Something for current students to ponder....

[jesspt]

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Here's an article that calls into question many of the concepts we are traditionally taught in physical therapy school regarding the cause of musculoskeletal pain, as well as how we treat it. Those of you who are well into your PT school curriculum might find it interesting, and if so, hopefully it will spark some discussion.

 

[Nailey13]

I don't have much time to reply to this, but I wanted to share a few thoughts. My main question, I suppose, is where do the implications of this article leave us as students preparing to enter PT school in the coming year(s)? The foundation of orthopedic physical therapy seems to have been (and will likely continue to be) the identification of PSB factors and the "treatment" of these "irregularities" through manual therapy and exercise prescription. If very little can be done (other than short-term mitigation of symptoms) within the scope of the orthopedic practice setting (i.e. weekly appts. with patients), should that have some effect on how we advertise our services as practitioners? I.e. are we ethically obliged to say, "We can only provide you with a short term fix (if even that is possible)"?

The therapists I've shadowed thus far have made it clear to their patients that lasting results can only come from continued long-term adherence to the exercise regimes assigned during therapy. But [Lederer] seems to be saying that significant PSB modifications would take a tremendous (and perhaps impossible) effort.

Overall, this article is more than a bit disheartening and I for one don't really know how to process its implications (if true) for orthopedic care. This just leaves a bad taste in my mouth. 🙁

 

[jesspt]

I don't have much time to reply to this, but I wanted to share a few thoughts. My main question, I suppose, is where do the implications of this article leave us as students preparing to enter PT school in the coming year(s)? The foundation of orthopedic physical therapy seems to have been (and will likely continue to be) the identification of PSB factors and the "treatment" of these "irregularities" through manual therapy and exercise prescription. If very little can be done (other than short-term mitigation of symptoms) within the scope of the orthopedic practice setting (i.e. weekly appts. with patients), should that have some effect on how we advertise our services as practitioners? I.e. are we ethically obliged to say, "We can only provide you with a short term fix (if even that is possible)"?

The therapists I've shadowed thus far have made it clear to their patients that lasting results can only come from continued long-term adherence to the exercise regimes assigned during therapy. But [Lederer] seems to be saying that significant PSB modifications would take a tremendous (and perhaps impossible) effort.

Overall, this article is more than a bit disheartening and I for one don't really know how to process its implications (if true) for orthopedic care. This just leaves a bad taste in my mouth. 🙁

Nailey,

Why is it disheartening? Would blissful ignorance of some of this information make you happier? Perhaps, because it wouldn't be at odds with many of us traditionally view orthopaedic manual physical therapy. But, it's possible this article might make you a more informed clinician, and that's never a bad thing.

The therapists I've shadowed thus far have made it clear to their patients that lasting results can only come from continued long-term adherence to the exercise regimes assigned during therapy. But [Lederer] seems to be saying that significant PSB modifications would take a tremendous (and perhaps impossible) effort.

Where is their proof of this? If avoiding reccurance of low back pain were as simple as compliance with a home exercise program, why are exacerbations of symptoms so prevalent?

And yes, Lederer is saying that with gross or severe assymetry, likely in association with severe physical demands, PSB may play a role in the cause of the patient's symptoms. And, manual therapy is unlikely to be able to correct gross assymetry. We can more readily have an effect with making suggestions designed to reduce the physical demands.

If very little can be done (other than short-term mitigation of symptoms) within the scope of the orthopedic practice setting (i.e. weekly appts. with patients), should that have some effect on how we advertise our services as practitioners? I.e. are we ethically obliged to say, "We can only provide you with a short term fix (if even that is possible)"?

The author isn't stating that nothing can be done via physical therapy to help patients with low back pain. He is attempting to outline the severe limitations of the PSB model, and the fact that relying on concepts and theories that don't hold up under current best evidence likely take a clinician further away from understand low back pain and how to best treat it.

Reading something like this can be frustrating, but shouldn't be paralyzing. There are still plenty of things we, as physical therapists, can do to help patients with low back pain. It's just that spending a lot of effort to "correct" PSB "findings" shouldn't likely be among them.

 

[fozzy40]

Great article to share JessPT!

I agree with everything that Lederman wrote and with JessPT's comments. I would not be disheartened by this kind of stuff because it illustrates that there are limitations manual medicine, physical therapy, etc...however, there are limitations to everything! You will find that musculoskeletal literature is full of correlations BUT NOT CAUSATIONS. We tend to find that certain objective findings are found with certain symptoms. However, you can't say that the findings caused the symptoms.

Part of the problem, in my opinion, is that "we" (physicians, PT, OT, SLP, ATC, etc) all tend to think that there is only "one" major cause for musculoskeletal pain. The fact is that MSK problems are multifactorial. To study a single treatment with one outcome and expect to have a significant clinical outcome is a bit ambitious. We are all guilty of that.

One thing that Lederman fails to emphasize is that we have all treated patients using a biomechanical hypothesis...and...some get better and some don't! Those who don't improve probably have a lot more factors that need to be addressed to get a clinical improvement. Therefore, something is working!

Long story short, there is no magic bullet for MSK problems...treat within your scope and if there is no improvement then think outside of the box.

 

[MinnDasota]

well said Fozzy!

 

[Nailey13]

Why is it disheartening? Would blissful ignorance of some of this information make you happier? Perhaps, because it wouldn't be at odds with many of us traditionally view orthopaedic manual physical therapy. But, it's possible this article might make you a more informed clinician, and that's never a bad thing.

Hey, hey now 😉. Let's not be mean. I was only saying that the article initially made me feel a bit downhearted only because I (in my naivete) have and continue to put a lot of faith in the power corrective exercise. It was only the "least" little bit alarming to hear someone call into question the foundation of orthopedic physical therapy (its foundational status is certainly up for debate).

I've been trying to gather as much information about physical therapy as a whole (there's a reason I frequent this forum and a reason I read the article, Jess). Dissent on key points and the only comparatively recent push towards evidence-based practice make me worry about the firmness of the tenants on which I'm preparing to base my course of study. That's not to say that I am questioning my choice to pursue physical therapy nor am I saying that I would prefer to "stick my head in the sand." As I said before, I'm disheartened, and I stand by that assessment.

I am incredibly enthusiastic about the practice of PT, have personally seen incredible results in the orthopedic setting, and am very much looking forward to starting the application process next year. I'm always the person looking for definitive answers though, and what I need to realize is that there will always be dissent (and that this dissent is essential for progress).

 

[facetguy]

The 'structural model' of LBP has been challenged for some time now, as the author suggests, so much of what he says shouldn't be a complete surprise. In the author's defense, he states that exploring the neuromuscular factors was beyond the scope of his article. But I think this is where we'll see more and more emphasis in the literature. And we already know that biopsychosocial factors are important in many cases, with some studies suggesting that 'emotional' factors (sometimes called "yellow flags") may be even more important and predictive than purely physical ones.

As far as being bummed out about the implications of Lederman's article and those like it, I disagree. I see the evolving models as an opportunity to learn new things about pain, biology, our patients, etc., and using this new information in the care of our patients and in better understanding what we do everyday. This means integrating new findings, not just new to the young student but new to all of us. As one quick example, there have been some recent studies examining changes at the cortical level in terms of motor control of spinal musculature and how those motor programs are altered in pain patients. It's early yet, but who knows how that may change our practices. From someone who does a lot of manipulation for spine patients, further exploration into how manipulation impacts these cortical pathways (which is currently underway) and not just local effects is a cool thing.

And Nailey mentioned short-term vs. permanent fixes for patients. The literature is pretty clear that for many spine patients there isn't a permanent fix as yet. These cases are much more likely to be chronic recurrent. Now, that's not to say any treatment rendered is a waste of time. But it is a reminder that our end-points need to be realistic for a good number of cases.

 

[markelmarcel]

I found the article intriguing because I have "abnormalities" in my back and it wasn't until I was made aware of them, and then tried to "fix" them, that I started having pain. So, I kind of agree with the asymmetrical thing not necessarily being a pain inducer, but more-so if the person is not in pain. If they are in pain, then yes, that could be a factor, but it could also just be that person is slightly different. As much as we study anatomy, everyone is slightly different. No vasculature (sp?) separates in the exact same spot, nor do nerves always split exactly where they are supposed to, etc, etc.

Sometimes these differences among us cause pain/problems, but sometimes the person goes through their entire life ignorant to those abnormalities.

I'll be interested to see how I am taught in regards to this after reading this article.

 

[facetguy]

It's funny how the universe works sometimes. I randomly stumbled upon this article tonight after having read JessPT's OP just last night.

http://saveyourself.ca/articles/structuralism.php

It's similar to the Lederman article, albeit less formal. Lederman's article is in fact mentioned.

 

[jesspt]

It's funny how the universe works sometimes. I randomly stumbled upon this article tonight after having read JessPT's OP just last night.

http://saveyourself.ca/articles/structuralism.php

It's similar to the Lederman article, albeit less formal. Lederman's article is in fact mentioned.

I love that web site. And, is common there, Mr. Ingraham highlights the main problems with the biomechanical model. And, taken from his blog post, they are as follows:

1. Not only are structural explanations for pain generally unsupported by any scientific evidence, the last 25 years of research results mostly undermines them.
2. Worse still, therapists can rarely agree on such diagnoses.
3. And, worse still again, most structural diagnoses are difficult or impossible to do anything about even if you can agree on them in the first place.
4. And, worst of all, patients are often indoctrinated with the disconcerting idea that the slightest crookedness, even a single minor "deformity," can be nearly crippling and requires expensive therapy to correct.
5. Finally, there are some significant alternative ways of looking at such problems that are potentially much more useful.

The article I posted, as well as the saveyourself web site are excellent things for students to begin looking at, particulalry when they begin to get out into their outpatient ortho clinicals.

 

[jesspt]

And just in case any readers here place great importance on core strengthening/stabilization, here you go:

http://www.osteohealing.com.au/Lederman%202010-%20Myth%20of%20Core%20Stability.pdf

 

[PTtoBe]

I read the Ingraham post, and found it a nice thought-provoking read. While he spends much time trying to debunk a strict Postural/Structural/Biomechanical (PSB) approach, he only glosses over a more systemic approach. He does make reference to "psychosocial factors" but not much beyond that.

I can tell you that our class was drilled relentlessly on the ICF Model, (International Classification of Functioning, Disability and Health), which better resolves Ingraham's grievances by including environmental and personal factors. Beyond that we spent some time learning about the nature of chronic pain (nociceptors upregulating resulting in increased sensitivity, decreased motion, and so on), which also seems to better account for the "squishy, messy physiology" that he seeks.

I can tell you that in my brief clinical exposure (I'm about to begin the meat of my internships) I've noticed some PTs downplay or pretty much ignore psychosocial factors that are likely at play in some patients. And even when dealing with patients themselves, some of them seem skeptical if you discuss some of these factors with them as contributing to their pain (e.g. how the recent stress of losing their job and apartment are related), and would prefer a black-and-white PSB explanation.

 

[jesspt]

I read the Ingraham post, and found it a nice thought-provoking read. While he spends much time trying to debunk a strict Postural/Structural/Biomechanical (PSB) approach, he only glosses over a more systemic approach. He does make reference to "psychosocial factors" but not much beyond that.

I can tell you that our class was drilled relentlessly on the ICF Model, (International Classification of Functioning, Disability and Health), which better resolves Ingraham's grievances by including environmental and personal factors. Beyond that we spent some time learning about the nature of chronic pain (nociceptors upregulating resulting in increased sensitivity, decreased motion, and so on), which also seems to better account for the "squishy, messy physiology" that he seeks.

I can tell you that in my brief clinical exposure (I'm about to begin the meat of my internships) I've noticed some PTs downplay or pretty much ignore psychosocial factors that are likely at play in some patients. And even when dealing with patients themselves, some of them seem skeptical if you discuss some of these factors with them as contributing to their pain (e.g. how the recent stress of losing their job and apartment are related), and would prefer a black-and-white PSB explanation.

So, how will you handle these interactions as you go out into your clinicals? Should clinicians give a PSB explanation that is likley false and non-contributory?

 

[mtm34]

we can always just grade V everything

 

[jesspt]

we can always just grade V everything

Not sure if this is supposed to be sarcastic, ironic, critical, or a genuine comment.

 

[Danae00]

Here's an article that calls into question many of the concepts we are traditionally taught in physical therapy school regarding the cause of musculoskeletal pain, as well as how we treat it. Those of you who are well into your PT school curriculum might find it interesting, and if so, hopefully it will spark some discussion.

I don't know if I found any of that surprising and it pretty much fits into what we have been taught in school. Low back pain is not well understood, psychosocial factors are huge, and we should be willing to try a variety of approaches and consult with and/or refer to other health professionals as necessary. That doesn't mean that ther ex is not appropriate. As someone else mentioned, it just isn't black and white.

I love the fact that physical therapy is now very focused on being evidence-based. Of course, this means that some commonly used interventions may be found to be ineffective (*cough* ultrasound *cough*). So we get to adapt, learn new ways of doing things that work even better, keep up with research (or even do it! so many cool research projects), and use our clinical judgement to come up with treatments that will work for our client. It's very exciting time to be a PT! 😍