Time to put away the magic bullet theory of back pain – Peter O’Sullivan talks…

Marienke van Middelkoop, and coworkers published a systematic review investigating the benefits of Exercise therapy for chronic nonspecific low-back pain (NSCLBP)[1]. They concluded that no exercise approach is superior to any other (from motor control to conditioning to back school) and that effect sizes for exercise are small in the management of NSCLBP. They proposed that better identification of subgroups and matching treatments might advance the management of these disorders.

While this maybe the case, what they didn’t highlight is maybe we should be doing something different in the management of these disorders. This review asserts the fact that NSCLBP is a complex disorder and highly resistant to change with generic approaches to management. For clinicians who spend the time to listen to the stories of people who suffer from disabling NSCLBP, these results will come as no surprise. The results tell a common story of failed interventions, ongoing pain and disability and a loss of hope in people with this disorder. This is in spite of the promises of well meaning clinicians and the enormous resources being spent on the disorder.

We know that people with NSCLBP disorders do not all present in the same manner. Given this, surely it is time to stop attempting to find the single magic bullet based on a biomedical model for these disorders. It simply hasn’t worked and for good reason. For example common popular beliefs and practice over the past decade that NSCLBP is related to a deficit in spinal stability has not resulted a decline in NSCLBP and associated disability. This belief is also not supported by a growing body of literature that documents that: NSCLBP disorders are commonly associated with excessive trunk muscle motor activity and the inability to relax these muscles (often associated with fear of movement, anxiety and negative beliefs about the spine); and that motor control exercises are no better than general exercise, and only slightly better than detuned shortwave (placebo). Yet stabilizing exercises continue to be prescribed and advocated as best practice for all with NSCLBP, suggesting that clinical practice is driven more by beliefs than by evidence.

It is widely agreed that NSCLBP should be viewed and managed from a bio-psycho-social perspective with physical, lifestlye, neuro-physiological, psychosocial and genetic factors known to be associated with the disorder. Yet few RCT’s reflect this in their interventions. There is also strong emerging evidence that broad subgroups exist in this population based on all these different domains, and that these different factors act together to contribute to a vicious cycle of pain that is unique to each person. Yet very few RCT’s have sub-grouped patients in any way – they instead assume patient homogeneity.

Adopting a flexible, creative and person-centred approach, in order to classify and manage these disorders based on their underlying mechanism/s seems logical. Interventions that target the mal-adaptive cognitive and physical behaviours (commonly reinforced by current biomedical beliefs and practice) that often underlie and drive these disorders, appear to yield greater benefits. This has the potential to reduce both the bottom up and top down drivers of pain. One would hope that no more funding will be given for RCT’s testing single interventions for these complex disorders, in order to tell us and our patients what we already know to be true.

About Peter

Peter O’Sullivan is Professor of Musculoskeletal Physiotherapy at Curtin University in Perth, Australia. Peter has published many excellent papers and is a highly sought-after speaker at conferences world-wide. His team, including his Norwegian collaborators, make an important contribution to our understanding of back pain and its management. He is clever.  His main role is a clinical one so he actually sees a large number of patients. Despite his obvious mass of talent, he remains a really nice bloke.  Clearly, he did not write this bio.
ResearchBlogging.org
[1] van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, & van Tulder MW (2010). Exercise therapy for chronic nonspecific low-back pain. Best practice & research. Clinical rheumatology, 24 (2), 193-204 PMID: 20227641

All blog posts should be attributed to their author, not to BodyInMind. That is, BodyInMind wants authors to say what they really think, not what they think BodyInMind thinks they should think. Think about that!

Comments

  1. Robert Angelo says

    Hi Graeme

    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.

  2. John Quintner says

    Hi Vegard
    You are right on the money. In my opinion, we need better scientific theory to deal with the observed clinical phenomena, as well as a new language with which to express it! Might I suggest that they are one and the same task to tackle?
    John
    PS For an introduction, please read our October 2008 paper in the journal Pain Medicine – “Pain Medicine and its Models: Helping or Hindering?” This might be of some assistance, although it is not an easy read (for anyone).

  3. Vegard Ølstørn says

    This is a very interesting discussion. It is like some of my chronic pain patients…I try from several angles to “sell in” the evidence of biopsykosocial approach, the “pain is in your brain etc” but still they are asking for this triggerpoint therapy as the magic bullet. I cannot find the right angle (perfect metaphor) to make them understand my approach.

    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

  4. susanna bell says

    John and Graeme,

    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

    John Quintner Reply:

    Hi Susanna
    Like it or not, we are all working in the same dualistic paradigm (which I believe is long past its use-by-date). As we are all capable of self-delusion, none of our belief systems should be immune from scientific scrutiny. If scientific support happens to be lacking, then we must admit and accept that this gap in our knowledge base exists. As I am not up-to-date with the literature, perhaps you or someone else reading this contribution could let me know the current scientific status of massage. Is there such an instrument as a “muscle tonometer’? How does one teach muscles to “work properly”? What are the measured outcomes of these therapies that purportedly enable the patient to “move without restriction or pain”?
    A more useful paradigm for those of us who work in this difficult (uncertain) area could be based upon the hypothesis that we as therapists of whatever ilk are attempting to engage with living organisms that at a systems level are characterized by the following properties: autonomy, self-organization (including autopoiesis) and self-reference. Of course, clinicians share these system properties with their patients. Little wonder that therapeutic outcomes are likely to be unpredictable (i.e. they are non-linear).

  5. Graeme Campbell says

    I’m not sure what constitutes the sports model in your neck of the woods but in terms of your question about applicability of that model to chronic pain (that was what you were asking wasn’t it!) & why not start work on muscular tone I offer:

    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.

  6. Graeme Campbell says

    Re: to what extent can sports physiotherapy provide a model for treating other types of patients, & I guess in the context of this forum I would take that to mean chronic pain patients. I think before going there we need to consider the Realpolitik:

    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??

  7. John Quintner says

    Hi Susanna
    Your post reminds me of the “holistic” dentist, who tends to your soul while drilling into your tooth. Restoring “the balance of the musculoskelelal system” to see if this relieves pain” smacks of yet another belief system that constitutes a circular (post hoc, ergo propter hoc) argument. No doubt similar belief systems are held by the ubiquitous iridologists, reflexologists, trigger point therapists, cranio-sacral balancers, massage therapists, colonic irrigationists etc.
    We are all hamstrung by body/mind dualism; this is evidenced by the so-called biopsychosocial approach which in practice easily defaults to these and other constrained deterministic viewpoints of purportedly scientifically-guided clinicians.
    The bottom line: Where best to spend the (shrinking) health dollar? Who will decide?

  8. susanna bell says

    I have been off e-mail for a couple of days because of a “Trojan horse”-type virus planted on my lap-top’s hard drive. Luckily this virus was easier to treat than “chronic non-specific low back pain”…. So I’ve returned to this site to find that the discussion has evolved in quite a few directions, which may be rather far from Peter O’Sullivan’s original posting. As I understood Peter’s position (and later in the discussion, Neil O’Connell’s), it was that the latest trials show that attempts to prescribe a single response to CLBP, whether it is exercise, or stretching, or behavioral therapy (for the last, see Eccleston et al. 2009) achieve only small effects, so there’s a good case for returning to a “flexible, creative, person-centred approach.”

    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.

  9. Katie Piraino, PT says

    These are older articles and may be outdated but Ivan Korr was trying to change the theories of osteopathic lesions and manipulation to neurological from mechanical a long time ago (1948). Why are we still debating that!!
    I will now stop posting as I agree the “trigger point” debate is very off the original point of the posting.

    Katie

    IM Korr
    Proprioceptors and somatic dysfunction
    J Am Osteopath Assoc, Mar 1975; 74: 638.
    IM Korr
    The spinal cord as organizer of disease processes: some preliminary perspectives
    J Am Osteopath Assoc, Sep 1976; 76: 35.
    IM Korr
    The spinal cord as organizer of disease processes: II. The peripheral autonomic nervous system
    J Am Osteopath Assoc, Oct 1979; 79: 82.

    IM Korr
    The spinal cord as organizer of disease processes: III. Hyperactivity of sympathetic innervation as a common factor in disease
    J Am Osteopath Assoc, Dec 1979; 79: 232.
    IM Korr
    The spinal cord as organizer of disease processes: IV. Axonal transport and neurotrophic function in relation to somatic dysfunction
    J Am Osteopath Assoc, Mar 1981; 80: 451.
    IM Korr
    Osteopathic research: the needed paradigm shift
    J Am Osteopath Assoc, Feb 1991; 91: 156.

  10. Graeme Campbell says

    And “Hi”once more Katie

    No idea if I was using the technique correctly or not. Whatever I did use seemed to work at the time. Correct technique seems to vary with who taught you & of course this applies to many techniques. However, if it works for you then there is something correct about it I guess. My thumbs, like many trained in Maitland’s manual therapy (i.e. most Australian PTs) were “damaged” well before learning Counterstrain. The paradigm that I think would be consistent with current neuroscience that explains this is perhaps the pain I experienced was due to some central sensitisation from repeated microtrauma, & by repeating an engram that my brain decided was threatening, that this was enough to set off a pain response irrespective of correctness of technique. Who knows? I’m as pain avoidant as the next guy especially when my homunculus is killing me.

    Never heard of Ivan Korr. There’s just too many schools of thought to keep up with, let alone having the $$$$ to go to all the courses. I suffer from AFIOS – (Anxiety From Information Overload Syndrome) so consider carefully if you should tell me about him…………… Just kiddin’ – who is he?

    Not sure how resetting the muscle spindle would be achieved by a 90 second hold in the weird positions Jones gets his patients in. And if that was the case, then so what? How do apply the putative change in spindle length to the motor control issues you speak about? Would stretching do the same thing to the muscle spindle or to the motor control; and is that the most efficacious way to change the motor control. I don’t know myself but you can see that the questions pile up & a lot of speculation could be involved.

  11. Graeme Campbell says

    Hi again Katie

    As to why there is focus on the B-P-S model? I think there are two important factors here (& probably others that don’t come to mind at present):

    There are so many competing schools of thought and associated techniques/methods and to date not a lot of evidence that any of them have achieved startling results. I know only too well how that might not match with your clinical impression of what you do. A dedicated advocate of a particular technique or method would perhaps hold that that is a reflection of how evidence is gathered (i.e. are the various methods getting a fair assessment & can Evidence Based Medicine (EBM) accurately reflect clinical reality), whilst the other side of the argument is that proponents of the various brands of treatment are fooling themselves as to how effective their methods are, & EBM has so far found them wanting. I’m afraid the latter view prevails.

    Spending money on biomedical interventions has proven costly & ineffectual for those with significant yellow flags, & such a cohort dominates the chronic pain population. I think the deal breaker on such an issue has been the recognition of the significant influence of yellow flags on outcomes & hence the pre-eminence of B-P-S in the literature, & I assume the relative ease of attaining funding. If government & compensable bodies recognise that a lot of their costs are due to the influence of psycho-social factors & that these are malleable, then that is the area that should be targeted. Hard to argue don’t you think? So one reason for the focus on B-P-S is cold hard cash – I remember Luke Parkitny (one of the site moderators here) coined the phrase Bio-psycho-socio-fiscal model or something like that, which tickled my fancy.

    The second reason that I see why the B-P-S has gained prominence is the emergence of the various brain scanning techniques. We can see that the brain changes in pain & that psycho-social factors also cause brain & other changes (e.g. neuroendocrine), & that they interact. Powerful science indeed & fascinating stuff!

    So I guess you are up against it if you want to advocate a particular biomedical method or technique, especially if it one that is a bit peripheral to the mainstream. The pendulum & politics aren’t on your side at the moment.

    I hope I’m not being too presumptuous in suggesting that you may not get a lot of interest on this site in discussing things like counterstrain.

  12. Graeme Campbell says

    Hi John
    (Somehow “Dear John” has too many connotations for me, so please excuse the familiarity in the address). Your update on fibromyalgia was quite illuminating – thankyou. Yes, the tender point criterion did seem to an add-on from left field that was hard to reconcile with the other phenomena that are seen with this population. It has undoubtedly done a disservice to the CWP population & great to see it has been disbanded.

    The “straw man” I was referring to is the one I feel you yourself have made of ‘Myofascial Pain Theory’, not the putative shaky theories that underlie the diagnosis/concept/myth or however you want to frame it. That is, we don’t really know enough about myofascial pain or trigger points to be categorically debunking them. Sure, you can point out the inconsistencies, epistemological short comings etc as healthy academic discourse mandates, as you have done in your paper. However, this is a long, long way from putting the issue to bed & as I said I think you have put the cart before the horse & was the reason for my initial response to you post. In the fullness of time we will hopefully understand what is going on, which I concede may turn out to be that the concept is unsound or is an epiphenomenon of some other process etcetera, etcetera .

    So maybe we should ask why is the issue/controversy still around? Why do we see articles like the one you have referred to in the January 2010 Pain Medicine? From my perspective I have no difficulty neither finding trigger points nor relating the findings to what Travell & Simons described & that is a powerful reinforcer to me of the concept and its utility, & presumably others who hold to the myofascial pain concept. I realise trigger points (TP) and myofascial pain are different but let’s just stick with TPs. If you deny the existence of TPs, if you can’t find them or if you are unconvinced that your palpation has identified what Travell & Simons described then we have a major point of divergence & perhaps never the twain shall meet. For example: is it that your camp (if I can put it that way) thinks the TP camp holds to a nonsense theory & will twist the facts until they fit what we believe, despite the fact that there is little inter-relater reliability with deciding on what constitutes a TP, what is clinically relevant etc. Conversely, as I expressed in my previous post the pro TP camp may hold that there is lack of expertise is TP detection, there are numerous variations in how they present & ignorance of the condition has led to poor studies etc etc.

    Now does that get us back to the six blind men & the elephant? Who is the sighted objective observer & who of us is one of the blind men?? And which of them is the most guilty of mangling American folk songs? On that, as Woody Guthrie might have said had he traded his guitar for academia:

    It as through this world I’ve travelled I’ve seen lots of clever men, some will convince with their experience, and some with their EBM !!

    John Quintner Reply:

    Hi Graeme
    Trigger points do indeed exist. It was no accident that Travell & Simons located many of them over major peripheral nerve trunks. In our 1994 paper we did leave the question of their pathophysiology an open one.
    On a more practical note, I believe that our theory determines how we practice, whatever our specialty may be. Trigger point aficionados have reverted to homoeopathic theory – “like” cures “like”. In this case, the trigger point has to be destroyed/eliminated by various means, including dry needling, spraying & stretching muscles containing them etc.
    Why is the issue still being debated? One reason is that locating trigger points and “treating” them is a big money spinner for physical therapists. Now Dr Marcus would have us believe that his invention (Muscle Pain Detection Device) eliminates the need for palpation! The dry needler can then poke numerous holes into and through the unlucky muscle (and get paid for so doing!).
    I think it might have been Sir William Osler who said: “When Mammon enters the room, science goes out the window.” Now there was a clever man!

  13. susanna bell says

    Katie,

    Thank you. Strain-counterstrain technique is used in osteopathic practice in the US–see Philip Greenman, Principles of Manual Medicine, 3rd ed, p.116–but it is based on assumptions and practices that are distinct and different from the Travell/Simons trigger point theory and practice in which strong pressure is applied to the trigger point until the muscle releases. I agree with your general point about the importance of addressing muscle tone. Experienced sports therapists use these techniques to restore normal tone as one component in their approach to treating an injury. But my main question is why there appears to be little interest in using these techniques for non-athletes, at the least to ensure that abnormal muscle tone is not contributing “chronic” pain.

    Susanna

    Katie Piraino, PT Reply:

    Interesting comments. I agree there is little evidence for trigger points. Jones avoided calling his tenderpoints triggerpoints because he believed that they were a sign of heightened muscle spindle activity not a pathology in themselves.
    As a technique it is used widely in therapy for non sports related injuries including chronic pain. I believe this is because there is no treatment soreness as it is not as aggressive as trigger point therapies.

    I posed the question to Lorimer in San Diego why he thinks manual therapies work. His answer was classic! Perhaps we are reducing the threat level in the brain! I believe this is a part of it. When a point hurts a lot on palpation then doesn’t after a simple positional release it has a powerful effect on the patient. Either way Ivan Korr or lorimer’s therories, or both it works!

    John Quintner Reply:

    Dear Ms Bell
    Which raises the two questions: (1) how “abnormal muscle tone” is diagnosed and (ii) how such a phenomenon might “contribute” to chronic pain. I suggest that we are discussing scientifically outdated nonsensical belief systems. As you well know, the history of medicine provides innumerable examples of such fallacies.

    By the way, I am sorry to say that “dry needling” of muscles is a popular treatment amongst physical therapists in Australia:
    With no apologies to Baroness Orczy:

    They seek it here, they seek it there
    Those therapists seek it everywhere
    Is it in muscle or is it in joint?
    That damned elusive Trigger point.
    They meddle with innocent muscles
    Poking and prodding each week.
    Ignoring evidence-based treatment
    La, they have a cheek!

    Graeme Campbell Reply:

    Hi John

    Your comments are entertaining as always.

    Can I make the following points:
    • Travell & Simons were at pains (no pun intended) to emphasize the degree of confusion, and different perceptions that surround the term myofascial pain & all the associated terms that overlap it. I think some of the above discussion reflects this. Surely then, it is no surprise that any research on the topic would be fraught with inconsistencies, problems with definitions, & I would opine quite variable skill sets in being able to detect a myofascial pain syndrome (MPS) as conceived by Travell & Simons. At the end of the day how can you then subject such a “construct” – as you call it – to rigorous scientific investigation (but perhaps that is one of your points)? If you accept that myofascial pain suffers from such problems, then how can you then make a statement like “You are obviously are unaware that nearly 15 years ago myofascial pain theory was exposed as epistemologically unsound and unsupportable on scientific grounds. Nothing has changed since then to alter my opinion.” What is this? Have you created a straw man, and in the crusade to rid the land of such villains, set him ablaze with a vicious attack of poetry!!? If we don’t know what we are testing, and don’t have a common understanding of it, then surely we aren’t in a position to credibly study it, let alone subject such studies to the EBM blowtorch. Methinks you have put the horse before the cart.
    • No evidence?? Hmmmm ….. Do years of careful observation & recording by Travell & Simons not count for anything?? I haven’t read the Chen article quoted above but Sikdar and colleagues have demonstrated echo-opacity differences in areas identified as having Trigger Points. See: Sikdar S et al; Novel Applications of Ultrasound Technology to Visualize and Characterize Myofascial Trigger Points and Surrounding Soft Tissue, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION, Vol 90, Issue 11, 1829-1838 (November 2009).
    • I note Milton Cohen & yourself are Rheumatologists. In my experience, Rheumatologists seem to have issue with MPS but not so with Rehab Medicine Specialists. Am I right? Is there a line in the sand between these two medical streams & is your view reflective of how your background has filtered your perception rather than something more objective (no disrespect intended). Of course we’d all be guilty of that to a greater or lesser extent but I wonder what it says about the debate on this controversial topic in terms of how MPS is studied; how our background influences our perceptions, which in turn influences our efficacy in delivering treatment.
    • Bit of a tangent here but Rheumatologists seem to commonly dispense the Fibromyalgia diagnosis, (or whatever it is called this week – (Chronic Widespread Pain (CWP)) and I believe you ascribe to the CWP diagnosis. This concept certainly has a lot of detractors, but it is appealing as a medical concept because there are lots of “objective” findings documented (e.g. neuroendocrine changes) but they are not found in all of the CWP people all of the time (apologies to Bob Dylan). Can we not apply many of the same arguments against CWP as those used against MPS?

    • If the argument about MPS is about the existence of Trigger Points, rather than their aetiology or biological basis, then I would offer that this is a matter of experience and palpation skill. I know this might sound arrogant but if you can’t find them (TPs) then I think you really need to ask yourself if you know how to look!! As a true believer in MPS and someone who has worked with them over the past thirty years I cringe at the lack of awareness (humour me here) and sloppiness in how it is assessed and “treated”. No wonder it has a bad name in some quaters. Yes we can apply the EBM arguments as propounded by Bogduk and such like, that this is just craft rather than true science (sic) and the academic vs clinical issues. But that is a whole new topic & we’ve steered away from the original theme somewhat already, plus it might be an unproductive argument anyway.
    • In terms of aetiology.– is this really relevant from a pragmatic point of view? It would be great if we understood what Trigger Points are or if they are manifestations of some other process, but we don’t, so if squishing, stabbing, and pulling the Trigger Point gets rid of them or attenuates them/it, and the related pain, then as a clinician I really don’t care. Results count in the clinical setting. Would you apply the same standards to all the medications that you don’t know the exact mode of action of, before you prescribed them? I think that is a ‘NO’ I can hear. I now work in a Pain Management Centre & find that incorporating self treatment of Trigger points augments patient outcomes in some cases. “Some” because it is a difficult cohort that I see, & like everything I have seen used as a treatment, there are no panaceas out there. I’ll keep using MPS as a concept until I find something to assess and explain the clinical presentation better and that delivers better utility. If I have to frame my treatment to the patient (or funding body) as performing shiatsu to an Ahshi point, getting a knot out of the muscle, performing graded exposure to a threat (e.g. stretch or movement in the direction the trigger point restricts) , desensitising the sensory cortex or affecting other neuro-plastic changes, then I will, because at the end of the day all I care about is if what I do is working for my patient and I don’t need a systematic review to tell me that.
    • I await my burning at the EBM stake!

    John Quintner Reply:

    Dear Graeme
    Travell and Simons made two fundamental epistemological errors. They are dissected in our 1994 paper. The latest attempts to hold up the “straw man” can be found in two articles that appear in the January issue of Pain Medicine. These two papers contain some wonderful examples of circular argument and begging the question. We have responded and our letter is awaiting review (although a modified version has been accepted).

    As for Fibromyalgia (aka chronic widespread pain), we (Cohen and Quintner) have always maintained that the label is bogus whereas the phenomena are real. Most rheumatologists have ignored our warnings and, in the latest version of the Classification Criteria, the American College of Rheumatology has removed the tender point criterion (11 of 18 TPs). We exposed the tautology in 1993 and it has taken all this time for the ACR to attempt to rescue the unhappy situation for our patients so labeled.
    Through your pragmatic approach to treatment (which occupies an evidence-free zone) I am afraid that you risk setting alight the pyre under your own stake. Bring out your evidence and I will be the first person to cut you loose.

    John Quintner Reply:

    Addendum to make my position on the Fibromyalgia construct quite clear (I hope).

    Where have all the tender points gone?
    Long time passing
    When will they ever learn?
    When will they ever learn?

    [with apologies to Pete Seeger]

    In what will be seen as a highly embarrassing back down, the prestigious American College of Rheumatology (ACR) is about to remove the “tender point” requirement for the diagnosis of Fibromyalgia.

    Back in 1990, a Committee of the said College announced criteria held to be necessary for a diagnosis/classification of Fibromyalgia – widespread pain and excessive bodily tenderness at 11 or more of 18 defined musculoskeletal sites.

    In their seminal article in the prestigious journal Arthritis & Rheumatism, these anatomical sites were appended to a sculpture by Antonio Canova depicting the Three Graces, the mythological nubile daughters of Zeus. This image was highly inappropriate, given that the mean age of the patients being studied by the ACR multi-centre Committee members was close to 50.

    The FM construct was fatally flawed from the beginning, as the tender points that were said to be central to the diagnosis strangely bore no necessary relationship to the anatomical distribution of pain. In addition, there were said to be “characteristic symptoms” of FM, such as fatigue, sleep disturbance, mood disturbance, etc.

    By eliciting these non-specific “characteristic symptoms”, rheumatologists were encouraged to make the FM diagnosis in their patients with less than 11 tender points. FM soon joined the Pantheon of illustrious rheumatological diseases.

    Over the last 20 or so years, there has been a huge expenditure of time, effort and money by many FM “experts” around the world, each striving to discover the essence of FM. Alas, it has all been to no avail! Round and round they went – reminiscent of the “caucus race” from Alice in Wonderland.

    Meanwhile many rheumatologists elected not to perform a tender point count on their patients. They found that they could easily recognise the condition without the need to locate and count tender points. The FM diagnosis became meaningless as it could be awarded to almost anyone with persistent widespread pain. Rheumatologists were even invited to entertain the concept of “regional fibromyalgia”.

    The sounding of the retreat by the ACR will ensure that whatever credibility the FM diagnosis once had will evaporate, relegating it and the patients so labeled to the symptomatic diagnosis of chronic widespread pain with “polysymptomatic distress”.

    In our body/mind dualistic Western society, this formulation will doubtless equate to psycho-socio-cultural distress along with the inference of psychogenesis of the pain and other symptomatology. Devoid of their tender points, the Three Graces will definitely not be smiling!

    FM is about to undergo the fate of the 19th century construct of “neurasthenia” – formulated by George Miller Beard as a potentially serious physical illness, but classed by Sigmund Freud in the early 20th century as a fundamental disorder of mental functioning, which could ensue from excessive masturbation. Thereafter it soon disappeared from the medical lexicon.

    This volte-face by the ACR will horrify consumers and bring the specialty of rheumatology into disrepute.

  14. Neil O'C says

    Hi Susanna,

    Thanks for your comment and glad you found the posts useful. I’m not sure that I would agree the trigger points are widely ignored. They are, in my experience, very popular in the therapies right now and have been for some time, but they are not without their problems. There is quite a lot written on them and they get a fair bit of attention in the acupuncture press.

    I suspect that they get less mainstream attention for a number of reasons, the main ones being that we don’t know what they are and we don’t know “if” they are (i.e are they a real pathological phenomena or not?). There is little evidence of efficacy for trigger point based treatments (little evidence at all in fairness although a recent review of acupuncture for myofascial pain concluded to the negative) and no firm consensus as to the underlying mechanisms.

    The finding of multiple tender spots in chronic pain syndromes may of course mean that there is some local myofascial pathology driving the symptoms, but equally (and to my mind more likely and more in keeping with the evidence) it might just reflect a sensitized pain state, characterized by widespread hyperalgesia and allodynia.

    So I guess the vote is out….

  15. susanna bell says

    I’m a historian of science in the U.S. involved in a study of therapeutic “paradigms” (theories, fundamental philosophical assumptions, and associated therapeutic practices) that address “chronic non-specific back pain.” Thanks for the discussions in this posting and the previous one (“Hell’s Own Elephant”). I’ve found them most helpful for understanding the status of debate in this fascinating field.

    These postings also raise a further question: Why does manual treatment of latent and active myofascial trigger points aimed at restoring hypertonic muscles to normal tone, which is used fairly widely in sports therapy, receive relatively little attention in other therapeutic settings? At least, this is the situation in the U.S.—perhaps Australia is different.

    Two examples of this lack of attention: First, the April 2010 issue of Best Practice and Research Clinical Rheumatology discussed in these postings doesn’t include an article on trigger point therapy. Second, a historical example: Rosomoff, Fishbain, et al., found that a very high percentage of people who would have been diagnosed as having “no organic findings” on standard physical examinations (and therefore would have been diagnosed as having a “chronic” condition) actually had trigger points with associated referred pain patterns (Rosomoff et al., 1984). Yet this interesting finding seems to have been ignored in subsequent studies. For example, Geisser et al., proponents of the “bio-psycho-social” paradigm, note the Rosomoff result but then ignore it by citing studies that address only “manual therapy”—mainly spinal manipulation (Geisser et al., 2005). One can infer that, in our sedentary societies, in which weakening of some muscles and overuse of others are risks, some percentage of people afflicted with hypertonic muscles and LBP are being regularly assigned for discussions with behavioral psychologists.

    On the hand, treatment of latent and active trigger points is integrated into sports physiotherapy, not as a “magic bullet” but as an integral part of multidimensional treatment that also includes stretching, strengthening appropriate muscles, patient education, and return to a sport. The technique is also used as a component of diagnosis, along with patient history, standards PT tests, etc. (Mallac, 2009, personal communication; Larsen, n.d.). Returning hypertonic muscles to normal tone may be sufficient to reduce or even eliminate pain. If so, this would provide one key to the etiology of pain. If not, the possibility that hypertonic muscles are a contributing factor could be excluded.

    I’ve found some recent small studies that report promising results of treatment of trigger points (e.g. Trampas et al., 2010; Fernandez-de-las-Penas, 2006). However, in general, at least from a U.S. perspective, despite acknowledgment of the work of Travell and Simons, the techniques don’t seem to be in widespread use outside sports therapy. I’d appreciate having suggestions about the reasons for this marginalization. I realize that some possibilities are the lack of a “gold standard” for assessing trigger points (Huguenin, 2004). However, recent research suggests that there are new ways to confirm the existence of trigger points (see, e.g. Chen, et al. 2007). A further question is why this field has been rather marginalized compared with research focusing on aspects of the bio-psycho-social model.

    References:

    Chen, Q., et al. 2007. “Identification and quantification of myofascial taut bands with magnetic resonance elastography.” Arch Phys Med Rehabil 88. 1658-1661.

    Fernandez-de-las-Penas, et al. 2006. “The immediate effect of ischemic compression technique and transverse friction massage on tenderness of active and latent myofascial trigger points: a pilot study.” Journal of Bodywork and Movement Therapies 10, 3-9.

    Geisser, ME, et al. 2005. “A randomized, controlled trial of manual therapy and specific adjuvant exercise for chronic low back pain.” Clin J Pain 21(6), 463-470.

    Huguenin, L. 2004. “Myofascial trigger points: the current evidence.” Physical Therapy in Sport 5, 2-12.

    Larsen, U. “Trigger points therapy.” Sports Injury Bulletin. n.d. On line.

    Larsen, U. “Trigger points treatment techniques.” Sports Injury Bulletin. n.d. On line.

    Mallac, C. 2009. Personal communication.

    Rosomoff, H. et al. 1989. “Physical findings in patients with chronic intractable benign pain of the neck and/or back.” Pain 37, 279-287.

    Trampas, A, et al. 2010. “Clinical massage and modified proprioceptive neuromuscular facilitation stretching in males with latent myofascial trigger points.” Physical Therapy in Sport. Article in press.

    Travell, J. and Simons, D. 1983. Myofascial pain and dysfunction. Baltimore: Williams and Wilkins.

    Katie Piraino, PT Reply:

    HI Susanna,

    I think you have hit on a relevant point for us clinicians. I find Strain Counterstrain (briefly mentioned in Travell and Simons see jiscs.com for more info) very effective and yet it is not known in the UK or Australia although there have been courses offered this year by the Jones Institute.
    Addressing the tone of the muscle directly in combination with motor control issues is very effective.

    Graeme Campbell Reply:

    Hi Katie

    To my knowledge Counterstrain, Muscle Energy, and Craniosacral techniques were first introduced to Australian physiotherapists by Loren Rex – American Osteopath -in the mid 80’s. The muscle energy stuff in terms of SIJ problems has certainly taken off – see Barbara Hungerford’s, or Trish Wisbey-Roths work. I occasionally see the odd mention of counterstrain but the physio profession in Australia in my opinion is very fad orientated & whilst counterstrain (also called indirect technique) was never that popular it appears to have fallen by the wayside, but I could be wrong. Speaking of such I used counterstrain myself for a period & when it works, it works really well. However, not well enough on enough people to justify keeping it in my tool bag. My thumbs got really sore too and then it was convenient to I wonder if my “successes” were just excellent placebo responders. BTW, Jones did not offer any explanation as to why his technique worked. Was that a sign of intelligence??

    I wonder if Jones triggers, Chapmans reflexes (a Chiro concept), the sixteen points purported to characterise fibromyalgia etc etc, are manifestations of a common mechanism, are subgroups of something else; are different things altogether; are issues that need to be investigated further; or whether if we believe in something & convince our patient of that something then we have entered into a therapeutic relationship that works by another mechanism, with the paradigm we use somewhat redundant. For instance, pain could be a ‘need state’ as Pat Wall stated, and attending to pain by your treatment of choice (as negotiated between therapist and patient), then perhaps that is enough to satisfy the brain & pain is attenuated. Perhaps I could be provocative (& even cynical) & say that by using what is fashionable – whether it be core stability, CBT, EBM, therapeutic neuroscience education (a la Butler & Moseley), graded exposure to threat, or whatever else is currently leading edge that that is how therapeutic efficacy is attained. That is, therapist believes paradigm, which is particularly powerful if we are an expert -> conveyed to patient -> patient believes -> need satisfied. The old “use it while it still works” joke come to mind.

    Katie Piraino, PT Reply:

    Hi Graeme,

    It is funny you said your thumbs were sore. Randy Kusenose who now directs the Jone’s Institute said when he was in Australia the few people who knew anything about Strain Counterstrain were not doing the technique remotely correctly as Jones taught it. It is so gentle me OA thumb can easily handle it with no soreness.
    Why is there no talk of Ivan Korr’s work in this debate?

    Katie Piraino, PT Reply:

    Jone’s met with Ivan Korr long after developing his technique (or discovering as he would prefer) he then surmised he was resetting the muscle spindle reflex.

    John Quintner Reply:

    Dear Ms Bell

    You are obviously are unaware that nearly 15 years ago myofascial pain theory was exposed as epistemologically unsound and unsupportable on scientific grounds. Nothing has changed since then to alter my opinion.

    References:
    Quintner JL, Cohen ML. Referred pain of peripheral neural origin: an alternative to the “Myofascial Pain” construct. Clin J Pain 1994; 10: 243-51.
    Cohen ML, Quintner JL. The horse is dead: let myofascial pain syndrome rest in peace [letter]. Pain Medicine 2008; 9: 464-465.

  16. Ummm, Peter… the conclusion in the Hancock et al paper is wrong. 97% of the patients receiving spinal manipulative therapy received a low velocity technique. Technically the intervention provided by Hancock et al wasn’t the intervention advocated for those who respond to manipulation. The original researchers (Childs et al) performed high velocity thrust manipulation to patients.

    peter o'sullivan Reply:

    I suspect there would be little difference. Studies comparing mobilisation vs manipulation have shown little difference.
    There’s a research project for you.

  17. peter o'sullivan says

    some articles are:
    DANKAERTS et al, (2006) Spine, Spine, 31, 2017-2023.
    DANKAERTS et al, (2009) Spine, 34, 1610-1618.
    GEISSER et al, (2008) Clin J Pain, Volume 20, Number 2
    GLOMBIEWSKI et al, (2008) Psychosomatic Medicine 70:125–131
    many more exist that document the loss of flexion relaxation of the back muscles during forward bending.

    Bodhi Haraldsson Reply:

    Thx Peter, got my night reading materials for the week now 🙂

  18. Bodhi Haraldsson says

    Hi Peter
    Thx for a great article.
    Could you elaborate on this statement and perhaps direct me to some of the research you are referring to: “NSCLBP disorders are commonly associated with excessive trunk muscle motor activity and the inability to relax these muscles (often associated with fear of movement, anxiety and negative beliefs about the spine)”

  19. Tom Waklaki says

    How bout this Eyal Lederman and his core stability myth?

    The principle of core stability has gained wide acceptance in training for prevention of injury and as a treatment modality for rehabilitation of various musculoskeletal conditions in particular the lower back. There has been surprising little criticism of this approach up to date. This article will re-examine the original findings and the principles of core stability and how well they fare within the wider knowledge of motor control, prevention of injury and rehabilitation of neuromuscular and musculoskeletal systems following injury.

    http://www.cpdo.net/myth_of_core_stability.doc

    Graeme Campbell Reply:

    Hi Tom

    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!

  20. Thank you Peter with this great dialogue we must have with intervention and care with people that are suffering with chronic low back pain. Over the years, I have come to appreciate the need to understand the plasticity of the nervous system when approaching this area. Using Feldenkrais, PT and working with other team aproaches (psychotherapy), I feel your recommendations are right on, keep the dialogue coming.

  21. Vegard Ølstørn says

    Great post,
    ‘ This has the potential to reduce both the bottom up and top down drivers of pain.’ This is, as I see it today, only possible via the bio-psycho-social approach. I often wonder if the biomedical model in chronic pain conditions keeps the patient in the vicious cycle of pain more than helps the pt out of pain. Pretty logic if the ‘magic bullet’ is stimulated 2 times a week , week in and week out, in a hypersensitive system where beliefs are reinforced by the biomedical therapist approach.

    Looking forward to more research coming from your group,
    Cheers

  22. Katie Piraino, PT says

    It is so refreshing to read this discussion.

    I had the privilege to work with Nicky Hunter in the UK who has pioneered the bio-psycho-social approach in occupational rehab. I was too immature and too fresh out of a manual therapy residency to fully appreciate her work at the time. I am now a true convert. Here is a study of hers:

    http://occmed.oxfordjournals.org/cgi/content/full/56/7/497

    Sadly I believe the medical system (or lack of) will inhibit rapid change in the US. But there are many of us out there trying!

  23. I think sometimes for patients with chronic low back pain it seems as though there are two factors not considered in research and maybe not even thought about by the majority of clinicians.

    First off, chronic back pain doesn’t happen over night… the patient had some kind of a journey to get to the stage of having chronic back pain. Every patient probably has a different journey and research hasn’t focused on what might be potential commonalities in individual journeys. (Not to irritate anyone, but sometimes I think medical providers/clinicians contribute to the problem of chronic back pain.) If predictable factors could be teased out, could there instead be a better game plan for reducing the incidence of chronic low back pain? (In other words, why have various health care systems failed individuals with back pain?)

    And second… search on twitter for back pain – there are so many mixed messages out there for what the heck to do about back pain it isn’t even funny. Medical providers generally don’t have a united, cohesive, agreement between the majority in the real world. The guidelines for low back pain aren’t always followed in the acute stage, due to a variety of reasons – stubbornness, maybe unawareness, lack of understanding of pain on behalf of primary care physicians, lack of understanding of pain on behalf of society, litigation, the search for the holy grail for why someone has pain.

    This topic is definitely an interesting and engaging one.

  24. Clearly there are patients with pain (and discomfort) who after years of inadequate examination and maltreatment goes into a chronic and more or less psycological pain behavior. If they initially were met by professionals who could sort out musculoskeletal lesions properly, it is my belief that this group would be substantially smaller. My own, and some of my collegues, experience with the general health services today (and even hospitals with professors in physical rehab) is that the lack of skills in this area are widespread. If we all are going to tip over and go for the bio-psycho-social approach (psyciatrist light) , who is going to diagnose and treat musculoskeletal lesions? Is it really going to help the majority of these people if they are pre-judiced and met solely by psycological personell? I would say not. One of the main sources of pain in the lumbosacral area is the dura mater, as a conseqence of a disc-protrusion or prolaps (annular or nuclear) or stenosis , and in some it can stay inflamed (bruised) cronically, and may need de-inlammatory treatment (eg by triamcinolone acetonide epidural injection). I will also urge you to seek for the study “clinical evidence for the dural concept” by P. Bisschop et al. publiced in spine some years ago. Mental problems should be delt with by mental staff, not by me.

    Peter O'Sullivan Reply:

    Hi Vegar

    Hmmm…i do have a problem with your view.
    If you don’t want to deal with the head – and you work with people in chronic pain – you have a problem. All of these disorders have a major impact to the person which involves the head – and as Lorimer has stated you don’t have pain without a brain.
    Pathoanatomy as a basis for understanding NSCLBP has consistently come up as a limited and potentially negative approach for viewing NSCLBP. Watch out for recent research conducted by Briggs et al, (soon to be released in ‘Pain’). Interestingly in this study, people with a patho-anatomical belief of their back pain were more disabled than those without – even though their pain levels were similar.
    Separating the mind and body doesn’t help people with pain understand or deal with their problem. Rather, reinforcing patho-anatomical beliefs in many of our patients in my view has done untold harm to them.

    Ole Reidar Johansen Reply:

    Vegar, first off I agree with Peter. Just want to add that you will be affecting their head whether you want to or not. Being aware of how you potentially are affecting your patients is vital. Many – perhaps most – are not.

    Sarah Reply:

    Oh Dear. My heart just sank.

  25. Neil O'Connell says

    Hi Peter,

    I fully agree that a patient centred approach seems the most reasonable but I am less confident that there is yet strong evidence of broad subgroups in LBP emerging. The paper by Kamper et al. in the same edition (linked to in my post) is less encouraging on this score and clinical prediction rules haven’t produced a convincing breakthrough yet.

    Also it is interesting that while clearly better than waiting list controls, adding behavioural interventions to Physio, back education or medical care does not seem to lead to clear additional benefits according to the last Cochrane review on this topic.

    Cheers, great post.

    Peter O'Sullivan Reply:

    Hi Neil
    Thanks for your comments.
    I enjoyed your piece and agree we need to take this evidence seriously and re-look at what we are doing.
    It is true that adding behavioural interventions to physical interventions doesn’t add to outcomes. But does this represent the failure of 2 generic approaches to intervention with NSCLBP that are not person centred and taylored? Can we really separate the mind from the body – by doing exercise and behavioural interventions separately as these studies tended to do? It doesn’t make sense that a behavioural intervention just involves talking to someone without analysing and addressing the behaviours across multiple domains – physical, lifestyle as well as psych and coping etc.

    This leads on to the subgrouping issue….i think it depends on what is meant by subgrouping.
    Interestingly people like Steven Linton and Turk are heading down the subgrouping route, as they have identified that people with pain present with different underlying psychological issues and coping styles – and so in the psych domain it is clear that one size doesn’t fit all.
    This appears to be the same with lifestyle factors, neurophysiological factors (ie. widespread pain vs localised pain) and physical behaviours (which also vary hugely and can be broadly categorised).
    I think one of the problems with the clinical prediction rule approach – is that it is unidimensional and boxes people. It is unlikely to be helpful when you consider the complexity of these disorders as it lacks flexibility.
    An alternative view on subgrouping was outlined beautifully by Turk, Clin J Pain • Volume 21, Number 1, January/February 2005.
    I think his perspective is very helpful when we focus on underlying mechanisms that drive pain. There is growing evidence to support a broad view on broad subgrouping – see Boersma and Linton’s work, Dunn and croft, Turk (psychosocial factors) and dankaerts et al (physical factors) to name a few.
    One of our challenges i think is not to try and box people using clinical prediction rules – but develop a broad and flexible framework to asses and deal with the complexity of these disorders that reflects a biopsychosocial understanding of pain. Without some form of framework the therapist is lost for direction. If such a framework allows therapists to think outside the box and focus more on underlying mechanisms from a multidimensional perspective, rather than signs and symptoms, then this has to be better than the status quo. Of course time will tell.
    I think this highlights to us clinical researchers and clinicians that there is a lifetime of work on offer to try and make some sense out of this complexity.

    Finally….. i think this paper is a wonderful read for all clinicians…..
    Mazes, Conflict, and Paradox: Tools for Understanding Chronic Pain Cary A. Brown, Pain Practice, Volume 9, Issue 3, 2009 235–243.
    To me it highlights why the clinical prediction approach to subgrouping will likely fail.
    Discussion forums like this are great to chew the fat.
    thanks Loz.

    SnippetPhysTher Reply:

    Whoa… wait a minute on the thought of clinical prediction rules. There IS a time and a place for clinical prediction rules. The clinical prediction rule for manipulation for a person with low back pain is in the very early stage of having low back pain. The research is strong. I track my outcomes and implementing that into practice substantially improved my outcomes (both Oswestry and pain scale scores).

    The treatment based classification system also seems helpful – I have seen some outcomes of the approach applied in the outpatient setting (Fritz, Delitto, Intermountain Healthcare http://clinicaltrials.gov/ct2/show/NCT00769626 ) …. except, in my opinion, it misses a category of people who have neural sensitization (like positive slump testing) and when it comes to people with chronic back pain.

    Boxing and subgrouping can be a good thing. People with chronic back pain just seem very multifaceted with multiple potential factors. It’s almost like a value to each factor needs to be assigned to know the weight of the factor to know which are key factors to address – or what order to address them. I don’t even know if that makes sense. I guess it does seem laughable to rank factors that are variables for people with chronic back pain, but seems to me it might be helpful.

    Craig crawley Reply:

    I have to agree that subgrouping for chronic LBP seems doomed to failure, becuase each patient has a unique mix of contributors. It seems improbable that we could add a weighting to each variable because it would be differnt in each patient. I think we need to see each patient as a complete individual, with no clear rules.

    peter o'sullivan Reply:

    Re clinical prediction rules for spinal manipulation in acute back pain.
    Check this paper out – the clinical prediction rule for spinal manipulation isn’t as solid as it appears – when there was a placebo treatment.

    Eur Spine J. 2008 Jul;17(7):936-43. Epub 2008 Apr 22.
    Independent evaluation of a clinical prediction rule for spinal manipulative therapy: a randomised controlled trial.
    Hancock MJ, Maher CG, Latimer J, Herbert RD, McAuley JH.

    They concluded : ” The clinical prediction rule performed no better than chance in identifying patients with acute, non-specific low back pain most likely to respond to spinal manipulative therapy”.

  26. Hi Pete,
    As you know I have had an interest in CLBP patients ever since Perth course. I treat many of these patients in my clinic and have realised for number of years that I alone can not help them all. I have a great team of others who I can refer to where necessary, Tai Chi, yoga, NLP, Kinesiology accupuncture and Alexander practitoners. The physiotherapists skill is in identifying the main reason at the time of the subjective why this person has reached this place and is not able to heal themselves? Which of the many factors is the dominant trigger, physical, neuro-physiology, cognitive, psychosocial or lifestyle. Findng the right one can “change the brain” quite quickly so beginning the changes needed. As Lorimer says all cells in the body can do anything, think of the fantastic overlap/ cascade triggering the right one will bring to the body.
    Only swore at a patient once but it allowed her to be “pissed off with the medical profession/life” and it quickly changed her 13 year old pain !
    Look forward to catching up in Italy ?!

    Alison Lingwood

    Peter O'Sullivan Reply:

    Hi Ali
    I am with you on this – i too marvel at the nervous system – finding the trigger/s ( and often there are many) takes time to listen to out patients with an open mind. I am a strong believer that if we care to listen – they will give us the clues. I am astounded when i examine physiotherapists at how poor we are at listening to our patients – trying to wedge patients into our narrow view of pain. Good communication must underpin this process.

    alison lingwood Reply:

    Yeah Pete,
    I love those lightbulb moments that then allow you into the system, either at the time or taking place before the next session. Observation / listening is definately the answer, the patients always give the clues if we are ready to pick up on them. Having read the comments of this discussion if people do not believe the top down theory they should try talking/ altering perceptions etc and then look at movement changes that can happen immediately or try repalpating an objective finding. You will be surprised! Once the patient is on your wave length and you have found a way in then the usual manual therapy stuff will work if it is needed. Thinking outside the box is forever stimulating and rewarding for you and patient.

    Have you seen http://www.Heartmath.com great non profit making company with good research on post traumatic stress, reducing BP and changing behaviour. I lend the hand held device to my patients for a couple of weeks if trying to normalise ANS or simply let them feel what it is like to be calm and more in control. Would be great to use it for research?!! Am I desperate to get back to OZ or what! Miss though date muffins !
    Ali
    – Show quoted text –

  27. I completely agree with Peter on the point that taking an integrated approach that combines our knowledge of pain mechanisms as influenced by such systems as the immune, endocrine and autonomics and how thoughts/feelings/beliefs/expectations/past experience have an impact on the final output, ie/ pain (mature organism model, thanks Louis). As physiotherapists we can afford the time with our clients/patients to create the right environment and employ strategies that modulate and moderate beliefs and understanding that may inhibit recovery or persist in giving the brain a reason to protect. Reduce the threat value via a biopsychosocial model of care seems logical and ‘wise’. Being creative in applying the science of ‘body in mind’ to allow patients to evolve (if they want to..) is an exciting prospect, even if it means many late nights ploughing through the literature!

    Peter O'Sullivan Reply:

    I cant agree more Richmond – it also involves breaking rules – and eradicating many of the belief systems that we have inherited as physio’s and manual therapists along the way. Its quite liberating though – both for patients and therapists.

  28. Evert Jan Das says

    Dear Peter,…(and everybody else!)

    Thank you for participating in this topic!!!

    I recently did a course (in Belgium) with Wim Dankaerts where i got a bit more familiar with the subrouping of CLBP patients…i learned a lot!! It really gave me in depth understanding of how (some) people with CLBP move in relation to there pain.

    I think we (as manual/physical therapists) should be paying much more attention to how people move (and of course the underlying beliefs related to these movements) and the correction of movement faults instead of trying to figure out where the pain is coming from (viewed from a biomedical perspective).

    In the end…we are promoting healthy movement!!! So why not focuse on that instead of trying to explain where the pain is coming from (read: disc, facet joint..etc). I dont think we are treating discs, facet joints…

    In my clinical reasoning I tend to not pay much attention to a biomedical explanation of CLBP complaints. I tel my patients that I do not no where their pain is coming from BUT I DO KNOW THAT THEY ARE NOT MOVING WELL!! Furthermore I tell them that there brain is getting “danger messages” and produces a protective pain response…

    Correcting their movement faults and showing “their brain” that a save environment can be achieved in this way is a big part of my intervention.

    Unfortunately I’m not getting spectacular results. So I keep wondering…what am I missing or what can I change to improve my treatment outcomes??? A study that was discussed on BIM (http://www.ncbi.nlm.nih.gov/pubmed/20167430) further confuses my clinical reasoning…

    I can only say…keep up the good work!!! I’m looking forward to reading much more of you’re publications (by O’sullivan PB but also by Moseley GL). It really helps me and my patients!

    Greetings from the Netherlands,

    Evert Jan Das

    (p.s. both of you…it’s time to do a course in the netherlands!!!!)

    Peter O'Sullivan Reply:

    Thanks for your comments Evert.
    Sure people with pain don’t move well – the big question is whether this is a cause or consequence of pain – or just one part of the vicious cycle. So only dealing with movement may result in marginal results.I also think we need to think of movement as a behaviour that is an expression of something (it may be fear, distress, anxiety, sadness, exhaustion or a lack of mindfulness or awareness). Thus may not change with just giving exercises. This has been shown with people with have high levels of catastrophising demonstrating more physical pain behaviours.
    I think it is clear that we have to look very carefully at the drivers of peoples pain and associated behaviours – and for each person it is different. For some it is emotionally driven, for some it is fear, for others it is life-style factors and stress related to it, for others they have no body awareness of the fact that their movement behaviours drive their pain. You cant separate the body and the mind – they are inextricably linked. A truly flexible bio-psychosocial approach to dealing with pain – allows the therapist to identify and address these issues for each person. Of course in some situations this requires cross referral for clinical psych and medical management. However i believe that physiotherapists are well placed to deliver these interventions if they are skilled in this approach. The RCT by Fersum et al utilising this model demonstrates some great support for this approach in NSCLBP ( currently in preparation for submission to publish).

    Craig crawley Reply:

    The issue of casuality between pain and movement is crucial and the main problem with the ‘stabilty’ model that has been popular for sometime now. Research I have read suggests that top down modulation of pain is a primary problem, which means that pain due to sensitivity can proceed and cause altered movement. This is why local ‘stabilty’ training is not sufficient. Furthermore: clinicans might tell patients that if they have adequate stability then they won’t have pain, leading the patient to think that pain means they are not stable, and hence at risk of harm. This is detremental and can actually increase fear responses, including excessive muscle guarding. Best the patient gains a more complete picture of the mechanisms contributing to their pain.