I see patterns

I see patterns, quick flashback to the Sixth Sense.

 

“Nonspecific LBP accounts for the great majority of cases of LBP and is defined as LBP for which there is no identifiable cause (e.g, injury or disease). As a result, treatment recommendations commonly involve a one-size-fits-all approach.”

This is reality. When someone has back pain, it is a guess and a poor one at that as to what is the cause of the back pain. Herniated discs? Sure. Arthritis? Sure, why not. Spinal stenosis? Must be. Cancer? Naw, this one we could rule in or out with imaging. The sinister (read really bad) stuff can be picked up through imaging and is assumed to be the cause of pain. What else is out there? Lumbago…WTF is this about? My favorite is back pain. For real, this is how it works. The patient goes to the doctor with a complaint of back pain and after the end of the session, the doctor says…You have back pain. Here’s your script for back pain. See me in a few weeks.

The problem when we can’t identify different causes of back pain, then all back pain is treated via a “shake and bake” or cookie cutter approach. Is Suzy’s back pain the same as Johnny’s, probably not since the symptoms aren’t even in the same location, but it is still coming from the back so it must be treated the same way. There’s a reason that we as the industry of healthcare have failed in treating back pain…we can’t even define it.

 

“The current treatment classification system (ie, a small group [5%-10%] of patients with identified specific pathology versus the large group [90% -95%] with nonspecific LBP) is clearly not working well.”

Have you seen the numbers?! Not working well is an understatement. Here are some scary stats. The 5-10% that physicians can diagnose are those sinister (read really bad) problems.

“Subgrouping patients in LBP does not need to be complex or difficult”

Everyone subgroups patients. Tony Delitto has stated in an article (It’s late and I don’t want to go find it so trust me…I’m a professional) that everyone classifies patients, but the classifcation system may be very rudimentary. For instance, if someone comes in with a history of back pain and has failed at therapy elsewhere, we would say that this person may fail again. This is a way of classifying, albeit not a good one, but one way. There are methods of classifying back pain (don’t see this as diagnosing) based on signs and symptoms and response to movement or other interventions. This is a slightly more sophisticated way. There are methods that have withstood the rigor of research and demonstrate moderate reliability in the assessment of back pain.

 

“A good example in the LBP field is the STarT Back trial that used a simple prognostic tool (9 questions only) to match patients to treatment packages appropriate for them.”

I was fortunate enough to hear Nadine Foster, one of the authors of the original study, speak at a spine conference in 2013. The questionnaire can help clinicians, especially the primary care coordinator (Physician Assistant, Primary care physician, orthopedist, Advance Nurse Practitioner) determine if the patient may improve without treatment or if PT could be beneficial. The final category that a patient could be classified into is the inclusion of physical therapy with the addition of a psychosocial approach to pain.

 

“Clinicians are usually favorable to the idea of individualized treatments for nonspecific LBP.”

If all back pain were created equal, then I’d be in favor for all treatments being equal. When a patient comes in looking crooked with 9/10 pain, then that patient should not receive the same treatment as someone that has 1/10 pain and is looking to return to sports. Different presentations call for different solutions. There is an excellent book out there for patients and insurance companies called: Rapidly Reversible Low Back Pain by an orthopedic surgeon. He follows the thought and ideas of Robin McKenzie.

“Put simply, if there is a subgroup that does well, it must be balanced by a subgroup that does poorly.”

This research is out there, but because it doesn’t meet the stringent standards of most research studies, it is frowned upon. The problem with the study is that the authors of the study aren’t blinded to the treatments and patient classification. This means that the authors could be biased in one way or another. Aside from this, the study is a legitimate study assessing varying treatment for low back pain. There was one group that did very well and one group that did poorly. One group was in the middle of the two, but leaned more towards poor than well. Check out the study from Audrey Long

“Two aspects of human nature that could explain this situation (treatment effect) are that we tend to see patterns where none exist (patternicity) and that we presume we have more control over events than we truly do (illusion of control).”

This is great stuff. I actually printed off the articles so that I could read them later. I’d love to believe that this isn’t me…but wouldn’t everyone. I’d love to believe that I actually see dead people…I mean patterns and no, not the patterns that people create when they see a shadow and believe it’s a ghost. It does intrigue me though to learn more about pattern recognition.

“…we must conclude that in general, the current research initiatives and achievement in this field are far from optimal and not yet ready to be implemented in clinical practice.”

I wish I could agree with this, but then we are treating all patients the same. If we can’t give individualized instruction to each patient, then it doesn’t matter who the patient sees for their problem. It doesn’t matter that one person’s back pain started 2 years ago and hasn’t subsided or that another’s started this week and is expected to improve with time. Both patient’s would get the same treatment approach if we can’t classify.

 

 

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. 

Results based care

Results based care

 

I’m going to get away from typing out all of the quotes, which is what I have been doing for the previous year, for the sake of time. I have opinions that can be expressed without the need for the direct quotes. I’ll still link to the article so one can go back to read it if interested.

 

Health care is changing. We are moving from a fee-for-service type of setting to pay-for-performance setting. Some of us are thinking “about damn time!”

 

Fee for service indicates that a person gets paid for doing things to do. For instance, if I keep you for 90 minutes and do a bunch of stuff with you, then I would get paid much more than if I only spent 45 minutes with you. Now, if I see you for 90 minutes and see you 3 times per week for 4 weeks, then I would make a lot more money from the patient than if I saw for 45 minutes 1-2x per week. There is absolutely no incentive to get a patient better quickly. Do the patient’s realize this? I hope that this article goes viral so that the patient’s have a better opportunity to read this information. Some health care providers would hate for this to happen and other are thinking “HELL YEAH!”

 

Pay for performance: Some of the ways that this is being done is that a certain dollar amount is allocated for a specific diagnosis and this amount is paid regardless of how often or how many times I see the patient. I now have a huge incentive to get you better fast and to make you as independent as possible so that you no longer need to seek treatment for the same issue. If the patient can get better faster, then there is more money to be made in healthcare because we are not treating out of fear, but instead out of ambition. Some companies are afraid to discharge a patient because there may not be another patient taking that spot anytime soon. I’ve worked in these situations multiple times before, so I am not talking out of my A$$. Treating out of ambition allows the therapist to apply the evidence as best fits for the patient in front of us in order to get that patient better faster. No offense, but I want my patients to get better and leave. Hopefully, to never come back for the same thing again. I was listening to an episode of Mechanical Care Forum in which the therapist (Mark Miller) was describing an embarrassing moment in which Mark had a patient returning to therapy for the same complaint that the patient was there previously. He was proud because he thought the patient was coming back because he did such a good job the first time and the patient was satisfied with the treatment, but Robin Mckenzie, one of the most influential PT’s of the last century, noted that if the patient was actually better and if Mark did his job then the patient would know how to address the situation without seeking help again. I want to treat with the hope that the patient will only come back because they have a separate issue that needs a consultation for treatment. This is the ambition that I am talking about.

 

The article speaks of staying up to date on the literature, regularly attending continuing education classes, learning new approaches, tracking outcomes and adjusting treatment according to the patient. I would love to say that 100% of PT’s are performing all of the above in the list, but I can’t. There are countless articles speaking to the reasons that PT’s give for not staying up to date with the research, which indicates that there are some aren’t doing their professional or social duty. I take this stuff seriously. It’s Easter and I am typing about the stuff I just read. It sucks to take time away from work in order to find the articles, read them and then try to put the information out on the World Wide Web for patients and other therapists to read and criticize. I’d love to relax with my beverage of choice and just not think about it, but my patients and society, as a whole deserves better from my profession and me.

 

Anyway, Medicare is moving more towards a pay for performance method of healthcare and their goals are pretty aggressive. Medicare will have up to 50% of patients on this type of fee schedule by 2018 and for those that are still fee-for service, medicate will tie the payment to outcome measures in 90% of the cases by 2018.

 

I’m doing my part to educate, educate and overeducate the patient in order to get the patient on board with treatment. If I can get the patient to play an active role in the treatment, then I know that I have a better chance of getting that patient better.

Themes taken from:

Jannenga H. Tracking for success: Why outcome measures are essential to your practice. IMPACT. Jan 2017:53.

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.

Call a spade a spade

  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”.

 

  1. “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.

 

  1. “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.

 

  1. “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.

 

  1. “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.

 

  1. “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.

 

  1. “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.

 

  1. “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.

 

  1. “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.

 

  1. “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.

 

  1. “…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.

 

  1. “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?

 

  1. “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

What do pigs and humans have in common?

“The majority of in vitro research has examined repeated axial loading with the spine in a neutral position from which observed herniations are extremely rare.”

 

This means that loading much weight onto your shoulders doesn’t appear to affect the disc negatively, aside from compressing it. Picture the people doing strongman, powerlifting, Olympic weightlifting or Crossfit. All of these sports are safe regardless of how much weight is being used, as long as technique remains good, while under the weight.

 

“The most consistent development of disc herniation with repeated loading conditions was achieved by Gordon et al. In vitro human lumbar motion segments were flexed from a neutral posture to 7 degrees of flexion with a small axial twist motion. All 14 of the motion segments examined failed with herniations of the Intervertebral disc (either nuclear protrusion or extrusion) with an average of 40,000 loading cycles to failure. It appears that load, motion, degenerative condition, and repetition require further investigation as prerequisites to disc herniation.”

 

Stu is one of the great gurus of back pain. He states in his papers that he does not endorse a specific number of flexion cycles to create a herniation. This is individual for each person. Also of note is that the above experiment is not done on a live person, but on a cadaver. This means that there is little compensatory motion that can occur, which may occur in real life. For example, there is one paper (don’t have it currently, but I will find it for later) that postulates that the posterior longitudinal ligament (a strong ligament on the back of the spine) may be a protective mechanism for back pain, which would then work to prevent a disc herniation by absorbing some of the flexion load. It’s just an idea though and is no more right or wrong than the number of loading cycles found in the above quote.

 

“The cervical spines of 26 porcine specimens were obtained immediately following death. Pig cervical spines have been shown to be the section closest to human lumbar spines for anatomical and biomechanical characteristics.”

 

The authors make is sound so humane that they waited until the pigs died, but then went on to say that the mean age was 6 months. They died for science. What is most important though is that this study was performed on pig spines! The results can be correlated to humans, but again this will not be precise because the subjects aren’t real live humans.

 

“The remains of any soft tissue and discs were dissected from the cranial and caudal endplates.”

 

The muscles were removed. The muscles, tendons and ligaments provide active and passive support to the joint. Without this support, we are only looking at how the spine joint moves in a vacuum. This again makes it hard to take the results of this study and apply them to humans. We can though take the idea of the study and generalize it to another spine.

“Herniation occurred with modest levels of compression and flexion/extension movements but with a high number of motion cycles. Specimens tested in the lowest compressive force group had nuclei that were intact after 86,400 flexion cycles…All herniations that were created during testing occurred in the posterior or posterior-lateral areas of the annulus.”

 

The first thing to take from this is that the spinal segment is strong. It can withstand over 80,000 cycles of flexion/extension, without resting, and some were able to withstand the force without significant anatomical changes. All herniations were posterior or posterior lateral. This is consistent with what we see in the clinic. Very rarely is there an anterior herniation, but in real life there is also a very strong ligament on the anterior portion of the spine, which would impede a herniation in this direction.

 

“…highly repetitive flexion/extension motions and modest flexion/extension moments, even with relatively low magnitude compression joint forces, consistently resulted in Intervertebral disc herniations. Larger axial compressive force resulted in more frequent and more severe disc injuries…there is no doubt that disc herniation is a cumulative process that can result with modest forces if sufficient flexion/extension cycles are applied.”

 

This is a mouthful. Let’s start by saying that if you spend a lot of time in a flexed (slouched posture position), this may lead to a posterior disc herniation. It’s kind of like the straw that broke the camel’s back. It may not happen the first time, but the more often one spends in flexion the more that the nucleus (the pudding substance inside the disc) will travel towards the border of the disc (annulus). This article doesn’t state what happens to the disc when we rest and stop spending time in a flexed position. For instance, what is not stated is that if we flexion for an entire day, but then move in the opposite direction (extension), do we then counteract the effects of flexion? This article doesn’t say this, but one would have to infer if we could create a herniation that we can reduce a herniation with movement. More to come in future posts.

 

“While there may be a tendency to identify an event that ‘caused’ an intervertebral disc herniation, this work together with our other experiments have led us to form the opinion that this is only a culminating event and that the real cause had already occurred.”

 

This quote says it best and I will leave it at that.

 

Thanks for reading. If you would like to learn more about a topic, feel free to ask a question on here or at my Facebook page @movementthinker. I love reading research and if I can read something that may help you specifically then it is more functional than just reading stuff that I enjoy.

 

Callaghan JP, McGill SM. Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compression force. Clinical Biomechanics. 2001;16:28-37.

 

link to article

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