Resilience – What It Is And Why Is It A Big Deal For Recovery?

 

Resilience is a term used more and more by therapists, some might suggest it is a buzz word, so I wanted to put down my thoughts about this complex subject. I have wanted to write this blog for a while and the struggle I have had here is to keep it bloggy, not too academic and above all not too long! I have tried to strike a balance between research and also some personal experiences of resilience I have collected.

Before we get into it, there are 3 main points I would like to make in this blog.

Firstly, resilience is NOT about manning (or womaning) up, it is NOT SIMPLY about just keeping going. It’s a flexible, adaptable state that recognizes the importance of specific actions, mental or physical, that have a positive impact on life.

Secondly, resilience is not a binary state between resilience and not resilient. It is a continuum that we move along dependent on a balance of internal and external factors.

Thirdly that resilience looks and feels different between people. What you may regard as resilience MAY NOT be the same as the person you are working with.

What Is Resilience?

Resilience is defined by Sturgeon *HERE* as,

“Maintenance of positive physical and emotional functioning in spite of significant difficulty or challenge”

So resilience is both a physical and a psychological thing. It is important that we don’t separate the two, however (much like pain!). Although physical things often signify resilience, they require a strong psychological component to achieve and also give a lot of psychological benefits.

This is also a good read *HERE*

Karoly *HERE* defines resilience as (2006) as

“Effective functioning despite the exposure to stressful circumstances and internal distress”

Both definitions use the word FUNCTIONING and ‘in spite’ or ‘despite’ of pain.

This makes resilience a REALLY individual thing that looks quite different between different folk. We should not make the mistake of assuming what signifies resilience to us is the same as someone else’s.

Pain is definitely a stressful circumstance for many, and it really becomes a problem when it interrupts our functioning. Focusing on the stressor, pain, however, could be part of this problem. Essentially resilience should be seen as a problem of function rather than pain. This is an important distinction, as identification and engagement of functions must form the key focus (IMO) rather than the focus that many can have (patient & therapist), pain itself.

Sturgeon writes;

”Attempts to control a chronic stressor like chronic pain are often counterproductive and can magnify the negative effects of the stressor”

Sustainability

Goubert & Trompetter *HERE* introduce the concept of sustainability; this is defined as:

“ability of a person to move towards long-term positive outcomes in life in the presence of adversity”

Here is a nice graphic outlining sustainability vs recovery from their paper.

Screen Shot 2018 10 26 At 07.32.40

Sustainability targets the PERSON in pain rather than the pain itself. Perhaps sometimes the focus can be on the pain going away before function is resumed, but we could view this the other way around with functioning through resilience being the first step.

The concept of sustainability is important, as it looks more at positive traits rather than risk factors. This is a bit like Antonovsky’s Salutogenic approach *HERE* that focuses on health rather than disease.

So to sum up resilience, it is about PEOPLE and FUNCTION more than pain and withstanding pain (IMO). Working through ANY pain or injury will require some element of resilience. Acute back pain, one of the most prevalent painful issues, probably exemplifies the need for resilience, with the first-line treatment for back pain being the advice to remain active and engage in your normal activities *HERE*.

Perhaps initial resilience may mediate the transition to more persistent pain states?

Adaptability & Flexibility

Resilience should not be seen as a brick wall. A resilient person is not simply a cold piece of rock impervious to any stressor. It is not about toughness, it is instead a flexible and adaptive state.

It could be quite the opposite, in that resilient people might be willing to seek out help instead of the strong silent type who may not be as resilient as they appear externally, unable to appear weak or vulnerable by asking for help. Resilience may be the ability to open the pressure valve and allow the excess to release and lower the stress by identifying things that allow them to do this or provide a balance with stressful situations.

Pain Relief Vs Resilience

Therapy has long been driven by pain relief, and whilst there is no doubt this is a reason why people seek care, they also seek care because pain is disrupting their lives and functioning, perhaps even more so for this reason.

This paper by Ferrara found that disability was a greater reason for care-seeking than pain intensity *HERE*

So perhaps to understand resilience we have to understand to understand our patients functioning and what THEY view as key markers to signify resilience. Traditionally VAS scales and physical measures such as strength have been used to measure clinical success. But do these measures capture valued activities and what resilience might mean for the person? Perhaps not. This paper looks at this subject of what is measured clinically vs peoples ACTUAL goals *HERE*.

So in order to help people BE resilient a good place to start is to find out more about how THEY view resilience, what defines their effective functioning and how we might bridge the gap between their current and desired states.

Resilience Is Personal

Valued activities may provide balance during stressful situations. Especially people that suffer from persistent pain can lose sight of things they used to do and the things that might define resilience. These are the people that may need a guide or a coach to find some meaning or goal again.

The sustained engagement in cherished activities, or stuff that MEANS stuff, seems to be a huge marker of resilience. To get a better idea of some of the meaningful activities, I asked some of the folk on social media (not in-depth research I know) to let me know some of the things they found important during painful times.

Exercise seems to be a really important sign of resilience for people and it was amazing to hear so many success stories against some pretty adverse situations. On a side note, communicating patient success stories to other patients, delivered at the right time and in the right way, can be a very powerful tool in my experience.

  • Weightlifting
  • Capoeira
  • Yoga
  • Pilates
  • Boxing
  • Bike riding
  • Crossfit
  • Running
  • Walking
  • Bouldering
  • Various sports
  • Gymnastics
  • Dancing
  • Making things
  • Hiking

Work also featured heavily. Just day to day functioning seemed important. Much like exercise, our working lives are pretty varied from being a therapist to nursing to simply driving. The concept of family also featured heavily with helping and providing for them forming an important part of resilience for many.

Resilience seems to be a rich tapestry of different things. The clinical implication of this is being able to effectively listen and ask a few questions that allow us to find out more about what activities may signify resilience and then be able to guide someone towards them and also provide planning and support for engagement.

Here are some example questions I use:

“What would your perfect day without pain look like?”

“What have you stopped doing because of the pain?”

“Are there things you feel are important that you avoid because of the pain?”

I also picked out some quotes. I have not used any names : )

“For many years, my default position was to isolate myself, try to power through, and go out of my way not to seek out resources or strategies. I thought that was the way I was supposed to do it; “man up” and push through. For me, I think I discovered (still am) resilience when I learned about acceptance. Getting to acceptance, and I think I still struggle with that a bit to this day, was a difficult time as I had to admit that I could not do this on my own. I hated that feeling”

“Resilience is in all of us, but sometimes we need a guide to help us find our path forward, but there is always a path forward”

“I would say the thing that made me the most resilient was asking for help. From my mentors, friends, counselors and family. Vulnerability helped me be more resilient”

“I love riding my bike but on a steep hill climb, my pain would escalate 10 fold. I persisted and after 30 mins or so of cycling it would go back down to normal levels. The bike ride was more important for my mental well being than the back pain maybe that is why I persisted”

“Resilience for me is knowing that there are things you can and can’t control and you put energy and focus into those things you can control/accept”

“Resilience is I get up every day and work with injuries on others. Sometimes leaving bed is the hardest part”

 It could be balancing the stressful parts of life with things that bring us happiness and joy is most important and when we lose this balance is when we start to become more vulnerable and our job may be to help with this process.

What Components Make Up Resilience?

Both Sturgeon and Goubert outline some positive elements AND some risk factors involved in resilience.

Lets first start with the positive elements.

Optimism & Positive Emotions

Optimism appears to be a key characteristic, with optimism being related to lower levels of pain and this may support why predicted expectations are related to outcomes. Optimism should be viewed both from a clinician and patient viewpoint and withou,t doubt both viewpoint will interact within the ‘third space’.

Here are some good papers *HERE* & *HERE*

Questions we can ask ourselves:

  • Are you a generally optimistic clinician/person?
  • How optimistic are you about a positive outcome?
  • Do you discuss what a positive outcome might look like, especially in regards to improved function?
  • Can we highlight positive aspects from the person’s story/history, previous positive experiences to be optimistic about?

Although it is important to not seem disingenuous, the need for positivity and a positive emotional perspective on life and activity should be highlighted, although this should probably come after a validation of normal negative responses to a tough situation such as persisting pain.

I feel it is also important to highlight the negative aspects of negative thinking and behaviour.

Pain Acceptance & Sustained Engagement In Valued Activities

Pain acceptance is defined as acknowledging that one has pain, stopping attempts to control pain, and learning to live a richer life in spite of pain. This in turn can lead to more engagement in valued activities.

Sturgeon writes

“individuals with greater levels of activity engagement are better able to bolster their positive emotions through sustained pursuit of valued activities despite their pain”

This appears to be a key factor, both highlighted in the research and also in the in depth qualitative research I performed above on social media ; )

Social Support

People who actively seek out social support seem to have lower levels of pain. We know from work such as Riikka Holopainen’s *HERE* that people with persisting pain reported that their circle of life had shrunk and they had given up doing things they used to enjoy.

Pain can interrupt positive social interactions that are important for resilience, however, pain can also narrow our ability to identify these positive social interactions and positive resilience resources in general.

Risk Factors

Pain Catastrophisation & Avoidance

Higher levels of pain catastrophizing and fear are linked to higher levels of pain and pain catastrophizing can also lead to ineffective coping strategies such as an avoidance approach to coping. This behaviour is consistent with the affective-motivational side of pain that can often motivate people to avoid things such as social interactions and physical activities. Essentially this can limit the enjoyment and positive aspects gained from valued activities, often for fear of pain, and can reduce resilience behaviours. This prolonged avoidance can also lead to depression and disability.

I feel it is important to highlight avoidant approaches and also help someone to rationalise if they are actually helpful for them or not.

But it is also important NOT to simply label people avoiders. Avoidance like all things is complex. Some activities may display avoidance behaviours whilst other things are engaged in. It is a touch harsh to take an area of someone’s life they are struggling with and use it to define them.

Resilience Or Vulnerability

We must be mindful that resilience does not appear to be a stable state. People are not simply resilient or vulnera,ble. Instead they appear to have components of both aspects co-existing in a sort of balancing act. Sometimes we maybe more susceptible to vulnerability, even the most resilient is resilient until they are not. We may also be vulnerable in some areas of our lives but not in others. We could be physically resilient but emotionally vulnerable or the other way around. It could switch from day to day. The one thing we know about the experience of pain, and all the dimensions that go into it, is that it pain is predictably unpredictable.

Resilience should really be seen as a continuum. Different injuries may require different levels of resilience and the person will have a current resiliency state dependent on many factors in their life. Some people may be super resilient or the injury type or state may not require much resilience. As with all painful problems, this relies on clinical reasoning to apply the right care at the right time.

Screen Shot 2018 10 26 At 07.40.13

Take Homes

  • Resilience IS NOT TOUGHNESS
  • Resilience is about adaptability and physical and psychological flexibility
  • Resilience lies on a continuum
  • Resilience looks and feels different to different people
  • Optimism is key
  • Sustained engagement in valued activities is key
  • Pain catastrophization and avoidance behaviour are risk factors

How to Screen if the Cervical Spine is Impacting Shoulder Pain. (Yes it’s in Your Scope!)

We’ve spent the last couple weeks at The Massage Development Center exploring a variety of shoulder diagnoses and treatments. But what happens when shoulder pain isn’t coming from a source in the glenohumeral joint or its structures? Are you able to screen for these conditions?

Now, I am a physical therapist and it was in my training to look at the cervical spine when evaluating a patient for a shoulder injury.

However, depending on your schooling and licensure, it may not have been part of your education. From my understanding, if you are a massage therapist, even what state or province you work in determines if you can do a full screen of the cervical spine.

However, I want to argue it is in everybody’s scope of practice to do due diligence to take a good history and make sure an outside referral isn’t warranted. My goal with this post is not to teach a bunch of cervical screening tests, but to familiarize everybody with risk factors in patient’s history and signs and symptom that would warrant further investigation either from you or outside referral.

Recognizing Referral Pain

The cervical nerve roots and cervical discs can refer to the shoulder area. Your patient may come in complaining of upper trapezius pain or rhomboid pain but it could be a C6-7 nerve root radiculopathy causing pain.

The referred pain may continue further down the upper extremity or may stop in the shoulder region. The following table outlines the common areas for referral:

Nerve Root Shoulder area referral pattern:

C2 – Pain primarily in the posterior aspect of skull, headaches, ears, eyes
C3 – Pain in necks and Upper Trapezius
C4 – Pain in Upper Trapezius, lower neck
C5 – Pain in upper lateral arm, neck, shoulder Weakness in Deltoid and           Elbow Flexion
C6 – Pain in the dorsolateral arm, Neck upper/middle trapezius                       Weakness in biceps
C7 – Pain Middle trapezius/rhomboid area and neck Weakness in triceps
C8 – Pain in neck and middle/lower trapezius Weakness largely in hand
T1 – Pain in lower trapezius and forearm Weakness largely in hand

If your practice acts allow differential assessment and shoulder tests are negative, it is worth considering cervical radiculopathy. Research shows that grouping the Spurlings Test (also known as the Foraminal Compression Test), Upper limb nerve tension testing, Cervical Distraction Test and the patient presenting with involved side cervical rotation of less than 60 degrees has a 90% positive likelihood ration that cervical radiculopathy is present.

What if your practice acts do not allow you to perform special tests for the neck?

Ask some questions and observe, to help determine if it might be cervical radiculopathy.

First does it look like your patient has less than 60 degrees of cervical rotation of their symptomatic side? Do they describe their pain as “pins-and-needles or tingling or stinging” or occasional numbness? Do they have muscle weakness? Does the pain increase when they rotate to that side and concurrently extend their neck (a sign of compressing the nerve root)?

In younger patients, the most common cause of nerve root irritation is disc herniation or a direct blow such as in football or hockey game (a “stinger”). In older patients, the leading cause is stenosis or bony spurs.

If the answer to these questions is yes, you may want to consider having your patient follow-up with another healthcare practitioner if they have not had the cervical spine evaluated (particularly if they have significant weakness present). However, largely these conditions will respond to massage therapy and strengthening along with other physical therapy treatments and potentially other medical management.

However, you may have patients whose history is not as straight forward or the presentation may be more serious and you need to do a more immediate referral. The cervical spine structures can also refer to the shoulder complex for much more serious reasons.

Knowing When To Refer Out

Upper cervical fractures can irritate nerve roots and refer to the shoulder as well. These typically won’t refer into the glenohumeral joint proper but may refer into the upper trap area. You may wonder how somebody could be walking around with an undiagnosed cervical vertebral fracture, but it is actually not that uncommon.

A Dens fracture of C2, for example, is often not seen unless an open mouth x-ray is performed (which is not always standard protocol or people think they are “fine” after an MVA). It is typically injured with a hyperextension type of injury (i.e. whiplash in a car accident or hyperextension of the neck in football with another player falling on the injured player). The fracture can compress the spinal cord and cause swelling which can also cause the nerve roots to refer pain. The injury does have a good outcome potential with proper treatment.

However, if your patient has the appropriate mechanism of injury and has neck pain, neck swelling, complaints of swallowing and has muscle weakness and has not been evaluated for a fracture you should refer out prior to treatment.

Cervical Central Cord Compression is probably the most severe diagnosis to should be making sure you screen. This occurs when the spinal cord becomes compressed from bone fragments from a fracture or disc, swelling due to an injury from a trauma or a tumor.

Because it may take time for swelling to develop and compress the cord, symptoms may develop over many hours or days so they may be walking in your office now experiencing a medical emergency. Your patient will have a history of major trauma (fall, motor vehicle accident, a blunt blow to the spine). Classic signs of central cord compression include: gait disturbances (they may be walking with a wide base of support or say they feel unsteady since the accident), arm and hand sensory complaints and muscle weakness including very quick atrophy of the muscles, and complaints of sudden onset incontinence (not just a few drops, full bladder uncontrollably leaking).

If these are new-onset symptoms with a trauma history, immediately send your patient to a physician or emergency room. You cannot be too careful with this sort of diagnosis.

It’s also important to remember that shoulder pain may not be referring from the cervical spine at all but from another area of the body such as abdominal gas, heart issues such as a heart attack or from an organ such as the gallbladder. We shared such a case of referred pain in a post you can find here. In summary, it is important to get a good patient history prior to treating their shoulder to assess whether the cervical spine may be involved. If it is out of the scope of your practice to assess the spine, then make sure you know the red flags and history that would warrant a referral to an outside practitioner. The human body is so interconnected and we should never work in isolation!

References:

Childress MA, Becker BA. Nonoperative Management of Cervical Radiculopathy. American Family Physician. 2016;93(9):746-754

Clark, Charles R. The Cervical Spine. Fourth ed. 2005. Web.

Hashmi SZ, Marra A, Jenis LG, Patel AA. Current Concepts: Central Cord Syndrome. Clinical Spine Surgery. 2018;31(10):407-412
Hutting N, Scholten-Peeters GGM, Vijverman V, Keesenberg MDM, Verhagen AP. Diagnostic accuracy of upper cervical spine instability tests: a systematic review. Physical Therapy. 2013;93(12):1686-1695

Schroeder GD, Vaccaro AR. Cervical Spine Injuries in the Athlete. Instructional Course Lectures. 2017;66:391-402.

Neuroscience And Skilled Patient-Communication Are Essential When Dealing With Patients Suffering From Complex Pain Conditions

 

Patients with complex pain conditions, such as fibromyalgia, are now recognized as living with a chronic disease, according to the WHO (Nicholas M, 2019). While this is a huge step in terms of social recognition of the existence of pain in the absence of pathology, there’s still no cure or superior treatments available. Yet, it has become increasingly clear that self-management is essential and that patient education plays a pivotal role in self-management.

”Pain education, or PNE, has shown us a way forward in self-management of chronic pain. The next step is to embrace the narrative as a therapeutic intervention”

For more than 15 years patients have been educated to understand their pain as a result of hypersensitivity and/or reduced inhibition in the nervous system. However, in the same period only a minority of universities, colleges etc. world-wide meet the international recommendations for professional education on pain and neuroscience*. Consequently, many – even newly educated – healthcare professionals rely on their knowledge about anatomy and biomechanics to understand pain in the musculoskeletal system, despite obvious flaws in this theory (Palsson TS et al. 2019).

”Theories based on anatomy and biomechanics are inherently in conflict with a scientifically informed understanding of pain!”

As a skeptic, I’m comfortable with the concept of all theories being flawed (or ‘wrong’) and at the same time necessary for the clinician to make sense of the information (data) we get from our patients. Without theories, we would not be able to form a structure and make sense of experiences the patient shares. For the purpose of this blog, I choose to define a theory as any explanation that guide clinicians in their work (e.g. ‘hypersensitivity of the nervous system’ or ‘central sensitization’). Many theories are based on basic science (e.g. anatomy, physiology, and biochemistry) while others are not. My academic and research training has focussed on basic science, so this is where I will take my starting point, although I openly admit that my clinical aim is always to improve the disabilities and symptoms of the patient – not the underlying (theoretical) mechanism.

Neuroscience is to pain what biomechanics is to movement – not sufficient but essential and complex.

Traditionally, it was assumed that pain [insert your favourite body region] was related to structures in the anatomy, and brilliant thinkers such as Shirley Sarhman, Paul Hodges and Mark Laslett/Tom Petersen have provided (overlapping) theories that try to explain how ‘impaired’ biomechanics or anatomy can lead to painful experiences (Karayannis N et al. 2012).

Furthermore, these theories postulate a linear relationship between impairment-correction and pain-reduction, in other words; when impairments are corrected, the patient experiences pain relief. To many people (patients and professionals alike) this leads to the unfortunate and incorrect conclusion that if the patient experiences pain relief, then the theory must be correct. The unfortunate bit of this conclusion is that both parties tend to stick to such theories even when they are unlikely to help, and the theory is incorrect in assuming that if pain relief is observed after applying the theory, then they are causally related. In more scientific terms this has been called a correlation. A well-known example of this misunderstanding that degeneration of the spine could explain pain, while more recent evidence clearly shows this is not the case (see e.g. Brinjikji W et al. 2015) and a counter-recommendation that imaging should not be performed unless serious pathology is expected (Lin I et al. 2019).

However, the theories – flawed as they are – have provided many patients with both a novel understanding of their body and how it was related to pain relief. What has become increasingly clear over the last decades is that theories based on biomechanics or anatomy anywhere in the body cannot explain how movement causes pain, rather a neuroscience approach is necessary (Brumagne S et al. 2019).

The simplest version of the problem with anatomy/biomechanics as a model for pain seems to be that the link between consciousness and anatomy/biomechanics remains unexplored. The neuroscience approach, on the other hand, which tries to link the experience of pain to the transmission of signals from the body – including the brain – via neurons and non-neuronal cells, is a very well developed science, and even though our understanding of what consciousness is, remains theoretical, consensus is that signals in the body are the most likely measurable link between the objective (measurable), 3rdperson perspective and the experience, or 1stperson perspective, of pain.

“Neurobiology is not a core skill in most educations, but anatomy and biomechanics still is. This could be the reason for oversimplification of pain theories.”

The most famous neuroscience-based theory of how signals in the body relate to pain is arguably the Gate Control theory of Pain by Pat Wall and Ron Melzack, but there is a plethora of theories concerned with specific cell types (e.g. glia), neurobiological mechanisms (e.g. central sensitization), brain activity (e.g. Default Mode Network) and philosophy/cognitive neuroscience (e.g. predictive coding). Such theories are based on ‘sound, basic science’ and can be conceptualized as scaffolding systems on which clinicians can help patients understand their signs and symptoms, including pain, fear, behaviour, etc. Neither theory should be considered universal or ‘best’ for all patients, rather, a skilled clinician should understand the science behind and – perhaps most importantly – the boundaries of each theory.

How To Choose A Theory?

First of all, the theory must provide a good fit with the history of the patient. Luckily, most theories are adaptable and some even contain categories, which are open to interpretation and/or unable to be falsified clinically. E.g the theories of ‘overuse’ (biomechanics) and ‘central sensitization syndrome’ (neuroscience) are both based on clinical reasoning and could easily be applied to the same patient. They could even guide the patient to the same behaviour/action, albeit with different explanations:

SyndromeTheoryTherapeutic InterventionReference
OveruseSpecific tissues are over-loaded (damaged) and pain is the response to an inflammatory responsegraded exposure, education on [chosen theory]Physical stress theory: Mueller MJ and Maluf KS, 2002
Central Sensitization SyndromeThe nervous system is overactive and the patient needs to calm it downgraded exposure, education on [chosen theory]Nijs J et al. 2016

To make things even more complicated, Artus and colleagues found that studies on the treatment effect in patients with non-specific low-back pain plateaus after 6-12 weeks in most people, indicating that neither of the existing treatments is superior nor specific.

So, when no one theory seems to explain everything, how do you choose? According to Sackett et al. (1996), we need to infer to best practice based on best available:

  •  basic and clinical science
  •  theory
  •  patient-information.

However, since this is no guarantee for success it is insufficient to hope for improvement. Rather good, clinical practice implies the use of structured, patient-specific / functional and preferably validated, measurement tools to objectify when you’re wrong. In other words, once you have decided on an appropriate theory you should be able to predict a time-restricted and patient-specific outcome (i.e. a prognosis). These should be constructed in agreement with the beliefs, expectations, and priorities of the patient, and be specific and valid enough that improvements in your measurements reflect an improvement from the patient’s perspective. Since no causation can be established, relevant and consistent improvements can be considered sufficient to continue along with the same plan.

Unlike in the adventures of Sherlock Holmes or in matters of life-and-death, there is no binary (guilty/innocent or yes/no) answers when dealing with humans suffering from complex, non-specific pain. Thus, as clinicians, we must choose wisely and continuously monitor if the theory and accompanying interventions are benefitting the patient in ways that are meaningful to them.

Consequently, discarding a management plan based on the best available evidence can be the right choice if it leads to no change (or worsening). For obvious reasons, this necessitates a close and trustful collaboration between the patient and the practitioner.

How To Update Your Knowledge Of Science Without Becoming An Academic

As a clinician, you need clinical skills, such as communication skills, critical thinking/clinical reasoning and the ability to spot serious pathology. Ideally, you would also have to spend a few hundred hours studying aspects of neuroscience and philosophy. But chances are, the only basic science you’ve ever spend this long learning is anatomy and biomechanics. Consequently, it is very likely that you are strongly biased towards thinking that when it hurts during movement, movement is a likely cause or trigger of the pain. In other words, since most educations do not provide the knowledge necessary for complex reasoning based on neuroscience most clinicians still use anatomy and biomechanics to explain pain.

But answer this; how – if not via the neurons – should movement hurt?

To my knowledge, there is not a single theory that explains how movement generates consciousness and therefore also pain. The bias in my thinking is that I perceive pain as something we experience and not causally related to signaling in any part of our nervous system (rather they are correlated, and in the case of acute pain, this correlation is so strong that we perceive them as unified).

Coming back to the topic of this section; how to upgrade your knowledge without doing a university-based, post-graduate program? For most clinicians, the solution is weekend courses, in which they get in-depth knowledge about contemporary concepts of how to manage pain. Comparing these to international standards (e.g. IASP or EFIC curricula) clearly shows that there’s a bias towards some areas (e.g. patient education) and neglect of others (e.g. special groups, basic science and xxx). However, free information is available online and online educational initiatives are currently being developed by EFIC and IASP. I hope that, within the next few years, all aspects of the curricula will be covered and freely available. Furthermore, clinical exams – such as the EDPP – are already available to clinicians from all over the globe, providing a ‘peer-reviewed’ certification of the clinical skills.

If you prefer the lecture/classroom teaching style to online learning, or you just don’t want to wait, you can use the curricula most relevant for you to structure your own ‘port-folio’. I recommend looking for courses where the instructors themselves have qualifications within pain science (e.g. MSc’s in Pain or EDPx exams).

References

Nicholas M, Vlaeyen JWS, Rief W, et al. The IASP classification of chronic pain for ICD-11.PAIN. 2019;160(1):28-37. doi:10.1097/j.pain.0000000000001390.

Palsson TS, Gibson W, Darlow B, Bunzli S, Lehman G, Rabey M, Moloney N, Vaegter HB, Bagg MK, Travers M. Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area, Phys Ther. 2019 Jul 29.

Karayannis NV, Jull GA, Hodges PW. Physiotherapy movement based classification approaches to low back pain: comparison of subgroups through review and developer/expert survey. BMC Musculoskelet Disord. 2012;13:24. doi:10.1186/1471-2474-13-24.

Brumagne S, Diers M, Danneels L, Moseley GL, Hodges PW. Neuroplasticity of Sensorimotor Control in Low Back Pain. J Orthop Sports Phys Ther. 2019;49(6):402-414. doi:10.2519/jospt.2019.8489.

Mueller MJ, Maluf KS. Tissue adaptation to physical stress: a proposed “Physical Stress Theory” to guide physical therapist practice, education, and research. Physical Therapy. 2002;82(4):383-403.

Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173.

Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. BJSM. March 2019. doi:10.1136/bjsports-2018-099878.

Nijs J, Goubert D, Ickmans K. Recognition and Treatment of Central Sensitization in Chronic Pain Patients: Not Limited to Specialized Care. J Orthop Sports Phys Ther. 2016;46(12):1024-1028. doi:10.2519/jospt.2016.0612.

Artus M, van der Windt D, Jordan KP, Croft PR. The clinical course of low back pain: a meta-analysis comparing outcomes in randomised clinical trials (RCTs) and observational studies. BMC Musculoskelet Disord. 2014;15(1):68. doi:10.1186/1471-2474-15-68.

Artus M, van der Windt DA, Jordan KP, Hay EM. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatology. 2010;49(12):2346-2356. doi:10.1093/rheumatology/keq245.

 

Recommendations by IASP and EFIC can be found here:

https://www.iasp-pain.org/Education/CurriculaList.aspx?navItemNumber=647

https://europeanpainfederation.eu/education/pain-curricula/

Everything I Wish I Knew About Rotator Cuff Tears

They came in frustrated, it was a two-year ordeal, I had never seen this patient before, but they clearly needed some help.

“Jamie, for the past two years, I haven’t been able to lift my arm past this point”!

They raised their right arm to about 90° abduction. When asked I why they explained there had been a previous surgery to repair a torn rotator cuff. The frustration had more to do with life circumstances than just the limited range of motion.

Two years ago a surgery had taken place to repair this torn rotator cuff, but more concerning was the altered life because of it.

This person had a job they loved but were unable to do anymore due to the surgery.

You see, the job required holding their arms up for extended periods, so they had to quit that job in favour of a desk job. The worst part (other than the limited range of motion) was they HATED the new job. Sitting at a desk doing computer work was not what they had in mind as a satisfying career.

When asked why they weren’t doing the job they loved the response was bone-chilling to hear as a healthcare practitioner:

“My surgeon said I could never go back to that job, and the other therapist I went to told me that if I went back to my job, the surgery I just had would pale in comparison to the surgery I would need if I continued”.

I hope my face didn’t reflect what was happening in my head after hearing this, otherwise, the patient probably would have walked out the door. How could two other healthcare professionals say this to a patient!?

Reliability Of Orthopedic Tests

The rotator cuff consists of the “SITS” muscles: supraspinatus, infraspinatus, teres minor, and subscapularis which all work together to produce movement and stability of the glenohumeral joint.

While rotator cuff tears are quite common, it doesn’t always mean the person is going to experience pain as this generally depends on the degree of the tear. A partial tear is when one of the muscles is frayed or damaged, whereas a full tear indicates the muscle is completely torn, or the tendon has pulled off the bone.

When we look at some of the orthopedic tests recommended to use clinically as a test for rotator cuff tears, it is important to look at how accurate they are between sensitivity and specificity. Sensitivity is the ability to detect that something is actually happening (in this case it could just be a sore shoulder), whereas specificity is used as a true representation of the condition you are trying to test for (in this case specific to a rotator cuff tear).

There are three orthopedic tests generally used, so we will look at two of them here.

The drop arm test has a sensitivity of 73% and a specificity of 77% and also has a 26% chance of coming up with a false positive and a 4% chance of a false negative. This tells us this test isn’t likely to give us an accurate chance at predicting a full-thickness tear of supraspinatus or infraspinatus.

The external rotation lag test has a sensitivity of 46% and specificity of 94% which tells us that we have a good chance of a positive test indicating full-thickness tears in supraspinatus and infraspinatus. 

It has also been suggested that the subacromial bursa contains a high amount of nociceptors and doing the orthopedic tests we talked about could place pressure on the bursa, in turn recreating the pain.

While we can still use these tests to give us an idea what’s going on with a patients shoulder there is no guarantee these tests will conclusively tell us there is a full rotator cuff tear. While it can be more accurate to use imaging to see the difference between partial and full-thickness tears, there is poor relation between imaging and clinical signs. 

Using Education To Help

Time and again we are told biopsychosocial aspects are crucial to treating our patients, and this pathology is no different. Although the “bio” may be less important as we think. When looking at the movement of the glenohumeral joint in the scapular plane between symptomatic and asymptomatic people with tears, pain-free movement was still possible even with abnormal kinematics.

So this shows us that abnormal biomechanics alone are not the only reason for painful symptoms.

One study showed that 55% of rotator cuff tears are asymptomatic, had more to do with age, and didn’t correlate with pain. In fact, one study showed just how much age is a part of the degeneration and should be considered normal with age. They found:

  • Age 50-59, 13% had tears.
  • Age 60-69, 20% had tears.
  • Age 70-79, 30% had tears.
  • Those aged over 80, 51% had tears.

While asymptomatic tears can become painful, studies show it is probably more important to take care of pain management with these patients in order to maintain functionality, rather than being concerned about the tear itself. In fact, one study points out that our treatment should centre around clinical findings and not imaging results.

So, if we understand how pain management should be our primary concern, we have a massive opportunity to make a difference for these patients.

How many people over the years have come into your clinic either waiting on surgery or at least contemplating it for their rotator cuff issue? If we can educate them how this is usually an age-related issue (unless there was a traumatic injury), reduce pain, and increase their functionality maybe we can negate a surgery.

While surgery is usually recommended for full-thickness tears or more extreme disability, conservative measures can and should be recommended before going under the knife. The person I spoke about at the beginning of this post was obviously post-surgery for two years but still had limited mobility and functionality. This was certainly a case where biopsychosocial factors were a major influence. The person was told by two practitioners they would never get better and their shoulder would always be damaged, to the point they had to change careers. Once we actually got the shoulder moving, used a little education, and were told they were going to be okay…that shoulder went from 90° to 160° abduction. It was also followed up with the statement: “how the hell did you do that!?” It’s amazing how giving a patient a little confidence can make a massive difference. In the coming weeks, we will go over some movement techniques that can help with this.

Learn How Education Can Help Shoulder Pain

It can be a challenging area to work on, and certainly an area of the body where I have made the most mistakes in my career.

It is the most mobile, yet least stable joint, yes the shoulder is complex (pun intended).

Whether I was misinterpreting what I thought was happening, not using the right test, or maybe just plain old not listening properly to the patient, treating the shoulder can sometimes get a bit confusing.

There is a long list of possible injuries that could take place, dislocations, separations, labral tears, mobility issues, and of course the ever so scary term: frozen shoulder.

I mean, prior to being an RMT (in my old career), I was used to seeing and dealing with those traumatic injuries and knew exactly what to do when it came to a dislocation or separation, I would just sling the shoulder, pack the person up and send them on their way in an ambulance, but was never involved in helping the injury after that.

So how was I going to properly treat all of these other things and actually narrow down what was affecting a person?

Well, as it turns out, there are some guidelines we can look to.

Management In “Primary Care” 

When looking at much of the research on different pathologies there is a lot of reference to how something should be handled in “primary care”.

This is generally thought of as your main entry point into healthcare, where you see a doctor, they diagnose an issue, and then refer you out to a specialist, or prescribe medication, etc.

Unfortunately, at this time massage therapy isn’t typically classified in this realm (however we are starting to see Massage Therapists in hospital settings in the U.S. which is a GREAT start), but it is possible for us to get referral of a patient from a doctor. In fact, many extended health insurance companies here in Canada require a doctors referral before they will reimburse a patient for massage therapy.

So, it is important for us to know what is being done at the primary care level, so we can understand why a patient is being referred to us.

According to one systematic review, shoulder pain is the third most common reason a patient experiences musculoskeletal consultation in primary care with 1%  of adults experiencing new shoulder pain each year. The first thing that should happen is ruling out any red flags (many of which are similar to the red flags of low back pain we have reviewed before on this blog):

  • History of cancer, unexplained deformity, mass, or swelling (possible tumor).
  • Red skin, fever, (possible systemic infections).
  • Trauma, epileptic seizure, electrocution, loss of rotation ability (possible dislocation).
  • Trauma resulting in acute disabling pain, significant weakness, positive drop arm test (possible rotator cuff issues).
  • Sensory or motor deficit (possible neurological lesion)

Anytime things like this are seen, it’s most likely the patient will be referred for blood work or imaging to rule out any of the above.

Once the above are ruled out, the four most common reasons for shoulder pain and disability are:

  • Rotator Cuff disorders (impingement, tears, tendinopathies).
  • Glenohumeral disorders (adhesive capsulitis aka frozen shoulder, arthritis).
  • Acromioclavicular joint disease (osteoarthritis, separation).
  • Referred neck pain.

These are the types of conditions which would most likely be referred out to other practitioners, as conservative management is being recognized as the most beneficial. However, patients may be referred for surgery if:

  • Pain and disability last more than six, months after conservative management have taken place.
  • History of instability, or acute, severe post-traumatic A/C pain.
  • Uncertainty in the condition, or red flags present.

However, with long waits for surgery and consultations, there is a good chance we could see someone for pain management and rehab long before surgery ever takes place, and of course for post-surgical help as well. This makes it important to know there are more favourable results when there is only mild trauma (an A/C separation usually only gets surgery with fourth-degree and up, first to third-degree is typically just rehab), overuse before the onset of pain, or acute onset. The outcomes aren’t as great with increased age, severe or recurrent symptoms and females (not sure why as jobs like hairdressing, construction, and lifting heavy loads are labeled as high-risk occupations).

So, now that we know all of this, the question is, what can we do?

The Massage Therapists Role In Shoulder Pain

Looking through research on the clinical guidelines of the treatment of shoulder pain, there are a few modalities mentioned that are supposedly successful, but I would venture to say they have more to do with our therapeutic relationship and interaction with the patient than it does the actual modality.

The one thing that consistently comes up is patient education.

Regardless of the diagnosis given, education and acknowledgment of biopsychosocial aspects are a crucial part of pain management whether it’s the shoulder or any other part of the body. 

You may be thinking, “well, how can we educate a patient on this”?

There are various ways and probably one of the biggest is educating them on the diagnosis and what it means to them. Some of the names like: “impingement, frozen shoulder, arthritis, tears, tendinopathy” is simply enough to strike fear into the patient, causing them to catastrophize the diagnosis due to the name alone.

You will probably hear them say things like: “my friend, sp0use, relative, etc had this and never got better”. I’m sure we’ve all had patients say this to us several times in our career. Providing reassurance to them, showing how they can and will get better, even with this ominous-sounding diagnosis is a big influencer in the biopsychosocial aspects of pain. Helping them understand how their friend/relatives outcome is not the same as theirs and there are steps we can take to prevent the same outcome is crucial. This also requires some work on our part, to educate ourselves on the best treatments and outcomes for each of these diagnosis. We can continue to use whatever our favourite techniques are, but there are certainly some additions that need to be made (since your treatment style is probably what has them coming to you in the first place).

In the coming weeks we will dig deeper into the interventions we can use to improve and educate our patients on each shoulder issue. Hopefully then we can even help prevent some surgeries while pushing more toward conservative care with better outcomes. 

 

 

 

 

The Truth About Ankylosing Spondylitis That Massage Therapists Shouldn’t Ignore

We’ve been talking lots about low back pain lately, however, most of the time when we see low back pain in a clinical setting it is referred to as “non-specific” low back pain.

This basically means there is no underlying cause or incident that can be attributed to the patient’s pain, yet they are still undergoing a painful experience.

Part of our clinical intake and decision making should be able to point us in the right direction when the pain isn’t non-specific, especially if the patient is experiencing one of the red flags of low back pain. Some of these can be difficult to differentiate as there is usually a little bit of overlap between symptoms and really narrowing it down can present its own challenges, especially if you’re trying to prevent a patient from catastrophizing about their pain.

One of these situations is a condition called “Ankylosing Spondylitis” and the symptoms have some overlap with other red flags, so it’s crucial we are able to differentiate between this and other conditions, if for no other reason than to refer out to the appropriate health care professional for the person to get the proper care.

Signs, Symptoms & History

Ankylosing Spondylitis is an inflammatory rheumatic disease that traditionally affects young people and usually becomes noticeable around 26 – 28 years old, with men being affected more than women by a 2:1 ratio and they may have more structural changes than women.

While it is generally recognized around 26, 80% of affected patients are diagnosed under the age of 30 and only 5% develop the condition above the age of 45 (some important things to take note of with your intake).

This condition falls under a group of spondyloarthritides, of which there are five different conditions:

  • Ankylosing Spondylitis.
  • Psoriatic Spondyloarthritis.
  • Reactive Spondyloarthritis.
  • Spondyloarthritis associated with inflammatory bowel disease.
  • Undifferentiated Spondyloarthritis.

Regardless of which subtype a person has the main thing that occurs is inflammatory back pain starting with sacroiliitis and inflammation occurring in other spots on the spine along with some peripheral arthritis (usually lower limb) and in rare cases, causes issues with organs.

Generally, the symptoms start with a dull pain deep in the gluts and/or low back accompanied by stiffness in the morning that lasts for a few hours. It improves with movement but comes back with rest. Within a few months, the pain becomes persistent, felt on both sides and gets worse at night. The spinal stiffness and loss of mobility come on as a result of inflammation and the resulting damage caused by the disease. Some of the damage is due to bone remodeling and bone loss because of the inflammation involved.

The cause of the disease is unknown, but one of the predisposing factors related to getting this is the gene HLA B27, (not that you’ll be able to know if your patient has this) in fact, 90-95% of those diagnosed with AS (ankylosing spondylitis) are positive for this gene with the risk of developing the disease around 5% in those positive for the gene and even higher for relatives of patients, however, most of the HLA B27 positive people remain healthy.

Now, I realize a lot of that just sounded like a bunch of sciencey talk (which it kind of was) but how does it all apply clinically?

Well, what we need to look out for is:

  • Low back pain and stiffness for longer than three months, which is relieved by exercise, but not with rest.
  • Restriction of lumbar ROM with flexion/extension as well as side-bending.
  • Restriction of chest expansion in comparison to others of the same age and sex (not 100% sure how you would measure this).
  • Sacroiliitis identified through imaging.

The use of MRI is what usually identifies the sacroiliitis because of its ability to see active inflammation along with structural damage to the bones and cartilage that can be seen, which hopefully catches the disease early. However, the MRI alone isn’t en0ugh for a diagnosis. It is better diagnosed if at least three clinical, laboratory (gene testing), or imaging results are positive. Clinically  we would look for:

  • Morning stiffness longer than 30 minutes.
  • Improvement in back pain with exercise, but not with rest.
  • Waking due to back pain during the second half of the night.
  • Alternating buttock pain.

This is where our understanding of the red flags of low back pain comes in to play. Low back pain greater than six weeks and for those older than 18 are red flags due to a tumor, infection, or a rheumatological disorder. If the person has no history of cancer, the tumor is quite unlikely, and if there is no reason to suspect an infection, well… that leaves us with rheumatological issues that we may need to refer the patient to a doctor for further diagnosis.

Exercise And Massage Treatment

Our goals for treatment should be to reduce symptoms, minimize spinal deformity, disability, and in reviewing research there is one topic that continually comes up as a non-pharmaceutical treatment for AS…exercise!

There are many similarities between rheumatoid arthritis (RA) and AS, but some similarities are still present, so, much of the research revolves around RA instead of AS. It is recommended for people to get 30 minutes of moderate intensity exercise per week (brisk walking is suggested) 3 days a week, or the equivalent of 90 minutes/week. However, this can include dynamic exercise to improve muscle strength and aerobic endurance.

RCT’s showed how exercise was most effective in physical function and spinal mobility for patients with AS, more specifically supervised exercise was even more effective, and pool exercises were more popular than land based.  One study showed that a combination of self and manual mobilization at home helped with chest expansion, posture, and spinal mobility. 

Another study on the effectiveness of group exercise was done with one group who was supervised and the other was given the exercises/movements as homecare. The results showed a positive influence on the duration of morning stiffness, chest expansion, and overall well being after intensive supervised exercise classes, however, the home exercise group didn’t really show much improvement. It is believed that part of the reason for this is the psychosocial factors that come with being around other patients with similar problems and the education given in the classes. I would venture to assume there is a certain amount of motivation that comes with being in a group to actually “do” the exercises as well (part of the reason I push myself at CrossFit a lot harder than I do in the gym alone). The combined group exercise has also been shown as a more cost-effective treatment compared to standard treatment alone (use of NSAIDs). 

So, what does this all mean for us as massage therapists? 

Well, a lot actually, and in a positive way. Quite often “complementary and alternative treatments” are recommended in conditions like this and well… we just happen to be one of those treatments. When we look at what’s recommended, there aren’t any clinically controlled trials (although here is a case study that looks positive) on our effectiveness, but massage is shown to be SAFE! However, it is recommended when looking at acupuncture and chiropractic manipulations under the same light to view them with caution, so SAFE is GOOD.

As we have discussed so many times on this blog we also have an opportunity (and a responsibility) to look at the biopsychosocial aspects of what could be affecting our patients with AS. Since this generally happens at a younger age when people are typically in their most productive stage of life, there is a general fear around work disability which can be a contributor to the persons pain. This is one aspect where educating on how exercise can help prevent progression of the disease can be a valuable tool during treatment. One of the other issues is a lack of energy and fear of joint damage around exercise, which gives us another opportunity.

When we look at many of the exercises used in the studies we mention, they used: stretching, mobilization and strengthening for the back, aerobic, along with postural and respiratory exercises. While exercise may not be in all of our scopes, we generally, can do stretching during treatment and can also do active and passive range of motion (which is essentially mobilization). Not only is this part of the recommended exercises, but it’s also an opportunity for us to reinforce that movement and exercise is safe and promote resilience in their dealing with the condition. If exercise is in your scope, use the opportunity to go for a walk with your patient (they may need your reassurance and support to do this), do some active movement, some repeated motions to increase mobility, and above all reassure them this is not only safe, but beneficial!