Musing on back pain.
Bias, Chance or Truth?
In their book Clinical Epidemiology - The Essentials, Fletcher & Fletcher [1] make note of how our clinical observations can be subject to bias and chance; when these have been controlled or minimised, truth should emerge. I learned very early on that the tendency towards bias and chance during the post-graduate education period left me vulnerable to being swayed by people rather than the movement science. Ever since the CSAG review in 1994 [2] I have wondered how useful a medical/disease model for lower back pain [LBP] was to the patients I assessed and treated.
Now let's be clear right from the outset; I am biased. My view of how to treat LBP is an amalgamation of research I have read, applied and found useful. As a physical therapist, I have not been adequately trained in medicine, psychiatry or other allied disciplines to be deemed competent to treat my patients for depression, anxiety, mindfulness etc. etc. It is however, abundantly clear that the way people think and view the world can influence their recovery from musculoskeletal [MSK] pain syndromes. But does the way you think actually change your ability to manage the symptoms in your lower back? I do not believe this paradigm.
A weekend course does NOT constitute a qualification; it represents an awareness/taster of an idea or belief. I suspect that there would be outrage and shock if our military special forces, airline pilots or emergency services were "qualified" after a Saturday/Sunday training session.
Movement Impairments - Cause or Source?
Treatment by physical means, and a focus upon the movement system, is my unique focus [3]. I make no apologies for distancing myself from the shift in physical therapy practice towards telephone calls masquerading as treatment or handing out leaflets and hoping patients figure it out for themselves. Two events in 1998 changed my direction of thought and practice pattern forever ::
* 2 days with Professor Shirley Sahrmann in the Gleeson Lecture Theatre [Mar 1998, Chelsea & Westminster Hospital] & subsequent Mary McMillan lecture [4].
* A secondment to work in the Ergonomics Department at Nottingham City Hospital [1998-1999 with Professor Sue Hignett] & subsequent post-grad study/cert in Occupational Health [5].
So why was this such a shift for me?
Independently of each other, both Prof. Sahrmann & Prof. Hignett pronounced their focus upon the causes of pain problems rather than trying to ameliorate the symptoms or sources of pain. Put bluntly, the body tissue that hurts [::defn ::source:: ligament, muscle, tendon] can be cooked, frozen or electrocuted by a therapist, but what discussion is taking place with the patient about the cause [::defn - cause:: sustained or repetitive movement that is physical stressor]. I have rarely found passive treatments rewarding for either the patient or physiotherapist.
That said, we cannot deny that at the right time [6] in an injury continuum, modalities like taping, acupuncture, manual therapy etc can help people recover. Indeed, my own sporadic injuries [e.g. calf strain 6 days before Army selection] benefitted tremendously from taping [7]. Shame Rocktape couldn't improve my eyesight on the Snellen test otherwise I would have used it on my eyes too!
What I truly believe is that over a lifespan, making people autonomous should be a key goal. You wouldn't dream of having your teeth brushed for you, by the dentist, morning and evening for the rest of your life?
In their book Clinical Epidemiology - The Essentials, Fletcher & Fletcher [1] make note of how our clinical observations can be subject to bias and chance; when these have been controlled or minimised, truth should emerge. I learned very early on that the tendency towards bias and chance during the post-graduate education period left me vulnerable to being swayed by people rather than the movement science. Ever since the CSAG review in 1994 [2] I have wondered how useful a medical/disease model for lower back pain [LBP] was to the patients I assessed and treated.
Now let's be clear right from the outset; I am biased. My view of how to treat LBP is an amalgamation of research I have read, applied and found useful. As a physical therapist, I have not been adequately trained in medicine, psychiatry or other allied disciplines to be deemed competent to treat my patients for depression, anxiety, mindfulness etc. etc. It is however, abundantly clear that the way people think and view the world can influence their recovery from musculoskeletal [MSK] pain syndromes. But does the way you think actually change your ability to manage the symptoms in your lower back? I do not believe this paradigm.
A weekend course does NOT constitute a qualification; it represents an awareness/taster of an idea or belief. I suspect that there would be outrage and shock if our military special forces, airline pilots or emergency services were "qualified" after a Saturday/Sunday training session.
Movement Impairments - Cause or Source?
Treatment by physical means, and a focus upon the movement system, is my unique focus [3]. I make no apologies for distancing myself from the shift in physical therapy practice towards telephone calls masquerading as treatment or handing out leaflets and hoping patients figure it out for themselves. Two events in 1998 changed my direction of thought and practice pattern forever ::
* 2 days with Professor Shirley Sahrmann in the Gleeson Lecture Theatre [Mar 1998, Chelsea & Westminster Hospital] & subsequent Mary McMillan lecture [4].
* A secondment to work in the Ergonomics Department at Nottingham City Hospital [1998-1999 with Professor Sue Hignett] & subsequent post-grad study/cert in Occupational Health [5].
So why was this such a shift for me?
Independently of each other, both Prof. Sahrmann & Prof. Hignett pronounced their focus upon the causes of pain problems rather than trying to ameliorate the symptoms or sources of pain. Put bluntly, the body tissue that hurts [::defn ::source:: ligament, muscle, tendon] can be cooked, frozen or electrocuted by a therapist, but what discussion is taking place with the patient about the cause [::defn - cause:: sustained or repetitive movement that is physical stressor]. I have rarely found passive treatments rewarding for either the patient or physiotherapist.
That said, we cannot deny that at the right time [6] in an injury continuum, modalities like taping, acupuncture, manual therapy etc can help people recover. Indeed, my own sporadic injuries [e.g. calf strain 6 days before Army selection] benefitted tremendously from taping [7]. Shame Rocktape couldn't improve my eyesight on the Snellen test otherwise I would have used it on my eyes too!
What I truly believe is that over a lifespan, making people autonomous should be a key goal. You wouldn't dream of having your teeth brushed for you, by the dentist, morning and evening for the rest of your life?
References ::
1. https://www.amazon.co.uk/Clinical-Epidemiology-Essentials-Robert-Fletcher/dp/0781752159/ref=cm_cr_ar...
2. http://bjgp.org/content/bjgp/47/421/501.full.pdf
5. http://www.lboro.ac.uk/departments/design-school/staff/sue-hignett/
6. http://bjsm.bmj.com/content/bjsports/46/4/220.full.pdf
7. https://www.researchgate.net/profile/Catherine_Moore11