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RESEARCH COMMENTARY
Ejona (Ona) Jeblonski, DPT, COMT
Fellow in Training, MAPS Accredited Fellowship in Orthopedic Therapy

Chris R. Showalter, PT, COMT, OCS, FAAOMPT
MAPS Fellowship Program Director

Mobilization Increases Dorsiflexion in Chronic Ankle Instability (CAI) Patients


 
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Where is the Clinical Reasoning?

January 04, 2017

RESEARCH COMMENTARY

Vincent J. Kabbaz, MMPT, COMT, FAAOMPT

The profession of Physical Therapy has gone through many stages over the years based upon evolving research and various practice ideals. We have seen the following trends in orthopedics:

• Manual Therapy (Maitland 2005, Paris 1979, Kaltenborn et al 2014, Grimsby & Rivard 2009),

• Clinical Prediction Rules (CPRs) (Flynn et al 2002),

• Hands-off Exercise Therapy (Meakins 2015), and

• Cognitive Behavioral Therapy (O’Keeffe et al 2016).


However, are we really assessing and treating patients adequately by following trends and research, or are we missing components that each individual patient may present with?

At the University of South Australia, where I was fortunate enough to receive both my Bachelors’ of Applied Science in Physiotherapy and Masters’ in Manipulative Physiotherapy, I was taught two very useful concepts by my massage therapy instructor, Margot Mernitz. The first was that “The really good therapists are able to visualize a person’s condition from the macroscopic to microscopic levels”. The second was “You should be able to clinically justify everything you do with a patient.” With these two pieces of essential advice, a therapist is able to look at the gross motor activities and then visualize the possible affected tissues on the anatomical, physiological, cellular, and biochemical levels and create and test hypotheses about the affected tissues more effectively. Thus, the question remains that when we primarily follow clinical practice guidelines and research, “Are we taking too many short-cuts that leave the patient wanting?”

 

Different Perspectives on the Management of the Spine and Peripheral Joint Disorders

Professor Gwendolen Jull recently published a professional viewpoint “Discord Between Approaches to Spinal and Extremity Disorders: Is It Logical?” (JOSPT Nov 2016, Vol 46, Number 11). In this paper Prof. Jull presents perspectives on the differences in how spinal and peripheral extremity disorders are managed. In doing so, she highlights how common treatments of injuries to different body part are not necessarily managed in relation to the stage of pathology, and potential sources of symptoms. This includes the trend to consider symptoms that may be due to centrally modulated pain, without considering the possibility of peripherally evoked nociceptive pain. In essence, Jull is highlighting a hazardous trend in orthopedic manual therapy (OMT), a lack of sound clinical reasoning in patient assessment and management.

Jull illustrates this by presenting two scenarios of the same patient. The patient has the same biopsychosocial presentation, phenotype and genotypic make up. The only variables are in the injuries themselves. In scenario one the patients sustains a soft tissue sprain of the ankle in a basketball game. In scenario two, the same patient sustains a whiplash injury in a motor vehicle accident on the way to the game.


PRICE for the Ankle but not for the Neck…Why?

With the ankle sprain, Jull describes the commonly used management approach PRICE (protection, rest, ice, compression and elevation). The use of an ankle brace, crutches and rest is warranted. The whiplash injury, still an acute soft tissue injury by nature, is managed in a much different, and opposite way. The common management strategy is to not recommend a soft collar, or rest, but rather the person is advised to “Stay active, resume usual activities, and commence exercise.”

The obvious discord between these two management approaches is quite staggering. Both body regions contain muscles, tendons, ligaments, bones, joints, articular cartilage and let’s not forget the nerves! So why is this “discord” in treatment occurring? Do the tissues of the neck differ so greatly, or are less susceptible to injuries as those of the ankle or low back? Jull suggests that even the evaluation methods are different. If we consider on a microscopic cellular and biochemical level what may occur with an acute whiplash injury, tissues may be compressed, stretched and traumatized. An inflammatory cascade will begin which will sensitize the tissues. The same biological effects occur following injury no matter where it may occur in the body. When you sprain your ankle, the last thing you want to do is walk on it immediately afterwards. In the same way, you may want to rest your neck tissues for a couple of days to minimize further trauma and enable the acute inflammatory process to stabilize. Thus a collar may be a very prudent thing to give a patient for 2-3 days to rest the tissue. Then it may be appropriate to start gentle movements, joint and nerve mobilizations and perhaps some gentle low grade strengthening to start muscles and tendons to rebuild themselves.

 

How then do we determine when to rest and when to exercise?

The answer…ASSESS and use CLINICAL REASONING.

The Patient Has the Answers  

The answer to the question above lies with the patient - their pain level and ability to move will help you determine when it is irritable enough for a neck collar and when it is appropriate to discontinue. Long term use will obviously lead to significant atrophy, but Jull is not talking about that. Jull is talking about a short term use of a simple and effective device to provide short term qualified rest. For an extremity disorder, a full evaluation is indicated - ROM, strength, flexibility, muscle testing, joint mobility testing - all with the aim of identifying the structure, or source of the symptoms.


1) Should Treatment Be a Hands-on or Hands-off Approach? Well, that Depends…

Jull states that in the latest version of Grieve’s Modern Musculoskeletal Physiotherapy, there is “...no consistency in principles of evaluation in the spinal region.”  Rather, there are seven different classification systems for the spine and lumbopelvic regions that essentially aim to put the patient into a treatment paradigm (or treatment box). Jull goes on to say that the identification of a structural fault in the spine is discouraged, despite evidence to the contrary that facet joint arthropathy in the neck can be “...quite accurately” identified with a clinical examination that involves segmental manual palpation of the neck. Furthermore, a hands-on treatment approach is currently recommended for the neck but a hands off approach is recommended for chronic low back pain. The reasoning behind this disparity in recommended treatment protocols seems fuzzy at best.


2) The Incorporation of Best Evidence

David Sacket cautions us to be careful to maintain balance between the three equally weighted components of EBP, namely:

1) Patient perspectives,

2) Clinical experience, and

3) Best evidence.

"Without clinical expertise, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.  Without current best external evidence, practice risks becoming rapidly out of date, to the detriment of patients." (Sackett et al 1997).

The patient’s perspective is also essential. They know their symptoms and will often tell you what the tissue needs – “if only you could get that knot out”, “feels like it is stiff”, “oh… that’s a good kind of pain” (when you move the stiff dominant segment). As consumers, patients have many options for health care and if we choose to value their opinions and collaboratively reason with them about what sort of treatment THEY want, then we will retain them as clients and they will grow our business and our reputation as a profession that will provide quality hands on patient-centric treatment.

 

3) What About Exercise…

Jull states that exercise programs are widely agreed upon for the extremities but there is little agreement on exercise approaches for the low back. The low back focus seems to be on movement based approaches, strength, endurance training and neuromuscular control with little emphasis given to proprioception and balance deficits. Perhaps the latter two components are not routinely assessed in low back disorders and hence not considered. Jull proposes that the use of patient-reported outcome measures may explain this factor as usually balance and proprioception are not routinely included.

 

4) …and New Evidence in Neurodynamics…

New research by Michael Shacklock et al (2016) on acute low back pain with radiculopathy down one leg, is showing that contralateral straight leg raising produces a caudad movement of the spinal cord that can reduce stress on the ipsilateral nerve root causing the leg pain, even with a disc protrusion. Using this information as a potential treatment may potentially be an example of providing qualified rest to the ipsilateral nerve root to help reduce stress on the nerve root after an injury, reduce further trauma or irritation to the nerve root and enable it to begin the healing process without adding to the inflammatory process.

 

5) …and/or Theories on Chronic Pain

Of further interest is Jull’s observation, with the growing knowledge base of pain science, that chronic pain may not have a substantial peripheral nociceptive component but is rather purely “in the brain”.  Jull provides some nice evidence to refute this generalization by describing how the pain from chronically painful osteoarthritic hips ceases and function improves rapidly after a total hip replacement. Also of interest is how following facet joint radiofrequency ablation of the medial branch nerve for chronic back pain…the pain of many years can quite suddenly be resolved and function restored. Obviously this harks back to the fact that with new knowledge, the old knowledge or biophysiologic and pathoanatomic principles do not become obsolete. Let’s not throw the baby out with the bathwater!

Further support for peripheral sensitization in chronic pain states comes from pain science physiotherapist, David Butler (2000), who describes the “inflammatory soup” present in the long term in peripheral tissue, and which can significantly sensitize the tissue and make it more painful than surrounding tissues. Jan Dommerholt (2011) also cites widely that there are an abundance of inflammatory and related chemicals that sensitize peripheral nerves and that are bound up in trigger points in tissues. Soft tissue and joint mobilization techniques can help to drive these chemicals out of the tissue they are sensitizing and into the circulation to be broken down by the liver and excreted.

Jull does give some support to the pain neurosciences by citing an ongoing RCT (Ickmans et al 2016) whereby education in neurosciences is provided to patients with one session of education before and one session after lumbar surgery for radiculopathy and primary outcomes measures of pain reduction, improvements in endogenous pain modulation and secondary outcomes of improvement in functional scale score and return to work are showing some promise.

Jull does state that the pain science model is superior to just teaching anatomy and biomechanics to a patient but that it “remains a unidimensional approach”, especially when compared to a biopsychosocial approach which is more multidimensional in nature and able to address all areas of the person’s condition - source of symptoms, contributing factors, management, prognosis, contraindications, pain mechanisms (where pain sciences come into play) and patient’s perspectives. The ability to understand the patient’s presentation from the macroscopic to the microscopic levels and clinically reason through a patient’s problems is accomplished using this biopsychosocial model (Jones & Rivett, 2004).

 

The Importance of Peripheral Nociception Sensitization

The bottom line of this is that, yes, pain is processed centrally in the brain and spinal cord, but don’t forget to look for the triggers that set up these central pathways in the first place - there generally is some tissue injury that should be assessed for the presence of peripheral nociception sensitization.

It is very important that we PTs, as a profession, do not get common practice, clinical practice guidelines, and CPRs confused with what the patient's essential issues are. Thorough assessment of the patient, and all the biopsychosocial components involved is essential. If conditions are not assessed thoroughly, issues that a patient has will be overlooked and the patient will not be treated appropriately. Furthermore, standard guidelines may not achieve superior results. Subsequently, PTs and the medical profession as whole, may develop a poor public reputation. We have seen this many times in practice when the patient tells us that the other PT or physician “...never assessed me like that…they never treated me like that…they only gave me some exercises and told me to come back in 2 weeks.”

 

Keeping Patients Happy – More Important Than You May Think

We need to remember that patients are our “clients” who are consumers and have a choice in what type of treatment they want. If we lose the patient, we are unable to help rehabilitate them, even if we are correct in terms of our treatment choices.  Nothing more can be done by the PT once the patient is lost.  When the patient is disgruntled, or just told to “do exercises for two weeks”, he/she may often seek various other practitioners, many of whom may have less extensive training than the PT. Practitioners who will put their hands on the patient and work the muscle and manipulate the joints.  In reality, PTs are the most qualified clinicians to address the patient’s neuromusculoskeletal system. We cannot lose site of the importance of “customer satisfaction” in our profession.

 

Clinical Reasoning Requires A Deeper and Continuous Patient Assessment

I believe that Jull is saying that the Physical Therapy profession is missing out on treating patients more effectively because what we should be doing is creating more hypotheses about the patient from the information they present to us. We should be assessing patients in a deeper way, and addressing all the patient issues and treating patients more effectively. Sound clinical reasoning is not hard to do. It involves assessing the patient for their individual issues and treating those issues within the construct of the source of symptoms, the stage of pathology, severity and irritability of the symptoms, any contributing factors that may be affecting the source of symptoms, prognosis, input, spinal cord/brain processing and output pain mechanisms, and precautions and contraindications. All these components are continually monitored during all treatments. Assessment does not stop after the initial evaluation, but rather continues throughout the treatment process to obtain the best possible treatment and results for the patient. So, if a patient will benefit from a soft collar for a short time to provide support and qualified rest to injured joints, ligaments, nerves, muscles and tendons, then why not use it until other treatments become indicated! Why leave our patients wanting!

 

Final THOUGHT:

Patient Assessment and Clinical Reasoning are the Keys to Success!

The Maitland concept is a free flowing, dynamic clinical reasoning process that focuses on the continual assessment of the Comparable Sign (CS) and its response to treatment techniques employed by the therapist. Treatment techniques range from very gentle for irritable and/or pain dominant conditions, to quite vigorous as necessary, for stiff dominant and stable disorders. The Maitland approach is patient centric with a primary focus upon patient values. Geoff Maitland's #1 Core Principle is, "Sublimation of self and a positive personal commitment to understand what the patient is enduring, and the effects the disorder has upon the patient." The Maitland approach has always been, and continues to be, concerned with the patient's needs above all.  Few philosophies of manual therapy can claim the same level of commitment to the patient's values and well-being, as the Maitland Approach. The Maitland-Australian approach combines relevant best evidence with highly specific techniques to empower patients to achieve the best possible rehabilitation of neuromusculoskeletal disorders.    

 

Cheers

Vincent Kabbaz, PT, MMPT, COMT, FAAOMPT

Senior MAPS Instructor

 

References

 

Butler D. “The Sensitive Nervous System” Noigroup Publications, Adelaide, South Australia, 2000. Pg 55.

Dommerholt J. Dry needling - peripheral and central considerations. J Man Manip Ther. 2011 Nov; 19(4): 223–227.

Flynn T1, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 2002 Dec 15;27(24): 2835-43.

Grimsby O, Rivard J. “Science, Theory and Clinical Application in Orthopaedic Manual Physical Therapy: Applied Science and Theory.” The Academy of Graduate Physical Therapy, Inc.; 1st edition, Sept. 2009

Ickmans K, Moens M, Putman K, et al. Back school or brain school for patients undergoing surgery for lumbar radiculopathy? Protocol for a randomized, controlled trial. J Physiother. 2016;62:165. http://dx.doi.org/10.1016/j. jphys.2016.05.009

Jones M, Rivett D. Introduction to Clinical Reasoning. In Jones M & Rivett (Eds) “Clinical Reasoning for Manual Therapists” Edinburgh, 2004, Butterworth-Heinemann, pp 3-24.

Jull G. Discord Between Approaches to Spinal and Extremity Disorders: Is It Logical. JOSPT Nov 2016; 46(11): 938-941.

Jull G, Moore A, Falla D, Lewis J, McCarthy C, Sterling M. “Grieve's Modern Musculoskeletal Physiotherapy, 4th Edition” Elsevier 2015

Kaltenborn, F  (Author), Evjenth, O (Contributor), Kaltenborn, TB (Contributor). “Manual Mobilization of the Joints, Vol. 2: The Spine, 6th edition.” Norli 2012

Maitland G, Hengeveld E, Banks K, English K. “Maitland's Vertebral Manipulation, 7th Edition” Butterworth-Heinemann 2005

Meakins A. https://thesportsphysio.wordpress.com/2015/04/02/the-problem-with-rehab-exercises/ 2015

Mernitz, M. School of Physiotherapy, University of South Australia 1992.

O’Keeffe, M., Purtill, H., Kennedy, N., Conneely, M., Hurley, J., O’Sullivan, P., … O’Sullivan, K. (2016). Comparative Effectiveness of Conservative Interventions for Nonspecific Chronic Spinal Pain: Physical, Behavioral/Psychologically Informed, or Combined? A Systematic Review and Meta-Analysis. The Journal of Pain: Official Journal of the American Pain Society, 17(7), 755–774. https://doi.org/10.1016/j.jpain.2016.01.473

Paris SV. “Spinal dysfunction: Etiology and treatment of dysfunction including joint manipulation: course notes” Unknown Binding – 1979

Sackett DL, Richardson WS, Rosenberg WM, and Haynes RB, Ed.  Evidence-Based Medicine: How to Practice and Teach EBM.   1st edition, Churchill-Livingstone, New York, 1997. page 2.

Shacklock M, Rade M, Airaksinen O. Advances in Neurodynamics for Acute Sciatica. Intouch 2016, Issue 4, 12-15.

 

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