Downplaying Pathology

One of my favorite podcasts is Dr. Oliver Thomson’s Words Matter. Through his podcast, Dr. Thomson addresses a wide range of topics relevant to my practice, both as a physical therapist as well as an educator. While an entire hour spent unpacking concepts surrounding the way a clinician approaches a patient presenting with back pain may sound rather niche-y and not of particular interest to an SLP, voice professional, or other professionals, but the episode that I just finished listening to is completely relevant for all of us. If you can broaden the context to include all aspects of diagnoses and envision how our patients enter our clinic, you’ll see the immediate relevance of the information covered in this episode.

One of the takeaways is revealed in the portion of the talk that looks at patient expectations in how we assess, and the expectation of all of the things that we will find wrong with the patient.

Much of this feeds into the traditional medical model that is ramped up in manual therapy evaluations. Our patients pay us to find out what is wrong with them and then do things to make them less wrong. In past articles I’ve covered my views on concepts of causation and pathology and how, when presented in the silo-based format of a specific manual therapy mindset, makes us seem the expert on finding problems with their fascia (or joint, or muscle, or trigger points).

They expect this from us, but by telling them what is wrong, we may be doing a disservice at many levels.

First off, our silo-based training makes every problem look like a problem based on our training. In my post life as an MFR therapist, every problem was explained in fascial-based language. But that language, and the concepts that underpinned it, are not ones accepted by the outside medical community.

So by telling my patient what was wrong with their fascia, I may have been telling mistrusts.

Second, by telling what is wrong with them I am reinforcing how broken they are. Sure, I am offering solutions (my services), but layering on pathological perceptions builds strongly on nocebic concepts (not a good thing).

In the podcast episode, Dr. Thomson and his guest, Dr. Ben Darlow, speak about how reinforcing the positive during an evaluation can step our patients back from the edge of feeling broken. While most want a diagnosis, what most really want is reassurance that they are NOT broken.

Most patients come to us having seen a few other professionals and, most likely, have been told some rather sorry explanations for why they are having problems. 

If the poor input came from someone at the top of the food chain, such as the ortho surgeon, or similar, those explanations are hard to undo. One cannot forget what they’ve already heard. But many of the bad explanations for problems come from those on a equivalent level, professional-wise. It’s not easy to undo the crappy thoughts injected into our patient’s brains by others, but we can start by telling our patients what is NOT wrong as we assess. The podcast explains this much better than I can, and there are a whole lot more gems that I believe all will benefit from.

You can listen to the entire podcast from the links at this page.

People Don’t Follow Guidelines For Back Pain Because There Is No Path To Follow

I get the opportunity to chat about back pain now and again around the world and one of the things I often talk about is the current guidelines around back pain. I will admit to often feeling a little apprehensive around this subject as the current guidelines run contrary to the way many HCP treat this common problem.

There is always a little gasp when manual therapy, acupuncture and ultrasound get relegated to adjunctive treatments. “Don’t shoot the messenger” is often my get out of jail card.

We know that clinical guidelines around most things within healthcare are not well followed. The big question is why?

We Are Humans!

Healthcare professionals are humans just like the people we are trying to help and suffer from exactly the same issues. For me there are parallels between getting clinicians to follow guidelines and getting people to be compliant, adherent, committed or whatever you want to call it to exercise programs or health improvement or even taking medications.

We all know that getting fitter is good for us as is reducing smoking, drinking and eating crappy foods. But that does not mean we always implement this knowledge. People still smoke and drink too much and don’t get the recommended dosages of exercise. Big societal messages are needed, but so is how to put them into practice at an individual level.

The big problem I see is how gigantically broad the guidelines are around treatment. Let’s take my favourite subjects’ activity & exercise, the guidelines are clear, movement is good, but the evidence base is not really clear when it comes to putting these recommendations into practice!

We might ask ourselves which exercise? How much? How should they do it? What should it feel like? Might it make the problem worse? How to get people to actually do it? If I look back at my clinical education in back pain treatment mostly it was based around Maitland mobilisations with little about exercise treatment and implementation.

So a simple guideline turns into a much greater clinical problem.

Providing A Path

Fundamentally we cannot expect people to implement something without giving them a way to implement it. We need to provide a pathway in much the same way we need to provide a pathway for the patients we work with around exercise.

How can you guide someone in something of you have no idea how to do it yourself?

Imagine getting a bit of flat pack furniture that did not come with any instructions. The pile of pieces that lay in front of you daring you to put them together. Some hardy souls, and probably those with a heap of previous experience, might attempt to put them together. Most normal folk, myself included, would simply put them back in the box and push them to the corner of the room. This conundrum is simply too much to handle.

You have all the pieces of the puzzle, but the problem is putting them together!

Education is another prime example. Education about what? Back pain? Pain? Treatment? Prognosis? All of the above? How to do it? Again there are many questions to unpack within the broad recommendation of education. I received no education in education at undergrad or post grad as I suspect neither have many of you reading this. Again this provides a barrier to implementation at the most basic level.

In the face of uncertainty and low confidence we return to our old habits that are ingrained within us and for many that is not based on current guidelines. Uncertainty provides huge inertia to change.

Support

Support is another factor that is often overlooked. How many people feel they cannot treat how they want to treat because of the working environment they are in and the people around them? This is something I often hear. Support again is a huge part of behaviour change and maintenance of that behaviour. A major part of self efficacy is built around social support and I doubt that it would be different in the work place.

The healthcare system that people work in can be a huge influencer of the way we practice in the same way our social systems affect our overall health and behaviours.

Takeaways

 

• Behaviour change is no different for HCPs than it is for patients

• If we want change we have to provide a path to change and support along the way

Why You Matter More Than Your Technique

Remember the first two terms of college? 

I remember it being REALLY stressful; in fact, they always said if you could make it through term two, you would be okay because it was the toughest. 

However, this was when we learned most of our technique classes. For us, term two was when we had a class called “Myofascial Release II .”

We learned a technique in that class that I still use today. The “Occipital Hold,” and we were taught how this was releasing the fascia around the occiput. 

Then five terms later, we had two more technique courses. One was MLD, and the other was Craniosacral. I don’t remember who taught us Craniosacral, but I probably owe them an apology. I was a bit of a jerk in that class because…well, I couldn’t feel the rhythms and pulses as it was being taught. As other students would exclaim how they felt these rhythms, I’d look across the room and say, “you’re full of s#*t you can’t feel anything!”

It wasn’t my finest moment; clearly, my ego and lack of palpation skills were at play, and I’m sure I owe some classmates an apology as well. 

The interesting thing is one of the techniques they taught us in that class was an occipital hold. With this technique, we were supposed to be altering the rhythm or flow of cerebrospinal fluid (I’m saying this strictly from memory as I haven’t studied any craniosacral since that time) along with possibly altering sutures in the skull. 

Now, I wish I could say I was some forward-thinking student that realized this at the time, but I only came to this revelation a year or two ago. 

Those two classes taught me the exact same technique but with wildly different explanations of what was going on. 

So, which one was right?

The Mechanisms Of Manual Therapy

An excellent paper was done, which looked at modelling a new approach to how studies in our field should be designed to understand better how to advance what works in our profession and what doesn’t. 

Part of the problem with many of our profession’s modality courses is how there seems to be a one-size-fits-all approach. That one technique can work on anyone for almost anything.(1) 

Well, there’s a lot more to a treatment than just the technique we use. So we can’t justify saying there is a “single thing’, or “single technique” that works exclusively on any given subject.

We know the mechanical stimulus from any manual therapy technique regardless of the intervention (joint mobs, spinal manipulation, Swedish massage, myofascial release, etc) results in neurophysiological responses in both the peripheral and CNS to help with pain inhibition. (1)

This helps demonstrate why we can’t take a mechanistic approach to treat patients. As the paper points out, to have a mechanical based approach, there are two prerequisites needed: 

  1. A mechanism contributing to a clinical population or subpopulation. 
  2. Biological effects of treatment have to be established. 

If both of these are met, a patient could then be matched to appropriate treatment (or technique), allowing for targeted application of that specific treatment. (1)

The issue here is there is no way to identify the main mechanisms of how any technique works. 

Now, I know that will ruffle some feathers as we quite often become attached to our favourite technique (and in no way am I saying you have to stop using the said technique; I encourage you to keep using it). Still, much of the research behind many of these techniques aren’t reliable. Often, the study is being done by the person who created said technique to prove its validity. And most of the time, they have excellent outcomes to prove their efficacy. 

However, what they aren’t taking into account is the contextual effects of what they’re doing. As this paper points out, this is a crucial part of any manual therapy intervention. 

How Our Treatments Are Multi-Faceted

There is far more than just our hands-on techniques that influence treatment outcomes. 

Just some of the non-specific factors to include are:(1) 

  • Patient beliefs
  • Provider beliefs, confidence, demeanour
  • The environment the treatment is provided in
  • Therapeutic relationship
  • Influence of community factors on the patient

There are many more but with this brief overview, let’s consider how this could influence research outcomes when strictly focused on a technique. 

If a patient believes the technique will help, well, it probably will. 

If the provider is trying to prove the efficacy of a said technique, chances are they are very confident of their proposed outcomes. They have probably also used the technique often, so they are quite capable and confident with the hands-on portion of using it. This would also influence their demeanour during their interaction with the patient, which also helps with a therapeutic relationship. 

Even the setting where the treatment is delivered can influence the outcome. For instance, an athlete would likely have a better result receiving treatment within the facility of their chosen sport. Someone with headaches would probably have a more significant effect in a darker room with less noise. 

So many of these contextual factors come into play; it demonstrates how we can’t strictly focus on one intervention or technique to show its effectiveness. 

As well there is this other wonderful thing called “Clinical Equipose.” 

We have touched on this in the past but essentially, what it means is a clinician having no preference as to what modality or technique they use. 

This is very important because bias towards a treatment is also associated with clinical outcomes. Because if a clinician believes a technique works and their expectation is that said technique always works, their expectations influence the outcome. 

Clinical Equipose is essential in a research setting because if the provider doesn’t care or isn’t invested in a particular technique, there can be no bias towards the intervention. As we have seen, this bias can influence outcomes. 

When we look back to my story from college and ask which technique description was right, the reality is neither one was right, but this is still a great technique. 

We know that what we do with our hands is a mechanical stimulus that results in neurophysiological responses to the nervous system. Everything we do is an influence on the nervous system. When we look at the occiput, this is an area that is HIGHLY innervated with nerves, and being nicely touched in the area feels really good! This is why an occipital hold is such a GREAT technique. So while we challenge the premise of some modalities (honestly, I wasn’t trying to pick on MFR or CST, it’s just a good example), it doesn’t mean we have to stop doing them. 

However, we have to look at the reasons why these work with the people we see. First off, your patients like you, and you do a good job. You’re confident with your skills. They come to your clinic with an expectation that you’re going to help them (and you do!). Their preference is to see you because they like what you do. Their belief system is that you’ve helped them in the past, so you’re likely to do so again. 

What we do have to change is the narrative behind some of these techniques. They’re not doing what many of us were taught, but they feel outstanding. So, if it feels good, you’re confident with them, and your patients believe you will help them, isn’t that better than a description that isn’t really plausible?

Oh, and to all my classmates and that teacher, I apologize. 

 

If you haven’t checked out our new podcast, head on over and subscribe HERE

References

  1. Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, George SZ. Unravelling the mechanisms of manual therapy: modelling an approach. Journal of orthopaedic & sports physical therapy. 2018 Jan;48(1):8-18.

The Muscle Of The Soul, Or Just A Good Stabilizer?

It may be the most popular muscle in the world. 

For some reason, it gets a lot of credit for things and stirs up more debate than any other muscle (at least from what I’ve seen). 

Yes, we’re talking about the muscle of the soul! The wonderful Psoas. 

It’s been given credit for many a thing, including but not limited to: 

  • anterior pelvic tilt
  • breathing disruption
  • manifesting physical symptoms of fear
  • knee pain
  • digestive problems
  • low back pain
  • and even somehow is part of our reptilian brain?

Whoa, this muscle is doing a lot!

When we look at some of these statements, they are often prefaced with “believed to,” and while people are entitled to believe whatever they want, some of these things are also taken as fact within our profession. 

When I was in college, this was often touted as the main reason people have low back pain. 

The muscle’s biomechanics showed us how a tight psoas was creating an increased lumbar lordosis when it was in a “shortened” position in everyone from office workers to cyclists. 

But what does the updated research say? Well…let’s get into that!

Biomechanics

First, it’s probably important to do a quick review (and yes, I had to look this up). 

It starts on the transverse process of T12-L4 as well as the intervertebral discs and inserts on the lesser trochanter of the femur. 

This research article(1) takes that a bit deeper and shows there are attachments on the anterior part of all lumbar TVP’s and the anteromedial aspect of the lumbar discs and bodies except on the L5/S1 disc. Where it attaches to the TVP’s is considered the posterior attachments, whereas the disc and bodies’ connections are considered the anterior attachments. There was an argument that those anterior attachments would pull the lumbar spine into and increased lordosis, but that  was with an assumption the attachments were more on the anterior surface of the vertebral body, not the TVP. 

When I was in school (and granted that was quite a while ago), we were taught that Psoas was primarily a hip flexor that worked along with Iliacus to accomplish the movement. However, some more recent studies(1) have shown it plays some other roles, including: 

  • advancing the lower limb while walking
  • controlling deviation of the trunk while sitting
  • some action with rotation, abduction, and adduction of the hip
  • lumbar spine stabilization
  • hip stabilizer

Interestingly, the study (1) looked at how the Psoas influenced hip pain in a hockey player, but not much discussion around low back pain. 

So, is the Psoas a culprit for patients presenting with low back pain?

Size And Role

A couple of studies looked at Psoas under MRI to compare cross-sectional size between those with low back pain and those without, and the results are pretty to interesting. 

They found those patients dealing with low back pain had a larger Psoas Major than those without pain. (2)

One possible reason for this is that Psoas is a lumbar spine stabilizer; the muscle’s hypertrophy was due to increased activity in those with some degenerative disorders in the lumbar spine, so it’s working as a support or protection for the area. (2)

When they looked at fat infiltration and whether it plays a role, there was a correlation with some atrophy of the lumbar paraspinal muscles, which would cause Psoas to increase its activity as a stabilizer for the lumbar spine. However, there was minimal infiltration of fatty tissue within Psoas. 

One other study looked at how Psoas was affected in older generations and did show there was a difference in size between men and women, which is likely due to hormone deficiencies after menopause. (3)

When there were degenerative changes with the lumbar discs or segmental instability in the spine, they noticed that Psoas actually got smaller. However, this is likely because more pain is associated with these degenerative changes, so the size change is because of disuse. This could also directly correlate to fear avoidance, where a person stops certain activities because they’re worried about reinjuring the area or making it worse, especially after getting what sounds like a scary diagnosis. 

To me this is a little bit of a chicken or the egg. Could Psoas be causing pain, or is it’s size adapting because of pain resulting from something else? I’d argue it’s the latter.

So now we understand that Psoas is more of a support to the lumbar spine rather than something that is pulling it into lordosis or causing pain; the question remains…do we treat it?

Well, there’s a lot of controversy around this, and I’d say it depends.

Although I know if I do a treatment in this area in the way I was shown in school, I can definitely feel the psoas “pop up” under my fingers. However, we also know there is A LOT of stuff in the way to be able to palpate something that deep. Because in reality, we can’t palpate something that deep even though we can feel it “pop up”. 

I have a person who comes in once a month for treatment and really enjoys getting their Psoas worked on. They feel it benefits them greatly for the activities they participate in. So, yeah, I’ll treat it for them. However, if this was a new person coming in and saying their back pain is a result of the Psoas, well then I’d be digging a bit deeper into their reasoning and having more of a conversation to educate them on how Psoas is probably helping more than it is causing an issue. It’s one of those things where our clinical experience and decision making have to come in to play. Some say we should never treat the area but we also have to take patient preference into account and what they believe will help them. If you’ve been treating the area and having reasonable success and your patients like it, then keep on keeping on. But change the narrative around it. Take the time to educate a little and see if it’s really necessary. Especially if you’ve been giving this kind of treatment and the person is uncomfortable during the treatment (let’s be honest, it’s a pretty sensitive area), then offer to change things up and try something different. Just make it a joint decision between the two of you and strengthen that therapeutic relationship. 

If you haven’t subscribed yet, check out our new podcast HERE, we’ll be discussing Psoas this week and discussing some of the research around it. 

References

  1. Sajko S, Stuber K. Psoas Major: a case report and review of its anatomy, biomechanics, and clinical implications. The Journal of the Canadian Chiropractic Association. 2009 Dec;53(4):311.
  2. Arbanas J, Pavlovic I, Marijancic V, Vlahovic H, Starcevic-Klasan G, Peharec S, Bajek S, Miletic D, Malnar D. MRI features of the psoas major muscle in patients with low back pain. European spine journal. 2013 Sep;22(9):1965-71.
  3. Sions JM, Elliott JM, Pohlig RT, Hicks GE. Trunk muscle characteristics of the multifidi, erector spinae, Psoas, and quadratus lumborum in older adults with and without chronic low back pain. journal of orthopaedic & sports physical therapy. 2017 Mar;47(3):173-9.