Mar 12, 2012

Stubbornly Mechanistic or Sticking With What Works?



Here is a review to a recent study on MDT. It examined whether pain responses to movement or position were linked to types of disc lesions.



 Ironically, it found that patients with extruded discs and a certain lack of intra-discal pressure centralized better than those with normal or protruded discs with normal intra-discal pressure.

Despite the continuing mechanistic explanations (or lack thereof) for why MDT works, it just does. It's troubling to me that the biopsychosocial only approach does not bother to fix a patient's posture.  Is is true that plenty of people slouch without pain or peripheralization; however, once they actually have symptoms, it is such an easy treatment, that often leads to immediate chances in increased ROM, decreased and centralized pain, absent reflexes sometimes return, strength tests increase, why wouldn't you start with correcting someone's posture? Think of it as a quick way to decrease CNS with education!

Whether the repeated end range loading bombards the CNS with proprioceptive input, thus decreasing a perceived threat and increasing movement tolerance, or the hydration of the annulus and position of a nucleus is changed, it works! Maybe it's both, or maybe it's neither. Anyone who has used MDT with success could tell you countless cases where going to end range was the ONLY way someone started responding. Possibly, the mechanoreceptors provide more input when pushed to end range?

Recent studies show that MDT had superior outcomes to thrust manipulation approach in the long term for 1 year follow up. Personally, I am waiting for a multi-modal study on MDT plus OMPT plus education with long term outcomes. Based on experience, I am sure that will have better outcomes than a manipulation alone < a book < education alone < exercise alone. I listed manipulation as the least effective because recent temporal studies show the effects of one mobilization lasting 5 minutes, and up to 24 hours for pain. The reason why the MDT approach works better in the long term is because the patients are constantly self mobilizing. So whatever the mechanism behind the improvement, it works because of the repetition and education.

An excellent PT visit is more than just one type of treatment, it is an experience in patient/clinician interaction, education, movement, and a combination of what works clinically and then by evidence. Someone recently worded it well, so I will paraphrase it, we cannot discount practice based evidence. Restricting your practice to following only the evidence will limit your patient outcomes as much as it helps them.

16 comments:

Dr. Ben Fung said...

Great post! I agree: what works... works. My mind gravitates towards the mechanically oriented due to my background in Bioengineering (which is why MDT and I get along great). And, you hit the nail on the head!.. The entire spectrum of the human experience must be addressed for comprehensive care. If it works, and, it empowers our patients - it's a win for everyone! Always inspired by your wisdom, Dr. E! Keep it up!

Dr. Erson Religioso III, DPT said...

Thanks Ben! It was motivated by all the recent shares/posts by the naysayers on various blogs and social media. One in particular which stated clinging to explanations like "tight" ITB and disc model is purely financially motivated. If it was financially motivated, I wouldn't actually be slow and slightly nervous in my practice from getting a string of recent patients better in less than 6 visits while not getting as many evals in! I don't bash their impractical methods of treatment, but they insist on being "better" and being "evolved" clinicians, when in fact, the treatments are similar, but the explanations are different. It is sad we can't just get along and some have to think they're better than others, when all they do is promote clinical dissonance rather than collaboration.

Kinetic Integration said...

It is an interesting post, what is more interesting is why you are ardent on sticking with all the MDT jargon while you freely admit its contradictions. I am referring to 'mobilization', 'mechanical diagnosis' etc. These words, while as harmless as any word, point to and reinforce a specific cognitive framework by both the clinician and the patient; a mechanical one.

This framework, while perhaps not as harmful as other diagnostic labels in medicine does assert that the dysfunction is in the tissues. In my opinion, in patients with persistent pain and in cases of acute pain this can actually be a disservice. Even in cases of acute pain there is no clear consensus about the amount of tissue damage and its correlation with perceived pain. Additionally clouding the therapy session with mechanically based jargon as a mechanism of causality initially and then switching to a neuro-pain matrix approach latter further confuses the patient.

The neuro-pain matrix approach is not just "education" as it is alluded to in your post but an entirely different way of conceptualizing the patient. Part of it is educational. BUT it is not ONLY a cognitive educational model to be dumped on the patient. It requires the therapist to re-strategize how they implement interventions. The advantage gained is not only for the patient but the therapist as well.

The words you do use matter, they form your conceptual framework and of those you inform. Instead of regarding the patients' pain behaviors as 'problems' we now interpret them as legitimate responses to a perceived or actual threats. We are attempting to shift the conversation from defect and deficit to defense and protect. That is what neuro-pain matrix is about.

'Mobilizations' are simply movements--they do not isolate a joint, muscle, or tissue and cannot be proven to be so. Lets be clear, I am not arguing against these movements and their efficacy. I use similar movements for many of my patients and myself and have found them to be successful.

We are not static or rigid mechanical systems--contrary to the things we create--each individual is not laden with latent dysfunctions that lie just beneath the surface but rather we are dynamic self organizing systems that have power to reorganize our interpretation of ourselves and the world around us, given we are put within the proper context. Language, words, diagnosis can serve to reinforce this context just as much as a movement and posture.

In regards to posture, it is interesting how you use the word 'fix'. If you walked into a MIT robotics laboratory and you saw a humanoid robot attempting and failing at some task, would you have the authority to 'fix' this? Why as physical therapists do we feel that we have such an authority to make similar judgments when the human body is nearly infinitesimally more complex than the prior example. As I type this post I am twisted completely slumped and have one leg on the desk--no pain. Posture, unlike your post alluded has not been correlated with pain, period.

That is the what and the why of its importance to be specific about the aforementioned. Many physical therapists may feel that this is a bit pedantic. It is my opinion that this hot mess of pain has been created by our medical system and rests in large portion with how our medical system (therapists included) conceptualize and articulate it through language.

While we can focus on what we do with our hands we would do well to focus on what we do with our mouths.

This post while pointed is designed to highlight differences in my conceptualization and that of Dr. E (as I perceive it) and is not an attack on him as an individual or clinician. I respectfully thank you Dr. E for providing a forum to discuss such issues.

Eric

Hamp said...

Eric,

Do you take issue with treatments (mobilizations/manipulation, postural correction, etc.), or the semantics of how we describe those treatments?

Dr. Erson Religioso III, DPT said...

>>These words, while as harmless as any word, point to and reinforce a specific cognitive framework by both the clinician and the patient; a mechanical one.

This framework, while perhaps not as harmful as other diagnostic labels in medicine does assert that the dysfunction is in the tissues. IN MY OPINION, in patients with persistent pain and in cases of acute pain this CAN actually be a disservice>>

Thanks for the thoughtful reply Eric. While it is true the conceptualization is different, both of these models are purely that, just models. I capitalized the points I couldn't bold using disqus.

1) IN MY OPINION.... yes, it's only your opinion of my model versus your model. How is it a disservice when neither can be fully proven and the patients education and treatment make them better? They also stay better, learn an easy home program that for the most part enables them self treatment?

2) CAN be a disservice... There is absolutely no harm in using a model that works, is believable, and ends with good patient outcomes. You only think it's harmful... that makes the interaction between you and the patient harmful I suppose if you don't believe in the biomechanical model. I believe in it, it works, how does that harm the patient

The disservice is attempting to get an acute patient (or even chronic fast responder) to believe that for some strange reason (in the absence of true trauma), your brain has identified a threat and has limited your motion, made radiating pain, weakness, loss of sensation, made OTHER joints along the chain also restricted, but not necessarily painful, made connective tissue around the painful and adjacent dysfunctional areas restricted? It's just not a practical in any way approach. While the research supports changes in the brain with pain immediately after injury, acute and fast responders just do not need or worse even buy this approach and explanation.

3) I fully realize that there are most likely much less mechanical effects using any type of OMPT and more neurophysiologic effects due to the rapid changes we see. However, until the biopsychosocial approach actually comes up with some treatments that are actually different than educating with a different model, and using manual therapy and exercise, it's not easily applicable. My interactions are still preventing catastrophization by showing the patient what causes their complaints (movements and/or positions), and what alleviates their complaints.

Just because your current posture does not cause pain, does not mean it is good for you. It's not no pain, no problem... does a frozen shoulder without any pain, not pose a problem for the patient if their ADLs are all severely limited? Does the wounded soldier who makes it all the way back to base carrying a comrade who cannot walk, not have a wound himself? A failing robot is something that can be programmed and fixed. I do not need infinitesimal variables to correct posture, just 1 or 2, and whatever the mechanism, whether it's mechanical and/or reduction of perceived threat, it works very well in many cases. Showing cause and effect makes a big difference. I doubt the perceived threat in regard to posture, because many patients are genuinely surprised that correcting their posture makes them feel better, move better, and centralize their complaints.

As we are talking about this in the context of PT, if we break down what physicians can provide as only shots, pills, and surgery. The only things we can provide is education, exercise, and hands on techniques. The framework we use does not change our practice act. Your approach, while admirable, is not easily implemented for chronic/persistent patients, and is not needed when a patient is going to get better in my visit average for 6-8 treatments.

You choose to only use one approach, I can freely use both approaches in patients who need or require elements of either. Thanks for keeping the discussion civil.

Kinetic Integration said...

Semantics, but the point is the semantics we use with our patients has everything to do with how and if we can help them.

Jay said...

Just curious if you (Erson, and others) are aware of of Peter O'Sullivan's work from Curtin University, Perth Western Australia. While in the undergraduate course (which I have completed) we cover this to a mild-moderate amount, it is the most rounded approach to Physio/Physicaltherapy that I have come by.

A good place to start is here:
http://bodylogi.apexhost.net.au/Content/contentFiles/PDF/Classification_of_LBP_2005.pdf

Dr. Erson Religioso III, DPT said...

Wow Ann, you worded it better and more eloquently than I could have while all those thoughts swirled around in my head. Amen!

Ann Wendel said...

Oh, how apropo. Just this moment my article on Turf Wars was published on The WebPT blog.

http://bit.ly/znZb4G

Sigurd Mikkelsen said...

...just want to add one comment to the MDT-study you are referring to. I'd guess the same as you, Dr. E, if MDT were to be put up against manip alone, book alone, education alone, exercise alone, MDT would be the winning team. First presumption might be the mechanical mobilizing nature of the technique, but what about this "explanation"?

My guess is as simple as this - because MDT encourages the patient to physically and mentally participate in the treatment. Yes, exercise would partly do that too, but most likely without that meaningful context of MDT where the patient has to self-regulate, interact, monitor, h*s own symptom response - a very different aspect of MDT in contrast to the other interventions mentioned.

Head-to-head studies of other "techniques" partly paint the same picture, take for instance the MET/PNF/contract-relax/strain-counterstrain "muscle" biased techniques. The one thing these techniques have in common is again - active participation of the patient.

Take-home message from this: all techniques involving active participation of the patient are likely to be superior to most passive techniques such as mobs/manips. And another important thing, if the participation of the patient is put into a meaningful context as to mentally explore symptom free movement capacity vs. just do this exercise - my guess again - it'll be superior.

I like to think this is more due to the patient-introvert, explorative, curios, attentive nature of these techniques - more than due to the joint/muscle explanation alone.

As to the ITB-post you are referring to, people still believe its the mechanical visoelastic nature of stretching that causes ITB "lengthening", but numerous studies strongly suggest that increased ROM is due to increased tolerance to stretching, in other words, the "pain" perception is altered... Same conclusion comes from authors that have investigated ballistic vs. static vs. post-isometric stretching. The perception is changed.

One last point - a neurological brain based explanation is way more difficult and abstract to comprehend, than a mechanistic one. This obviously goes for both the patient and the therapist. My explanations neuro vs. mechano is moulded down to what I think goes best home with the patient, preferably with the less dissonance allowed. How I discuss these models with other therapists is a whole other platter.

Thanks for the post and stimulating comments so far!

Anthony Distano said...

Great thread! I began the shift from biomechanical to biopsyhcosocial in my practice as a chiropractor. I have found the only thing that I really had to change was my explanation of pain. I found it quite easy and liberating to just explain to patients that pain is produced AND controlled by the nervous system and the way to help your nervous system "turn down" AND/OR "mute" the volume on pain is by movement. The movement may produced by me via manual therapy BUT will always have to be produced by you with exercises.

I still can use the same manual therapy techniques in the same manner I would you under the biomechanical model and still use my clinical assessment (SFMA) to aid with exercise presciption....just with different reasoning (to reduce threat to the CNS rather then targeting isolated tissue/joints). By using this approach, I feel I can keep my individuality as a practitioner AND be incorporating what we know about neurobiology of pain......just my two cents!

Dr. Erson Religioso III, DPT said...

Agreed Anthony! Thanks for your post, btw, I'm taking the SFMA next month and am really excited to add another assessment tool and I already have an eclectic treatment toolbox. My only disagreement with most of this thread is the need to completely "shift" the paradigm and go one the evolved way, or stay a dinosaur. I am shifting much of my explanations for rapid changes to biopsych, especially the stretch tolerance (- thanks @SigMik - I love that theory!), but some people just don't "buy" it, so I see no harm in using a supposed outdated model if the outcomes are the same, and maybe even better if the patient believes it.

Dr. Erson Religioso III, DPT said...

Thanks Sigurd! Love the stretch tolerance theory, makes more sense in the context, although I always wonder why the nervous system makes "adherence" or restrictions in the connective tissue so easily palpable on areas that do not hurt, but are related either neurologically or along the chain. My guess for all studies is no one approach will ever on meta-analysis, work for all conditions because everyone is an individual and requires 1:1 attention, interaction, treatment, and education.

Dr. Erson Religioso III, DPT said...

Today's discussion is an example of civilized discussion. It can happen, but I am with you in the frustration that it is the same discussion over and over.

Mark Kargela said...

Great discussion on this topic. I am currently finishing up my MDT program and hope to be certified by September. I also come from a long history of manual therapy training with strict biomechanics theoretical constructs. I was refreshed this past weekend taking a spinal manipulation course from Australian DO Peter Gibbons and DO/PT Philip Tehan. Osteopathic training is heavy into biomechanical constructs as well. It was nice to see them speak to the fact as that that a strict biomechanical theoretical construct has not been been supported by the literature and that there are many mechanisms at play with the effects of manipulation with a likely large neurophysiologic component. They said multiple times that there are many possibilities of effect, but the honest answer is that we do not know.

The study that Erson mentions on the superiority of MDT versus manipulation is a great example of the separation and division within our profession based on theoretical constructs. One could raise many questions on the methods of that study and how manipulation was applied (by chiropractors) and how it was supported in treatment by other interventions. As we all know, manipulation is never done as a "stand-alone" intervention and is complemented by other things such as mobilization, exercise...etc. This study did have other interventions outside of chiropractic manipulation but chiropractic training is often much different in the form of therapeutic exercise and other additional components that a physical therapist may add to a treatment program containing manipulation. I do know chiropractors who are very evidence-based in their application of complementary interventions and do not just take a crack it and move on philosophy. Manipulation is a part of MDT force progression, yet seen as a last resort based on their expert opinion and little more than that. The fact remains that we do not completely understand why a lot what we do works.

There is fascinating research out there that has really directed to start looking at a more comprehensive biopsychosocial model in our interventions. Strip these theoretical constructs from their titles (MDT, manipulation, Mulligan MWM, Paris progressive mobilizations, Maitland gd I-V mobilization and manipulation) and they are all the same. They are all either passive movement ( accessory movement, physiologic movement, or combinations of the two) or active movement with many variations of delivery. I see them all as things that nicely co-exist within a patient's treatment program and often manipulate with a directional preference self-mobilization and exercise focus.

The only thing that we know as absolute fact is the change we create within our patient that is demonstrable after delivery of an intervention be it a manipulation, passive McKenzie self-mobilization (to end range of course), or a therapeutic exercise. Whether it was the brain that was the primary player is likely but not understood. I agree with Erson completely that we cannot just abandon models just because it does not have a neurophysiologic education focus. For some patients this education is not met with understanding and I have had some patients get frustrated with it. These patients sometimes need a more simpler model (restoring mobility, centralizing pain,...etc) to gain understanding and establish a positive expectation that the brain can run with.

In the end I think we will continue to see the use of the same interventions as time passes with the same positive outcomes in a lot of cases, but as we gain a better understanding of central and peripheral neurophysiologic mechanisms the reason "why" they work will likely evolve.

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