Mar 20, 2013

MDT or traditional OMPT for Lower Back Pain


MDT has the bases covered when it comes to what the research recommends for treatment of lower back pain.


  • education
  • self treatment
  • manual therapy
  • prevention!

This post was inspired by a patient who I covered on the blog last year as an acute lumbar lateral shift. She facebook messaged me over the weekend, saying "I threw my back out again." Instead of panicking, she asked me quickly what she should be doing. I told her shift corrections against the wall and progress to extension as soon as they are no longer painful/blocked.

That was 4 days ago. When she came to me in the same acute state last year, she was moderately shifted away from the painful side, and had high fear avoidance. This time, due to self management, she was only 3-4/10, mildly shifted and ready to get moving. Here were the main differences between this year and last year

  • she was extremely compliant with avoiding prolonged postures and her simple HEP from last visit
  • she knew exactly what to do before she verified it with me via facebook
  • instead of panicking and avoiding all movements, she found her directional preference and started self treatment only 1 hour after onset
  • she noticed at first she had full movement, THEN lost movement due to pain
    • this was key and a good observation... normally upon onset, we do have full movement and as the CNS takes over and perceives a threat, we rapidly lose movement
  • she worked diligently at restoring her SGIS to correct her shift
  • she took two days off of work instead of struggling to get to work, only to get written up for wearing sneakers instead of high heels (which are a requirement at her job - yes, this happened last year when she could barely stand upright)
    • during these two days, she religiously performed her HEP
  • I still used IASTM on her paraspinals, did some quick psoas release (new pain free version coming up on the omptchannel.com this week) to restore her blocked extension
  • she will be following up in two days, but she went from severely limited extension to mildly limited extension and full SGIS bilaterally with no shift in one visit
Thanks to the education the patient received, there was a big difference in not only her pain, function, and movement this year versus last year, but also her fear avoidance levels. Several years ago, she was one of those patients that when told to bend forward, needed a hole in the ground to reach her end range. After restoring full function and returning to marathons and yoga last year, she was STILL afraid of lumbar flexion, even though I reinstated it into her recovery of function phase. This year, she was ready to move and be moved. Last year, since she was shifted and had higher fear avoidance, it took 8 visits to reduce and another 4 to get her in running shape. This year, I think it will be maybe 3-4 visits.

The joke in PT school was of the 80% of the population who get LBP at some point in their lives, 80% also resolve within 4-6 weeks. So odds are, you're going to get the patient better. Research presented in MDT courses also looked at similar population in terms of recurrence, and those recurrence rates were somewhere between 60-70%. So what's the difference between MDT and traditional OMPT - the education and empowerment the patient typically has with a simple HEP that can be used to make rapid changes. OMPT can make a difference as well, both methods in the long term, as seen in this study. However, will the patients getting basic movements/advice/stabilization be able to self treat and improve rapidly as well as a patient with a MDT HEP? I am not so sure. Ow, I threw my back out... time to do some bird dogs to restore timing!


5 comments:

Harrison Vaughan said...

Great story here Dr. E! This is a case of a very successful and dedicated patient. I like many aspects here including her ability to self-treat most importantly, but also her confidence in coming back to you (a physical therapist) for advice and guidance. This is ahead of the game in most regards around the country. Most still go back to PCP, ER or whatever other means other than the practitioner who got them better!

I am not a MDT 'therapist' (meaning I don't have the training in it) but I do love the treatment approach. I do still feel being able to go back to a therapist for manual therapy, education, guidance, confidence, whatever is needed majority of the time (if not, we don't have a job!). I can't remember where I got this quote from, but I teach it to my interns and it fits nicely after your post:

"We all use a mechanical diagnosis and treatment approach. If you don't want to call it McKenzie, then don't. Repeated movements for a mechanical change is not copyrighted, but don't ignore this very successful avenue because it bears a clinician's name."

Harrison

Kevin said...

While I am usually in agreement with most of your posts Erson, but the McKenzie study you referenced is loaded with bias and ignores currents preliminary subclassifications. If a patient centralizes with repeated motions, they should be treated with repeated motions. So the argument against manipulation in this study is irrelevant. I am also not a big fan of the 2 opinions regarding more patients leaving the manipulation group due to treatment effect. Without specific data, this is only an assumption. Additionally, Stratford 1998 noted the MCID for LBP to range between 5 and 8 for individuals starting with a 13 on the RMDQ. This being the case neither group met the higher end of the MCID and the confidence intervals cross significantly. Also, chiros creating the HEP for the patients leaves a bad taste in my mouth but that is my identified bias. Finally, bird-dogs were part of the Hides 2001 study that demonstrated a significant decrease in LBP recurrance as compared to general care (30% versus 84% over a 1 year period). Let's not throw the baby out with the bathwater. Patients with higher likelihood of benefitting from repeated motions should get repeated motions, manipulations = manipulation, stabilization = stabilization, mix=mix. I think we need to move past the this "system" is best overall thought (we haven't even discussed patient expectations or the impact of therapist confidence on it!). If a single system was best for all, a lot of people would be out of work. I think you agree with this statement by the continued use of IASTM with your patients. As for advice for future recurrences, you should likely have your license revoked if you are not giving this information to patients. Would you not agree that there is much more to learn given none of the systems/treatments gets 100% outcomes....?

Dr. Erson Religioso III, DPT said...

Kevin, thanks for your reply! I'm certainly not throwing out other things that work, merely stating the MDT works better for prevention as my bias is obviously MDT. Bird dogs may prevent recurrence in a high amount of patients, but what happens when the recurrence occurs? Do they actually help with an acute exacerbation or a lateral shift? I wouldn't know as my MDT bias for HEP, then SFMA I haven't instructed them in years.

I also wasn't advocating MDT over manipulation in all instances, for me it's all about the HEP. I still also use IASTM, manipulation, MWM and neurodynamics, but for me it's all about getting the patient to end range so they can maintain it at home. I don't use one system for Tx, but I do primarily for HEP, then use others like some FMS/SFMA correctives for those that need it.

In terms of directional preference only needing repeated motions, a study last year showed that patients who met the CPR for lumbar thrust also were in the derangement category. This fits the current thought that CPRs are prognostic for future outcomes as long as they receive appropriate Tx with education. I'm for anything that works as long as the patient is given the means to self treat and not only when they're better, but also during a flareup.

Dr. Erson Religioso III, DPT said...

that's a great quote HV, I like MDT for it's classification system plus the empowerment of the patient. Also, one of my bigger messages to patients is first try to self treat, then call and come in immediately and use their direct access. That's why she came right back!

Catherine Torres said...

what are the causes of back pain? does this really helpful for back pain?

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