were then seated in their assigned posture for 10 minutes, and the questionnaire was readministered.”

This is actually a pretty good way to test the intervention or “treatment”. A test performed before the treatment and immediately after the intervention is the best way to minimize the number of variables looked at during the second testing. For instance, if I give you an anatomy test and tell you to take the same test after studying and watching t.v and sleeping, it’s hard to say which of the three changed the score on the second test. We can assume studying, but it’s not certain. If all you do is study or sleep or watch t.v., then we can narrow down what would’ve caused a change in score.

“Before leaving the clinic, patients were instructed as to the position they were to adopt, whenever seated, over the next 24-48 hours”

This is the part in which the “scientific rigor” of the study will break down. Over the course of 48 hours, there are so many possibilities of making a pain better or worse and the sitting posture is but one variable. Any outcomes taken after this point waters down the results.

Prior to the interventions, there were no differences between the groups with regards to pain location, leg pain or back pain intensity.

“…while there was a 21% decrease in BPI (back pain intensity) for the LP group, there was a corresponding 14.5% increase in pain for the KP group…reduction in leg pain for the LP group after only 10 minutes of sitting…the very marked reduction in leg pain (56%) for the LP group contrasts with no significant change in pain for the KP group”

There were a greater percentage of patients that responded well to sitting with a more upright posture than those that sat slouched and some of those that slouched actually got worse over time. The advice that out moms gave to stand up tall appears to hold true for some folks.

“…adoption of a LP resulted in 48% of these patients having pain that centralized above the knee after only 10 minutes of sitting…10% for the KP group…24% of the KP group’s pain peripheralized below the knee at POST-TEST 3 compared to 6% for the LP group.”

The first thing to take from this is that an upright posture is not for everyone, in that 6% of those that sat upright actually got worse. Getting worse means that the symptoms that you have from your back actually gets worse into the leg, calf or foot. Now, 48% got better in that the leg pain reduced within 10 minutes. What this means for the patient is that sitting taller is worth a shot if you have pain that radiates into your leg. If you get worse from sitting up tall…stop. It’s really that simple to start with. A lumbar roll could be a useful device to get you to sit more upright. This could be homemade such as a rolled up towel, a purse or a forearm by putting your arm behind your back at about the belly button area.

EXCERPTS TAKEN FROM:

 

Williams HM, Hawley JA, McKenzie RA, van Wijmen PM. A Comparison of the Effects of Two Sitting Postures on Back and Referred Pain. Spine. 1991;16(10):1185-1191.

 

Link to article

 

 

 

 

 

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

Paint by number

I recently finished my transitional Doctorate of Physical Therapy degree.  There was long hours involved and lucky for you, I saved all (well…maybe most) of my work.  Here is an oldie, but a goodie (voice of Kasey Kasem)

 

A Critical Appraisal of Clinical Practice Guidelines for Low Back Pain (LBP)

 

P: For patients with back and/or leg pain

I: what is the level of evidence regarding varying interventions, outcome measures, risk factors, and assessment processes

C: throughout the profession of physical therapy

O: that can be used in the course of care of individual patients

 

Reviewer:

Vincent Gutierrez, PT, MPT, cert. MDT

 

Search:

Ovidsp with title terms “low back pain” and “guidelines” with keyword of “physical therapy”. The results were limited to articles published in the previous two years.   Seven citations were found.

 

Date of Search: March 1, 2014

 

Citation:

Delitto A, George S, Van Dillen L, et al. Low Back Pain: Clinical Practice Guidelines Linded to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. JOSPT 2012;42(4):A1-A57.

 

Summary:

 

The purpose of this guideline is to provide physical therapists with information, based on strength of the current evidence, regarding risk factors, clinical course, diagnosis/classification, differential diagnosis, examination, and interventions in the treatment of low back pain, with or without leg symptoms.

 

Content experts, appointed by the Orthpaedic Section of the American Physical Therapy Association (APTA), researched the above information. The authors independently searched the following databases: MEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews to initially acquire the content matter. The articles were limited to articles published prior to 2011 and the authors searched the reference list of each article in order to prevent the omission of a relevant article. The articles were leveled according to the criteria from the Centre for Evidence-based Medicine and were then were issued a grade of recommendation as previously described in the research.

 

The authors provided a comprehensive list of both International Statistical Classification of Diseases and Related Health Problems (ICD) Codes 10 and International Classification of Functioning, Disability and Health (ICF) codes.

 

The authors determined that based on lesser quality studies that data does not support a cause of LBP and risk factors are weakly associated with LBP.

 

Based on lesser quality studies, the data supports performing interventions that reduce the likelihood of transitioning from acute to chronic LBP and reducing the likelihood of recurrences.

 

Based on evidence from high quality studies, it is recommended to sub-classify patients based on signs and symptoms, such as the Treatment Based Classification System. Based on moderate evidence, the following signs and symptoms are useful in classifying patients based on the ICF and ICD-10: mobility impairment in the thoracic, lumbar or sacroiliac regions, referred or radiating pain into a lower extremity and generalize pain.

 

Based on evidence from high quality studies through expert opinion, it is recommended based on moderate evidence to consider performing a differential diagnosis to when serious medical conditions are suspected.

 

Based on high quality studies, there is strong evidence to recommend utilizing the Oswestry Disability Index (ODI or the Roland and Morris Disability Questionnaire (RMDQ) in order to monitor change pre-post intervention.

 

Based solely on case control studies, it is recommended based on opinion that clinicians should assess activity participation limitations.

 

Based on multiple high quality studies and few case studies, the authors provide strong evidence for recommending manipulative therapy in the treatment of LBP. These recommendations are only provided for patients with symptoms above the knee.

 

Based on high quality studies, the authors recommend performing trunk coordination, strengthening and endurance exercises to reduce pain and disability with patients ranging from subacute to chronic and also patients status post microdiscectomy. This recommendation is based on strong evidence.

 

Based on both high quality studies and case control studies, the authors recommend utilizing repeated movements or procedures, in a specific direction, to promote centralization. This is based on strong evidence.

 

Based on lesser quality evidence and case controlled studies, the authors recommend flexion exercises, combined with other interventions, for reducing pain in older patients with chronic symptoms. This is based on weak evidence.

 

Based on lesser quality studies and case series, the authors recommend lower quarter nerve mobilization procedures to reduce pain in patients with subacute and chronic LBP, with lower extremity symptoms. This is based on weak evidence.

 

Based on research ranging from high quality studies to expert opinion, it is recommended that clinicians avoid educational techniques based on pathoanatomy and extended bed rest. Recommended advice is centered on the inherent strength of the spine, the neuroscience explaining pain, the overall favorable prognosis of LBP, the use of active (as compared to passive) coping mechanisms, and early return to activity. This is based on strong evidence.

 

Conclusion:

Based on the Clinical Practice Guidelines above, the following is recommended based on strong evidence: utilizing an outcome measure such as the ODI or RMDQ, manual therapy, trunk coordination, strengthening and endurance exercises, promoting centralization, and performing patient education.

If you have back and want to be seen by a therapist that reads research for fun, come see me at 

FUNCTIONAL THERAPY AND REHABILITATION

now a part of the Goodlife family

903 N 129th Infantry Dr. 

suite 500

Joliet IL

8154832440