How Specific Do Treatments For Pain Need To Be?

Specific; On TargetPain is what drives people to consult a medical professional more than any other symptom.

The vast majority of pain is benign, somatic (musculoskeletal) in nature, though some somatic pain has a visceral component.

Most of the time, complex examinations and treatment rituals are performed, in order to diagnose and treat said pain.

Patients feel like they are getting good value, practitioners feel like they are providing it.

But is it necessary to go through all these examinations, and aim for all these specific hands on, taping and exercise techniques to help people get better?

I’m going to argue, that no, it isn’t.

Can We Be Specific With Assessment?

A typical assessment of someone in pain consists of the following:

  • History
  • Neurological and orthopaedic testing
  • Active movement
  • Passive movement
  • Palpation/provocation

It can also include

  • Functional/task specific assessment
  • Capacity testing: strength, endurance etc

Based on all of this, a clinician then formulates a diagnosis, which dictates a management plan.

However, and this is a massive “however”, it could very well be that we are wasting our time.

Let’s have a look at each of those components, and see how specific they can be.

History

The clinical history is probably the most important part of an initial consultation. Combined with general information about a patient (age, occupation, family status etc) and how they carry themselves, a clinician can hypothesise a working diagnosis prior to any further assessment, which usually serves to confirm or refute the diagnosis.

For certain presentations, the history is quite diagnostic.

For example, neuropathic pain occurs when there is damage to a nerve, causing it to have what’s called an ectopic discharge. Without going into too much depth, when patients complain of burning, lancinating pain, often that will point us towards a diagnosis of neuropathic pain.

On the flip side, a recent study questioned whether commonly held true concept of clicking in the knee being related to meniscal damage. It was shown that equal numbers of people with and without meniscal injuries experience things like clicking and catching. (1)

Neurological and Orthopaedic Testing

The neurological examination consists of things like a cranial nerve examination, reflex testing, sensory testing and motor/strength testing, along with neurodynamic testing.

Unfortunately, neurodynamic testing often yields false positives (so not that specific).

Strength testing, at least the manual version, is very unreliable, and thus not specific.

Isokinetic strength testing is more reliable, however most clinics do not have this equipment. Some clinics have hand-held dynamometers, which increase reliability of strength testing. (2)

Additionally, strength testing only tells us there may or may not be a weakness, not why. Additionally, strength is not related to pain, though it is important for both injury risk and activities of daily living.

Sensory testing is helpful, while reflexes don’t really tell us much except that reflexes are there or not.

Orthopaedic tests, those which clinicians use to rule in/out certain tissue based injuries are notoriously unreliable. Even those which have demonstrated high sensitivity and specificity are subject to error as a result of neurological changes when we are in pain.

Active Movement

Okay, by now you should be sensing where I’m going with this.

Active movement tests the ability to perform that movement. Yes, certain tissues/structures are involved in certain movements, but that doesn’t mean that movement is a specific test.

For example, raising your arm out to the side as high as you can involves multiple muscles acting at the shoulder joint. If it hurts to do so, it implicates all these muscles involved, as well as the tendons, ligaments, joint, nerves etc.

Is it helpful to know? Most of the time.

Is it specific? No.

Passive Movement

See above.

Yes, passive movement takes muscles out of the picture, at least from a contractile point of view. That doesn’t mean that if active movement hurts, and passive doesn’t, that the problem is with a muscle.

Thus, not specific.

Still valuable, but not specific.

Palpation

Most practitioners, especially osteopaths, believe their palpation skills are reliable means of assessment.

They’re wrong. (3)

Palpation is not reliable, and thus definitely not specific.

Still valuable, but not specific.

Can We Be Specific With Treatment?

The short answer: it depends on the treatment.

Let’s look at my common methods of treating pain:

  • Education
  • Manual therapy
  • Graded exposure
  • Movement therapy/exercise rehab

Can any of them be specific?

Education

Education can address specific themes and topics, but the challenge with education, as is the case with any communication, is that what is heard and understood is not always what is intended. We are at mercy of the interpretation of the receiver. Language is more than words. It is influenced heavily by our social circles and our cultural experiences. (4)

But because teaching people about their pain, how to manage it and how to prevent future flare ups is a hugely important part of practice, this means these are simply challenges to be overcome.

I’ve said before, that education is the only thing that stays with a patient after they finish working with me. The caveat to this is, education that is effective. Saying things is not educating. Helping someone understand is educating.

As important as it is, I think it is a stretch to say it has a specific effect on pain. We can’t measure the effect it has, and say what amount of pain reduction was attributable to what amount and type of education.

Manual Therapy



I’m going to upset a lot of my colleagues by saying you can’t be that specific with manual therapy.

But it’s true.

Think about it, all we can truly touch is the skin. Not muscles, not ligaments or tendons, and not bones. The skin.

We can direct force to deeper lying tissues, like those mentioned previously, but this depends on the magnitude and direction of the force, as well as where the target tissues are situated.

Physics dictate that the only force that can be efficiently transmitted to bone has to be perpendicular to bone. Any horizontal or tangential force is dissipated by the frictionless interface of the skin/fascia. (5)

Another strike against the blow of specificity is the way the body is innervated. No one section is supplied by a single neurological level. Hence, because of convergence of multiple levels, we end up with less specificity.

Finally, when it comes to spinal movement, there is a plethora of research showing that you cannot isolate movement to a single vertebral level. Even neck manipulations, which allow the best contacts compared to thoracic and lumbar manipulations, result in movement of adjacent interverterbal joints.

So strike specificity off the list of things manual therapy is.

Graded Exposure

What about graded exposure? Many people conflate graded exposure with exercise rehabilitation. There are similarities, in that they are both (should be) progressive. However, graded exposure borrows from psychological research, and in theory, addresses psychological factors relating to pain and activities just as much as the physical factors. It’s kind of obvious when you think about it: gradually doing the things that hurt, or that you are worried about hurting makes it easier to do them over time.

Worried about bending over to garden all day? Let’s start with kneeling for a short period of time. Then you can gradually (the graded part) do more (the exposure part) until you are bending over gardening all day

There are two arguments about whether graded exposure is specific:

  1. It works for the specific task/scenario, hence it has a specific effect
  2. The same can be achieved in other means, hence it doesn’t

In my experience, the former holds true more so than the latter.

Here’s an example:

A patient of mine who was very active injured himself playing hockey. The injury came about because he wasn’t physically prepared for the demands of hockey, despite being physically fit and active. That and plain old bad luck – he simply moved in a way that loaded his back too much, which was in part due to the circumstances of the game at that moment.

After history and assessment, I was able to narrow it down to a diagnosis of “acute low back pain, without referred pain” (remember, we can’t really be that specific).

Treatment was manual therapy (didn’t really make a big difference), stay active (kind of hurt, but didn’t make things worse), some gym work for posterior chain (was able to train, but didn’t help pain), time (definitely made a difference) and gradually increasing hockey load (really helped).

Does that mean it (graded exposure) has specific effects that cannot be achieved any other way? I really don’t know. Let’s call this a maybe, at best.

Movement Therapy/Exercise Rehab


Like manual therapy, the fact that so many approaches can work holds the answer: if everything works, then nothing works. 

Or less cynically (and this is my position, because we know this works for many pain presentations), if everything works, the effects are non-specific.

Honestly, aside from the specific adaptations of exercise, which can definitely be important to an individual based on their capacity (power, strength, endurance, mobility etc), or lack thereof, when it comes to pain, the most important thing is to do something, do it appropriately (not too much, not too little) and continue to do it (consistency).

This can shatter the hearts (and wallets) of professionals who espouse a specific approach as “the only approach”. Of course it works. But not because of the reasons you say it works.

Do We Even NEED To Be Specific?

So here is the big question, or rather two questions:

  1. How specific do we need in order to be effective?
  2. Can we be that specific?

We could argue that currently, we are not very effective at treating low back pain, for example. Most of the time we can help people manage it, and the condition takes it’s natural history, which for most, is a resolution over a long enough time-frame.

But could we be more effective if we were able to be more specific?

There is still so much unknown about pain, that it is very difficult to answer.

We do know that pain typically has a blend of biological factors, including local tissue factors and central nervous system factors. We also know that pain consists of psycho-emotional-social components, which play a large role in the nature and course of pain.

We can’t measure the exact contribution of each, and nor can we isolate tissue factors – even evidence of tissue damage on imaging or surgery is at best, correlated with pain. Sacreligious? Perhaps, but, if we go “full academic”, you can’t separate the non-tissue factors from the resolution of pain. For years, surgeons thought sub-acromial impingement improved because of surgical decompression (it didn’t) (6). Same with arthroscopic surgery for arthritic knee pain (7).

Clinically, I have seen people with total and partial knee replacements still experiencing pain, more than 12, and in some cases 24 months post surgery. This doesn’t mean there is no effect of the surgery, but we aren’t 100% sure what it is.

Anyway, I digress.

With most non-specific pain presentations, by nature, we can improve people with non-specific interventions.

Neck pain for no apparent reason? Here’s a scientific valid approach:

  1. Rule out serious pathology.
  2. Rule out tissue injury (via history and assessment).
  3. Rule out complications/comorbid factors.
  4. Educate.
  5. Provide coping strategies
  6. Neuromodulate with chosen intervention, if desired (see above).
  7. Improve function (see above).
  8. Let time and physiology do the rest.

We can apply this concept to nearly all non-specific pain and be evidence based.

In fact, you can apply this to many instances of specific pain too.

Let’s Get Critical

Earlier this year a study on managing lateral hip pain (gluteal tendinopathy/trochanteric bursitis) was published in BMJ:  Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial (8)

 After critiquing this study, you could easily come to the conclusion that there was a lot of confirmation bias taking place in how much effect these interventions were having, and how much of that effect was due to the specific nature of the intervention (there was no general exercise arm as a comparison).

The methods of intervention were pretty generic:

  1. Education (basically, avoid compression of the tendons by not sitting and moving in certain ways) and exercise (a standardised hip exercise protocol) was one group
  2. Corticosteroid injection was another
  3. Wait and see was the third

Everyone got really excited on social media when this was published, because “exercise works!”, and “I do exercise with my patients” so there was lots of back patting and confirmation bias all around.

However, in my opinion, the interventions didn’t result in that much improvement over a wait and see approach in the main outcome measure (Visual Analogue Scale or VAS, a numerical pain scale). In fact, average pain intensity (score out of 10) changed from 5 to 3 in the wait and see group, while the intervention groups (education + exercise or corticosteroid injection) improved from 5 to 2 on average (there was only a minor difference between the two groups).

Consider the cost for that 10% improvement over wait and see:

  • The education + exercise was 14 sessions, which, if we take an average of $80 per consult, is $1120.
  • A corticosteroid injection under ultrasound guidance, ranges from between $150 and $300 on average.

So was all that effort of exercise, expense of education and injections worth it? Yes, in the short term, there was a big difference at 8 weeks over wait and see. However, if you told someone they had to spend $1000 over 8 weeks to end up 10% better than doing nothing at a year, how many people would still take that option?

Now let’s look at the other main outcome measure, the Global Rating of Change or GROC. The GROC is a single-item instrument that asks each patient to indicate whether and to what extent they perceive change has occurred, typically relative to the date of the initiation of care. The GROC uses a Likert scale to indicate the direction of change (ie, worsening or improvement) and the extent of change (ie, “tiny” to “very great”).  (9)

However, there is contention that the GROC doesn’t reflect functional changes (9), as it is a subjective assessment, but unlike the VAS it isn’t assessing pain, which is subjective, but the participants perception that something has changed. The problem with this, is the recency illusion and the availability heuristic inherently skew the results.

So when we look at the GROC scores: we see that at 8 weeks there is a big difference between the education + exercise and wait/see group, which makes sense, because the education/exercise program was 8 weeks long. But over time that difference was reduced, which is explained as follows:

Our data showed that a patient’s current FS exerts a strong bias on perception of change, even for short recall periods (fewer than 30 days), and this effect increased as transition time lengthened. (9)

So where does that leave us? Time to draw some conclusions.

Conclusions

That was really a long winded way of saying, no, we don’t need to be specific, because even when we try, we can’t be.

The constituents of good care are listed above. This much is clear, though some will debate the manual therapy aspect, others debate the exercise aspect, the moderates will say these 4 interventions are all good in various degrees.

What is emerging, is that what you do isn’t as important as how you do it, and who you do it with (the therapeutic alliance is a big predictor of outcomes in pain). It is also important to not do the wrong things – i.e. those that are clearly ineffective, but moreso, those that actively do harm.

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 

How To Recover From Any Injury

Image credit: Marcus Needham

Pain is a complex, emergent experience.

Tissue injuries are not.

Tissue injuries occur when the loading on the tissue exceeds its capacity.

This can be an acute issue – think of a sprinter suddenly straining their hamstring mid race – or a chronic issue – think of a builder developing elbow pain over time.

In both circumstances, the principle is the same.

The formula for managing an injury is fairly simple on a macro level:

  1. Decrease the volume, intensity and/or frequency of aggravating activities to manageable levels
  2. Improve biomechanical efficiency
  3. Increase capacity with progressive overload


What is challenging is how to achieve these objectives in living, breathing humans who have needs, wants and annoying things like emotions that make us behave irrationally.

This is where a clinician needs to have excellent listening and communication skills, be a master of persuasion and thoroughly understand the physiological and biomechanical aspects of movement, stress and adaptation.

This post is going to outline a few of the methods I use to achieve the above outcomes.

Decrease Volume/Intensity/Frequency of Load

The most obvious thing to do when we are injured is often the hardest.

Why?

  • Necessity. We all need to continue working, caring for family or performing our activities of daily living (ADL). It can be hard to offload your injured body part when there is a baby crying or a load of laundry that needs doing. Let alone when you have a work deadline to meet.
  • Desire. This is an emotional issue. Many of us desire to continue doing something as it brings us pleasure, status, or allays a negative emotion like guilt or fear. For example, it is common for people to want to continue to push themselves exercising whilst they are injured because of body image issues.

However, in most cases, an all or nothing approach is not required.

You don’t have to stop something completely to reduce the loading effect.

Here are two examples from a patient who has lateral hip pain that I’ve diagnosed as a gluteal tendinopathy. In these cases we are reducing the volume of the load primarily:

  • Use the fitness tracker in her phone to estimate her daily activity level. Work out at what activity level her symptoms flare up. Stay below that activity level while gradually building up during recovery.
  • Track her walks accurately (pace/duration) and work out at what level her symptoms flare up. Stay below that activity level while gradually building up during recovery.

Here is another example of how I reduced the intensity of the load in a builder with elbow pain. He couldn’t stop working, and a lot of what he did (using tools) aggravated his injury.

  • Use tennis grip tape to wrap around the handle of his hammer. This increases the circumference of the handle, which reduces the mechanical leverage of the forearm muscles, taking the load off the tendons at the elbow.

In most cases, there are ways to continue doing what you need or want to do, with some modifications. And in most cases, this is actually better than complete rest.

Improve Movement Efficiency

Everybody knows Roger Federer. You don’t have to be a tennis fan to appreciate his skill and technique. He makes things look easy.

As we improve our skill at a task, we become more efficient as well. It takes less effort and as a result we tend to load our body less.

Roger Federer demonstrates this – his supreme technique has helped him accumulate very few injuries in his career, despite a demanding schedule and advancing age.

However, we don’t need to look to elite sport for examples of movement efficiency.

Think of your local pizza parlour. If it has been around for a while, watching the chefs put a pizza together is a picture of movement beauty (okay, I really love pizza). Every time I try and replicate this at home I just end up tired with a very messy kitchen bench.

Or let’s keep it closer to home. When I was younger, I didn’t know how to iron a shirt well. My mum could iron all of my dad’s and my brothers’ shirts in the time it took me to do one. All that effort, all that time under load. It’s easy to see how my inferior ironing skills could lead to more load on my body. Even though my mum was doing more total work, her body was adapted to it, and she did it in a way that was smooth and effortless. Contrast that to me, not adapted to ironing (still not) and very tense and inefficient.

When it comes to rehab for an injury, it’s not just the capacity of the tissue that we have to worry about, but the efficiency of movement, which affects the loading on that tissue for each movement/activity.

Improving movement efficiency is a topic in and of itself.

My approach is based on the following formula: 

The input is related to sensory information from the nervous system. The better the quality of sensory information, the better the output. This is why rehab should begin on the sensory side. Sensory input can be improved with manual therapy, which is likely one of it’s biggest roles in modern practice.

Processing is based on cues and context. We can change both, but we have no idea how it will affect the processing. I’m not a big fan of the word processing, as it sounds to much like a computer, and we are not a computer or machine.

I discuss this in more detail here, and also here.

Increase Capacity

Remember at the start of this post when I said:

Tissue injuries occur when the loading on the tissue exceeds its capacity.

Well it makes sense that as well as reducing the load on the affected tissue(s), we increase the capacity as well. This has two benefits. No, actually, it has three benefits:

  1. Loading tissues helps with repair.
  2. Loading tissues that are painful helps (re)build confidence in the injured tissue.
  3. Increasing tissue capacity protects against future injury.

I like to use a two pronged approach here:

  • A targeted exercise approach
  • A graded return to activity approach

This isn’t revolutionary. It doesn’t have to be. It just has to be done well.

In the targeted exercise approach, I use a simple progression. I like someone to be able to (where possible) perceive the tissues properly (sensory awareness) before we work on the following:

  • Isometric to dynamic
  • More stable to less stable
  • Simple to complex
  • Less task specific to more task specific

There is some evidence to suggest local loading, particularly with isometrics has a pain relieving effect, which is why I start there.

More stable positions allow people to focus on the movement or activation required, without the extra motor and sensory demands of stabilising their body in space.

Starting simple allows more mental energy to be directed to recruitment patterns, while progressing to complex reinforces these patterns in different contexts.

Finally, starting less specific to the task allows for the load to gradually be progressed as tissue capacity increases.

Graded Return to Activity

This is an expansion of the first topic, reducing the load.

Put simply, we simply reverse the process, gradually increasing the load until the tasks can be performed normally again.

A good rule of thumb is to progress no more than 10% per week, to allow the person and the tissues to adapt. You cannot go too slowly, but you can absolutely go too quickly.

Conclusions

This is my current approach to treating tissue injuries.

You have to remember that not all tissue injuries present with pain, and not all painful presentations are related to tissue injuries.

When pain is the primary problem, we can use a similar approach if localised tissue sensitivity is deemed to be the main contributing factor.

Finally, we know that past injury is a big predictor of future injury. So while the pain from an injury subsides as the tissue heals (the tissue will heal if you give it a chance, regardless if you rehabilitate function or not), if you want to minimise your chance of re-injury in the future, it pays to be thorough.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.