Category Archives: Back Pain

Words can be therapeutic

Creepy Magnetic Poetry (Healing Words)

I’ve come across three interesting and intersecting publications, all pointing out to one degree or another the importance of word choice in the context of healthcare. Sometimes I get in a zone where I’m focused on the task at hand, and my use of words is either non-existent or poorly chosen, so I have found these helpful.

The first publication is from a recent con-ed I went to, put on by ISPI entitled The Low Back is Having Brain Surgery, presented by Adriaan Louw. I remember a little bit about pain in PT school, but I don’t remember anything like this. It is amazing how pictures and word choice (both pre and post-op) can impact a patient’s recovery. I’ve been more aware of my words about pain and recovery regardless of their diagnosis (and is it time to stop the “Pain and Torture” joke? It does not help either the patient or our profession). I hope I can attend several other courses as well as get a copy of Explain Pain.

The second is an article entitled The Talking Cure for Healthcare that came out in the WSJ a week after I went to the course. It isn’t about PT specifically, but communication in a medical context. Poor communication “can hurt the quality of care, drive up costs and increase the risk of lawsuits. And under new Medicare rules, providers won’t get as much money if they rack up poor patient-satisfaction scores or too many preventable readmissions…Doctors are trained to ask permission to enter a room, introduce themselves and put patients at ease. And then they should be clear about how long an exam or procedure will take, when results will be back, what they are doing and why, what patients should expect and what the plan for the future is. Before leaving, they are expected to thank the patient and family and let them know it has been enjoyable to work with them.” Wow! I think I have good patient rapport and I explain what I am doing and why, but this article was a great reminder of how I could do things differently and what to be aware of when I am more focused on the task than the person. It is about them and their recovery.

The third is a research study that I had seen mentioned on Twitter but hadn’t had an opportunity to read it until the last week or so – Cognitive Treatment of Illness Perceptions in Patients With Chronic Low Back Pain: A Randomized Controlled Trial (April issue of PTJ). This post is not meant to examine the report in detail (although it appears to have “statistically significant and clinically relevant improvements in patient-relevant physical activities at 18 weeks.”). They wanted to see if addressing the patient’s perception about their symptoms would improve their activity limitations. The intervention had four phases – examining the illness perception, challenging the maladaptive perceptions, developing alternative perceptions, and testing/ confirming the new perceptions. What I found interesting is that rather than finding an anatomical cause of the pain and then doing manual therapy, exercise, or a modality, they spent time listening to the patient and dialoging about the problem, examining the person’s beliefs about the pain, and helping them to a new belief and testing it out, and that made a difference.

Now out of school for four years, I’m almost out of the “new professional” classification, and I have grown a lot (thanks in large part to the residency). In PT school we are taught how to take a good history – how long have you had the problem, what makes it better or worse, etc so that we are good clinicians upon graduation. For me, part of becoming a better clinician is seeing how our word choice can impact a patient both in recovery as well as their satisfaction with rehab as a whole. I’ve always had good rapport with my patients (well, most of them), but these publications about the importance of words have helped me further my “soft” clinical skills.

Photo credit: Creepy Magnetic Poetry (Healing Words), originally uploaded by MousyBoyWithGlasses.

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Radiation Fibrosis, and LBP/muscle activation in gait for seniors

Two interesting articles that are not part of my required curriculum but are applicable to my recent caseload:

Radiation Fibrosis Syndrome – I can’t access this article through the UMN, but I did do a PICO question during school for reduced ROM due to radiation-induced fibrosis.  I recently had a patient with radiation fibrosis resulting in reduced ROM/ strength/ sensation – if you have had a patient undergo chemo or radiation years ago, it may be helpful to know the treatment parameters (radiation field, chemo agents used, any surgical procedures, etc) to give a better picture for past medical history and how it may direct your treatment and impact outcomes.

Low back pain and muscle activation during gait in older adults – again, I don’t have access to this article, but I’ve requested a copy.  It will be interesting to see the discussion section, given their results: “The control group participants activated their lower rectus abdomini muscles (P < .05) and right internal oblique muscles significantly more than did the LBP group (P < .05), whereas the LBP group activated their left lateral erector spinae and both lumbar multifidi sites significantly more than did the control group (P < .05).”

Spinomed orthosis in new study

I will pull the study later (I have to read a few papers about hip fractures tonight), but this looks interesting.  Apparently in a randomized trial,two spinomed braces improved trunk strength and therefor posture, and they improved quality of life (reduced pain, improved ADL’s).

Large increase in fusions for stenosis

Titanium pedicle screws

From the NYT this morning – as the article points out, earlier studies showed no improvements in pain or function, so why the increase in surgeries when stenosis hasn’t increased by the same amount?

Photo credit: Titanium pedicle screws, originally uploaded by warrenski.

Manual therapy & exercise for osteoporotic fx pain

osteoporosis_female

This is a very interesting and preliminary study, especially with a recent patient with vertebral fractures secondary to osteoporosis. I would like to have seen more specifics (What grade of mobilisation?) What exercises were given?), but it looks promising.  I hope they have a follow-up study planned with a larger sample and publish it with more information.

Bennell KL, Matthews B, Greig A, et al.  Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial.  BMC Musculoskeletal Disorders. 2010, 11:36 doi:10.1186/1471-2474-11-36.

Picture credit: osteoporosis_female, originally uploaded by go elsewhere…

TENS – not recommended for LBP

Axial view of herniated lumbar disc.

I read about this in the Medscape newsletter, but can’t access the journal Neurology to review it. The American Academy of Neurology has issued a practice guideline/ evidence-based review (link to the information release here) recommending that TENS not be use for chronic LBP, but should be considered for pain from diabetic polyneuropathy.

I can’t read the study so I can’t comment, but the Medscape article did mention that an absence of evidence is not evidence of absence, referring to an editorial that is in the same issue as the systematic review (I can’t copy or link to the Medscape article either due to copyright) and noting that meta-analyses are limited by the quality and quantity of trials. The guideline calls for further trials and makes specific recommendations for them.

The editorial did state that “this updated evidence-based review is valuable in providing the limits of our evidence base… Nevertheless, it is not unreasonable to take a practical position that, in spite of the relatively weak scientific and clinical evidence, TENS still represents a valuable therapeutic alternative in neurologic pain disorders.”

Picture credit: Axial view of herniated lumbar disc., originally uploaded by James Marvin Phelps (mandj98)

HEP adherence for neck and LBP

Crick

While I have an outpatient that suffers from something other than back or neck pain, I found this intellectually stimulating as it is about the different aspects of adherence. What makes a patient do all the exercises in a HEP? Why do they do all the repetitions you prescribe? And what about the prescribed number of times per week? What should you consider as you develop a HEP for a patient? (note: this article is not specific to geriatric populations).

Medina-Mirapeix F, Escolar-Reina P, Gascón-Cánovas JJ, Montilla-Herrador J, Jimeno-Serrano FJ, Collins SM. Predictive factors of adherence to frequency and duration components in home exercise programs for neck and low back pain: an observational study. BMC Musculoskeletal Disorders 2009, 10:155 doi:10.1186/1471-2474-10-155.
Why the study matters: Exercise has been shown to be a benefit to those with neck and back pain but adherence to a HEP is problematic with an estimate of 50% or less. Adherence can be impacted by socio-demographics, social support, motivation, illness, environment, the program itself, or the provider itself. Self-efficacy (SE) is a consistent predictor of adherence, whereas pain intensity has shown variability in predicting adherence. In healthy people there is evidence that determinants to the frequency of the HEP is different than the determinants of the duration of a HEP, but it is unknown if these differences are found in those in PT and performing a HEP for chronic neck and LBP.

Hypotheses: The researchers did not clearly delineate a hypothesis, but the purposes of the study were to determine whether patients with neck or low back pain have different rates of adherence to exercise components of frequency per week and duration per session when prescribed with a home exercise program, and to identify if adherence to both exercise components are predicted by distinct factors.”

Outcome measures: Mailed questionnaire “about the quality of clinical encounters with the [PT] during the intervention program, environmental factors and adherence behavior to [HEP] during the last week.” Predictive factors were measured before, during and after PT treatment. The questionnaire utilized a Likert scale (5=always to 1=never) for perceived barriers and emotional support, and an adapted version of a SE scale about the subjects confidence in performing the HEP. Patient satisfaction with clinical encounters was rated on a continuous scale (0-10) and the behavior of information-providing was rated yes/no (clarifying doubts, giving information about the condition, and justifying advice). Adherence was “measured as compliance to each prescribed component (frequency and duration) to the HEP (never, seldom, often, almost always, always). Adherence was then treated as dichotomous with adherent being always or almost always.

Subjects/ patients: Subjects were included if they had chronic (>3 months) of non-specific neck or LBP and received PT in primary care centers in Spain. Exclusion criteria included 70 yrs old, illiterate or unable to write, cognitive deficit (Alzheimers, dementia, etc), unable to attend all sessions of PT, or if the PT ordered a cessation of the HEP .
Intervention: This study was prospective, examining patient adherence one month after PT to assess short-term adherence to the HEP. The HEP was different for each patient but the PT recorded the type (strength, stretching), total number of exercises per session, days/week to be performed, and estimated duration each session should take.

Results: There were 317 possible subjects with 50 being excluded. Of the 267 eligible participants, 104 had neck pain and 163 had LBP. 250 (93.6%) participated in the interview at baseline and 184 (68.9%) returned the survey. Non-respondents did not differ significantly when compared by gender, location of pain, education level, sick leave, work participation, pain intensity, and pain disability. “However, the proportion of patients above 59 years is higher among respondents.”

Adherence rates: 70.1% were adherent to duration and 60.7% adherent to frequency.

Predictive factors for frequency were use of PT in the past, participation/ adherence to previous HEP, being given >6 exercises, environmental factors and SE, having doubts clarified, satisfaction for treatment and good adherence to duration.

Predictive factors for duration were participation and low adherence in another HEP, exercises fitting into daily routine, emotional support, SE, supervising exercises in the health care centers, and adherence to frequency.

What I would like to know more about: Apparently all patients receive four weeks of PT and are then d/c’ed – what drives that decision? Was adherence to strengthening compared to stretching? Wouldn’t excluding those who do not attend all PT sessions automatically skew your results, likely improving your adherence percentages to the HEP (34 of 317 excluded; additionally they only analyzed survey respondents and did agree that excluding non-respondents may have biased the results, but believed that intent-to-treat analysis would influence the analysis with non-adherence entered for those who did not respond)? One of the exclusion criteria is if the PT ordered them to not perform the HEP – since they received it upon d/c, how could that be an exclusion criteria (16 of 317 excluded)?

How this will affect my clinical practice: Working in a SNF with an outpatient clinic, I can’t really say this will affect my clinical practice as I don’t have anyone with back or neck pain at the moment. For my outpatients I do keep the number of exercises to 4-5 at the most, I encourage self-efficacy, instruct them on the purpose of the exercise, and help brainstorm how to incorporate them into a daily routine. However, regardless of setting I think that adherence should be considered – both how adherence is measured as well as how to improve it. I will be giving the guest lecture to the UW DPT students regarding adherence to exercise for older adults – if I come across any new nuggets I will post them.

Picture credit: Crick, originally uploaded by Martin Kingsley.