Biopsychosocial Role of Manual Therapy – Moving beyond Symptom Modification

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“An important role of human body is to protect itself, in particular the health of the nervous system, a somewhat important system that sustains conscious human existence, which has physical, cognitive, and emotional layers attached to it. It is likely not helpful to label these protective behaviors as bad or good, but to recognize in some circumstances that these protective behaviors may begin to limit function. Often, movement and physical behaviors of the body are perceived as part of the musculoskeletal system alone, however cognitive and emotional states, which are intricately bound to social/cultural demands and expectations, also influence body behaviors, including postural and ideomotor tendencies that could manifest as protective strategies of the human body. Some of these protective behaviors may limit movement and movement variability and this could be sensitizing to the peripheral nervous system because nerves might not be experiencing adequate blood/movement/space, chemical irritation might not be dispersed quickly enough, and/or they could be undergoing possible noxious mechanical deformation. While the goal should always be to have the client independently explore variability and quality of movement, sometimes they simply can’t find the area of their body to move, have poor sensorimotor awareness and coordination, and generally have difficulty creating movement variability without some guided tactile input from another person. There is notable evidence in research that somatosensory neuroplastic reorganization is constant and that certain areas of the body are poorly mapped, such as the back/pelvis/hip. Furthermore, a sense of self is more than simply “where are the body parts”, how humans see themselves internally via interoception has been recognized as an important component of their behavioral and emotional states. Lack of movement, movement invariability, and pain experienced with movement may result in changes of these body maps that make sensorimotor awareness and coordination challenging. Tactile input and tactile cues do not necessarily need to be considered “manual therapy”, however, many traditionally taught manual therapy techniques can easily be “re-framed” in ways that could help someone to better “get to know their own body and behaviors”, including influencing somatosensory mapping and sensorimotor behavior through various forms for clinician “manual” input. I would argue that in our continued efforts to improve on the application of a biopsychosocial framework, we move beyond using manual therapy simply for “symptom modification”, but rather helping a person to better understand their body and the behaviors it exhibits, not only in the clinical setting, but in broader biopsychosocial contexts. “ – Leonard Van Gelder

Triggers of Acute LBP

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Often as a culture, we have associated lifting heavy things and being in awkward positions as triggers of acute LBP. While these are important factors, the risk of them causing an initial episode of acute LBP is SIGNIFICANTLY increased when combined with psychosocial factors:

“transient exposure to stress and fatigue triples the odds of developing immediate back pain, whereas distraction increases the odds by a factor of 25” – https://www.ncbi.nlm.nih.gov/pubmed/25665074

Regard recurrent cLBP triggers, a recent study  looked at 6 physical factors factors that play a role in a ‘flare-up’ of LBP and compared them with stress and depression. They looked at the following physical factors:

1) lifting a heavy object (≥35 lbs.) between 1-5 times, or >5 times,

2) running/jogging,

3) vigorous, non-contact sports (i.e. tennis,swimming, cycling, etc.),

4) vigorous contact sports (i.e. football, hockey, soccer),

5) physical trauma such as a fall, motor vehicle accident, or other trauma,

6) prolonged sitting (>6 hours),

7) prolonged standing (>6 hours)

8) physical therapy (PT) for LBP.

Rather than heavy loads and intense activities as triggers of LBP ‘flare-ups’, instead they found “prolonged sitting (>6 hours) and stress or depression triggered LBP flare-ups.”. Good news for those of us in rehab, the data supported that “PT was a deterrent of flare-ups. ” – https://www.ncbi.nlm.nih.gov/m/pubmed/28700451/

Research Review Brief – Education vs. Symptom Based Modification for cLBP

Research Review Brief

An educational approach based on a non-injury model compared with individual symptom-based physical training in chronic LBP. A pragmatic, randomised trial with a one-year follow-up – Sorensen, et al.

Population

207 patients 18-60 years (52% female)with LBP for at least 4 out of the last 12 months with the last 14 days =/>4/10 on a VAS. If they had leg pain, the back pain had to be a worse complaint. All subjects made it through the study with no drop out in either groups (impressive!)

Treatment Groups

Group 1 (EDUC):  105 Subjects received an educational approach designed to improve confidence in the robustness of the spine and two movements: Seated flexion and rotation
Group 2: 102 Subjects received Symptom Classification Based Treatment – MDT(by certified MDT) Directional preference, Stabilization, or intensive dynamic exercise. IN ADDITION: group 2’s physical therapists could at their own discretion referred for pharmacology, manual therapy, or physician for injection to complement their symptom based plan

Outcome Measures

Pain, Activity Limitation, FABQ, Back Beliefs, physical activity, work ability, quality of life

Results

Primary Outcomes: Non-significant trend towards activity limitation being reduced mostly in the educational group although this could not be determined as clinically relevant.

Secondary outcomes: Improvement in fear-avoidance beliefs was better in the educational  group. All other variables were about equally influenced by the two treatments.

The median number of treatment sessions was 3 for the educational group and 6 for the physical training group.

Conclusion:

“We have demonstrated that, among patients with cLBP, the educational/cognitive intervention with few consultations was at least as effective as an individualized, multidisciplinary physical-training approach. ‘At least’ refers to the observed overall trend of more improvement in activity-limitation with EDUC. ”

“There was a statistically significant difference at 2 months in favor of EDUC in the proportion of people improving by a Minimal Important Change (MIC) in activity-limitation (5 or more points on the LBP Rating Scale).

“Post-hoc regression analysis showed a relationship between improved activity limitation and improvement in FABQ, and FABQ was more improved in the EDUC group at all three follow-ups, on balance these data appear to favour the EDUC approach.”

 

Full article Available Here.

Finding Ease Part 2 – Sitting

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***Please read Finding Ease Part 1 – Making Peace with Posture and Pain prior to reading and watching the video below:

Ah, sitting, Western culture’s perceived demon. Is it really that bad? The alternative of standing all day isn’t fairing well in research or in practice, so perhaps it is time that we reconsider making peace with sitting.

One of the questions I ask about sitting, is how often are most of us really “using a chair as a chair”? Are we resting in a chair, or are we desperately trying to meet the cultural phenomena of “good posture” and not allowing our body to take a rest? We look at the phenomena of lumbar flexion-relaxation in standing during bending behaviors and we see that it is hard to let our lumbar extensors rest when we are in pain. It has also been shown that in some cases, even after pain resolves it is still hard for us to “let the back go”. When we look at sitting behavior of the lumbar extensors in pain-free individuals, there is a nice relaxation of the lumbar extensors during slouched sitting. Coincidentally, much like standing trunk flexion, people experiencing low back pain have decreased flexion relaxation in sitting.

Clinically, I see this every day with my patients who cannot tolerate sitting well. Even when slouched, they struggle to really be at ease in any chair. There is this disconnect between finding comfort and holding their body how they believe they “should” be holding it. They can’t give themselves permission to shift to a more comfortable position, and if they do change, its seems like their only option is a big giant “ants in the pants” change to find momentary relief for their nerves that have been screaming for blood, movement, and space. My early attempts at telling people simply to “relax” were relatively fruitless. People didn’t start getting more comfortable with long bouts of sitting until I transitioned to an experience-based approach to exploring options and introducing variability throughout the body for finding ease in the sitting. All the while combining the experience with pain science education. Thanks again to Joe Witte for inspiring the foundation for this experience, I have definitely am doing a dis-service to the simplicity of his approach.

Find Ease Part 1 – Making Peace with Posture and Pain – Including Application video

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What is a “good posture”? When  295 physiotherapists across the world were asked this question, they could not agree on what it looks like. If you were to ask more than one person who claims to work on posture this same question, odds are pretty good you will get different answer. Despite a lack of agreement, people still believe that a “good posture” exists. On the other end of a spectrum, a number of scientific research studies have failed to demonstrate that “bad posture” (whatever that means) causes pain; most could not find a connection and those who found a correlation could not separate out cause from effect. For those of you unfamiliar with the literature, please check out Ben Cormack’s Definitive guide to Posture & Pain in 3 minutes flat post for a brief abbreviated overview. Despite these contradictions, the widely held belief that a “perfect posture” and a “bad posture” exists continues to be spread.

As much as I would love to believe we all recognize that the complexity of pain makes something as simple as posture simply a grain of salt in the big picture of the worldwide disabling epidemic of pain, this recognition does not appear to be trending much better, yet…  A slight glimmer of good news occurred as some international news circuits have picked up on a recent study which nicely demonstrates that the fear-mongering “text neck” does not cause pain and the Guardian recently had a great post regarding the myth of sitting posture. If these don’t get you thinking, check out a great video from Greg Lehman titled “Perfect posture doesn’t exist“.

If you think about it, it never really made sense, take a moment to look at life around the world and recognize how what many perceive as “bad postures”, are in fact, a normal variation in the demands of daily living. The body is remarkably resilient and designed to take on the stresses of daily living:

Part of the problem in interpretation of “good” or “bad” posture is the illusion that somehow, we are all keeping certain postures during the day. The truth is, we rarely keep the same posture for long. Dreischarf et al. looked at 208 adults with no current low back pain and monitored their lumbar spinal postures via electronic sensors for 24 hours. They found that the average range of change during the day was 8-33 degrees of lumbar lordosis! What we think of posture is just a tiny snap shot in the motion picture that makes a person’s day:

Another problem is that what we perceive as a “bad posture”, may simply be representative of an unconscious protective behavior. If you introduce a noxious stimuli to someone’s back, IE: inject a high concentration saline in their back, they will change their posture. As shocking as it may sound, our body wants to protect itself, and it will change its behavior with, or without, your input. What the body perceives as threatening is more than simply nociceptive input, your emotions influence your posture as well. Moderate to severe depression is associated with classic “poor postures” and fear of pain reduces lumbar flexion to provide just a few examples. If you combine fear of pain with minor injury such as a workout which produces normal “muscle soreness”, your body may avoid lumbar flexion. Furthermore, if you have an episode of back pain, even if you do not have fear about it, your body will change you trunk musculature to behave in a more protective manner.

So where am I going with this?

I think we are looking at posture too much like a stand alone “thing”. Rather than being a cause, or a victim, it seems posture itself is a biopsychosocial representation of human needs, experience, and expression. It is reflective of a moment in time (or series of moments) and a person’s relationship to posture in that moment. Biologically, our nerves may need blood, movement, and space and posture change may be needed for that to occur. Culture and society may deem certain postures necessary, or conversely, inappropriate, and this may conflict with the needs of the physical body at the time. Emotions could be drivers and/or expressions of posture, ideomotor expression is a fascinating phenomena. Are we at peace with our body, avoidant and ignorant of our needs, or does it appear like it is is constantly on alert for a possible threat? If we are stuck in state of threatened existence, how do we find ease? Is it enough to tell some just to “relax”, do some breathing, move more, or do they need a little more guidance?

Below is the first of a series of “finding ease” guided experiences I wanted to share regarding how I believe we can use physical, cognitive, and emotional strategies to find ease in a posture for a moment. I must give a massive shout out to Joe Witte, a local physical therapist who is also a Feldenkrais practitioner, who cued me into these strategies for laying down, sitting, and standing. However, I will acknowledge I have essentially butchered the original non-verbal guided beauty of how he introduced me to this approach, but this is intentional. My belief is that simple experiences, such as this example of laying down, are ideal opportunities of effective therapeutic neuroscience education that may be helpful to unravel beliefs and open a person to new options for potential change in their life. Combining education, with an experience, body awareness, postural and movement variation, and re-assuring human contact has offered a number of my patients life changing insights into the complexity of their pain and a very real sense of hope that they did not previously have. Many of my patients cannot find comfort in a laying posture, and it is often the easiest place to build awareness and introduce change for other positions and movement, so this is where we start:

 

There and back again

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This post is far more personal/autobiographic in nature than anything I have previously posted. I hope it does not detract too much from my intentions for this blog, but I have found that reading and hearing other clinician growth/life stories has tremendously helped my professional growth. I hope that perhaps this post may be meaningful for someone else.

Preparing for the journey:  Pain and Movement

I was exposed to the experience of persistent complex pain early in life. Shortly after birth, my family started to question why I was in near constant distress. Countless medical care visits later, I received my first pain diagnostic label; chronic cluster migraines, at age 2. This made for a challenging childhood, I missed many typical school age experiences and averaged ~50 days of lost school a year. I know it was a terrible burden on my family, and the physicians didn’t help the problem by telling my family to watch out for possible suicide efforts, as historically, cluster migraine was labeled the “suicide headache”, now that is nocebo!! Imagine as a parent, or a sibling, how that felt to think about? I was thankfully oblivious to this information until later in life. I can relate with the social implications of persistent pain quite closely. I can also relate with my patients on how pain negatively influences your relationship with movement. I wanted to move, I was a kid, I wanted to go out and play and hangout with friends, but the fear of triggering a cycle of pain sometimes prevented you from wanting to try to move. Despite this, I had this intense inner desire to move, and by grace and with the resiliency of youth, I was able to find a movement experience that fit my needs, falling in love with martial arts, and later stunts and movement choreography. With martial arts, I progressively, yet unconsciously, found a balance between intense physical training and rest though a 7-year sedentary career in information technology during the dot.com boom in the 90s. Perhaps this paced rest-to-work ratio was part of what made such a profound dent in in the frequency and intensity my headaches in those years. Likely, these effects were combined with the reduction of social pressures by dropping out of high school at that time… Regardless, all other medical interventions had failed prior to that point to improve my pain.

Another important observation to note about that time was when I instinctively recognized there was something more to human movement than the physical domain. Movement at times would resonate with me emotionally, it stimulated me cognitively, and as I explored different martial arts styles, I found the cultural  variations of essentially the same movements fascinating. Long before I knew the science, or what the words meant, there was this unconscious awareness that movement and pain was bio-psycho-social in nature.

The Journey There

In 2002, I was training and teaching at a kung fu school which decided that they wanted to expand their strength and conditioning offerings for their San Shou (Chinese Kickboxing) program. The school owner invited me to join him in attending a Perform Better seminar that year. I gladly accepted the opportunity because at that time only thing I knew about “Conditioning” was working yourself into the ground combined with traditional “Chinese torture” conditioning methods. There were several great speakers at that seminar, and being blissfully ignorant to the world of performance enhancement, made me feel like a kid’s first experience in a candy shop. I cannot recall all the speakers for the seminar, but I was most influenced by Mark Verstegen and Michael Boyle that day. Michael made a statement during his presentation that finalized my decision to become a physical therapist. It was the early days of the joint-by-joint, correctives, and of course, “core stabilization.” We had previews of the Gray Cook Movement trend to come and looking at the landscape today, it is shocking how little has changed in the last 16 years. I was also introduced to the idea of mobility work with various tools and rollers and this magical “fascia” and phenomena called “Trigger points.” I had dabbled with manual therapy before then, in particular with “trigger points”, having received treatments which had given me some short-term benefits for aches and pains from time to time. It made sense to me that hands on care had some value. If I’m honest, it didn’t take much to sell me on the dream of being a manual therapist to “fix” and train people, I still had aspirations to grow up to be the legendary martial artist and Chinese Medicine “bone-setter” “Wong Fei-hung.”…

I remember the thrill of the experience of being at that seminar clearly to this day. It created that feeling of the days of learning that “secret” technique in martial arts. I was enamored by all of it; I loved the “structural” thinking and the “healing” potential of the concepts of the biomechanical/pathomedical model. Being an IT guy at the time, the idea that there was some sort of “ideal” motor control and motor pattern for all sorts of movements that every person should be adhering to avoid “dysfunction”  seemed so logical, people had to be fixed! This started my first “binge phase” of learning. Before I went back to school to become a physical therapist and athletic trainer, I already had purchased the red tome of Travel and Simons, picked up a copy of Florence Kendal, and memorized Netter’s musculoskeletal pages, excluding the nerves of course, what good were those to fascia?! I bought a treatment table and lined up my “victims” to develop and practice my new-found skills using hands and other modes of manual therapy combined with my growing collection of “correctives”.

Doubts on the Journey

Fast forward through the roller coaster of information and skills I explored between the years of 2002 to 2010. It was a head first dive into a wide variety of manual techniques, Thomas Meyer Anatomy Trains, FMS and SFMA, Vladimir Janda, Stuart McGill, Pavel Tsatsouline, and countless other concepts and “thought leaders” at the time. No questions asked, if the pros were using it, I had to learn it. Besides, there must be evidence for these things somewhere right…? All I knew was, I wanted to be a movement expert and a highly skilled manual therapist, I had no concerns about the tens of thousands of dollars I invested in these resources along the way, or thousands of hours exploring them. But some tiny doubts started to creep up as I started to realize how much of my own training time was used for preparation and mobility work, and it was beginning to cut into skill training. Plus, I started getting frustrated because none of it was really helping any of my body aches and pains, instead, it seemed as though they were starting to become more frequent and persistent…

In 2008, I started to wonder why it was so hard to find research to support all these amazing outcomes we believing we were seeing in the field. So, I did what any other sane person would do, I decided I should start learning how to “science this shit of this” and begin adding to the literature myself. As is classic me, I fumbled my way into learning the scientific method with whatever resources and mentorship was available to get the job done. I chose something simple at that time which was the “hot topic” of dynamic vs. static stretching and chose to look at their roles in agility performance because nothing had been published at the time in that area. You can see the results of that experience here.  There are many things that can be learned in the process of developing, conducting research, writing, peer-review, and publishing a research article. The most important thing I learned was to be very systematic/procedural about literature review and begin to question my biases. By no means am I saying somehow I have succeeded in completely overriding my biases, but it was enough for me to start questioning some of my core beliefs about movement, manual therapy, and pain. The literature review process for stretching also brought me into the world of the nervous system and how it would be impossible for me to truly know about movement if I didn’t understand the nervous system better. Up to this point, my understanding of ROM and mobility was based on traditional biomechanics and the stress strain curve, so this was eye opening to be learn non-mechanical properties had a more profound role in available ROM. It was also when I first time was exposed to the idea that nociception does NOT guarantee pain, nor was pain it’s only role, but that it had other important biologic purposes. Of interest to me at the time, nociception’s role key role in stretch tolerance, the cornerstone of ROM and mobility. I didn’t realize how important that bit of learning would be in my current growth, because I still had my blinders on and had a fairly structuralist based mindset, but my curiosity was increasing.

Fast forward two more efforts to contribute to scientific literature, both of which had their own positives, negatives, and flaws (here and here). After completing these, I decided to take a break from being involved in active research to focus just on clinical practice with my new thinking in place. I have no doubt I will revisit the role of being a researcher again in the future.

Finding Ground

From movement and manual therapy came the opportunity to learn about pain science. I figured a good part of my life I had experienced some form of pain, sometimes finding relief for short periods of time, but I wondered why no treatments or magic trick seemed to have lasting benefits. So naturally, it was time to learn more about pain. Between natural curiosity, expanding available literature, and the “hivemind” that is internet social media (filled with its own opportunity and pitfalls), there was a great deal to learn. The constant feed of people smarter than myself on Blogs, Twitter, Facebook, and sites such as SomasSimple forced me to constantly question my interpretations of literature. There were times I felt my beliefs and interpretations were under constant threat and the ground beneath me was going to give way, but I knew that struggling with these ideas were vital toward my goals. It was a challenging time but my own struggles with pain made me realize the biomedical model was woefully inept at addressing the Complexity of Pain and I finally had to embrace the biopsychosocial framework.

It is hard for me to make a single list of all the people who inspired me and helped me understand pain better and how to implement it into clinical practice, but I must at the very least mention Adriaan Louw, Lorimer Moseley, David Butler, Louis Gifford, Diane Jacobs, Greg Lehman, Peter O’Sullivan, and Todd Hargrove. I owe Adriaan for not only helping me connect some important dots in pain physiology, but for changing my life in a short conversation he had with me about the fears I had about my own pain problems. His approach resonated with me and greatly influence my education style a great deal. I recommend anyone who works with people in pain consider taking part in the Therapeutic Pain Specialist program at the International Spine and Pain Institute.

With my foundation and framework somewhat stable, I began to nearly exclusively treat complex and persistent pain problems. The demand was so high in my community, I could not keep up with the number of referrals myself. To meet these needs, I developed an outpatient pain treatment division for Generation Care. This meant beginning to develop a curriculum and a system to start sharing my ideas with other clinicians. Through 2017, I had 10 clinicians suffer through my attempts to get ideas out of my head and try and making meaningful applications to their clinical practice. I can proudly say we have made a successful team to take on extremely challenging cases in our community and I look forward to new additions joining this year as the demand is not slowly down.

Back again

This brings us to 2018. Before the start of this journey, there was pain and movement. When I started the journey, it was about movement and manual therapy. As the journey continued, I reconceptualized pain and realized understanding pain meant understanding movement and manual therapy better. Now, the realization is there is a person behind all these things, which is an amazing conversation in and of itself. But in the meantime, I have a new-found love for all things movement, manual therapy, and pain.  Having realized how valuable it was for me to take a multitude of perspectives and interpretations of science and clinical experience, I felt it was my turn to give back by sharing my interpretations. This year, I will officially offer my first full course: Pain Science, Movement, and Manual Therapy. This course work is designed for Physical Therapists, Athletic Trainers, Occupational Therapist, Chiropractors, Physical and Occupational Therapist Assistants, Massage Therapists, and physicians who work in rehabilitation settings. The course work is designed both for those new to these topics, but also to offer some twists for those who already have experience, and are familiar, with these topics. These will be offered in 2018 with live classes and by 2019 I will hopefully have the online with live lab hybrid classes ready to go as well. By 2019, I also hope to expand to offering courses dedicated toward my physician colleagues as their needs are truly unique compared to the movement based rehabilitation profession. I am teaming up with a fantastic advisory board to make these products with the goal of improving communication and patient care through shared understanding of pain and science based interventions across multiple disciplines. Every effort will be made to keep the courses current with the evolution of research and changes in my own thinking. Change and improvement is inevitable, this will be reflected in revisions of the course as the years move forward. I look forward to the process and I hope I can be a small part of helping someone else in their journey.

The Complexity of Pain

Teaching people about the complexity of pain is extremely challenging, you must meet each person where they are at. It is not cookie cutter, there is no script, what is meaningful for one person may not resonate with another. You can provide too much information and you can provide too little. While we cannot predict what every patient needs to help them take the next step forward, themes and patterns of information that patients are missing that help connect the dots for them do arise. The late Louis Gifford is one of the pioneers who had a knack for this. Louis has made countless contributions to our understanding of pain. His development of the Mature Organism Model (MOM) was an extremely valuable contribution to both our understanding and education of patients regarding pain. Below is an effort to bring the “Complexity” of the MOM to the patient.

 

 

Confident Ambiguity

I currently work with a large percentage of patients who experience “complex ” and/or “chronic pain”. Many have multiple surgical intervention histories (most repeat surgeries), every known non-invasive treatment (multiple episodes of PT/chiro/body workers), and every known pharmacological intervention known to man. All of these patients share a similar story, they were all told that “X,Y,Z” would resolve their pain or dysfunction with absolute certainty, everyone told them it was a simple fix. Yet, here they are continuing in pain, or in worse pain, in front of me.

As I sit back and review many of these cases, the most consistent theme I see of why they continue to suffer is that the traditional differential diagnosis has failed them. Many were told they had a specific diagnosis and were given a specific treatment. Differential diagnosis is based in the contemporary utilization of “Occam’s Razor”, which is the principle that “Among competing hypotheses, the one with the fewest assumptions should be selected.” (Side note: Historically it has been argued this  statement is an inaccurate reference to Occam and was created by later philosophers) . Utilization of Occam’s razor is critical to many aspects of healthcare, in particular emergency medicine. However, regarding pain, it is a principle which falls far short. Pain is complex, not simple.

The absolute, “this tissue/disease is the issue”, which is both culturally and healthcare driven, is why we are in a chronic pain epidemic.When it comes to pain and movement, physical medicine and rehabilitation professionals need to come to terms with the complexity of pain. It is never a single factor, even if there is a single predominant source of nociception. This also holds true for acute injury, you must account the environmental factors and the processing, as well as the outputs:

 

Gifford Scrutinise Image

Louis Gifford’s Mature Organism Model – 1998

This understanding makes pain and movement complicated, it makes things a bit gray, there is no absolute. You must make a clinical decision to guide the treatment, you need to be able to identify red flags quickly, you need to identify some important tissue issues, but you also must be able to confidently proceed with fair degree of uncertainty with a great deal of grace and skill.  I call this skill, “Confident Ambiguity”.

Confident ambiguity allows a clinical decision to be made in the absence of an absolute diagnosis, and the absence of absolute certainty. Classically, you would look at it as a list of possible diagnosis, within your differential, but now you are asked to not just identify the possible biomedical diagnosis but also the psycho-social factors and assume for all of them to be present concurrently with a constant dynamic shift, as well as combined presence, in any given moment (Louis Gifford calls it the “Shopping basket”).

Research and clinical prediction rules help, but they need a larger framework to address all the concurrent layers of a biopsychosocial model. Personally, I, as well as many others, have been drawn to Ronald Melzack’s work on the neuromatrix at face value to help with developing a constant confident inventory of inputs/outputs  in the biopsychosocial model. At all times, while interacting, assessing, and treating, in the back of my mind I play the “input/output” game, which at first appears challenging, but over time is very re-assuring both for yourself and your patient based on the dynamic nature of the interaction. This same approach has been beneficial with performance enhancement.

Neuromatrix

Melzack, Ronald and Joel Katz. “Pain in the 21st century: The neuromatrix and beyond.”Psychological knowledge in court. Springer US, 2006, 129-148

Every pain experience and every movement dysfunction cannot simply be broken down to single tissue damage, single disease, length tension relationships, muscular imbalance, tissue restriction, or any other musculoskeletal emphasized diagnosis. You must learn to accept the fact that the tests you delivered ,which you so confidently felt were reproducible to a specific tissue or movement pattern, may at least in part be a “neurotag”, a pain and/or movement memory that is driving everything you see and feel.

Microsoft Word - Figure 5

Furthermore, lumping the patient into a primary “psychosocial” driver of pain is a also problem, one cannot ignore sensory input, regardless of whether it is nociception or any other sensory input perceived as a threat.

Pain is complicated, pain is messy, if we don’t treat it as such, you will be lost and you aren’t give the patient everything they need.

Todd Hargrove’s: A Guide to Better Movement

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I haven’t updated in a while due to time devoted to opening a new clinic called Generation Care Performance Center.

However, I felt compelled to make a quick, blunt, review of Todd Hargrove’s: A Guide to Better Movement: The Science and Practice of Moving With More Skill And Less Pain. Simply put, this book is the most important book on movement in the last 20 years, possibly in existence up to this point. It will become a required reading for every movement professional to truly understand movement and pain. I have made pitiful attempts to touch on some of the concepts of this book in the past, but Todd has so elegantly written words which convey a clear understanding of the integration of movement in the Neuromatrix, that  I don’t know if I could ever add to it (but will foolish try at some point!). This book is fully accessible to both the clinician and the patient/client. Thank you Todd for your efforts, your clarity, and how incredibly affordable you have made this knowledge in an age of academic inflation. If you don’t buy this book, you are doing a disservice to your patients, and yourself. Buy it now!

Don’t Blame the Structure – The Role of Belief and Movement in Orthopedics

**Updated 2/16/14**

The purpose of this post is to have a central link on this blog which will contain brief summaries of the growing evidence demonstrating a continued need for us to examine the role of belief and movement interventions prior to pursuing surgical interventions for many common orthopedic conditions.

Please let me be clear that there are certainly clear need for surgical intervention for the management of symptoms, even in the absence of medical necessity. In fact, the structure may be involved and may have initiated the output from the brain, but may not necessarily be responsible for continued symptoms. However, the emphasis on structure has resulted in a growing trend towards excessive, unnecessary, expensive, and risky surgical procedures for the management of pain and movement dysfunction. These procedures are occurring despite clear evidence indicating that just because a “damaged” structure innervated with nocioceptors is removed or “repaired” and the patient feels better and/or moves better, the structure itself does not fully explain for the existence of the symptoms, nor does it fully explain for improved symptoms. The advent of placebo surgeries and increased number of true randomized controls for surgical intervention have opened a whole new realm of understanding of the role of structure in the human body.

This post is incomplete as it stands and will be constantly updated. I welcome any and all recommended additions to it, with the hope that it will grow into a stand alone section of the blog itself:

Arthroscopic Debridement for Knee Osteoarthritis
First, the landmark study by Moseley et al. which started it all in 2002 which showed that both  arthroscopic debridement (‘cleaning up”) and lavage (‘washing out’) were no better than placebo surgery for moderate to severe osteoarthritis: http://www.ncbi.nlm.nih.gov/pubmed/12110735

Second, Kirkley et al. addressed some the questions brought about from critics about the pain measures from the Moseley et al. This study compared arthroscopic debridement and lavage to physical therapy and conservative medical therapy and found again that  neither arthroscopic debridement nor lavage provide any additional benefit over physical therapy and conservative medical therapy: http://www.ncbi.nlm.nih.gov/pubmed/18784099

Third, Herrlin et al. found that arthroscopic debridement with physical therapy was no different than physical therapy alone: http://www.ncbi.nlm.nih.gov/pubmed/17216272

Fourth, Katz et al. looked at individuals with a meniscal tear and evidence of mild-to-moderate osteoarthritis on imaging found that arthroscopic partial meniscectomy with physical therapy had no better outcomes that physical therapy alone: http://www.nejm.org/doi/full/10.1056/NEJMoa1301408

Finally, the 2nd edition of the “Treatment for Osteoarthritis of the knee” from the American Academy of Orthopaedic Surgeons officially states “We cannot recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee.” and their first recommendation in this association statement was “We recommend that patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engage in physical activity consistent with national guidelines.” with the following clarifying statement written within the recommendation that “The exercise interventions were predominantly conducted under supervision, most often by a physical therapist”.

Arthroscopic Meniscectomy
Most recently (December 2013), Sihvonen et al. compared  arthroscopic partial meniscectomy for patients age 35-65 with degenerative meniscal tears without knee osteoarthritis with placebo surgery and found that their outcomes were no different: http://www.nejm.org/doi/full/10.1056/NEJMoa1305189?query=featured_home

This is in agreement with earlier studies which also showed that arthroscopic partial meniscectomy followed by supervised exercise was no better than supervised exercise alone:
http://www.nejm.org/doi/full/10.1056/NEJMoa1301408 – (May 2013)
http://www.ncbi.nlm.nih.gov/pubmed/17216272 – (2007)

Spinal Fusion for Low Back Pain
A study which followed up on previous randomized controlled trials of spinal fusion versus exercise and behavioral therapy for chronic low back pain found that there no difference in outcome after 10 years and there is no evidence for continued deterioration of symptoms in the absence of surgical intervention. Making strong suggestion for avoiding fusion due to the increased risks of surgical intervention for spinal fusion: http://www.ncbi.nlm.nih.gov/pubmed/24200413

A meta-analysis of  666 patients (402 cases) over 4 randomized control trials demonstrated no benefit of spinal fusion over conservative treatment. The authors concluded the evidence was so strong that no further research was necessary: http://mobile.journals.lww.com/intjrehabilres/_layouts/oaks.journals.mobile/articleviewer.aspx?year=2014&issue=03000&article=00002

No different in outcomes between conservative treatment and lumbar fusion after 10 years:
http://www.ncbi.nlm.nih.gov/pubmed/24200413

Vertebroplasty
Multi-center trial which compared vertebroplasty to a simulated procedure (placebo) without cement for OSTEOPOROTIC SPINAL FRACTURES. The capital letters are for the fact that for the simulated procedure, those vertebrae are still “not secured” or “healed”. Despite this, outcomes between groups for pain and pain related disability were similar at 3 months. The authors did an excellent examination of cross over effects, well worth reading the full text: http://www.nejm.org/doi/full/10.1056/NEJMoa0900563

A similar study design was performed which also confirmed that the fractures were unhealed via MRI and expanded the follow-up to 6 months. Similarly no benefits for vertebroplasty over sham was noted: http://www.nejm.org/doi/full/10.1056/NEJMoa0900429

Miller et al. discuss verbroplasty and the placebo response here: http://pubs.rsna.org/doi/full/10.1148/radiol.11102412

A meta-analysis of these two studies concludes that the hypothesis of the possibility of a specific subgroup benefiting from vertebroplasty is unlikely to have unique benefits from vertebroplasty: http://www.bmj.com/content/343/bmj.d3952

Inappropriate imaging, excessive specialist referral, and lack of physical therapy referral for Low back pain
A recent study on trends in the management of back pain examine the treatment of back pain from January 1, 1999, through December 26, 2010. The researchers found a worsening trend in the management of back pain inappropriately referred for imaging and specialists when they should have been referred to physical therapy first: http://archinte.jamanetwork.com/article.aspx?articleid=1722522

Non-surgical intervention of atraumatic full-thickness rotator cuff tears
A multicenter study of 452 patients who are treated with physical therapy first rather than initiating surgery for full-thickness (complete) rotator cuff tears found that 75% of the patients after 2 years opted not to have surgery due to a satisfactory outcome from physical therapy alone: http://www.ncbi.nlm.nih.gov/pubmed/23540577

Achilles Ruptures treated non-operatively have equivalent outcomes to operative interventions
A randomized study of 144 patients with an average age of 40 revealed that non-operative treatment of achilles ruptures had no difference in functional strength, range of motion, calf circumference, functional scores, or re-rupture rate between groups. In addition, a greater number of soft tissue complications were noted in the operative group: http://www.ncbi.nlm.nih.gov/pubmed/21037028

Is ACL reconstruction the best management strategy for ACL rupture?
A systematic review and meta-analysis of ACL repair versus non-operative repair demonstrates poor available evidence for ACL interventions as a whole, but that current evidence appears to indicate that a non-surgical intervention should be attempted prior to considering surgical intervention. http://www.thekneejournal.com/article/S0968-0160(13)00199-3/abstract

MRI detection of disc herniation has no indication on outcome and is associated with lesser sense of well-being
In a study which examined both surgical and conservative treatment of sciatica and lumbar disc herniation, the presence of disc herniation on MRI after 1 year had no association with the outcome. 85% with the presence of disc herniation after 1 year of treatment still had a favorable outcomes: http://www.ncbi.nlm.nih.gov/pubmed/23484826

This is in agreement with previous research which revealed that not only was MRI findings not representative of the patients symptoms or outcomes, but that knowledge of the MRI findings resulted in a lesser sense of well being: http://www.ncbi.nlm.nih.gov/m/pubmed/16244269/

Surgical Scraping for Achilles Tendinopathy
In a study of patients with bilateral chronic achilles tendinopathy, surgical scraping performed on one side (the most painful side). Despite having expected to need a second surgery for the opposite side, 11 of the 13 patients had full resolution of symptoms bilaterally after unilateral scraping. Many already had full satisfaction bilaterally within the first 6 weeks. The authors make a good discussion why they believe these improvements were centrally mediated, not mechanically oriented: http://www.ncbi.nlm.nih.gov/pubmed/23193327

No difference in outcomes between arthroscopic acromioplasty and supervised exercise for shoulder impingement syndrome
A randomized control trial of 140 patients with shoulder impingement syndrome showed no differences in pain or function at any point over a 5 year follow-up. Furthermore, surgical intervention was not considered cost effective and the recommendation was that structured exercise should be the treatment of choice for shoulder impingement: http://www.ncbi.nlm.nih.gov/pubmed/23836479

Shoulder Impingement Syndrome and Central Sensitization
A trial which compared 17 age matched patients awaiting arthroscopic subacromial decompression to a matching asymptomatic control group and identified a significant proportion of these patients presented with notable central sensitization. Those with the most pronounced levels of central sensitization had significantly worsening outcomes at 3 months post subacromial decompression than those with lower levels: http://www.ncbi.nlm.nih.gov/m/pubmed/21464489/

Examining peripheral and central mechanisms in shoulder pain
Why does my shoulder hurt? A review of the neuroanatomical and biochemical basis of shoulder pain: http://www.ncbi.nlm.nih.gov/pubmed/23429268

The pain of tendinopathy: Physiological or Pathophysiological: http://www.bodyinmind.org/wp-content/uploads/Rio2013.pdf

The central nervous system e An additional consideration in ‘rotator cuff tendinopathy’ and a potential basis for understanding response to loaded therapeutic exercise: http://www.ncbi.nlm.nih.gov/pubmed/23932100

Multiple abnormalities of the hip are normal imaging findings in asymptomatic individuals, including labral tears
In a random sampling for 45 volunteers (60% males) with an average age of 37.8 y/o, MRI imaging revealed “Labral tears were identified in 69% of hips, chondral defects in 24%, ligamentum teres tears in 2.2%, labral/paralabral cysts in 13%, acetabular bone edema in 11%, fibrocystic changes of the head/neck junction in 22%, rim fractures in 11%, subchondral cysts in 16%, and osseous bumps in 20%”: http://www.ncbi.nlm.nih.gov/pubmed/23104610

Cervical surgery with physical therapy versus physical therapy alone resulted in similar outcomes after 2 years
Although surgical intervention demonstrated a more rapid improvement in the first year, these differences were no longer present after 2 years. Due to the decreased risks and decreases costs, physical therapy was recommended prior to considering surgical intervention: http://www.ncbi.nlm.nih.gov/m/pubmed/23778373/

MORE TO COME..