mechanical lbp & the frequent flyer...objectives participants will be able to: identify...
TRANSCRIPT
Mechanical LBP &
The Frequent Flyer
NIKKI BRADLEY, PT, MPT, OCS, CERT MDT
Objectives
Participants will be able to:
Identify mechanical low back pain
Use Mechanical Diagnosis & Therapy (MDT) classification system to
subgroup LBP and subsequently guide treatment
Differentiate between a lateral shift and a relevant lateral component
Treat a lateral component using MDT principles
Understand common practice errors in mechanical therapy
Discuss clinical decision making in mechanical therapy as applied to
patient cases
Case 1-
Larry
Referring Dx:
L Hip pain
History:
55 y.o. male
Constant L buttock pain
No Numbness/ tingling.
Typically has ~ 5 episodes a year of back pain. Sees chiropractor.
Current symptoms began 1 month ago after 3-day road trip
Aggravating factors: Sitting, standing, rising from chair, walking, lying down
Relieving factors: Oxycodone
Current Baselines:
6/10 L buttock pain
Concordant sign: Increased pain with rising from chair
Neuro Screen (-)
Hip tests (-)
Case 1-
Larry
Current Baseline:
6/10 L buttock pain
Concordant sign:
Increased pain with
rising from chair
Provisional classification:
Derangement
Directional Preference-
Extension
Mechanical Exam:
Repeated Extension in Lying (REIL, or press ups): Increases buttock pain during// better after
Improved ROM Extension, Improved concordant sign
Visit 1 Issue HEP: REIL (press ups) 10 reps every 2-3 hours.
Education on self –monitoring symptoms, precautions (when to stop), posture.
Visit 2: Pt reports pain peripheralized to thigh. Pt worse; stopped HEP after 2nd day.
Worse with Extension. Now what??
Case 2-
Lisa
Referring dx:
Hamstring Strain
History:
27 y.o. female
Intermittent R posterior thigh pain above knee. Denies LBP. No Numbness/ tingling.
Began 4 months ago when increasing running
distance, adding hills
Currently not running due to pain
Aggravating factors: Driving, Running, Sitting
Relieving factors: StandingCurrent Baselines:
0/10 R thigh pain
Concordant sign: Pain with driving > 20 min
Neuro Screen (-)
Resisted Hamstring testing: Strong Painfree
Palpation: (-)
Case 2-
Lisa
Mechanical Exam:
Repeated Flexion in Stand: Produced thigh// worse
Repeated Extension in Lying (REIL, or “press ups”): Decreased thigh// No better
Visit 1 Issue HEP:
REIL (press ups) 10 reps every 2-3 hours
Visit 2: Pt reports symptoms/ function are SAME.
Pt unchanged with Extension. Now what??
Current Baseline:
0/10 R thigh pain currently
Provisional Classification:
Derangement
Directional Preference-
Extension
Do not accurately
describe the
frequent flyer
Do not help guide
treatment
“Acute”
“Chronic”
The “Frequent Flyer” =
Recurrent episodic
The Difficulty with
Common LBP
Assessment/
Treatment
Pathoanatomic diagnosis does not explain the behavior of the pain
Known lack of correlation between imaging findings and severity of pain
Tousignant-Laflamme Y, Longtin C, Brismée JM. How radiological findings can help or
hinder patients' recovery in the rehabilitation management of patients with low back
pain: what can clinicians do?. J Man Manip Ther. 2017;25(2):63–65.
Imaging findings in Asymptomatic
Patients
Caution when interpreting the
clinical significance of imaging
findings
We cannot rely on imaging to
guide treatment
Pathoanatomic model is not a
reliable guide for developing
effective treatment plan
Brinjikji W. Systematic literature review of imaging features of spinal
degeneration in asymptomatic populations. AJNR Am J Neuroradiol
2015 Apr;36(4);811-6
Mechanical Treatment: Evidence for
Reliability & Treatment Efficacy
97% of all back pain is Mechanical
Subgrouping is the key to successful management
Review evaluated 22 systems that classify populations with low back-related leg pain. Mechanical Diagnosis and Therapy (MDT) scored the highest of any system, with criteria based upon purpose, validity, feasibility, reliability and generalizability.
It was recommended that clinicians should use specific repeated movements to promote centralization in patients with acute, subacute or chronic low back pain, with the recommendation based on Grade A, ‘strong evidence’.
Long et al- Establishing directional preference (DP) and matching specific exercises based upon these findings resulted superior outcomes in the matched group including pain, function and medication use.
Stynes S, et al. Classification of patients with
LB-related leg pain: a systematic review. BMC
MSK Disorders 17:226. 2016
May S, Alessandro A. Centralisation and
directional preference: a systematic review.
Manual Therapy 17. 2012
Long A, et al. Does it matter which
exercise? A RCT of exercises for
LBP. Spine. 29:2593-2602. 2004
Chien JJ. Bajwa ZH What is mechanical back
pain and how best to treat it? Curr Pain
Headache Rep 2008 Dec;12(6) 406-11.
Nociceptors transmit 3 types of pain
CHEMICAL
Inflammatory process following
trauma, injury
Inflammatory or infective disease
MECHANICAL
Structures are compressed,
deformed, pulled taut
THERMAL
Relay hot/ cold
sensations
Americanpainsociety.org
Dubin AE, Patapoutian A.
Nociceptors: the sensors of the
pain pathway. J Clin Invest. 2010;120(11):3760–3772.
What structures in the spine are innervated?
Potential sources of pain-
Intervertebral disc (outer annulus)
Facet capsules
Interspinous ligament
Longitudinal ligament
Vertebral Bodies
Dura mater
Nerve root sleeve
Nerve connective tissues
Blood vessels
Local muscles
Cannot selectively stress
individual structure with
clinical tests
Kuslich et al found the predominant
source of back pain to be the disc,
and the source of sciatica to be
compressed nerve roots. (provocative
testing under conscious sedation)
Bogduk 1993, 1994, Kuslich et al 1991, Rankine et al 1998, Schwarzer et al 1994, 1995
Differentiating Mechanisms of Pain
CHEMICAL PAIN
Inflammatory process
Constant
Recent onset (injury or insidious)
Typical signs may include redness, heat, swelling, tenderness
Relative easing factors: rest, NSAID
All movements lastingly aggravate pain
No movement/ position can be found to abolish pain
MECHANICAL PAIN
Typically intermittent
Can be constant
Symptoms are affected by movement, posture, body position
Often variable function day to day
Loss of ROM correlates with symptoms
Better with movement in one direction
Worse with movement in opposite direction
→ Activity modification, NSAID’s, Medical Rx → Movement, Posture ed, Exercise
What is MDT?
Mechanical Diagnosis & Therapy
Classification system
Evidence based assessment and treatment
Seeks to differentiate between mechanical and non-mechanical sources of
pain and functional limitation
Mechanical changes are assessed using repeated end range movements and
sustained positions
Guides clinician to required management strategy
What MDT is not:
Not reliant on a pathoanatomical diagnosis
Not a cookbook approach
Treatment value lies in individualized assessment- using an algorithm to
determine a pattern, guide treatment and predict prognosis
Not just exercise
Includes Manual Therapy where indicated
Includes posture advice and lifestyle changes
Not just Extension
Other loading strategies include Lateral forces, Flexion, Contractile
forces (Extremities)
Mechanical Diagnosis & Therapy
Focus:
Patient education
Self directed treatments
Reduce dependency on Clinician
Empower the patient to control his/ her symptoms
Exercise + Lifestyle Modifications (posture; movement competency)
Manual techniques??
When self generated treatment is not successful, the use of manual techniques is considered
Hands on techniques are used to enable patient to return to self treatment
Mechanical Classification
Derangement
Specific Presentation
Specific Treatment
Dysfunction
Specific Presentation
Specific Treatment
Posture
Specific Presentation
Specific Treatment
Classification:
Derangement
Internal derangement causing
anatomical disturbance in the normal
resting position of the joint
Obstruction of movement due to
internal displacement of articular tissue
Treatment: Loading strategies to reduce, abolish, centralize symptoms
and normalize mechanics (ROM)
Expected time: Improvement in
baselines immediately/ within hours
Classification:
Dysfunction
Structurally impaired soft tissues
Contraction, scarring, adherence,
adaptive shortening
Pain is caused by mechanical
deformation of these structurally
impaired tissues
Trauma, inflammatory, degenerative
process
Pain will persist until remodeling has
occurred
Treatment: Repeatedly stress the tissue
Expected time: Several weeks for
remodeling to occur
Classification:
Posture
Mechanical deformation of soft tissues
or vascular insufficiency
Prolonged positional stress affecting
articular structures, contractile structure,
joint capsule/ ligament
NO loss of ROM
Treatment: Posture training
Expected time: within minutes, correction of posture abolishes
symptoms
Centralization
In response to therapeutic loading strategies pain is progressively abolished in a distal to proximal direction, with each progressive abolishing being retained over time until all symptoms are abolished and remain better
If back pain only is present this moves from a widespread to a more central location and then is abolished
Centralization refers to PAIN
Centralization requires Directional Preference
Directional Preference does not require symptoms - can use other baselines in the absence of symptoms
Peripheralization= Pain emanating from the spine spreads distally into or further into the limb as a result of loading strategies - and remains worse- Lasting change.
Copyright to McKenzie Global Holdings Limited (MGHL)
Centralization & Prognosis
Predicting Outcomes
The McKenzie Method also has a proven ability to predict patient outcomes
through classification and the determination of Centralization or Directional
Preference.
If a patient with spinal pain is classified as a Derangement and can centralize
their symptoms in a short time after initiating MDT, the prognosis for a rapid and
lasting improvement is very good.
Werneke M, Hart DL. Centralization phenomenon as a prognostic factor for chronic LBP and disability. Spine. 26;7:758-65. 2001
Skytte L, et al. Centralization: Its prognostic value in patients with referred symptoms and sciatica. Spine. 30;11:E293-9. 2005
Werneke M, et al. Association Between Directional Preference and Centralization in Patients with Low Back Pain. J. Ortho. Sports Phys. 41:22-31. 2014
Heidar Abady A, et al. Application of the McKenzie system of Mechanical Diagnosis and Therapy (MDT) in patients with shoulder pain; a prospective longitudinal study. J Man Manip Ther 25:5:235-243. 2017
Mechanical Classification
Used with permission- Copyright to McKenzie Global Holdings Limited (MGHL)
4 Phases of Treatment - Derangement
1. REDUCE
DERANGEMENT
2. MAINTAIN
REDUCTION
3. RECOVER
FUNCTION
4. PREVENTION
Derangement:
Clinical
presentation
History:
Symptom variability; Inconsistent Pattern
•“Some days I can bend over and other days I cannot”
Known Aggravating & Relieving Factors
Symptoms change with Movement & Position
Constant or Intermittent Pain
+/- symptoms into LE
Often recurrences of pain over time with worsening disability
Derangement:
Clinical
Presentation
Exam:
Loss of movement
• ROM limited by Obstruction
• and/or ROM limited by Pain
Pain during movement
Deviation with movement
Repeated movements: Symptoms can be made better or worse. Mechanics change concomitantly.
Dysfunction:
Clinical
Presentation
History:
Chronic, without specific incident
Symptoms are always local
(-) LE symptoms -No radiculopathy
Symptoms are always intermittent
• Produced when tight structures are loaded
Consistent pattern to pain
• “Every time I reach, I feel it”
Dysfunction:
Clinical
Presentation
Exam:
Loss of mobility and/ OR pain with ROM exam
Pain is at ENDRANGE
No peripheralization
Repeated movements:
• Symptoms will be Produced// No worse (in the restricted plane)
Posture:Clinical
Presentation
Intermittent pain brought on by prolonged static loading of normal tissues
No pathological changes
Pain is always local
Typically provoked with poor sitting posture & abolished with change of position
No loss of movement
Repeated movements: No Effect
MECHANICAL EXAM1. Identify Clear Baselines
MECHANICAL
ROM
LIMITED DUE TO PAIN OR STIFFNESS?
SYMPTOMATIC
CONSTANT OR INTERMITTENT?
INTENSITY
LOCATION
BE SPECIFIC
IDENTIFY MOST DISTAL SYMPTOM
FUNCTIONAL
CONCORDANT SIGN
WHAT IS IMPORTANT TO THE PATIENT?
RISE FROM CHAIR
GAIT
TIE SHOES
NEUROLOGICAL
MYOTOMES
DERMATOMES
REFLEXES
NEUROTENSION
2. Repeated Movements
KEY TO MECHANICAL
EXAM IS REPEATED
MOVEMENTS→
NEEDED FOR SUBGROUPING
WHY REPEATED MOVEMENTS?
DO ENOUGH TO EXPOSE A
DIRECTIONAL PREFERENCE
PARADOXICAL RESPONSE TO MOVEMENT IS
COMMON
INITIALLY DIRECTION
THAT IS MOST PAINFUL IS THE THERAPEUTIC MOVEMENT
BUILT IN SAFETY MECHANISM
Why Repeated
Movements?
Single movement testing can be misleading
and result in misinterpretation of Directional
Preference
One rep may relieve the pain temporarily
With repetition: Worse as progressive obstruction occurs
Flexion
Initially obstructed and painful
With repetition: Better as reduction occurs
Extension
Mechanical
Baselines
Deviation?
Willingness to move?
What limits movement: Pain or Stiffness?
Pain DURING movement? → indicates Derangement
Pain at ENDRANGE of movement?
If symptoms are unchanged → PT adds Overpressure
Note Side GLIDE (not lateral flexion)
MDT Repeated Movement Exam
Assessment: Loading Response
Peripheralized, Worse →
Change Position/ Load
Change Direction
Centralized, Better →
Continue
Increase// No worse
Decreased// No better →
More repetitions (test over a few days)
Progress Forces
Consider lateral
DURING
Increase
Decrease
Produce
Abolish
Centralizing
Peripheralizing
No effect
AFTER
Worse
No Worse
Better
No Better
Centralized
Peripheralized
No Effect
Force Progression
Concept of force progression in MDT:
Patient Applied forces → → → progressing to Therapist applied forces
Ensures Safety: tissue response is monitored at progressive levels of force
Empowers the patient (Use the least amount of force necessary)
When to progress forces?
Pt is improved, but not completely
Plateau in progress over a few days
Inconclusive response “Yellow light”
Increase/ No better - OR - Decrease// No worse
Midrange End rangeEnd range + self OP
End range + PT OP
Mobilization Manipulation
Role of Overpressure
Press Up
Painful
Press up with OP
Decreases pain= Derangement
Repeated movement with overpressure (OP)
can help confirm classification
Lateral Shift
vs.
Lateral
Component?
Lateral Shift vs.
Relevant Lateral Component
Lateral Shift
Postural Deformity
Obvious
Exists when vertebra above has laterally flexed in the relation to vertebra below, carrying the trunk with it
Often Kyphotic deformity also present
Contralateral or Ipsilateral
Named by shoulders
Lateral Component
Not a deformity
Not seen in standing observation
Will be exposed during movement exam
Exposed/ Confirmed with a failure to
respond to Extension
Repeated or Sustained Extension: Worse
Lateral Shift Deformity
UnmistakableOnset of shift
occurred with pain Patient can’t
correct voluntarily
Pt can’t maintain correction
Correction affects intensity of symptoms
Correction causes centralization or
worsening of peripheral symptoms
Relevant Lateral Component
Not visible Unilateral/
Asymmetrical Symptoms
Worse with Sitting
&
Worse with Standing
Loss of Frontal plane ROM
SideGLIDE
Sagittal plane movements:
No improvement OR Worse
Improvement with lateral movements
Lateral Shift Deformity: Treatment
Lateral Shift Correction at wall
PT Manual shift correction
Lumbar Rotation in Flexion
Work toward being able to return
to self-generated correction at
wall, then restore sagittal
If unable
If unable
Lateral Component - Treatment
Lateral component often reduces
with sagittal plane
Exhaust Sagittal plane first before
Frontal plane movements:
Progression of Forces
Sustained Extension
Procedure Overview
Extension Principle
+ Progression of Force as needed
Extension Principle + lateral component
+ Progression of Force as needed
Lateral Principle
Lumbar Flex Rotation
Goal is always to return to sagittal plane
Indication
for Lateral
Procedures
Asymmetrical Symptoms
Flexion and Extension BOTH aggravate symptoms
Loss of Side Glide ROM
Sagittal plane: Peripheralized, Worse, or Unchanged
Plateau with sagittal plane
Continue to get Increase// No worse or Decrease// No Better response with Extension progression of forces
Extension Principle
Legs wide
Glutes/ Trunk extensors relaxed
Achieve End range
Progression of Forces
IF Increase// No worse OR Decrease// No better
Extension in Lying with self Overpressure -
Lock elbow/ Exhale/ sag hips
Belt Fixation
Extension in Lying with PT Overpressure
Extension mobilization
Extension manipulation
Force Alternative: Sustained Extension
Load Alternative: Extension in standing
Extension Principle with lateral
component
Progression of Forces
Extension in lying with hips off center
Extension in lying with hips off center with PT Over Pressure
Sagittal plane overpressure
Frontal plane overpressure
Extension mobilization with hips off center
Rotation mobilization in extension
Rotation manipulation in extension
Lateral Procedures: Side Glide in Stand
Correct performance
- Shoulder stays against wall
- Elbow at ribs
- Feet together
- Pelvis should not touch the wall
- Watch for transverse plane compensation
- Watch posture in sagittal plane
- Achieve End range
- Maintain progressive improvements in range
Lateral Principle
Use for
1. Lateral shift deformity - to correct the shift
2. Derangement that worsens with Extension
3. Derangement that is unchanged with Extension over 1-3 day trial (with
Progression of Forces)
Common
Pitfalls:
Unclear Baselines
Clearly identify starting point
Symptoms: Specific location, Intensity
Mechanics (ROM)
Concordant Functional Sign
Neuro signs
Repeat initial baselines back to patient
“Remember how that feels. We’ll be
rechecking that movement to monitor for
change throughout the exam”
Consider using white board to involve patient
in exam findings
Common
Pitfalls
Unclear Classification
Derangement vs Dysfunction vs Posture
Classifications have differing treatment
strategies; Differing expectations
Day 1: Make a Provisional Classification
and Directional Preference
Day 1 hypothesis will be proven/ unproven
over next few days
You can’t treat what you don’t understand
Common
Pitfalls
Fear of making patient worse
If unclear response, consider provocative testing
Don’t be afraid to move them
Confirm Classification + Directional preference- mechanical clinician’s #1 goal
If you suspect posterior derangement but unable to confirm, use repeated flexion for 1-2 days. IF worse, now you know what you have and can effectively treat.
Most challenging scenario is pt coming back the same (yellow light)
Common
Pitfalls
Failure to Exhaust Sagittal plane
Abandoning Extension too quickly
Follow Progression of Forces
Consider Force alternatives (sustained)
When to progress forces?
Increase pain// No worse
Decreased pain// No better
“Yellow light” → Progress forces
Common
Pitfalls
Failure to Achieve Endrange
“Further, further, further”
Achieving end range too soon
Significant derangement may need time
to work through reduction
Not enough repetitions
“Give it heaps”
Lateral shifts often need several repetitions
consistently repeated over time
Common
Pitfalls
Wrong load
Standing vs Lying vs Sitting
Extension responders often need unloaded
(prone)
Ex: may respond poorly to Extension in
Stand but reduce with Extension in Lying
More likely to achieve end range in lying
position
Lateral responders often need loaded
position (standing)
Produce// No worse OR Decrease// NO
better? Consider Load modification
Common
Pitfalls
Failure to identify a lateral component
Presentation of Lateral component:
Extension increases, peripheralizes, and
worsens symptoms
OR
Plateau over several days with Extension
Mechanics not changing
Symptoms not further improving
Common
Pitfalls
Choose 1 Direction
Don’t add other exercises before
confirming Classification & Directional Preference→
Confounds the mechanical response
Limit other variables initially until
mechanical response is clear
This includes pt’s daily activities
Goal is to empower the patient to
ultimately self manage
Common
Pitfalls
Unclear Instructions to patient
4 Phases of Treatment
Self monitoring baselines
Often stiffness precedes an episode of
pain
Manage stiffness to prevent development
of pain
Perform reductive exercise as first aid
when symptoms first arise
Perform reductive exercise before/ after
potential aggravating activity
“Use your reductive exercise as you would
a pain pill.”
Common
Pitfalls
Insufficient frequency of HEP
Frequency of HEP is necessary to understand mechanical response
Every 2-3 hours and additionally upon onset of symptoms
“If you only do these 1x a day, it likely will not be enough to understand the pattern of how your pain behaves.”
Just like a pain pill, Need correct medication & correct dosage
Frequency of HEP is necessary to achieve and maintain reduction
Necessary frequency per day may vary based on daily activity and symptoms
How much sitting, standing, bending did you do today?
Common
Pitfalls
Failure to Avoid Aggravating factors
Is pt compliant with HEP but continuing to
slouch, bend poorly?
Clinician failure to help patient make
connection between Movement
competency → Symptoms
“I did my exercises and I’m no better…
I also spread 90 loads of mulch this
weekend.”
Case 1- Larry
Derangement? Yes
Lateral component?
Asymmetrical symptoms
Loss of Left Side Glide
Peripheralized & Worse with Extension
Visit 2:
Check HEP compliance [Satisfactory]
Check HEP form [Correct]
Review pt’s other activities--
Overuse of flexed postures? [No]
Case 1- Larry
Baselines: 6/10 L buttock & lateral
thigh pain
Concordant sign:
Increased pain with rising
from chair
Visit 2
Lateral procedures:
Repeated Extension in Lying with hips offset to R:
Increase thigh pain// Worse
Repeated L Side Glide at wall: Decreased
thigh// better. Improved L Sideglide ROM.
Improved Extension ROM.
Case 1- Larry
Baselines: 2/10 L buttock pain
Concordant sign:
Increased pain with rising
from chair
Visit 3:
Pt returns better.
L Sideglide ROM: Now painfree and full
Repeated Extension in Lying: Decreased buttock// Better. Improved
Extension ROM. Improved concordant
sign.
Transition back to sagittal plane:
HEP:
REIL 10x, every 2-3 hours + Additionally
as needed to manage inc in symptoms.
Posture correction
Case 1- Larry
Classification:
Derangement
Relevant Lateral
component
Restored Frontal Plane
Progressed back to
sagittal plane
Visits 4-5:
Maintain reduction of Derangement (posture + frequent HEP)
After 2 weeks of consecutive days without symptoms→ Recover Function
Core stabilization in Neutral Spine
Visit 6: Teach Prophylaxis program→
Extension program 2x a day
Lumbar roll with sitting
Frequent change of position
Self monitor baselines
Increase frequency of HEP PRN for
episodic symptoms
Case 2- Lisa
Current Baselines: 0/10 R posterior thigh pain
Concordant sign: Pain
prod with driving >20 min
Visit 2
Progression of Forces:
Repeated Extension in Lying with self OP:
No effect
Repeated Extension in Lying with PT OP:
Produced thigh// No worse
Extension mobilization: Produced thigh// Better.
Restored Flexion without pain
REIL with self OP: No Effect- maintained
improved baselines
Case 2- Lisa
Current Baselines: 0/10 R posterior thigh
pain
Concordant sign:
Resolved. No pain with
driving.
Visit 3
Pt returns better.
Continue with current HEP: REIL with self OP
every 3-4 hours
Maintain reduction of derangement
Reiterate sitting posture with lumbar roll
Limit frequency of flexion
Reinforce hip hinge training
Case 2- Lisa
Classification:
Derangement
Directional Preference:
Extension
Needed Progression of Forces
Needed therapist manual
techniques to improve
effectiveness of self treatment
Needed to utilize mechanical
baselines as symptoms not present at eval
Visits 4:
Recover Function
Return to running program
Visit 5: Teach prophylaxis program→
Extension program 2x a day
Lumbar roll with sitting & driving
Frequent change of position
Self monitor baselines
Increase frequency of HEP PRN for
episodic symptoms
HEP Prior/ After potentially aggravating
activity (running)
When Extension
doesn’t work…
Do you know what you have?
[Classification]
Have you progressed forces?
Have you tried going lateral?
Have you addressed & reinforced
lifestyle factors?
Posture, Movement competency,
Frequency of flexion
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Re-current Low Back Pain: It’s Not a Low Back Problem
Matthew VanderKooi PT, MS, OCS, COMT, FAAOMPT, FAFS
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Is the Best Provider Managing Care? Musculoskeletal education is lacking in medical Schools
It is NOT improving!
Average test scores remain at 51%.The only sub-group close to a passing grade of 70% were students taking an elective
musculoskeletal course (average score = 67.5%).(J Bone Joint Surg Am 2012 Oct 3; 94(19):e146(1-7).)
Choice of providers matters!Timing of interventions matters!How movement is managed matters!
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Risk is Driven by Imbalance
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Dynamic Systems Theory
movement patterns emerge from the interplay of the constraints between and within the elements of the system.
A dynamic system is composed of multiple interacting components
The movement is either efficient and sustainable, or inefficient and unsustainable leading to injury.
Holt KG, Wagenaar RO, Saltzman E. A dynamic systems/constraints approach to rehabilitation. Rev Bras Fisioter. 2010 Dec;14(6):446-463
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Regional Interdependence Any condition or disorder initiates a series of
responses that involves multiple systems of the body-musculoskeletal, neurophysiological somatovisceral, and biopsychosocial .
Definition- “a patient’s primary musculoskeletal symptoms may be directly or indirectly related or influenced by impairment form various body regions and systems regardless of proximity to the primary symptoms.” Sueki et al. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. Journal of Manual and Manipulative Therapy; 2013, vol. 21 no 2
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Regional Interdependence
Eg.• Interventions at the thoracic spine have been found to
affect cervical spine, shoulder and elbow Sx Cleland et al., Berglund et al.
• Interventions the hip have been found to affect knee symptoms. Souza and Powers
• Relationship between ankle impairment and low back pain Brantingham et al.
Sueki et al. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. Journal of Manual and Manipulative Therapy; 2013, vol. 21 no 2
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Regional Interdepedence
Fear avoidance, pain catastrophizing and anticipation can impact function and pain.
Education on pain can alter CNS function “An integrative model that eliminates the dichotomy
of having to choose between a biomedical, neurophysiclogical, or biopsychosocial models.”
Sueki et al. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. Journal of Manual and Manipulative Therapy; 2013, vol. 21 no 2
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Can I find the lesion?
“. . . Identifying relevant pathology in patients with LBP has proved elusive and is identified in less than 10% of cases.”
• Fritz, JM et al. Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to Physical Therapy. JOSPT June 2007, Volume 37, Number 6.
We’re not as good as we thought we were!!
This presentation does not fit the text book!!
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The Goal of Clinical Decision Making
Find the constraints or limitation in the dynamic resources (physical, psychological, social) of the individual to accomplish the desired task in the necessary environment.
The tissue in lesion or pathological tissue (Patient identified problem) may be the most significant constraint leading to the functional limitation, but likely not the only one, especially if tissue lesion onset was gradual in nature.
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Observe patient identified activity limitation, or activity that increases pain (Task/Environment).
Lumbar Scan Neurological scan/screening test Special Tests Clinical Prediction Rule criteria
Examination Strategy
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Task Observation-Finding body structure and function limitation (constraints)
Too much or too little motion at body region Lack of Dynamic Control of motion at body region. A breakdown in complexity, or a loss of variability, in the movement process
is viewed as a sign of dysfunction.
Holt KG, Wagenaar RO, Saltzman E. A dynamic systems/constraints approach to rehabilitation. Rev Bras Fisioter. 2010 Dec;14(6):446-463
Isolation of a body segment when task does not demand it (as opposed to
integrated movement up and down the movement chain) is a sign of dysfunction. Applied functional Science The Gray Institute
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Example-What should I see?
Walking stance position reaching with bilateral hands to floor• Calcaneal eversion, ankle dorsiflexion, tibial internal
rotation, knee abduction, knee flexion, hip internal rotation, adduction, and flexion, lumbar relative extension to pelvis followed by flexion (sacral nutation-counter nutation)
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Test the Hypothesis
Every treatment tests the hypothesis. Hypothesis needs to be continually reformed based
on results of testing. Asterisk sign Continuous process. Hypothetical question-treatment models.
Christensen, Nicole and Jones, Mark A Current concepts of Orthopaedic Physical Therapy 2nd Edition Independent Study course 16.2.1 APTA
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Psychosocial
Prognosis affected by: Depression Nonspecific physical problems (Mx areas) Rumination- compulsively focused attention on the symptoms
of one's distress, and on its possible causes and consequences Catastrophizing Stress at baseline Should be documented in assessment of evaluation
Hill and Fritz, Psychosocial influences on Low Back Pain, Disability and Response to treatment Physical Therapy Vol: 91:5 May 2011 pp 712-719
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Psychosocial
Mediators (link between intervention &desired outcome) Perceived control of pain Self efficacy (measure of one's own ability to complete tasks
and reach goals)Hill and Fritz, Psychosocial influences on Low Back Pain, Disability and Response to treatment Physical
Therapy Vol: 91:5 May 2011 pp 712-719
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Occupational
Prognosis affected by: Heavy physical demands Ability to modify work Job stress Social support Job satisfaction RTW expectations Fear of Re-Injury
Shaw WS et al. Addressing Occupational Factors in the Management of Low Back Pin: Implications for Physical Therapist Practice Physical Therapy Vol 91, 5 May 2011 pp 777-789
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Summary of Different Types of Flags.
Nicholas M K et al. PHYS THER 2011;91:737-753©2011 by American Physical Therapy Association
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Psychosocial Treatment considerations
Treatment needs to consider flags (yellow) Active PT-aerobic fitness and low back strength positive outcome for pain
catastrophizing. Education in understanding of condition
• (Low back how)
Educate on Perception of symptom legitimization Educate on Personal control of symptoms
Hill and Fritz, Psychosocial lnfluences on Low Back Pain, Disability and Response to treatment Physical Therapy Vol: 91:5 May 2011 pp 712-719
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Psychosocial Treatment considerations
Treatment needs to consider flags (yellow) Evidence-resume activities despite the presence of pain Decrease emphasis on anatomical structures as cause of pain Emphasis on pain management not relief Learn to live an active life in spite of pain Focus on Activity and Participation not pathology and impairment (ICF)
Need to collaborate with patient-pt. active role
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Psychosocial Treatment considerations
Treatment needs to consider flags (yellow) Explore patient beliefs and refer to them in explanation of patients pain. Graded activity or graded exposure Graded activity is quota based exercise in spite of symptoms Graded exposure is gradually exposing patient to activity that is feared starting at
lower level of intensitiesNicholas MK, and George SZ, Pscychologically Informed Interventions for Low Back Pain: An Update forPhysical Therapists Physical Therapy Vol
91, 5 May 2011 pp765-776
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Occupational Considerations
Treatment needs to consider flags (blue) Don’t ignore Advice that RTW is therapeutic-better outcomes if stay at work. Focus on Participation rather than impairment Challenge negative thoughts Problem solve with client having a central role in decision making process while
taking their perceptions into accountShaw WS et al. Addressing Occupational Factors in the Management of Low Back Pin: Implications for Physical Therapist Practice Physical
Therapy Vol 91, 5 May 2011 pp 777-789
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Readiness for Change
Clinical decision making in the context of readiness for change
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TAKE HOME –Identify Classification, address the symptom, but Treat the impaired movement (Regional
Interdependence) with in the context of the individual, (biological, psychological, sociological) task, and
environment
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Questions?
Thank you!
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Recurrent Lower Back Pain: Treating the Frequent Flyer
DAN RUSSO, PT, CIMT
UW HEALTH
When the Mechanics Approach Alone isn’t Working
“Frequent Flyers” What’s in a name?
The Term “Frequent Flyer,” implies that something isn’t working.
If we are doing our jobs well, patients don’t come back.
“You didn’t fix me the first time.”
“I keep getting hurt.”
“Something really complicated is going on here.”
“Maybe I have cancer.”
Etc…
So how do we approach this?
Refer to a physician for medication?
Call your favorite CI?
OR
Disagree with the Patient?
Tell them how good we are at our jobs?
Maybe…
New Zealand acute low back pain guide
2004 published guidelines
https://www.healthnavigator.org.nz/media/1006/nz-acute-
low-back-pain-guide-acc.pdf
2/3 of guide = Assessing Psychosocial Yellow Flags
Many Options to Consider
David S. Butler &
G. Lorimer Moseley
https://www.noigroup.com/
bodyinmind.org
Many Options to Consider
Adriaan Louw, PT, PhD
The International Spine and Pain Institute (ISPI)
https://www.ispinstitute.com/
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Many Options to Consider
CSM 2019
Pain Talks: Conversations with Pain Science Leaders on the Future of the
Field
Carolyn McManus, MPT, MA
Kathleen Sluka, PT, PhD
Steve George, PT, PhD
Carol Courtney, PT, PhD
Adriaan Louw, PT, PhD
Well, There’s No Protocol for That: Physical Therapy in a Trauma Setting
Daniel W. Flowers, PT, DPT; Sharon Dunn, PT, PhD; Megan Flavin, PT, DPT; Amanda Mahoney, PT, DPT; Erin McCallister, PT, DPT; Margaret Olmedo, MD
New Zealand acute low back pain guide
2004 published guidelines
https://www.healthnavigator.org.nz/media/1006/nz-acute-
low-back-pain-guide-acc.pdf
2/3 of guide = Assessing Psychosocial Yellow Flags
New Zealand…guide:“Ongoing management”
Review the patient’s progress each week until they have returned to
usual activities
Give the Green Light to be active at each review
Identify and address potential barriers to recovery at each review
Agree on a plan – and encourage autonomy and self-
management
If progress is delayed, reassess Red and Yellow Flags at 4 and 6
weeks
Consider specialist referral at 4-8 weeks to prevent ongoing
problems
Pain assessment: Patient
Great Resource from:
bodyinmind.org
Inactive as of Aug, 2019 – still a great
resource
Types of Pain
Tissue pain (Nociceptive)
Joints, muscle, ligaments, etc…
Peripheral Neuropathic
Central Sensitization
Centrally Driven
Central Sensitization
Tissue Pain (Nociceptive):Mechanical Problem*
Did something happen?
Was there an “injury?”
ACL: contact versus non-contact injuries
Common sense: If nothing happened → tissues not disrupted
If that’s the case, pain is likely due to something else.
Muscle spasm
Neural tension
Central sensitivity
Etc…
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Tissue Pain (Nociceptive):Mechanical Problem*
Don’t repeat what didn’t work last time
Change approach: What are you missing, what’s the “driver”?
Driver = behavior, biomechanics, weakness, etc… that is causing
the symptoms set
Treating wrong tissue?
Stabilization vs mobilization? (or vice versa)
Is a BEHAVIOR driving the symptom(s)?
OR is the driver more complex?
Peripheral Neuropathic & Centrally Driven (includes Central Sensitization)*
Multiple area sensitivity, light touch allodynia, Cold Hyperalgesia, pressure hyper-sensitivity,
Report of High disability levels, and of high pain levels
Pain behaviors.
Pain flare ups, unpredictable pain episodes. Socially modified pain reports
Self report of fears, anger, catastrophizing, anxiety, depressed mood, injustice, jealousy.
Poor pain concept, poor body perception concept
Thought driven report of pain, thought driven aberrant muscle activity
General guide to
contributing mechanisms
PCS = Pain Catastrophizing scale;
PKQr = Revised Pain knowledge
questionnaire;
FABQ = Fear Avoidance beliefs
questionnaire.
Patient Cases
Some Takeaways
Words Matter: Our ability to explain our diagnosis to patients has a
direct link to their outcome.
Treat the source of the problem.
Don’t prescribe press ups for ankle pain (unless is radicular)
If the issue is fear and inactivity, reassure them & get them moving.
MOVE:
Fairly unanimous in research I have seen: Patients do better when the
move more.
Patients are NOT “crazy”
They are in REAL pain and often unaware that they are compensating.
Pitfalls of Treating the Flyer
Manual therapy:
Touch patients: they will do much better
Manual therapy after 2wks or 4 visits (same approach) should raise your alarm
Pivot to education and movement
Posture:
Pay close attention to “induced scoliotic curves”
Correct with external cues
Don’t Rush & Take Time to Listen
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References:
1. New Zealand acute low back pain guide : incorporating the Guide
to assessing psychosocial yellow flags in acute low back pain. New
Zealand Guidelines Group; Accident Compensation Corporation
(NZ). [Wellington, N.Z.] : New Zealand Guidelines Group, 2004.
2. Body in Mind. https://bodyinmind.org/