Mobilisation with Movement

Wow, 2 big hitters in a  week! Professor Peter O’Sullivan last week and Professor Bill Vicenzino this week. All that on top of the Queen, Barak Obama and Leinster winning rugby’s Heineken Cup European final. Enough said about Jedward.

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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)

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

Enjoy the clinical challenge

David

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Peter O’Sullivan Interview

Special treat today…

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.

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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.

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Let us know your thoughts

Hope you enjoy

Enjoy the clinical Challenge

David

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Cognitive Functional Therapy

In today’s post I want to feedback on a three-day workshop I just completed with Prof. Peter O’Sullivan, Physiotherapist from Curtin University, Western Australia. Most of you will be aware of Peter’s published work in many of the prestigious scientific journals and he’s been a great advocate of the role of physiotherapy in the management both of musculoskeletal pain and more specifically spinal pain. Peter is well-known for his earlier work on classifying movement impairment patterns and applying specifically targeted treatment strategies relative to the movement dysfunction. Readers will be aware of the increasing numbers of movement impairment based systems now popular (Shirley Sahrmann, Grey Cook, Gary Gray, Bobath, Klein-Vogelbach, Carr & Sheppard as well as all the bodywork systems).

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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I haven’t done my Exercises

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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Pain and the Brain – the mind/body connection

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.

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