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.
Physical therapy in a tweet. https://t.co/Lrx84gstCC
— Nick Efthimiou (@NickEfthimiou) September 5, 2018
Can We Be Specific With Assessment?
A typical assessment of someone in pain consists of the following:
- Neurological and orthopaedic testing
- Active movement
- Passive movement
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.
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
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.
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.
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.
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:
- Manual therapy
- Graded exposure
- Movement therapy/exercise rehab
Can any of them be specific?
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.
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Sometimes the low-tech option is actually incredibly high-tech. Research into manual therapy is demonstrating that the majority of the effects are neurological and not structural. This is a great thing, as the nervous system is highly adaptable and responsive. Despite all the advances made by medicine over the last century, nothing can replace a skilled set of hands and a caring, thinking brain. #integrativeosteopathy #osteopathy #osteo #manualtherapy #neuroscience #touch #fitzroynorth #melbourne
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.
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:
- It works for the specific task/scenario, hence it has a specific effect
- 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:
- How specific do we need in order to be effective?
- 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:
- Rule out serious pathology.
- Rule out tissue injury (via history and assessment).
- Rule out complications/comorbid factors.
- Provide coping strategies
- Neuromodulate with chosen intervention, if desired (see above).
- Improve function (see above).
- 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)
The methods of intervention were pretty generic:
- 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
- Corticosteroid injection was another
- 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.
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.
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.