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Study Design. A systematic review of randomized controlled trials. Objectives. To assess the effectiveness of the most common conservative types of treatment for patients with acute and chronic nonspecific low back pain. Summary of Background Data. Many treatment options for acute and chronic low back pain are available, but little is known about the optimal treatment strategy. Methods. A rating system was used to assess the strength of the evidence, based on the methodologic quality of the randomized controlled trials, the relevance of the outcome measures, and the consistency of the results. Results. The number of randomized controlled trials identified varied widely with regard to the interventions involved. The scores ranged from 20 to 79 points for acute low back pain and from 19 to 79 points for chronic low back pain on a 100‐point scale, indicating the overall poor quality of the trials. Overall, only 28 (35%) randomized controlled trials on acute low back pain and 20 (25%) on chronic low back pain had a methodologic score of 50 or more points, and were considered to be of high quality. Various methodologic flaws were identified. Strong evidence was found for the effectiveness of muscle relaxants and nonsteroidal anti‐inflammatory drugs and the ineffectiveness of exercise therapy for acute low back pain; strong evidence also was found for the effectiveness of manipulation, back schools, and exercise therapy for chronic low back pain, especially for short‐term effects. Conclusions. The quality of the design, execution, and reporting of randomized controlled trials should be improved, to establish strong evidence for the effectiveness of the various therapeutic interventions for acute and chronic low back pain.
To evaluate the effectiveness and cost effectiveness of specially trained physiotherapists in the assessment and management of defined referrals to hospital orthopaedic departments.
Randomised controlled trial.
Orthopaedic outpatient departments in two hospitals.
481 patients with musculoskeletal problems referred for specialist orthopaedic opinion.
Initial assessment and management undertaken by post-Fellowship junior orthopaedic surgeons, or by specially trained physiotherapists working in an extended role (orthopaedic physiotherapy specialists).
Patient centred measures of pain, functional disability and perceived handicap.
A total of 654 patients were eligible to join the trial, 481 (73.6%) gave their consent to be randomised. The two arms (doctor n = 244, physiotherapist n = 237) were similar at baseline. Baseline and follow up questionnaires were completed by 383 patients (79.6%). The mean time to follow up was 5.6 months after randomisation, with similar distributions of intervals to follow up in both arms. The only outcome for which there was a statistically or clinically important difference between arms was in a measure of patient satisfaction, which favoured the physiotherapist arm. A cost minimisation analysis showed no significant differences in direct costs to the patient or NHS primary care costs. Direct hospital costs were lower (p < 0.00001) in the physiotherapist arm (mean cost per patient = 256 Pounds, n = 232), as they were less likely to order radiographs and to refer patients for orthopaedic surgery than were the junior doctors (mean cost per patient in arm = 498 Pounds, n = 238).
On the basis of the patient centred outcomes measured in this randomised trial, orthopaedic physiotherapy specialists are as effective as post-Fellowship junior staff and clinical assistant orthopaedic surgeons in the initial assessment and management of new referrals to outpatient orthopaedic departments, and generate lower initial direct hospital costs.
Clinical reasoning refers to the cognitive process or thinking used in the evaluation and management of a patient. In this article, clinical reasoning research and expert-novice studies are examined to provide insight into the growing understanding of clinical reasoning and the nature of expertise. Although hypothetico-deductive methods of reasoning are used by clinicians at all levels of experience, experts appear to possess a superior organization of knowledge. Experts often reach a diagnosis based on pure pattern recognition of clinical patterns. With an atypical problem, however, the expert, like the novice, appears to rely more on hypothetico-deductive clinical reasoning. Five categories of hypotheses are proposed for physical therapists using a hypothetico-deductive method of clinical reasoning. A model of the clinical reasoning process for physical therapists is presented to bring attention to the hypothesis generation, testing, and modification that I feel should take place through all aspects of the patient encounter. Examples of common errors in clinical reasoning are highlighted, and suggestions for facilitating clinical reasoning in our students are made.
This review of low back pain and sciatica over the past 3500 years tries to put our present epidemic of low back disability into historical perspective. Backache has affected human beings throughout recorded history (Table 1). What has changed is how it has been understood and managed. Two key ideas in the nineteenth century laid the foundation for our modern approach to backache: that it came from the spine and that it was due to injury. Backache had always previously been considered a rheumatic condition. Only from that time were backache and sciatica considered and treated together. Their management was increasingly dominated by the new orthopedic principle of therapeutic rest. What is new is chronic disability due to simple backache. Apart from rare cases, this only began to appear in the late nineteenth century. It escalated after World War II. It appears to be closely related to changed understanding and management of backache: specifically to the idea that backache is due to serious spinal injury or degeneration and to medical prescription of rest. This is reinforced by the improved social support which makes rest possible. Sadly, we must conclude that much low back disability is iatrogenic.
The present paper describes a theoretical model for exaggerated pain perception which has been generated from a multidisciplinary team approach to the problem of chronic low-back pain. The model is an attempt to explain how and why some individuals develop a more substantial psychological overlay to their pain problem than do others.Central to the model is the concept of ‘fear of pain’ which, it is suggested, leads to differing responses in different individuals. The two extreme responses are those of ‘confrontation’ and ‘avoidance’, although most individuals probably exhibit a mixture of the two. The former, it is argued, leads the individual to resume an increasing range of physical and social activities as the organic basis for the pain resolves and, as a consequence, ensures minimal psychological overlay. By contrast, an avoidance strategy is thought to produce a number of physical and psychological consequences which promote the development of the invalid status and the phenomenon of exaggerated pain perception.The model suggests that the type of strategy adopted (i.e. confrontation or avoidance) is influenced by a number of psychosocial factors.
This report aims to present an orderly approach to the treatment of Chronic Regional Pain Syndrome (CRPS) types I and II through an algorithm. The central theme is functional restoration: a coordinated but progressive approach that introduces each of the treatment modalities needed to achieve both remission and rehabilitation. Reaching objective and measurable rehabilitation goals is an essential element. Specific exercise therapy to reestablish function after musculoskeletal injury is central to this functional restoration. Its application to CRPS is more contingent on varying rates of progress that characterize the restoration of function in patients with CRPS. Also, the various modalities that may be used, including analgesia by pharmacologic means or regional anesthesia or the use of neuromodulation, behavioral management, and the qualitatively different approaches that are unique to the management of children with CRPS, are provided only to facilitate functional improvement in a stepwise but methodical manner. Patients with CRPS need an individual approach that requires extreme flexibility. This distinguishes the management of these conditions from other well-described medical conditions having a known pathophysiology. In particular, the special biopsychosocial factors that are critical to achieving a successful outcome are emphasized. This algorithm is a departure from the contemporary heterogeneous approach to treatment of patients with CRPS. The underlying principles are motivation, mobilization, and desensitization facilitated by the relief of pain and the use of pharmacologic and interventional procedures to treat specific signs and symptoms. Self-management techniques are emphasized, and functional rehabilitation is the key to the success of this algorithm.
To evaluate effectiveness of an exercise programme in a community setting for patients with low back pain to encourage a return to normal activities.
Randomised controlled trial of progressive exercise programme compared with usual primary care management. Patients' preferences for type of management were elicited independently of randomisation.
187 patients aged 18-60 years with mechanical low back pain of 4 weeks to 6 months' duration.
Exercise classes led by a physiotherapist that included strengthening exercises for all main muscle groups, stretching exercises, relaxation session, and brief education on back care. A cognitive-behavioural approach was used.
Assessments of debilitating effects of back pain before and after intervention and at 6 months and 1 year later. Measures included Roland disability questionnaire, Aberdeen back pain scale, pain diaries, and use of healthcare services.
At 6 weeks after randomisation, the intervention group improved marginally more than the control group on the disability questionnaire and reported less distressing pain. At 6 months and 1 year, the intervention group showed significantly greater improvement in the disability questionnaire score (mean difference in changes 1.35, 95% confidence interval 0.13 to 2.57). At 1 year, the intervention group also showed significantly greater improvement in the Aberdeen back pain scale (4.44, 1.01 to 7.87) and reported only 378 days off work compared with 607 in the control group. The intervention group used fewer healthcare resources. Outcome was not influenced by patients' preferences.
The exercise class was more clinically effective than traditional general practitioner management, regardless of patient preference, and was cost effective.
Ultrasound therapy is used frequently to reduce pain and related disability, mainly by physiotherapists. The objective of this review was to evaluate the effectiveness of ultrasound therapy in the treatment of musculoskeletal disorders.
Published reports of randomized clinical trials investigating the effects of ultrasound therapy on pain, disability or range of motion were identified by a systematic search of MEDLINE, EMBASE and the Cochrane databases, supplemented with citation tracking. The quality of methods of all selected publications was assessed systematically by two independent and 'blinded' reviewers, using ten validity criteria. Data from the original publications were used to calculate the differences between groups for success rate, pain, disability and range of motion. Statistical pooling was performed if studies were homogeneous with respect to study populations, interventions, outcome measures and timing of follow-up.
38 Studies were included in the review, evaluating the effects of ultrasound therapy for lateral epicondylitis (n = 6), shoulder pain (n = 7), degenerative rheumatic disorders (n = 10), ankle distorsions (n = 4), temporomandibular pain or myofacial pain (n = 4) and a variety of other disorders (n = 7). In 11 out of 13 placebo-controlled trials with validity scores of at least five out of ten points, no evidence of clinically important or statistically significant results was found. Statistical pooling was only feasible for placebo-controlled trials on lateral epicondylitis, and produced a pooled estimate for the difference in success rate of 15% (95% confidence interval -8%-38%).
As yet, there seems to be little evidence to support the use of ultrasound therapy in the treatment of musculoskeletal disorders. The large majority of 13 randomized placebo-controlled trials with adequate methods did not support the existence of clinically important or statistically significant differences in favour of ultrasound therapy. Nevertheless, our findings for lateral epicondylitis may warrant further investigation.
Study Design. A review of controlled trials. Objectives. To determine which interventions are used to prevent back and neck pain problems as well as what the evidence is for their utility. Summary of Background Data. Given the difficulty in successfully treating long-term back and neck pain problems, there has been a call for preventive interventions. Little is known, however, about the value of preventive efforts for nonpatients, e.g., in the general population or workplace. Methods. The literature was systematically searched to locate all investigations that were: 1) specifically designed as a preventive intervention; 2) randomized or nonrandomized controlled trials; and, 3) using subjects not seeking treatment. Outcome was evaluated on the key variables of reported pain, report of injury, dysfunction, time off work, health-care utilization, and cost. Conclusions were drawn using a grading system. Results. Twenty-seven investigations meeting the criteria were found for educational efforts, lumbar supports, exercises, ergonomics, and risk factor modification. For back schools, only one of the nine randomized trials reported a significant effect, and there was strong evidence that back schools are not effective in prevention. Because the randomized trials concerning lumbar supports were consistently negative, there is strong evidence that they are not effective in prevention. Exercises, conversely, showed stable positive results in randomized controlled trials, giving consistent evidence of relatively moderate utility in prevention. Because no properly controlled trials were found for ergonomic interventions or risk factor modification, there was not good quality evidence available to draw a conclusion. Conclusions. The results concerning prevention for subjects not seeking medical care are sobering. Only exercises provided sufficient evidence to conclude that they are an effective preventive intervention. There is a dire lack of controlled trials examining broad-based multidimensional programs. The need for high quality outcome studies is underscored.
Peripheral tissue pathology causes a rapid and enduring increase in the excitability of spinal cord neurones. This review examines some of the basic and clinical research which suggests that the central nervous system is capable of making a contribution to clinical signs and symptoms. Mechanically produced clinical responses of pain and movement behaviour may not always be indicative of their source or cause. Certain implications for physiotherapy are discussed. The actual systemic effects of mechanical stimuli, as used clinically by physiotherapists, need to be investigated.
The precise source and cause of mechanically evoked sensory and motor responses can sometimes be surprisingly difficult to identify. Accurate interpretation of these responses may be confounded by peripheral as well as central nervous system mechanisms. Examples of such peripheral nervous system mechanisms likely to be of relevance to therapists have been selected from basic and clinical research. Symptomatic relief has been inferred to endorse the diagnostic specificity of mechanical stimulation. The extent to which this would be valid for relief acquired by neurological means is discussed in terms of endogenous pain inhibitory systems.
Treatment and prevention of the commoner forms of musculoskeletal disorder depend on an approach to diagnosis that takes full account of both ætiognosis and prognosis. The factors that contribute causally to the first attack may differ from those which conspire to prevent recovery; and among the latter, inactivity plays a major role. Rest and absence from work following episodes of acute musculoskeletal pain may serve to prolong the resulting disability and encourage the development of degenerative changes in the musculoskeletal system. Although inactivity can function independently in the aetiopathogenesis of musculoskeletal disorders, it also interacts with other contributory factors. Biomechanical and psychosocial factors concerning inactivity and avoidance of pain are closely interrelated, thus affecting the selection of outcome-measures in therapeutic trials and preventive studies.
This paper challenges current clinical models and systems for assessing and managing on-going pain states to incorporate a broader biological and therapeutic framework. Included is an acceptance of the current criticisms made towards a purely tissue based/modality based paradigm for pain treatment. The mature organism model proposed is presented as a workable conceptual starting block for incorporating mechanisms of pain into the broad science of stress biology and the biopsychosocial model of pain.
This paper discusses the cognitive-behavioural approach to chronic pain management and the special part physiotherapists have to play in this flourishing area.
The physical performance of chronic pain patients is of major concern both for their assessment and for treatment evaluation. However, there are few widely used physical tests, a shortage of reliability and validity data on published tests, and an over-reliance on self-report or on clinical measures of dubious generalisability. A set of tests was designed to cover speed and endurance in walking, stair climbing, standing up from a chair, sit-ups, arm endurance, grip strength, and peak flow. Standard instructions and testing conditions were used by a trained tester on a population of chronic pain patients before and after a cognitive-behavioural chronic pain management programme. Reliability, validity, and acceptability of each test was examined, and recommendations made for their relative utility.
The last decade and a half have seen an international increase in healthcare, litigation and social costs associated with common musculoskeletal pain such as low back pain and whiplash. In the UK it has been estimated that less than 10% of those with back pain account for 90% of the social costs for the condition (Mason, 1994). In one large-scale study 3% of newly registered cases of back pain, those who remained off work for up to one year accounted for 33% of the all wages replacement benefits paid for back pain during that period (Watson et al, 1998). Furthermore, almost 11% of the total wages replacement costs in one year were paid to people suffering from back pain.
This article reviews the literature on frozen shoulder in order to advance clear, current information regarding its clinical presentation, natural history, aetiology, pathology and treatment.There is confusion about diagnostic terminology and the exact definition of frozen shoulder. The condition appears to be a complex multi-structural and multi-aetiological problem, both intrinsic and extrinsic to the shoulder. Despite some advances in knowledge of the pathoanatomy through the introduction of arthroscopy, frozen shoulder is still regarded as an enigma.
This review deals with physiological and biological mechanisms of neuropathic pain, that is, pain induced by injury or disease of the nervous system. Animal models of neuropathic pain mostly use injury to a peripheral nerve, therefore, our focus is on results from nerve injury models. To make sure that the nerve injury models are related to pain, the behavior was assessed of animals following nerve injury, i.e. partial/total nerve transection/ligation or chronic nerve constriction. The following behaviors observed in such animals are considered to indicate pain: (a) autotomy, i.e. self-attack, assessed by counting the number of wounds implied, (b) hyperalgesia, i.e. strong withdrawal responses to a moderate heat stimulus, (c) allodynia, i.e. withdrawal in response to non-noxious tactile or cold stimuli. These behavioral parameters have been exploited to study the pharmacology and modulation of neuropathic pain. Nerve fibers develop abnormal ectopic excitability at or near the site of nerve injury. The
The histodynamic response to long-term "non-traumatic" immobilisation was studied in young adult Beagle dogs by means of radiomorphometry and histomorphometry, the right forelimb being encased in plaster and the left forelimb serving as a control. The dogs were killed at two, four, six, eight, twelve, sixteen, twenty, twenty-four, thirty-two and forty weeks and the third metacarpal, radius, ulna and humerus removed for analysis of the contributions of the periosteal, haversian and endosteal envelopes to the bone loss at the mid-diaphysis. The bone mass responded to long-term immobilisation in three stages. First there was a rapid initial loss of bone, reaching its maximum (some 16 per cent of original mass) at six weeks, to which all three bone envelopes, to some extent, contributed. A rapid reversal followed, the bone mass approaching the control values between eight and twelve weeks after immobilisation. A second stage of slower but longer lasting bone loss ended twenty-four to thirty-two weeks after immobilisation; the periosteal envelope was the main contributor (80 to 90 per cent of the total loss). The third stage was characterised by maintenance of the bone mass which had been reduced by some 30 to 50 per cent of original values. This pattern was qualitatively similar in all four bones but the distal bones lost more bone than the proximal bones. The extent of resorption surface and the total histologically "active" periosteal envelope increased parallel to the phases of bone loss. The linear mineralisation rate did not differ significantly between the experimental and control sides.
Hip fractures occur frequently among the elderly, often with severe medical, psychological and social repercussions. This research takes a new look at hip fracture rehabilitation, focusing on meanings and post-fracture prognostic indicators. An innovative methodological approach to narrative analysis is employed which combines ethnographic and epidemiologic techniques. Analyses of injury narratives from 80 elderly subjects interviewed soon after initial hospitalization are presented, focusing on three categories of meaning: explanatory models, sense of disability, and futurity. Insights from these narratives, as well as from questionnaires and observations, shed light on the experience of hip fracture for the elderly. In addition, aspects of the initial narratives are considered in relation to ambulation outcomes at 3 and 6 months. Those individuals who perceive their problem in a more external or mechanical fashion (caused by the environment) show greater improvement in ambulation at 3 and 6 months relative to those who show no evidence of this thinking or who perceive it as an internal or organic problem (in terms of disease or illness). Greater improvement in ambulation at 3 and 6 months is also noted for subjects whose perception of disability was consistent with more autonomy, independence, and a sense of connection with the world around them. The present study demonstrates the potential utility of narrative analysis as a data reduction approach. It also suggests the possibility of new psychosocial prognostic factors for hip fracture rehabilitation.
This paper reviews reports of phantom limb sensations which resemble somatosensory events experienced in the limb before amputation. It also presents descriptions of this phenomenon in 68 amputees who took part in a series of clinical studies. These somatosensory memories are predominantly replicas of distressing pre-amputation lesions and pains which were experienced at or near the time of amputation, and are described as having the same qualities of sensation as the pre-amputation pain. The patients who experience these pains emphasize that they are suffering real pain which they can describe in vivid detail, and insist that the experience is not merely a cognitive recollection of an earlier pain. Reports of somatosensory memories are less common when there has been a discontinuity, or a pain-free interval, between the experience of pain and amputation. Among the somatosensory memories reported are cutaneous lesions, deep tissue injuries, bone and joint pain and painful pre-amputation postures. The experience of somatosensory memories does not appear to be related to the duration of pre-amputation pain, time since amputation, age, gender, prosthetic use, level of amputation, number of limbs amputated, or whether the amputation followed an accident or illness. The results suggest that somatosensory inputs of sufficient intensity and duration can produce lasting changes in central neural structures which combine with cognitive-evaluative memories of the pre-amputation pain to give rise to the unified experience of a past pain referred to the phantom limb. Implications for pre- and post-operative pain control are discussed.
Because there is increasing concern about low-back disability and its current medical management, this analysis attempts to construct a new theoretic framework for treatment. Observations of natural history and epidemiology suggest that low-back pain should be a benign, self-limiting condition, that low back-disability as opposed to pain is a relatively recent Western epidemic, and that the role of medicine in that epidemic must be critically examined. The traditional medical model of disease is contrasted with a biopsychosocial model of illness to analyze success and failure in low-back disorders. Studies of the mathematical relationship between the elements of illness in chronic low-back pain suggest that the biopsychosocial concept can be used as an operational model that explains many clinical observations. This model is used to compare rest and active rehabilitation for low-back pain. Rest is the commonest treatment prescribed after analgesics but is based on a doubtful rationale, and there is little evidence of any lasting benefit. There is, however, little doubt about the harmful effects--especially of prolonged bed rest. Conversely, there is no evidence that activity is harmful and, contrary to common belief, it does not necessarily make the pain worse. Experimental studies clearly show that controlled exercises not only restore function, reduce distress and illness behavior, and promote return to work, but actually reduce pain. Clinical studies confirm the value of active rehabilitation in practice. To achieve the goal of treating patients rather than spines, we must approach low-back disability as an illness rather than low-back pain as a purely physical disease. We must distinguish pain as a purely the symptoms and signs of distress and illness behavior from those of physical disease, and nominal from substantive diagnoses. Management must change from a negative philosophy of rest for pain to more active restoration of function. Only a new model and understanding of illness by physicians and patients alike makes real change possible.
The purpose of this article is to introduce the hypothesis-oriented algorithm for clinicians (HOAC), which is designed to aid physical therapists in clinical decision making and patient management. The HOAC consists of two parts. The first part is a sequential guide to evaluation and treatment planning; the second part consists of a branching program used for reevaluation and the analysis of treatment effectiveness. Problem statements used in the HOAC are similar to those used for problem oriented medical records. The HOAC, however, requires therapists to state hypotheses about why the problems exist and to generate criteria that can be used to test the hypotheses. The benefits of the HOAC are that therapists must clearly state problems in a consistent manner, generate and list hypotheses and test criteria, develop treatment strategies and methods based solely on the hypotheses, and systematically review treatment. The rationale for treatment is identified clearly in the algorithm, facilitating the identification of inappropriate treatments (ie, those not related to the hypotheses). In addition, the branching program is used to identify where in the treatment process failures may be occurring and when a therapist needs to make a referral or seek assistance from a colleague.
The purpose of this descriptive study was to analyze physical therapists' clinical problem solving and compare the results with physicians' clinical problem solving. Ten skilled physical therapy clinicians were observed as they performed an initial interview with a patient. Their performance was audiotaped and later analyzed. The therapists defined their problem lists and developed treatment plans early in the interview, as they gathered data. This clinical problem-solving sequence is comparable to a method reported in the literature that is used by physicians. This model of clinical problem solving based on actual performance of clinicians can be used to train physical therapy students and, perhaps, to refine clinical evaluation skills.
The development of a new scale to measure somatic and autonomic perception, the Modified Somatic Perception Questionnaire or MSPQ is described. It has been derived specifically for use with chronic backache patients, although its utility with other chronic pain problems is currently under investigation. Following pilot studies on anxious patients and normal controls a pool of items was subjected to reliability checks and parallel-form analysis. The final 13 item scale was derived from a pilot study of 102 chronic backache patients and its construct validity confirmed on a further study of 200 backache patients. Sex differences in the use of the scale were integrated into the final version. The scale was compared with the Zung Depression Inventory and the first three clinical scales of the M.M.P.I. Individual items were compared with clinical symptomatology rated independently by an orthopaedic surgeon. In a small experimental study the MSPQ was compared with electromyographic readings from the erector spinae muscles and biceps, with the rating of pain using the McGill Pain Questionnaire, and with experimental ischaemic pain using the submaximum effort tourniquet test. In other studies the scale has been shown to be of importance in the understanding of functional disability. Its predictive validity in response to treatment is currently under investigation in studies of spinal fusion, chemonucleosis and multidisciplinary pain programmes. The simple 13 item four-point self-report scale is easy to administer, has high patient compliance and, in conjunction with measures of depressive symptomatology and inappropriate signs and symptoms would seem to be of considerable promise in the understanding of the sequelae of backache and much more sensitive than traditional measures of personality structure.
The authors have calculated the mathematic relationship between measured elements of illness behavior in chronic low-back pain. Objective physical impairment accounts for about one-half the total disability that also is affected by psychologic reactions. The most important psychologic disturbance in low-back pain is emotional distress, measured on questionnaires as increased bodily awareness and depression and presenting clinically as inappropriate descriptions of symptoms and inappropriate responses to physical examination. Simple methods for the assessment of distress and illness behavior in chronic low-back pain are developed and described.
The relationship to pain level of extent of injury (as measured by number of teeth extracted) and attention paid to the injury (as measured by frequency of pain ratings) was studied in patients with dental postoperative pain. Patients had either 2 or 4 impacted wisdom teeth removed and rated their pain either 2 or 5 times during the experiment. A positive correlation was found between extent of injury and reported pain level as well as between frequency of pain rating and pain level. The correlation between frequency of pain rating and pain level was found only in patients with 4 teeth extracted. To our knowledge, this is the first study which quantitatively evaluates the relationship between amount of injury and level of pain. This study also suggests that the degree to which manipulations of psychological variables alter an individual's pain perception may depend on the extent of injury.
Chronic pain patients typically display reduced activity level attributed to pain and implying a positive correlation between exercise or activity and pain complaints. This study correlated observed pain complaints with amount of prescribed exercise performed by chronic pain patients when exercising to tolerance. Patients were in evaluation of earliest stages of multi-modal treatment. Exercises were physician prescribed to assess use of involved body parts and to promote general activity level. Patients were instructed to do exercise repetitions until pain, weakness or fatigue caused them to stop. Patients decided when to stop. Observations of amount of exercise performed were correlated with observed visible or audible indications of pain or suffering (pain behaviors). Results indicate a consistent negative relationship, i.e., the more exercise performed, the fewer the pain behaviors. This finding is contrary to the frequently observed physician prescription with chronic pain to limit exercise when pain increases.
One of the most important advances in the treatment of musculoskeletal injuries has come from understanding that controlled early resumption of activity can promote restoration of function, and that treatment of injuries with prolonged rest may delay recovery and adversely affect normal tissues. In the last decade of the nineteenth century two widely respected orthopaedists with extensive clinical experience strongly advocated opposing treatments of musculoskeletal injuries. Hugh Owen Thomas in Liverpool believed that enforced, uninterrupted prolonged rest produced the best results. He noted that movement of injured tissues increased inflammation, and that, "It would indeed be as reasonable to attempt to cure a fever patient by kicking him out of bed, as to benefit joint disease by a wriggling at the articulation." Just Lucas-Championnier in Paris took the opposite position. He argued that early controlled active motion accelerated restoration of function, although he noted that mobility had to be given in limited doses. In general, Thomas' views met with greater acceptance in the early part of this century, but experimental studies of the last several decades generally support Lucas-Championneir. They confirm and help explain the deleterious effects of prolonged rest and the beneficial effects of activity on the musculoskeletal tissues. They have shown that maintenance of normal bone, tendon and ligament, articular cartilage and muscle structure and composition require repetitive use, and that changes in the patterns of tissue loading can strengthen or weaken normal tissues. Although all the musculoskeletal tissues can respond to repetitive loading, they vary in the magnitude and type of response to specific patterns of activity. Furthermore, their responsiveness may decline with increasing age. Skeletal muscle and bone demonstrate the most apparent response to changes in activity in individuals of any age. Cartilage and dense fibrous tissues also can respond to loading, but the responses are more difficult to measure. The effects of loading on injured tissues have been less extensively studied, but the available evidence indicates that repair tissues respond to loading and, like immature normal tissues, may be more sensitive to cyclic loading and motion than mature normal tissues. However, early motion and loading of injured tissues is not without risks. Premature or excessive loading and motion of repair tissue can inhibit or stop repair. Unfortunately, the optimal methods of facilitating healing by early application of loading and motion have not been defined.(ABSTRACT TRUNCATED AT 400 WORDS)
This randomized clinical trial was designed to determine the effect of treating low back pain as a benign, self limiting condition by light normal activity.
Patients on sickness leave from work for more than 8 weeks were randomized into two groups: intervention (n = 463) and control (n = 512). Those in the intervention group were examined, provided information, and given instruction. Outcome was measured by return or failure to return to work (still on sickness leave).
Survival analysis showed a highly significant (P = 0.000) reduction in sickness leave in the intervention group as compared with the control group. At 200 days 60% were still on sickness leave in the control group vs. 30% in the intervention group. A multivariate analysis with age, sex, and treatment as cofactors showed that sex had no effect on length of sickness leave and that treatment retained its effect when adjusting for differences in age composition.
This study indicates that low back pain treated as a benign, self limiting condition recommended to light mobilization gives superior results as compared to treatment within a conventional medical system.
Injury of the collagenous structures comprising tendons and ligaments, either from acute trauma or from repetitive strain lesions, results in protracted periods of disability. The resolution of such injuries often fails to restore the normal morphologic and functional characteristics of the structure and, therefore, either compromises the future performance of the individual or predisposes to an increased risk of recurrent injury.
One of the most important advances in the promotion of musculoskeletal healing has come from understanding that treatment of injuries with prolonged rest may delay recovery and adversely affect normal tissues and that controlled early resumption of activity can promote restoration of function. Experimental studies of the past several decades confirm and help explain the deleterious effects of prolonged rest and the beneficial effects of activity on the musculoskeletal tissues. They have shown that maintenance of structure and composition of normal bone, tendon and ligament, articular cartilage and muscle, requires repetitive use and that changes in the patterns of tissue loading can strengthen or weaken normal tissues. Although all the musculoskeletal tissues can respond to repetitive loading, they vary in the magnitude and type of response to specific patterns of activity. Furthermore, their responsiveness may decline with increasing age. Skeletal muscle and bone demonstrate the most apparent response to changes in activity in individuals of any age. Cartilage and dense fibrous tissues also can respond to loading, but the responses are more difficult to measure. The effects of loading on healing tissues have been studied less extensively but the available evidence indicates that repair and remodeling tissues respond to loading and that, like immature normal tissues, repair tissues may be more sensitive to cyclic loading and motion than mature normal tissues. Early motion and loading of injured tissues is not without risks, however. Excessive or premature loading and motion of repair tissue can inhibit or stop healing. Unfortunately, the optimal methods for facilitating healing by early application of loading and motion have not been defined. Nonetheless, experimental studies and newer clinical investigations document the benefits of early controlled loading and motion in the treatment of musculoskeletal injuries, and show that optimal restoration of musculoskeletal function following injury or surgery requires early controlled activity.
Written from a neurologic and therapeutically conservative perspective, this review advocates fundamentally medical and pharmacologic management of upper extremity neuropathic pain syndromes, including chronic regional pain syndromes, formerly classified reflex sympathetic dystrophy (RSD) and causalgia. Mandatory steps include, first, a prompt serious attempt to localize the nerve lesion whenever possible using complete, sophisticated neurologic examinations, then thoughtfully selected conventional neurophysiologic and radiologic tests. Strongly discouraged are promiscuous use of "RSD" to describe all neuropathic pains, and diagnostic reliance upon thermography and uncontrolled sympathetic blocks. Conservative multidisciplinary diagnostic and treatment teams should often possess a nucleus of neurologist and hand therapist, plus additional consultants including psychiatric. Every physician and therapist managing neuropathic pain must consider psychologic and wellness issues within their responsibilities. Prompt referral to an experienced surgeon is crucial for decompression or repair of relevant, significant, objectively proven (ideally neurophysiologically) nerve and root lesions. Ambiguous professional colloquialisms, "central pain" and "central sensitization," unfortunately provide value-laden pretexts for premature invasive treatments, and animate the truly dreadful concept "central RSD". Various classes of conventional oral non-narcotic adjuvant analgesics are reviewed, and the inevitability of their empiric, non-formulaic administration. No patient-specific, rationally-identifiable molecular receptor/switch can be deduced clinically or tripped mechanistically to terminate chronic pain. Two promising new non-narcotic centrally-active medications, gabapentin and tramadol, are highlighted as harbingers of future progress. The neglected subtle art of prescription writing is stressed, particularly for medication-sensitive patients. Medical cost containment should promote critical, long overdue outcomes studies comparing conservative and invasive pain treatments.
In the past three decades, a scientific revolution has occurred in the understanding of the experience of pain. However, a clinical revolution based on the new science is yet to occur. Pain is a multidimensional experience with many contributing and interacting biological/pathobiological mechanisms. These mechanisms may be nociceptive, peripheral neurogenic, central, affective/cognitive or relate to output systems such as the motor and autonomic nervous system. With a better understanding of pain-related neurobiology and some clinical decision making skills, reasoned attempts at a diagnosis of pain can be made. The essential question and first step related to clinical integration is to ask, "what is (are) the predominant mechanism(s) in a given patient's pain state?" This paper provides the underlying clinical biology of pain mechanisms and proposes pain patterns related to the mechanisms.
Despite the very high costs associated to musculoskeletal pain, its socio-economic impact is still unknown. In this editorial the author asks who is benefiting from the current situation and tries to throw light upon perspectives from the health system and the patients themselves.
Manual therapy is based on a biomedical model of illness and places considerable reliance on the patient's report of pain. Reported pain intensity is assumed to bear a close relationship with underlying nociception but research has shown that the experience of pain is also influenced by a wide range of psychological factors. Firstly, response to pain provocation (whether palpation or induction of biomechanical stress) can be affected by fear of an adverse outcome (such as pain) and fear of injury. Secondly, a patient's global rating of their pain may be widely influenced by factors in addition to nociception such as distress, fear and mistaken beliefs about the nature of pain and likely outcome of treatment. The manual therapist needs, therefore, to conduct and understand biomedical assessment within a biopsychosocial framework. In appraising the patient's response, the therapist may find it helpful to incorporate specific assessment of subjectively reported fear or behavioural indicators of fear such as guarded movements or behavioural signs. Therapists need to understand that in manual therapy, they are frequently managing the patient's pain behaviour and distress, rather than simply the nociceptive component of their pain.
Chronic pain syndromes such as chronic low back pain are responsible for enormous costs for health care and society. For these conditions a pure biomedical approach often proves insufficient. Numerous studies have shown that there is little direct relationship between pain and disability and suggest that the biopsychosocial approach offers the foundations for a better insight in how pain can become a persistent problem. The main assumption is that pain and pain disability are not only influenced by organic pathology, if found, but also by psychological and social factors. In this contribution, a behavioural analysis of chronic musculoskeletal pain will be discussed, with special attention to the role of pain-related fear in the development and maintenance of chronic pain disability, and the behavioural rehabilitation perspective of chronic pain management.