Category: PTs

1. “Although numerous propositions have been put forward in the literature about how we might usefully subclassify low back pain (LBP), we must first consider the potential utility and futility of such aspirations and ask, “Will it change the outcomes of patients?”

 

This first statement in the paper is great. All therapist classify patients using either a sophisticated method (which will be spoken of in this paper) or a method that lacks sophistication (a patient’s education level, income level, etc). The big question that we have to ask is “does any of it really matter”.

 

2. “Within this arena, there are two schools of though-nominalist and essentialist. Nominalists define a disease by its symptom profile (CLBP = back pain of duration > 3 months). Essentialists state that each specific disease has an underlying pathophysiology, implying treatment of the disease requires treatment of the pathology”

 

This is fun for me to read. I never though of it this way, but I guess that I would be a nominalist in most cases. Rarely do I believe that the underlying pathophysiology must be treated in order to resolve symptoms. Let me give you an example. For patients that have degenerative disc disease (this is a very common diagnosis in the clinic and most will have this over the course of the lifetime) there is nothing that I will do to regenerate the disc, but I may be able to teach the patient how to either shut off the pain or manage the pain. This would be the nominalist in me. The essentialist in me has another example, which is also a real example in the clinic. There was a patient coming to therapy for treatment of his shoulder. In the process of treating the shoulder he developed back pain (not while in the clinic with me). Anyway, he neglected to tell me about the back pain, but later in the course of care (all within a couple of weeks) went to an urologist for urinary issues. He never told his urologist about the back pain and was advised to use a catheter to urinate! Anyway, he told me about his catheter issues and I was curious. I asked if he was experiencing any back pain or leg pain and sure enough he was. I called a surgeon that I trust and the patient was in surgery within a day. He had an issue that required surgical correction of a pathological issue. In this case, I am an essentialist. Now that I think about it, I am not sure if one can root for only one team.

 

3. “These classifications can broadly be divided into three groups: (1) those that consider clinical descriptors, (2) those that describe prognosis, and (3) those that consider response to treatment.”

 

I am credentialed in Mechanical Diagnosis and Therapy, formerly known as the McKenzie Method. In this respect I am a little biased and it is important that you guys know that I am biased towards one method before reading the rest of the article. MDT would be a patient response approach.

 

Other systems, such as the Treatment Based Classification System (TBCS), which wasn’t even considered in this article it looks like, is a system that is based on clinical prediction rules. This means that if you come in and say some key words and test positive on some key tests that it would dictate a specific category of treatment, which is completely different from a patient that speaks of different key words and test negative on key tests.

 

4. “We identified 28 classification systems of CLBP (chronic low back pain)…systems that described subclasses based on pathoanatomy, pahtophysiology, or clinical signs and symptoms without attempting to predict outcome or direct treatment were labeled as ‘diagnostic’…systems attempting to predict outcome irrespective of treatment were termed ‘prognostic’…systems that suggested treatments for different subclasses were termed ‘treatment based’…16 diagnostic, seven prognostic, and five treatment-based classification systems for CLBP.”

 

Typically, when I am writing a blog post I go to the back of my library (actually a trunk in the crawlspace) and grab an article that I read years ago. (I know…I am a nerd because I keep research articles that I read years ago). Anyway, re-reading the highlights of this article is like reading the article for the first time. I forgot that there were this many classification systems out there. Typically only a few are spoken of in the clinic and these are: the movement impairment system, Quebec Task Force, Mechanical Diagnosis and Therapy, Treatment Based Classification System and the Canadian Back Institute Classification System.

 

I will have to read the highlights of the article again in order to figure out which system fits into which category.

 

5. “The first description of a treatment based system was by McKenzie, who classified patients into three main syndromes based on physical signs, symptom behavior, and their relations to end-range lumbar test movements”

 

Is it wrong that I was pounding my chest when I was typing the above sentence? This reminds me that I will have to write a blog on the history of MDT. One can see the history of MDT in the book Against the Tide.

 

6. “Riddle and Rothstein assessed 49 physical therapists with varying clinical experience, in their ability to classify 363 patients according to the McKenzie system. Their ability to agree at the subsyndrome level was poor…Agreement among examiners was only marginally improved for classification into the three main syndromes…Agreement among examiners was better in three studies that assessed physical therapists who completed a certification in the McKenzie method with percent agreement ranging from 74% to 91% for subsyndromes and 93% to 100% for main syndromes.”

 

This tells us a few things. First is that those certified in using a method are actually good at using the method and those that aren’t certified aren’t as good at using a method. I think that this thought process would hold true for many aspects of different professions. I actually had a discussion on FB about this topic and I don’t think that it is the magic of the certification that increases agreement, but the hours upon hours of studying that went into preparation for the test that increases therapist’s competency of using a method. When a therapist is certified though, the agreement is close to perfect.

 

7. “Movement System Impairment classification…proposed by Van Dillen et al and includes five categories based on signs and symptoms elicited with direction-specific tests in the direction of lumbar flexion, extension, rotation, rotation with flexion, or rotation with extension…shown to be reliable in three different studies”

 

I’ll have to read more about this system because at a glance it sounds eerily similar to McKenzie’s method. Both appear to have a “directional preference” based treatment and avoidance (I’ll assume only temporarily) of the aggravating factors.

 

8. “Canadian Back Institute Classification system…recognition of syndromes or patterns of pain with no direct reference to pathoanatomy…the classification was based on the location of dominant pain, whether the pain was constant or intermittent, and which movements or postures exacerbated or alleviated the symptoms…shown to be reliable in one study.”

 

Again…these systems are starting to sound familiar and similar to each other. Figure out the symptom location, what makes them worse, what makes them better, is it mechanical or chemical and then name it for what it is. This appears to be the same in the three classification systems.

 

9. “Movement and Motor Control Impairment (MCI) classification system by O’Sullivan proposed treatment based on subgroups of patients with CLBP categorized by five distinct patterns based on a specific direction of MCI…flive categories included flexion pattern (loss of motor control into trunk flexion resulting in excessive abnormal flexion strain), flexion/lateral shifting pattern (MCI around the lumbar spine with a tendency to flex and laterally shift at the symptomatic segment), active extension pattern (MCI around the lumbar spine with a tendency to hold the lumbar spine actively into extension), passive extension pattern (loss of lumbar motor control around the lumbar spine with a tendency to passively overextend at the symptomatic segment), and multidirectional pattern (MCI around the lumbar spine in multiple directions)…The percent agreement was 70%.”

 

It seems like this system is all about a loss of control at the lumbar spine. The agreement of classification isn’t bad at 70%. I struggle with this system because it does not appear to be a patient response based system. I’ll have to read more into this system. The first thing that I think of is “how do we know if we are doing the right thing and how long do we have to wait in order to determine if we are moving in the right category.

 

10. “An RCT assessed the classification system by McKenzie by randomizing 260 patients into two groups: Group A was treated with the McKenzie method, and group B was treated with intensive dynamic strengthening training…tendency toward a difference in reduction of disability using the Low Back Pain Rating Scale in favor of the McKenzie group at the 2-month follow-up assessment, but no differences at the end of treatment (4 months) and at the 8-month follow-up evaluation.”

 

Some would look at this and say that MDT was no better than strengthening at 4 and 8 months. Others would look at it and say that MDT was better than strengthening at 2 months. If you were a patient, which would you rather have? Would you rather be better at 4 months or two months…knowing that you would be at the same place in 8-months? This study doesn’t seem too realistic in that once a patient is improved with MDT, then the treatment would transition towards a functional strengthening phase.

 

11. “…overall strength of evidence …is High for the McKenzie and Movement Impairment Classification systems, especially when examiners have been extensively trained; Insufficient for the Canadian Back Institute Classification; and Moderate for the MCI Classification”

 

This sentence sums it up. MDT has moderate evidence to support that it is highly reliable. The Canadian Back Institute Classification system has low evidence to show that it is insufficiently reliable.

 

If I were a therapist going to learn a new method, I would have to start with MDT based on the volume of studies demonstrating reliability.

 

12. “Once it is established that patients can be classified reliably, it then must be demonstrated that by directing a specific treatment at the subgroup, one can expect an improvement in treatment outcomes.”

 

This means that once we know what we are seeing…can we fix what we see? What is the purpose of classifying a patient into a group if the treatment for that group is ineffective?

 

13. “This suggests that the ideal classification system should minimize the number of subgroups to ensure that the user can become confident (and competent) it its use with little training.”

 

Holy smoly do I disagree. We just said that the subgroups must lead to a specific treatment that performs better than other forms of treatment. If we minimize the number of subgroups, then we are minimizing the impact of subgrouping. For instance, if we state that there is only one subgroup, then what is the likelihood of the treatment for that one subgroup helping all of the patients? We already know that it’s pretty low…this is how we got into this mess to begin with. In the past, all low back pain was treated very similarly, with horrible effects. Now, if there is only one subgroup, we can be assured that most people would fit into this subgroup. Therefore, the therapists would be highly reliable in choosing the group in which to place the patient. THIS DOESN’T MEAN THAT IT WILL ACTUALLY BE EFFECTIVE TREATMENT!

Back pain is very costly in the US. We need to do a better job of minimizing the disability from LBP and educating the patients regarding back pain natural course and how to live and manage this ailment. There have been other systems created since this article was published in 2011 and we will see how these systems fair over time.

Excerpts from:

Fairbank J, Gwilym SE, France JC, et al. The Role of Classification of Chronic Low Back Pain. Spine. 2011;36(215):519-542.

 

link to article

Crooked patients 

1. “A lumbar lateral shift (LLS) is defines as a lateral displacement of the trunk in relation to the pelvis…repeatedly associated with discogenic pathology…McKenzie reported that 90% respond rapidly to manual correction.”

 

In school we learn the theoretical aspect of the shift, but when you see your first patient that is shifted the though process immediately goes to a mixture of “oh shit and piss on yourself excitement”. The shift can be extremely painful and students, if not treating this in a clinical, may not be prepared for a patient in a true 10/10 pain status. After so many years in practice, it is just another puzzle to solve now. The excitement has gone away and lucky for the patients, so has the “oh shit” response.  

 

Patients come into the clinic “crooked”. Scott Herbowy once said it is like looking around the corner to see if the dog is hiding.  

 

2. “…prevalence of LLS is difficult to establish, but estimates range from 5.6 to 80% of patient with low back pain (LBP).

 

This statistic is so far away from informative, that it shows that it is present in any where from 5-80 out of 100 patients with back pain. I don’t see it in 80% of the patients, but 5% may be more applicable to my population in the clinic.

 

3. “Lumbar spinal fusion, perhaps the most invasive of these (surgical) procedures, is increasingly common in the United States. However, its effectiveness is questionable…”

 

If you are going to have a fusion, go so someone that is either certified or diplomaed in MDT first. Some things can’t be undone, and this is one of those things. Make sure that there are no other options of getting relief prior to undergoing something that may not be effective and can not be undone.

 

4. This article is a case study of a patient that has a lateral shift deformity in the presence of an “X-stop” device, which is typically used to prevent lumbar extension in the case of spinal stenosis. The patient centralized with side gliding mobilizations and was issued side gliding against the wall in order to close the affected side. The patient responded well to this motion within the initial 4 visits and the final 4 visits were used to improve functional performance without the return of the lateral shift. The X-stop makes this case interesting because typically patients that are post-surgical are excluded from most research.  

 

5. “The rapid centralization of symptoms observed in this patient is similar to that reported in previous case reports describing a lateral shift correction. Centralization or peripheralization during repeated movement testing has been positively correlated with pain provocation during lumbar discography.

 

Centralization phenomenon is something that trained clinicians are looking for during examination of the spine. When noted, the results are typically great, but if the peripheralizes (opposite of centralization), then the patient’s results are typically poor, at least if it happens with all movements tested.  

 

First point to make from this is that if you have back pain, seek out a trained therapist in order to address your symptoms. Always start conservative before going invasive for pain based symptoms. If you have progressive weakness or have a loss of bowel and/or bladder function go the doctor immediately, but aside from this stay conservative first.  

 

Second, people get crooked. If the crooked is not associated with pain, it may be that the person has always been crooked. Not all crooked people need therapy.  

 

Excerpts taken from:

 

Peterson S, Hodges C. Lumbar lateral shift in a patient with interspinous device implantation: a case report. JMMT. 2016;24(4):215-222.

 

1. “The condition has been identified as the leading contributor to ‘years of life lived with disability’ in the world including the United States.”

 

Big surprise, we are talking about back pain again. I see a majority of my schedule as back pain for the previous 8 years. There is no loss of people with back pain. This is an epidemic. The only reason it is not treated in such high regard has cancer, AIDS, Zika, and others is because it’s not deadly and does not cause major deformities. Because back pain is so common, it’s treated with little urgency such as the common cold.

2. “In Australia, LBP is estimating to reduce gross domestic product by $3.2 billion annually and is the leading cause of early medical retirement for older working people.”

Think about that! You go to school and you load up on student loan debt. After school you get a job paying much less than you think you’re worth. Then you get sidelined by low back pain and are forced to retire well before you’re ready. It doesn’t have to be this way! Not all low back pain is the same, and when you figure out what type of back pain you have it becomes a lot easier to prevent recurrent issues of back pain.

3. “Directional preference classification is characterized by a reduction in distal pain and/or observation of the centralization phenomenon with the application of repeated or sustained end-range loading strategies to the spine that remain better after assessment. Centralization is defined as a progressive change in pain from a more distal location to a more proximal location that remains better after applying repeated or sustained end-range movement to the spine… hallmark characteristic of the McKenzie derangement classification.”

There is no doubt that a directional preference correlates with great outcomes. There is no doubt that centralization correlates with great outcomes. The thing that needs to happen is that therapists need to be trained to see these during the initial evaluation. A majority of patients demonstrate a classification utilizing the McKenzie method, based on the research of Stephen May. The derangement classification is the largest classification syndrome based off of Stephen May’s previous research, but there are other syndromes. Typically, it’s the derangement syndrome that the research attempts to study. I see very few articles on the other two syndromes in the mainstream research journals.

4. “There is some evidence that improvement in size and recruitment of the muscles of the spine, including the transverse abdominis, is associated with improved function in the short-term when patients with low back pain receive motor control exercises compared to general exercise or spinal manipulation. However, increases in transvere abdominis and lumbar multifidus thickness using real time ultrasound have also been observed immediately and one week following spinal manipulation in people with low back pain, suggesting that increases in transverse abdominal recruitment may not be specific to motor control exercises.”

OK, a muscles ability to contract is not dependent on its side. A muscle’s ability to contract is based off of that muscle’s ability to receive the nervous system input from the central nervous system. Should there be something that allows for better neural activity, we expect to see an increase in muscle contraction and possibly an increase in muscle size. This is important because we may not have to train a muscle in the traditional sense in order to making muscle contract better.

5. “The McKenzie method was prescribed according to the principles described by McKenzie and May… Delivered by two therapists who had obtained the level of credentialed therapist from the McKenzie Institute International… Mechanical therapy, including patient and therapist generated forces utilizing repeated or sustained and range loading strategies in loaded or unloaded postures, according to the patient’s directional preference..that guided by symptom response. The aim was to reduce, centralize, and abolish peripheral symptoms… Once symptoms centralize, any movement loss was then treated with repeated and range movements in the direction of movement loss… Received a copy of treat your own back to supplement treatment and self-management.”

The patients included in the study were all patients of the derangement syndrome. When assessing a patient utilizing the McKenzie method, we are attempting to classify the patient into one of three syndromes. This has a high reliability when performed by therapists that are highly trained. The hallmarks of the derangement syndrome is centralization, this occurs when symptoms move from a segment far away from the spine towards the spine. The symptoms in the furthest position from the spine have to decrease or abolish. This is accompanied by the directional preference. A directional preference is as stated, when we move you in a specific direction…your body prefers that. Your body tells us it prefers that direction by centralizing symptoms, improving range of motion, improve strength, or improving other neurological tests such as reflexes and dural tension testing. One can also have a directional preference in the absence of centralization, as extremities also demonstrate directional preferences.

6. “Initially, promotion of independent contraction of the deep stabilizing muscles, such as the TrA and multifidus, was facilitated by pelvic floor contraction…Objectively, skill mastery of TrA recruitment was measured by palpation and visual assessment for a reduction of overactivity of the superficial trunk muscles…practice daily…attend the physical therapy clinic twice a week for the first 4 weeks and once per week for the remaining 4 weeks”

This is beat into students during PT school…understanding the impact of performing TrA contractions on low back pain. The problem with this theory is that the research is scant on cause and effect. We know that patients with low back pain have smaller multifidi and TrA muscles, but we can’t say “chicken or the egg” yet. We also can’t say if the back pain caused the smaller muscle or if the muscle was smaller and then it caused back pain. More research needs to take place. The topic of centralization and directional preference was briefly touched upon while I was in PT school and the topic of TrA was hammered into us. Now it appears that centralization and directional preference are being taught more in PT schools based on the students that I get as a clinical instructor.

7. “Participants allocated to the McKenzie method group attended an average of 5.4 +- 2.5 treatment sessions over an average of 38.6+-18.8 treatment days, while participants in the motor control group attended an average of 6.5+-2.7 treatment sessions over 47.3+-22.7 treatment days”

This doesn’t look like a huge difference, but this indicates that those being treated by a MDT credentialed therapist, one less session was required. Think about this again. Each session is performed at a cost to insurance companies (read Medicare) of about $100. At this point, each patient would save $100 to insurance companies when seen by a credentialed MDT therapist. This, over the long term, has dramatic effects on the total cost of spending in the US.

8. “…no statistically significant effect for treatment group for muscle thickness…at an 8-week follow-up in a population of people reporting chronic LBP classified with a directional preference. Global perceived improvement was the only secondary outcome that demonstrated a significant between-group difference, which favored the McKenzie method”

Let me say this slowly. Using a directional preference based exercise provides the same result as actually training a specific muscle in terms of muscle size! This is huge! We all are taught that to make a muscle bigger (hypertrophy) requires up to 6 weeks of performing an exercise in order to specifically improve a muscles size. This indicates that a muscle’s size can increase without any direct exercises to improve a muscle’s size.

The final piece of this is that those treated with MDT based principles actually felt better than those receiving motor control exercises (read this as core stabilization).

You walk into any clinic in America (aside from those that are doing MDT) and you will see bridges, bird-dogs, pull your belly into your spine exercises, and of course the traditional hot pack and e-stim. These types of treatments may not be the best. Ask your therapist how your back pain is classified. If they can’t give you a straight, honest, and well reasoned answer…FIND A NEW THERAPIST!

9. I am bolding this, because it is important to read straight from the article. There will be no explanation needed.

“Results from our study suggest that in patients with a directional preference, receiving exercises matched to their directional preference is likely to produce a greater sense of improvement than receiving motor control exercises.”

Excerpts taken from:

Halliday MH, Pappas E, Hancock MJ, et al. A Randomized Controlled Trial Comparing the McKenzie Method to Motor Control Exercises in People with Chronic Low Back Pain and a Directional Preference. J Orthop Sports Phys Ther.2016;46(7):514-522.