From there we began an interesting half hour telephone conversation.  By way of background I should add that I work very closely with the Orofacial Pain Specialist who referred her and on that basis knew that there had been some degree of “priming”.

Our conversation went along these lines.

Good afternoon Mrs. Smith I believe you wanted to have a word with me regarding your scheduled appointment this afternoon?

Yes I won’t be able to make it, I am in too much pain

Oh you are calling to cancel the appointment?  The message I had received was that you wanted to discuss whether it would be appropriate for you to proceed with assessment?

Oh no I am in too much pain.  I couldn’t possibly make it.  Can I reschedule next week?

What do you think would be different next week?

Oh it should settle down by then.  I have been prescribed some new medication, which I am hoping will be effective.

Have you had a lot of medication in the past?

Yes I have tried them all. The last doctor didn’t tell me that I had to take the “nerve tablets” for weeks so they did nothing for me when I took them occasionally.  I have had this problem since my husband died six years ago; I have seen three Rheumatologists and two Pain Specialists and none of them can do anything for me.  Have you ever heard of Fibromyalgia? And none of them can do anything for me.  Do you treat patients with this type of problem?  Do you think you can help? What kind of treatment do you do?

Well undoubtedly you have a complex problem, which many skilled practitioners have failed to resolve.  I wouldn’t do you the disservice of flippantly saying on the telephone that I could help you when so many others have obviously failed.  Why do you think treatment hasn’t helped?

Well I have been a bit depressed since my husband died six years ago and I have tried every kind of treatment – Osteopathy, Chiropractic, Massage, Physiotherapy, Hot Stones.  So I have tried everything I could and nothing seems to work.  I also suffer from depression and that doesn’t help.  But the doctor has given me new tablets so maybe that will improve things.  Can I book an appointment to see you tomorrow?

No.

Oh so you don’t want to see me?

No I didn’t say that.  I said we couldn’t schedule an appointment for tomorrow.  Do you feel the severe incapacitating pain that you have today will resolve sufficiently by tomorrow?

I don’t know.

How long do flare-ups usually last?

Oh can be a few days.

Well my suggestion is that you try at least one week with the new medication (Neurontin) that has been prescribed so you can judge the effect of that medication.

Well it’s just another tablet.  I really don’t think it is going to help very much.

But a few minutes ago you suggested that you thought it was going to be a great help

Yeah I suppose so.  Maybe it will.  But I have tried so many I don’t have much confidence anymore.  What do you think?

I  think you need to try the medication for a week and see if it makes much difference to your symptoms.

Do you think it would help?

I am not going to predict if it’s going to help or not.  I think you need to see whether it’s of any benefit and make a judgement.

But the doctor says it would take 6 weeks to work.

Yes indeed there can be a whole series of progressions on the drugs that you are on and it can take a 6 week period to work through.  However, I think you will have a good indication in one week whether things are improving or not. 

If you call me in one week then we can talk about whether you’re ready to commence Physiotherapy, what you’re expectations are and what you’re commitment to the rehabilitation process is?  You tell me that you get great benefit from Chiropractic Manipulation so I would take it as a good indication that physical treatments have some role to play in your management.  However it is clear that they are not the full solution and we need to address other issues, which may involve posture, muscle conditioning, ergonomics, pain management etc, etc.

Why do you not continue with chiropractic if it has been helpful?

Oh you seem to understand my problem so well.  Can I not come and see you tomorrow?

I need to make this absolutely clear that no individual clinician is going to wave a magic wand and solve the symptoms that you have been experiencing.  It is likely going to take multiple specialists in different areas to assist and also a significant change in your strategy of seeking a solution from what you have described so far.  I would do you no favours by seeing you tomorrow, simply adding another opinion to the long list of opinions that you have sought and in all likelihood not living up to your expectations of miraculous improvements.

Oh, yes, I see. So do you not want to treat me? I can’t go on like this.

I don’t want you to feel that I am refusing to treat you.  What I am trying to do is ensure that you are in a good place to respond to treatment.  As we have discussed, you obviously have a complex problem and there is obviously no point in repeating speculative treatments, which have been tried in the past and failed.

I am very willing to try to help you but I think we need to clarify each of our respective roles in order to increase the likelihood of a positive outcome.  So I will put the ball in your court and wait for a phone call from you next week to discuss the plan to move forward.  Talk to you then.

This conversation struck a chord with me as I reflected on the thought processes of both parties and the strategies used in response to the conversation.  I tried to adopt a style, which was challenging but not too confronting whilst at the same time recognising some fundamental belief system changes I felt were required.

The fact that I deferred arranging for a new appointment was partly to address the trial medication issues as discussed above (incidentally, my expectation is that there won’t be a significant change with the medications or the side effects will be to unacceptable) and secondly so that there can be no misconception that scheduling an appointment was purely for the purposes of me seeking financial gain (as I work in a Private Practice setting and hence my desire to be separated from the long list of other money grabbing failed clinicians). So I ask myself these questions:

Will she call in one week?

Is she likely to comply with a treatment regime?

How far can I go with challenging her distorted belief systems?

Is she likely to comply with a long-term management regime?

Is her depression likely to be an insurmountable compounding variable, which ultimately forms a roadblock?

How do you think I handled this situation?

What would you have done differently?

Let us know your thoughts.

Enjoy the clinical challenge.

David

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Post tags: clinical history, Communication, distorted patient befiefs, pain, Physical therapy, physiotherapy, psychosocial

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However, there was a temporary resurgence of interest in musculoskeletal applications of respiratory assessment over a decade ago with the evolution of core stability research.  Don’t worry – we’re not going to get into another laborious discussion on the merits of core control here!

For those whose memories are short, part of the theoretical modelling of  mechanisms of core control as proposed by Hodges and Jull was the synergic interaction of four muscle groups which formed an internal cylinder within the trunk. (see thoracolumbar fascia for  review) These muscle groups consisted of:

The anterolateral abdominal wall.

The deep spinal musculature and associated thoracolumbar fascia.

The pelvic floor

The diaphragm

The conceptual model was that the diaphragm generated a base line level of resting tone to provide mechanical resistance to stiffen the internal muscle cylinder  comprised of the synergic muscles listed above and thereby facilitate spinal support.  Superimposed upon this diaphragmatic postural function was the intermittent phasic contraction associated with the respiratory cycle.  This fitted in nicely with the much described muscle activation model (Bergmark) of sustained tonic low level activation with superimposed bursts of phasic activity related to functional demand.

This became relevant to physiotherapists because of the common observation of breath holding when executing exercises aimed at core muscle activation.  In fact many exercises, both rigorous, high load and fine dexterous tasks, are often associated with temporary breath holding simply associated with concentration on the task.  However, from an instructional perspective, it was deemed important that physiotherapists recognise breath holding as a potential compensatory strategy to artificially achieve core stability, with the obvious disadvantage of not being sustainable for any longer than the period of breath holding.

Around this time also, in the field of occupational medicine, it became evident from EMG studies that prolonged sitting and typically in poor posture, compromised diaphragmatic excursion (simply as a consequence of the mechanical restraints of the thorax and ribcage) and thereby potentiated a compensatory strategy of inhibiting / relaxing the anterolateral abdominal wall as the path of least resistance relative to superior diagrammatic excursion into the restricted chest cavity.

Superimposed upon this sustained static loading scenario, was the frequent clinical observation of elevated / rounded shoulder girdles whether habitual, stress induced, ergonomic or breathing compensation induced, which all fed into a cycle of musculoskeletal compensation.

For some years, well known American physiotherapist Peter Edgelow, has been highlighting the merits of specific breathing control in treating thoracic outlet disorder’s (That well known clinical hot potato at which so many different therapies get thrown).  Edgelow’s contention, also substantiated by the opinions of Travell & Simons’ in the myofascial world, contended that scalene hyperactivity associated with respiratory dysfunction had the potential to either change thoracic outlet dynamics by virtue of their rib attachments, or simply by increasing muscle tone and reducing the diameter of the thoracic outlet and hence the potential for neural irritation.  Coupled with the adaptive changes in this area were potential tightness of the Pectoralis minor and a protracted shoulder girdle all increasing the likelihood of anterior compression.

I have always found teaching breathing control challenging in the clinical situation, partly because of the difficulty in achieving patient compliance and also because of the difficulty in proving direct association with the clinical features.  With this in mind I was interested to see some recent developments in this area, which I intend to explore further.

The first is the work of a Canadian physiotherapist Laurie McLaughlin who presented at the 3rd international conference on movement dysfunction in Edinburgh a couple of years ago.  She is using some interesting techniques to evaluate breathing function and her work is outlined in more detail if you follow the link.

The second factor, (which partly initiated this post) was a recent notification from Human Kinetics on a book publication entitled ‘Breath Strong, Perform better’.  This looks an interesting one and is certainly on my ‘to read’ list.

For those who are interested in this subject the work of Simon Gandevia (who incidentally was a collaborator with Paul Hodges’ original work) has been a significant contribution in this field.  There is a concept in the sports science literature known as ‘respiratory entrainment’, which studies the pattern of respiratory activity in association with limb and body position.  This has been studied in cyclists and rowers in particular, with the view to attempting to understand mechanisms and also determine whether limb / body position and repetitive movement dictate the respiratory pattern or visa versa.

In the context of  the recent Wimbledon Tennis tournament, the much talked about grunting and groaning of female tennis players has achieved it’s usual amount of attention but also appears to be associated with these breathing control / mechanical force output requirements.

So perhaps as musculoskeletal physiotherapists it is time to reconsider our attitude to breathing control and to evaluate the multitude of variables which impinge upon this function from a musculoskeletal perspective,

Let us know if you have any useful clinical strategies or experience in dealing with this type of caseload.

Enjoy the clinical challenge.

David

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Post tags: breathing control, musculoskeletal practice, Physical therapy, physiotherapy, respiratory entrainment

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As physiotherapists there is something intuitively attractive about biological joint replacement relative to traditional implant devices. The attraction of normal biomechanical charactaristics, physiological tissue loading behavior and less surgical destruction are obvious advantages. I was excited to see this excellent 6min video from the wonderful TED website discussing these issues and future directions of biologic joint replacement in relation to knee pathology. We have discussed  knee replacement cases previously.

I have only seen 1 patient with a cartilage allograft to her patella. She was a 22 year old elite hockey player /athlete who had 6 arthroscopic debridements from the age of 16. Despite my enthusiasm and considerable effort with her rehabilitation she did not return to competitive sport. Nonetheless I think this is still a very exciting area and one I hope we will see more of. It will also be interesting to see how the mulit-national prosthetic manufacturers respond to this challenge? It looks like the future research in this area is focused in a different direction to the typical disciplines of materials science, mechanics and computer modelling.

Has anyone had experience with this type of caseload?

Let us know.

Enjoy the clinical challenge.

David

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Post tags: biologic joint replacement, manual therapy, musculoskeletal practice, Physical therapy, physiotherapy

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1. Pain does not provide a reliable measure of tissue state.

2. Pain is modulated by many factors from across somatic, psychological and social domains.

3. The relationship between pain and tissue state is less predictable as pain persists.

4. Pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger.

Returning to a theme we have discussed before (pain and the brain) the above are indisputable facts derived from scientific evidence produced in the emerging field of Multisensory Integration. This is a field of endeavour dedicated to understanding how the brain synthesises information from different senses to coordinate an appropriate coherent response. This is fertile ground for physiotherapists / clinicians treating pain disorders and dictates that we reconceptualise our model of pain and the framework for which we provide patient care.  Hint: the psychosocial model is only part of this.

At the forefront of this research is physiotherapist Lorimer Moseley, Professor of Clinical Neurosciences and Chair in Physiotherapy at the University of South Australia, Adelaide. He has written 75 papers and published in all the prestigious Pain, Neuroscience and Physiotherapy journals and has a list of awards too long to mention here.

We recently caught up at a seminar he conducted entitled “Pain and the Performing Brain”. As the title suggests the focus of the day was to explore the multi-modal factors which influence pain perception and how these impact on performance. Many concepts were presented and we were fortunate to extract some key take home messages in an interview I recorded which is posted below. Click here if you can’t wait.

Lorimer’s team have proposed a theoretical construct termed the “Cortical Body Matrix” to integrate the broad spectrum of sensory and perceptual factors which have been shown to influence the pain experience.  Readers may remember the neuromatrix concept proposed by Ronald Melzack some years ago in which the concept of an individual “neural signature” was proposed. I had the luxury of hearing the man himself explain how this concept evolved. In summary, developments in brain imaging demonstrated diffuse, variable and sometimes disparate cortical activity in response to painful stimuli – not explained by a “pain centre” which has now well and truly been put to bed (ie: it can’t be cut out or ablated by procedures!).

My admittedly limited understanding of the cortical body matrix concept is that it expands the envelope of sensory perception by incorporating elements of somatic, spatial and cortical processing into a paradigm which can be manipulated for clinical purposes.

Previous posts on Lorimer’s excellent www.BodyinMind.org site discuss aspects of  sensory conflict which can be used to “break-up associations” in the neuronal tag which combine to output the pain experience. Some of the strategies involve:

Access Strategies to Cortical Body Matrix

Visual illusion

Mirror illusion

Conflicting tactile /Proprioceptive /visual cues.

Limb positioning

Visual distortion (magnification of effected part)

Image recognition (body part aspects and orientation)

Clinical Conundrums

As clinicians we are  familiar with symptom reports of:

Swelling (when not visibly evident),

Heaviness (when identical size)

Localisation discrepancy (when obviously present)

Thermal sensory disturbance (with similar temperature)

Dysaesthesia (exploding, crushing, non-responsive, sluggish)

These can be coupled with…

Proprioceptive deficiencies

Blood flow changes

Sensory impairment

Spatial processing deficits

Motor abnormalities

Data was presented outlining the mechanisms behind these sensations with particular emphasis on the dynamic and contextual variations which occur across the spectrum of normal environmental conditions to ultimately modulate the pain experience.

This information forces us to move away from the modality specific – receptor pathway – sensory cortex model of  nociception to integrate domains of patient perception, prior experience, context, perceived threat, cognitive and emotive processes as parts of a neuronal matrix which ultimately outputs pain sensation.

I would also add factors such patient satisfaction, confidence in the clinician, perceptions of empathy, clinician credibility, body language, communication skills, personality, commitment to help, therapeutic environment as other, parallel sensory input’s -  at the risk of sounding a bit “new age-y”.

I don’t think we can continue to ignore (or at least not talk about) these factors even if they don’t lend themselves to such rigorous  scrutiny as the neurosciences and cause some ( discomfort as we saw here ) when we do.

To paraphrase Charles Spence (The Handbook of Multisensory Processes).

From the existing body of research there can be no doubt that our senses are designed to function in concert and that our brains are organised to use the information derived from multi-sensory channels cooperatively to enhance rapid detection, identification and response. Even experiences that appear to be modality specific have most likely been influenced by other sensory input whether perceptible or sub-conscious.

This raises questions regarding the hierarchy of information processing and the underlying mechanisms of excitation / inhibition within the brain.

How does the brain weigh up the different input it receives from multi-sensory stimuli to produce a final perceptual output / experience?

What factors combine to determine the most dominant, pervasive sensory cue in a given context?

What factors influence the dynamic nature of this response?

These are questions which Lorimer’s team and other neuroscientists are striving to unravel.

I was fortunate to interview Lorimer after his workshop and I invite you to listen to the audio below.

Prof Lorimer Moseley Interview

Here are some of the issues we discussed

- the transition from disillusionment with physiotherapy to subsequent rejuvenation in the path subsequently taken.

-  the use of visual illusions to illustrate discrepancies between sensation and perception.

-  calls for classification of pain based on mechanisms rather than structure or symptoms.

-  improvements in technology.

- proprioceptive deficiencies in low back pain patients and perceptual impairments of painful body parts.

- the clinical tools such as. “Explain pain” and the “Recognize” program

- evidence-based practice, the therapeutic relationship, outcome measures and perceptual components of human interaction – Where does this leave the double-blind clinical trial?

What a treat, got the intra-cellular juices flowing?

Enjoy the Clinical Challenge

David

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Post tags: clinical sensory stimulation, Communication, mind-body interaction, Pain Modulation, pain perception, Physical therapy, physiotherapy, psychosocial assessment, Reconceptualising pain

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The model that has been fairly well established in pain clinics and tertiary care settings which typically involve multidisciplinary pain management input from a variety of clinical specialities.  Too frequently, the practical reality is that by the time patients access these services they have become chronic and developed a spectrum of disability behaviours and are usually unemployed.  These confounding variables increase the rehabilitation challenge and reduce the possibility of a successful outcome.

Epidemiological studies suggest that individuals out of work for more than six months have less than a 50% chance of ever returning to full time work.  I must confess I find this statistic somewhat surprising and it doesn’t correlate with my clinical experience.  Interestingly the structure of state benefit schemes does appear to influence the period of disability.

Here in Ireland individuals remain on full pay for six months following which time their case is either transferred to a case management company (in the case of private sector employees) or in the public sector the disability assessment board are involved in assessing fitness to work.  From this point half normal pay rates are immediately instituted.  I have been impressed with how frequently patient’s attitudes and beliefs about their level of disability change as the six month mark approaches.  I do not think that they are specifically malingers or exaggerating their symptoms but simply that weighing up the balances (either consciously or sub-consciously) has allowed them to reach a decision to return to work with an acceptable level of discomfort. Interestingly other countries have shortened this period of disability support (eg Scandinavia) and statistical analysis has shown a similar pattern of absenteeism mirroring the period of full-pay social welfare support.

These are important factors to recognise as they are classed as ‘unmodifiable variables’ to which we clinicians have no direct control.  As such it is important to recognise them as potential confounders to treatment progress, if for no other reason than to maintain physiotherapist’s sanity.  It can be very taxing to work diligently on a systematic rehab programme and wonder why you are not seeing the effects of intervention, or the patient appears somewhat less enthusiastic about a rapid return of recovery (and return to work) despite your best efforts.  This can easily lead to a breakdown in therapist/patient communication.  That being said, in 22 years I have never had a patient specifically express that their intention is to stay out for the full period of allowable disability on full pay.  Usually this information usually needs to be gleaned by “under the radar” techniques and an intelligent line of questioning.

As the title of today’s post implies, as clinicians we must always consider the reasons why we ask questions, but also to consider that if we ask certain questions are we prepared to engage in a meaningful way with the answers that we get?  Given what we know of psychosocial factors and their influence in pain, then the onus is on the therapist to identify relevant risk factors, which would include some of the following:

Psychosocial Risk Factors

1. Beliefs and attitudes about pain.
2. Fear avoidance behaviour.
3. Catastrophizing.
4. Anxiety and phobia.
5. Distorted beliefs.
6. Conflicting information.
7. Perception of disability.
8. Depression.
9. Fear of pain.

Over the years as this debate gathered momentum there has been a recurring discussion about professional boundaries and what are appropriate and inappropriate psychosocial factors to address.  The clinical reality is that most of the common psychosocial issues contributing to musculoskeletal pain fall within the scope of practice of the treating clinician regardless of what their discipline.

Repeat: that most of the common psychosocial issues contributing to musculoskeletal pain fall within the scope of practice of the treating clinician regardless of what their discipline.

Only cases with overt mental health disease are outside the scope of practice of physiotherapy.  This places demands upon the therapist in terms of how they frame their questions.  How they interpret the answers they are given and how they analyse the information if it is not clear from the communication.  Simply delivering a pain questionnaire and transferring care to a group management programme is an abdication of responsibility in my opinion.  So with the immortal words of Jack Nicholson if you ask the pertinent questions ‘can you handle the truth?’ Are you equipped with the skills to challenge distorted belief systems, to address lifestyle and behavioural issues, to identify fear avoidance behaviour and replace these dysfunctions with an alternative better strategy?

It certainly won’t make for an easy life or even be met with rapturous enthusiasm but it still doesn’t mean we can ignore.

Enjoy the clinical challenge.

David.

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Post tags: challenging beliefs, Physical therapy, physiotherapy, psychosocial flags

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I caught up with Professor Bill Vicenzino to talk about his new book “Mobilisation with Movement” and explore more of his thoughts on Tennis elbow treatment.

Bill is prolific publisher and has added greatly to clinical management of chronic elbow pain. We discussed some of his ideas in  previous posts.

Today’s interview discusses these concepts in detail together with a review his new book  “Mobilisation with Movement” which is destined to become a core text of the manual therapy library.

Click in the link below to hear the interview. (30min)

Treat yourself  get hold of a copy – or put it on the birthday wish list.

Enjoy the clinical challenge

David

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Post tags: bill vicenzino, manual therapy, mobilisation with movement, Physical therapy, physiotherapy, tennis elbow

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Following on from last weeks discussion on Cognitive Functional Therapy (CFT) today’s post is an interview  with Professor Peter O’Sullivan discussing the origins of the CFT system and how this approach is so helpful to  “frontline” clinicians.

The discussion speaks for itself and is a summary of 3 days information.

What I find so refreshing about this approach is that practical strategies for identifying components of the pain experience are identified together with solutions tailored to the individual.

The message loud and clear was the onus on clinicians to provide a viable alternative to existing failed management strategies – on a case by case basis.

Most importantly this is not a passive approach (in the philosophical sense rather than manual therapy) but will involve challenging distorted beliefs or pain behaviors. This is the issue I feel we have neglected as clinicians but it is personally challenging, uncomfortable for both parties and requires significant communication skills which are not part of our core training. However, we cannot take refuge in education system failures, mythical professional boundaries or any other excuse we may find to avoid these uncomfortable clinical realities. Harsh but true.

Let us know your thoughts

Hope you enjoy

Enjoy the clinical Challenge

David

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Due to the complexity and multi-factorial issues involved in low back pain Peter and his research team have now evolved a system of approach known as Cognitive Functional Therapy. This system integrates not only movement pattern analysis but  incorporates a much broader holistic approach into the multitude of factors which we know influence the patient’s pain experience.

The concept of psychosocial profiling has been a discussion we have had several times on this blog . with so much conflicting evidence regarding the role of the physical findings and their contribution to low back pain. A practical clinical system has been developed to incorporate assessment of the most useful psychosocial variables which we know influence the pain experience. We know from the vast amount of research undertaken regarding the management of low back pain that there are a large number of variables which ultimately contribute to the pain experience. Prof. O’Sullivan and his team have formulated the treatment approach of cognitive functional therapy to incorporate these findings into a practical system of patient management that can be delivered by physiotherapists.

Factors influencing low back pain

(www.manualtherapyjournal.com/article/S1356-689X(07)00066-5/abstract)

Social factors

Psychological factors

Genetic factors

Pain/ neuro-physiological factors

Patho- anatomical factors

Physical factors

Prof. O’Sullivan spent a considerable amount of time on clinical case histories and highlighting the need for careful attention to detail in the subject of questioning. We’ve talked about the role of subjective questioning previously  and the critical importance of this aspect of patient / therapist interaction was one of the major take-home messages from this three-day workshop.

Peter demonstration strategies of subjective questioning and patient interview using a technique known as Reflective Questioning in order to enhance the patient’s analysis of their own  situation and the information they have received(for better or worse!). As physiotherapist’s we can frequently feel overwhelmed by the volume of information available particularly in the field of psychosocial issues. The framework was provided whereby clinicians can pick up on appropriate verbal cues and follow specific lines of inquiry in order to elucidate the role / relevance of specific psychosocial factors. Some of these well-known factors include:

Psychosocial Factors

Personality type

Beliefs and attitudes

Hypervigilance

Coping strategies

Pacing

Emotions

Behavior

Since the introduction of the psychosocial model for management of low back pain there’s been much debate regarding the appropriateness /willingness of physiotherapists to address psychological issues. I would go so far as to say that many have hidden behind the professional boundaries excuse for not exploring or challenging distorted beliefs and behaviors which patients may present with. Of course we also need to challenge our own beliefs particularly in the light of treatment tools me choose to use.

The overriding message from this Cognitive Functional Therapy workshop was that physiotherapists not only should get involved with exploring psychosocial issues but in reality have a duty of care in order to deliver the best possible treatment to the patient.

This places a great onus on appropriate training which is typically not incorporated into undergraduate programs. It also places an emphasis on personal development and interpersonal skills in order to recognize psychosocial risk factors and to determine which elements are modifiable and which are not- don’t go there if you can’t deal with it (you can’t handle the truth).

We have discussed the issue of therapist burnout in previous discussions and this is relevant again here because recognizing which factors are modifiable and which are not has profound implications on  therapist management strategy and ultimately on prognosis. Failure to recognize the confounding factors which may negatively influence prognosis frequently leads to a breakdown in the patient therapist relationship, distorts or sabotages patient compliance, and can seriously undermine physiotherapist credibility.

In reality approaching many of the psychosocial issues require physiotherapists to have a good knowledge of their own belief systems, their values and attitudes, variation in cultural perspectives on pain / disability and of course some practical recommendations or alternative strategies to improve patient’s specific functional deficits.

Some of these issues involve evaluating lifestyle changes and devising strategies which encourage habitual change – not just talk glibly about it!. We know from much of the research that resistance to change is one of the fundamental reasons why humans keep doing things which they know are bad and ultimately detrimental to the health. This is also ties in with readiness to change, the patient’s goals and objectives regarding benefits of  potential improvement in function (to use a marketing phrase “what’s in it for me”) and also the need in some cases to challenge distorted belief systems based on the evaluation of symptom behavior, radiological findings, provoking an easing factors and disability trajectory.

For too long physiotherapists have been comfortable identifying risk factors using validated questionnaires but failing to take the next step of dismantling psychosocial issues which are perpetuating physical impairment. In fact the clinical guidelines which indicate a lack of evidence for specific manual therapy in these patients suggest that group therapy, general exercise or advice being the interventions of choice.

One of the cornerstones of the Cognitive Functional Therapy-based approach to rehabilitation is that we as physiotherapists are well placed to administer this type of multi-factorial approach to management because our repertoire of skills involves movement analysis, strength and conditioning, localized musculoskeletal techniques, communication and a significant period of one-to-one contact time in which to engage with the patient.

Lookout for Prof. O’Sullivan’s regular published work and of course workshops conducted either by himself or Prof. Wim Dankaerts.

Cognitive Functional Therapy, the future of low back pain management delivered by physiotherapists. A patient centered approach incorporating evidence with the best practice to achieve patient focused goals. Making simplicity out of complexity – how exciting.

Enjoy the clinical challenge

David

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Post tags: Cognitive Functional Therapy, low back pain, physiotherapy, psychosocial assessment, psychosocial treatment

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I haven’t done my exercises was the message received.  Please cancel my scheduled appointment – this was the 2^nd cancellation in succession since previous review 2 months ago.

This got me thinking on the notion of home exercise in relation to

Patient compliance

Patient perception of exercise

Physiotherapist prescription objectives.

It is fairly intuitive for most Physiotherapists (at least in the musculoskeletal field) to prescribe some form of home exercise as part of a patient management plan.  In fact I would go so far as to say its pretty much second nature.  Now we can debate the type of exercise prescribed and the relative merits of the multiplicity of options available – but that’s for another day.  We recommend exercises because we believe it will improve the outcome.

The implicit assumptions include the following:

Prescribing home exercise will empower the patient to facilitate their own recovery

Speed up the rehabilitation process

Address-underlying cause or factors which may have precipitate the issue

Minimise dependence on health care providers which may result from a failure to control symptoms.

Whilst all of these objectives are admirable and are hard to criticise, the problem is that many patients do not perceive exercise in the same context.  In fact many patient satisfaction surveys highlight the fact that prescription of home exercise is a “turn off” for significant numbers of patients, particularly those who are paying for treatment.  In the field of manipulative therapy it is one of those determinants, which dictates whether patients may seek Chiropractic, Osteopathy or Physiotherapy as their primary input – “physiotherapists just give exercises”, “the chiropractor understands my spine” the osteopath knew exactly what was wrong”

But what can we conclude from such patient perspectives?

Are they lazy?

Do patients think that physiotherapists prescribing exercises is a delegation of our duty of care to treat and solve the problem?  “my problem is more complicated than just needing exercises”

Have we failed to communicate our message by clarifying the purpose of the exercise?

Do we have clear indications whether the exercises we prescribe are providing practical benefit?

Each of these headings warrants discussion in its own right (and will be the subject of future posts) because failure to recognise mutual perspectives can place considerable strain on the patient/therapist relationship and ultimately the ability to deliver care.  We have discussed the patient therapist relationship previously.

The platform for healthcare delivery can dictate part of the management strategy.  In my naive assumption, 20 years ago, when I left the NHS I thought patients paying for treatment would be more compliant with their home exercise regime.  I can say without hesitation that I have not found this to be the case so the logic that paying for treatment increases compliance would not appear to apply.

In a Public Healthcare System, the continuous pressure of waiting lists can present an attractive opportunity to prescribe home exercises and self-efficacy based care simply as a means of reducing pressure on the system.  Indeed we have seen some move towards this with the clinical standards on low back pain guidelines suggesting that general advice is as effective as other forms of manual therapy.

Whilst I disagree with this assertion, unless clinicians can prove otherwise, this will stand as the reference standard for management of low back pain.  My old friend and colleague Nick Carter in Portsmouth, UK is a great exponent of the methodological process by which Physiotherapists select, deliver and monitor patient home exercise programmes.

We spend sometime discussing this on a course we present collaboratively called Therapeutic Exercise and it’s a topic we will return to in future.  Suffice is to say at this point that if a random selection of exercises are simply thrown at a patient in the last two minutes of a treatment session it is not surprising patients don’t attach much credibility to it or value it as part of their management plan. If such a haphazard approach is part of the message delivered it is unlikely to have the desired impact.

So clearly there is an onus on the physiotherapist to determine which patients specifically need home exercise, which ones are likely to comply and which ones have no interest.  It used to be a major source of frustration when patients continuously made excuses for not doing their exercises or as it was more frequently the case, “not doing your exercises”.  As I mellow with time I am now less judgemental regarding patients commitment to facilitate their own recovery.  Understanding the Stages of Change paradigm is a helpful concept in this situation.

However, I now make it my business to determine which patients seek this type of management strategy, which ones aren’t interested and which ones remain to be convinced – provided the efficacy of home exercise can be demonstrated either in terms of symptom reduction or frequency of recurrence.  Adopting this type of strategy has been of great benefit in relieving frustration and creating the classic patient/therapist barrier where the Physiotherapist castigates a patient because they haven’t “done their exercise”. It is so easy to assume that lack of compliance is the reason for non-responsiveness to treatment.  In order to maintain clinical credibility it is very important that we Physiotherapist perform critical self-analysis to determine whether the lack of adherence to a home exercise regime is in fact a critical component of the patient’s symptoms, whether we  have selected the appropriate exercises ( this is a huge separate topic), whether there is a need for routine “maintenance” exercises or whether there is no role for home exercise.

These are important factors to consider because they profoundly influence the type of care delivered and the quality of the patient/therapist relationship.

Do you find patient compliance to be a source of strain on your therapeutic relationship?

Do you think patients have the right to choose to comply or not with a prescribed home exercise programme?

Do you think we have clear criteria for appropriate exercise selection tailored to individual requirements?

Let us know your thoughts.

Enjoy the clinical challenge.

David

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Post tags: home exercise programmes, outcome, Patient compliance, Physical therapy, physiotherapy, poor patient compliance

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Mind/body interaction and our perception of pain has been studied intensively in recent decades.  We have discussed pain mechanisms previously on this blog but suffice it to say at this point that the concept of the pain experience being simply related to activation of nociceptors, as a consequence of tissue trauma, is now widely recognised as only one potential mechanism in the perception of pain.  The IASP (international association for the study of pain) has defined pain as an ‘unpleasant sensory and emotional experience associated with actual or potential tissue damage’.  Now that covers a fair spectrum of sensations!

It has now become routine in physiotherapy practice to consider that, non-resolving / slowly resolving conditions, are attributable to central nervous system malfunction (sensitisation) and those which behave predictably fit neatly into the categorisation of nociceptive pain, attributable to local tissue trauma.  Here the resolution of symptoms is associated with the reduction in local inflammatory signs such as, swelling, sensitivity, tissue thickening and load tolerance.

The mechanism of sensitivity reduction is attributed to the resolution of the so called ‘inflammatory soup’, which perpetuates peripheral sensitisation and resolves in accordance with known tissue healing times.

The biological reality is that nociceptive stimulation has immediate central nervous system manifestations in terms of neuronal activation at the spinal cord level and regions of the mid brain (thalamus) and sensory cortex.  Much of the research looking at  central mechanisms of processing, have evolved from Ronald Melzack’s concept of the neuromatrix, which postulated a neural signature within the brain associated with an individual’s response to painful stimuli.  Much of this work has been expanded upon by physiotherapy’s own Lorimer Moseley , Herta Flor and other brain imaging specialists.

We know from much of the work on chronicity and disability perpetuating factors in low back pain, that there are multiple environmental and attitudal factors (classified under the flags system and here which also profoundly influence the level of symptoms and disability experienced.  The vast majority of research in this area seems to relate to persistent low back pain and whiplash.  If we were to consider many of the other musculoskeletal conditions with a high propensity to chronicity i.e. tennis elbow, plantar fasciitis, Achilles tendonitis and headaches the questions is whether these neuronal factors are the key determinates in perpetuating sensitivity, or whether we are still looking at a peripheral nociceptive mechanism?

Much of the interesting work by Moseley’s team involves illusionary stimuli to alter neuronal output or influence symptom experience.  This can involve manipulating perceived sensory input or altering the perception of motor output.  One interesting illusion, which illustrates mind/body interaction and its manipulation is the ‘thermal grill illusion’.

The Thermal Grill Illusion

Todd Hargrove has written eloquently on this and I have extracted some of his thoughts below.

The thermal grill illusion is a phenomenon of sensory motor mismatch.  The thermal grill illusion is created by placing the index and ring fingers in warm water and the middle finger in cold water.  This unusual sensory input apparently confuses the brain into thinking the middle finger is in boiling water because it somehow results in a feeling that the middle finger is painfully hot.  In a recent study researchers induced pain through the thermal grill illusion and asked the subjects to press their fingers together.  This cut the pain intensity by 64%.

However, they were unable to reduce the pain by doing several other forms of touching, such as touching the hands of the other people or by pressing their hands together in an overlapping fashion.  The researchers noted that the thermal grill illusion was reduced only when thermosensory and tactile information from all three fingers was fully integrated.  That is, the thermal illusion reduction required a highly coherent somatosensory pattern, including coherence between tactile and thermal patterns and coherence of stimuli between the two hands.  In other words, the pain didn’t go away until the brain received sufficient sensory information to correct the distortions in the body maps.

One of the debates regarding nociception is the debate between perceived and actual tissue damage and the mechanisms of excitation of nociceptors .  Whilst changes in sensory and motor firing patterns have been well documented in the presence of peripheral sensitisation (associated with tissue trauma), there appear to be other mechanisms of nociceptor sensitisation not directly associated with such evident trauma.

We know there are sub groups of nociceptors , which are chemo-sensitive, thermo- sensitive as well as the obvious mechanosensitive.  Perhaps there are other sub classes of nociceptors, which perpetuate unpleasant sensory bombardment of the central nervous system.  Although we have undoubtedly come a long way in our classification of pain mechanisms, there is a danger that the peripheral central mechanism pendulum has swung so far towards central mechanisms, that peripheral are being neglected.

How do you think the integration of pain mechanisms has influenced your clinical practice?

Do you use strategies that target the central nervous system to improve patient’s function?

Is anyone using illusionary techniques to treat musculoskeletal pain in their clinical practice?

Let us know your thoughts.

Enjoy the clinical challenge.

David.

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2011. | Permalink | 2 comments | Add to del.icio.us
Post tags: clinical pain, mind-body connection, musculoskeletal pain, nociception, Pain Mechanisms, Physical therapy, physiotherapy, Thermal Grill Illusion

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