I love your slight cynicism of the EBP approach and the bio-psycho-social model. Remember, sometimes a sore back is just a sore back. No deep dark pyschological multifaceted multifactorial subgrouped evidenced based inter/intra observer secrets.

Just a story to restore a little faith in our profession: In New Zealand ACC is the main funder for injuries. A couple of years ago, they were quite open with their numbers, and so as a point of curiosity I did a correlation between how much was spent on Physios and how much was spent by ACC (ie 80% of wages, surgeons, etc) using each city center as a reference point. It was nice to see they were inversely proportional, ie it seemed the more it spent on physio, the less it needed to spend on other expenses. In fact my figures were something like for every dollar spent they got an extra 98 cents back.

Consider: absolutely no subgrouping, no models, no validated outcome measures, just cold hard cash.

I really should have done something with those numbers.

So, hopefully, John and Graeme will try one more time to explain this to Susanna and I will curiously look at how you guys take “it a step down and feed her”. No offence Susanna, your questions are relevant, but, as I see it, you almost do not speak the same language here.

Vegard

Thanks for these latest reactions. On “restoring balance” –I can only report the results of interviews with physios who focus on manual and exercise therapies. They’re thinking in terms of normalizing muscle tone, getting the muscles to work properly and enabling the patient to move without restriction or pain—nothing mystical about it and certainly real from the perspectives of therapist and client. Clearly rheumatology is practiced within a completely different paradigm.

On cost, this would be interesting to explore in much greater depth than is appropriate here. Obviously this will vary with the national medical system. In the U.S., if someone has insurance (and as you no doubt know, this has been the subject of a huge political struggle here), treatment of chronic pain can continue forever, and the costs are enormous even though there are restrictions on the number of physio visits per year. Physical Medicine and Rehab docs are also involved (largely because of the system that requires medical referrals to physios), and those costs can be monumental. So starting by treating people with no obvious evidence of disc or joint damage with manual therapies aimed at normalizing tone at least seems cost-effective because it should take a high percentage of those people out of the “chronic” and “psycho-social” categories. I mentioned sports physios only because, as a result of the nature of their work, they get very good at diagnosing muscle problems. Obviously, physios in other areas do this very effectively as well.

Susanna

1. Isolating the key factor or factors in the case of chronic pain sufferer is difficult. Even in the case of trigger points or hypertonicity, the usual suspects in terms of manual treatment as you have described, often have limited or no lasting benefit. On the other hand it may be just what they need & you see remarkable results & I can testify to some examples myself. The question many will ask though is how can you predict such an outcome & justify the investment in treatment. The identification of subgroups seeks to resolve this but I’m doubtful that myofascial pain is going to get much of a look-in in this country. The competing health dollar is watching this space & psychosocial issues are the most salient factors identified in the complex presentation that is chronic pain. There is the argument that the psychosocial factors are a result of the biological problem but that is another encyclopaedia we are opening if we want to go there.

2. There are a number of treatments that work on the soft tissues & or acknowledge the relationship to the mind (although I personally tend to think they are just different manifestations of the same thing; i.e. the person!!). The one that stands out is Rolfing (from Ida Rolf) – which is fairly unknown here in Australia, but I think is more well known in Europe & the USA. Rolfers have or at least had the concept of the psyche being “held” in the body in terms of how the fascia adapted to, or “embodied” emotions. Physical release of the fascia was reportedly sometimes accompanied by emotional release and occasional epiphanies ending in resolution of chronic pain. Wilhelm Reich (before Rolf) coined the concept of ‘body armouring’ (but you might struggle to find info on him in the USA – you guys destroyed all his books in the only public book burning in USA history – you’re the historian so correct me if I’m wrong on that one). The work on core stability recognises changes in the muscular system as well as the motor & sensory cortices, & whilst this work has made some connection to the influence of psycho-social factors on the so called “core” muscles, there is a long way to go on this one. Advocates of whatever approach will choose the treatment that best serves their purposes, whether they are ethically, financially, or ego driven. Funding bodies will work along similar lines.

This is where the S-F aspects of the B-P-S-F model express themselves & I guess this varies according to what political system you live under (S-F = socio-fiscal – thanks Luke – see one of my previous posts). Sports – people in Australia & in the USA receive adulation far in excess of their contribution to society in my opinion, & we could perhaps spend many hours going into the socio-anthropology of sport & society, but in summary I guess they are seen as heroes, representatives of our village, culture, nation and deserving of special treatment. The plebian sports person is also held in some esteem because they are seen as taking initiative, looking after their health, having positive motivating factors etcetera. They “deserve” treatment. At the elite level they are worth a lot of money & all stops are pulled out to get them back to making a return on the investment of their club/team/sponsor or other means of support – only the best treatment for them & to hell if the return on the treatment is low, it is still moving them in the right direction.

Compare that to the chronic pain sufferer. Every second or third paper you read on chronic pain outlines the huge economic burden that these people have on society. Health professionals & the general public often do not understand why these individuals have ongoing pain. They are often stigmatised for one reason or another & often are damaged goods in terms of the effect their pain has had on them, or some might be just poor copers before their pain. They can be exhausting to be with & do not engender compassion across the board. In terms of how they are received, are they likely to be on the same playing field as the sports person? (pun intended). I don’t think so. In part I think this is reflected in how their treatments are funded by a bureaucracy that struggles to meet costs (public health system), or one that has its raison d’être to make profits for shareholders (insurers). Evidence based medicine (EBM) (so called) purports to rationalise costs & increasingly tends to dictate treatment of the chronic pain patient. No funding for a treatment that might only help 10% of the population, in contrast to the sports star, & whoa betide the heretic who might question such hard science. Is this double standards hard at work for you & me??? At one level I think the push for a “flexible, creative, person-centred approach” will help address this. Bring it on – but the question WILL be asked – who pays??

I think this connects with my original question in the following way: to what extent can sports physiotherapy provide a model for treating other types of patients? By definition, it’s person-centered, designed to return an injured professional athlete to his or her sport (and I assume that sports physios who treat top athletes don’t last too long unless they show results….). Sports physios may have an advantage because they’re likely to know their athletes’ strengths and weaknesses and they also know the major stressors of the relevant sport. Regardless of their level of knowledge of a particular athlete, they typically start, after a history and examination of movement, by checking muscle tone and treating trigger points (if they exist) manually (i.e. ischemic compression aka digging in at the offending spot…) simply as indicators of hypertonicity (see sports physio Ulrik Larsen’s articles, cited earlier). When a muscle releases, the release of tension arguably could have a benign effect on the mind—as Katie reports Lorimer Moseley’s view—but the main purposes are to restore the balance of the musculoskeletal system and to see if this relieves pain. As I said earlier, it seems like a good place to start—conservative, exploratory, and at least, the process removes one possibility of stress in the whole system.

Thanks for this very helpful discussion!

Susanna

Ref:
Eccleston, C. Williams, A. and Morley, S. 2009. “Psychological therapies for the management of chronic pain (excluding headache) in adults.” Cochrane Review.

Eyal Lederman & The myth of core stability. He does make some good points & particularly in relation to motor learning. However, he has many misconceptions about how core stability (CS) per se and particularly how it is taught, at least by the expert physio’s in Australia whose work I am familiar with. I’d use his critique with heavy doses of caution if I were you. One point in his paper that resonates with me though, is whether CS training puts excessive focus on the back & reinforces notions about there being something seriously wrong, and also that it can shift the focus away from the real issues that maintain the patient in their chronic state. Craig Crawley mentioned something along these lines in this thread earlier on. In the pain management centre where I work I regularly see patients who are fixated on having to get their CS “right”. Funny thing is, even if you accept that that is what they need, these same patients are such over achievers or so uncoordinated that they activate everything & have no chance of isolating a TrA contraction or “doing it right”. Had they not had it drummed into them that they needed CS (or misconstrued what was said to them) then they would possibly have made much more progress.

If you do a search on Paul Hodges you will see he has co-authored papers with Michael Nicholas (CBT psychologist), Lorimer Moseley (heard of him??), Mary Galea (a Feldenkrais Practitioner or with Feldenkrais training) and others who do not hold a peripheralist biomedical view of back pain. I think Hodges has moved on, a long time ago, from sole focus on TrA & Multifidus to have a bigger picture view of things & linking of body parts. The changes in the sensory & motor cortex in relation to core muscles are documented in a number of papers. That reminds me – I think you’ll find Lederman is out of date too.

Margaret Massery from the USA has a very interesting take on CS which involves the breathing apparatus & I think the next chapter in the CS evolution you might see is how the vocal cords relate to CS (Massery & Hodges did a study on this a few months ago – as yet unpublished). I would think that the next logical step after this would be to link the somatic manifestations of psychological phenomena to all this. For instance how does anxiety affect breathing; how does that in turn affect CS muscles; what affect does all this have of efficiency of movement; and lots of other sequelae. This should then take us a step closer to merging the bio with the psycho & recognising them as manifestations of the same thing. I’m not sure if the CS concept will survive all that though, & it may be a case of another one bites the dust in the history of PT fashion!