Read through your key lesion post again and it makes a little more sense. Imay have been too quick to judge (sorry). You talk about the differences intraining, but actually PT is trained in a similar manner and to look behind theanatomical site of the injury and figure out what sort of muscular weakness,joint hypomobility or muscle tightness may be contributing to the patientscomplaints (Huge difference between PT and chiropractic in terms of differentialdiagnosis).
What I find very limiting about this theory is the fact that many times withMsK and chronic pain there isn't necessarily an insult (i.e. broken footfollowed by immobilization with walking boot). I would like to give you anexample of this in a PT setting.
A runner comes in with anterior knee pain that comes on during the 3rd mileof his 10 k (atraumatic). Hurts when descending stairs and hurts when sittingfor greater than an hour. Classic presentation of patellofemoral pain syndrome(Tightness of the lateral retinaculum causing a lateral tilt of the patella;less surface area of the undersurface of the patella articulating with thefemur; same forces, less contact area = pain). Now, if the injury is more in theacute phase and you can manually bring the patella (by using a medial tilt)back to midline, than you can likely mobilize the patella while strengtheningthe hips and any weakness in the LE. This is a common presentation andtreatment utilizing hip strengthening (focusing on control of the femoralmotion during dynamic movements) that is very well validated by the literature.See last months JOSPT for newer stuff, but older research is certainly availablein the biomechanics literature.
If the injury appears without an insult, the key lesion theory falls apart.Most notably, chronic LBP is atraumatic and to deduce that at some point abroken ankle caused that is spotty at best. I appreciate that this research would be incredibly tough to do. You can point to differences in training allyou want, but give me something more than my patients love it and it works forme. I would appreciate a PM with some body of evidence.
As for PFS, I do see that a lot. Occasionally I can treat a single muscle (usually somewhere in the lateral quad) or inject it and get the patient relief, but in most cases I would teach them simple VMO strengthening. For patients where this is severe or if the patient has difficulty following instructions, I will send them to PT.
As I said before, sports med is one area where PT shines.
As for chronic LBP, thats where you are dead wrong- at least in some cases. If you are careful about the history- most cases of chronic LBP actually do have a traumatic history- though the patient often doesnt initially remember it or recognize its relevance. You need to trace back to the first sign of the LBP and ask them a detailed history of what sports they were doing and what kind of work they were doing at the time, along with whatever car wrecks or major falls they may have had within a year or two of the onset of their symptoms. The mechanism of injury will guide in how to conduct the physical exam.
For example: a patient presents with 5 year history of LBP. When pressed, they relay that they first noticed it ~August of '06 when they get a new job and are on their feet much of the day. The pain gradually worsens and now they have trouble with day to day tasks and have gained some weight. When pressed about trauma history, they do recall that they were T-boned at an intersection in February of 2006. They didnt think it was relevant since they did not think they were badly hurt, so they did not include it in their medical history.
Without the accident history- it would be easy to spend all your time focusing on structures of the low back, stretching tight muscles and strengthening weak muscles. Each time you work on them, symptoms gradually get better, and over a period of months they slowly improve.
My physical exam, however, would include a careful evaluation of the left upper ribs (location of the seatbelt), the cervical spine due to any whiplash phenomena, the shoulders (arms rigid against the steering wheel could easily translate to the torso) and right pelvis (foot on the break could easily translate to the torso, which is why we see pelvic fractures in MVA's). I do not anticipate problems at all of these regions, but with this history I do anticipate at least one of these regions will be grossly abnormal.
Normalization of the abnormal body region almost always results in immediate normalization of posture, and sometimes resolution of the low back pain even before treating the low back. No pain, no recurrence, happy patient. Total cost: a few minutes of your time during the physical exam and lots of extra thinking and anatomy training (if the problem is medical rather than pain related- then it takes extensive training in pathophysiology of the disease in question as well- usually more depth than the average physician gets in med school, more like what you'd see at the specialty level).
If you fix the problem you found and see no change in low back pain, sometimes there are overused structures in the lower back that need a day or two of rest before they feel normal again- or you can seek them out and fix them directly resulting in resolution of symptoms. You might also keep looking around the above regions for anything you might have missed.
If the patient still has symptoms on follow up- I consider it a treatment failure. You might target low back directly at this point- but improvements by direct action at tender and non-stiff structures are more likely to be transient- and if that approach doesn't resolve symptoms, that's when you go with patient take-home stretches/strengthening or rehab.
There is no purpose in having the patient suffer for months if you can fix once and for all in a few minutes- and usually a good DO can do this. It is also not that inconvenient to check these things over the course of a normal physical exam- so long as the doc has the proper training. Unfortunately most do not.
