Into the Darkness, Out of the Wilderness

What do you feel when you see a clinic or doctor’s office?

When I first became a physical therapist, I was excited to see the clinic, if a bit overwhelmed. Over the course of the first year, my emotions included a kind of preemptive tiredness, as if I knew that I would be pouring energy at the risk of feeling unreplenished. At an outpatient pain medicine clinic, I meet many people with low expectations for physical therapy or any other medical intervention, because they’ve seen it all before. I thought I could be different. I thought that my blend of knowledge, skills, and passion could offer new value. Maybe it does, but it’s just not enough for everyone — if anyone.

After hearing so many stories from patients, there’s a new feeling when I see the clinic. I think about how others feel when they come to a doctor’s office. They’re afraid of being judged, angry at jumping through hoops just to get help, ashamed that they can’t fix their problems themselves, sad that they don’t feel themselves, and worried for their future. I don’t think so much about what I can offer; I think about what other people offer. When we are patients, we bring our stories, our pain, and our entire lives.

The Dark

Now, when I see the clinic, I feel that I am walking into darkness. It’s like I’m stepping into their pain, if only for a few minutes so that we might find a way forward — a path to light. I don’t mean that I have the answers, but we can pool our knowledge, skills, and experience so that we can come closer to joy. This feeling is partially inspired by this tweet:

I still fall into a trap of thinking I could be a healer, but I’m more aware that the trap exists. This allows me to surrender any image of being like a mechanic, a salesperson, or a lecturer. I am not someone who possesses a thing to sell or a service to render. I’m just a person, with another person, trying to live. We meet in the darkness.

After realizing the beauty of sharing the experience of pain, I reflected on how I ended up feeling this way, so that other clinicians/patients/humans could do the same. Three fundamental ideas help me to make contact with others in the darkness:

  1. Find the “why.” One day when I was riding my bike to work, a sentence overwhelmed me: I want to liberate humanity from pain so that we can all find joy in life. I had just listened to Find Your Why and felt inspired to find my purpose. Although I used to see myself as a “wannabe liberator” — like a hero — I now see the foolishness of that idea. If there’s any protagonist, it’s the patient. Even so, we’re actually interdependent, so I’d rather emphasize the latter part of the sentence: “…so that we can all find joy in life.” I feel like myself when I can contribute to others’ happiness. My “why” is about meeting in darkness so that we can find light, or at least try to do so together instead of letting someone struggle alone. But to do that, we need to know where others are, where they have been in life, and why they feel what they feel. Therefore…
  2. Know the narrative. If there’s one tragedy of our current healthcare system, it’s that patients’ stories are not heard. Sharing an experience requires us to listen, but external forces like reimbursement, lack of appropriate insurance coverage, and so-called productivity are all assaulting the opportunity to connect with patients. People are reduced to numbers and their clinic visits are ending before they even begin. As much as I love evidence-based pain management, it’s no solution to this problem. Narrative-based practice, on the other hand, is more likely to honor the humanity of patients. We learn the narrative through embracing storytelling, through cultivating compassion and curiosity, and through noting the complexity and context of what led the patient to the clinic.
  3. Love yourself. I’m down on myself when people don’t improve. This ballooned to feeling a heavy shame about my ability as a physical therapist. Even though I had been trying so hard, reading articles all of the time, and going to conferences about pain, I just felt that the outcomes weren’t satisfying. I have since been trying to savor the good moments. I look to my fuel sources: my wife, kids, my friends, music, a candle, exercising, meditating, even writing this post. It’s not that compassion is fatiguing — “compassion fatigue” is kind of a myth — but I agree with whoever said that we keep the lamp burning by putting more oil in it. One of the most powerful and unexpected ways that I found more oil is through working with someone on her last clinical rotation. Though she might not have noticed it at the time, I reflected on my values and my career because of our conversations about the inner goodness of people and about how hard it is to help others as much as we want to help. She taught me that when we share a workplace with someone who is compassionate and has similar values, then it’s easier to love ourselves; we see that we’re not crazy — or at least we’re not too crazy.

Out of the Wilderness

As scary as it is sometimes to walk into the darkness, there is comfort in the clarity of purpose. There is an even deeper comfort in knowing that my own suffering amplifies the urgency of alleviating others’ suffering. I couldn’t have seen this though without feeling broken at some point.

Years ago I would have said that I want to be the best, most successful physical therapist with all of the coolest letters behind my name. Those aspirations vaporized when my mother died in her sleep in August, shocking my whole family. I lost a part of myself when my mom died, and cared less about conventional achievement. I lost interest in proving myself, maybe to a fault, but I walked through the motions of proving myself anyway. I felt no joy from metrics at work or from getting retweeted or published.
David Brooks might say that this was a transition from a climbing a mountain into feeling lost in a wilderness.

Brooks describes a “second mountain” that we climb when we make different commitments — to our relationships, to foregoing individualism, to transcend the self. Wandering in the wilderness allows us to reflect and to learn about ourselves so that we can change. Even though the pain from grief is not the same as the pain of patients, I see a part of me in them when they feel frustrated, angry, and afraid. I see my mother in patients because she was skeptical of physical therapy, too. (She walked out of a session because the PT said that the exercises were “supposed to hurt” after she said that they hurt too much. She never returned.) She always told me to remember to be kind to patients and to listen to them when they said they’re hurting. On Monday, I start my PhD in Health Sciences, and I dedicate the degree to my mother because it’s really largely because of her that I can make a positive impact on how providers treat people.
My second mountain is to fulfill her promise and to help other providers to do the same.

The only way that I could make it out of the wilderness is through others. My wife and family keep me from losing my head, and my coworkers went way out of their way to make sure I was okay. Patients found out what happened and spent so much time comforting me and helping me to move forward. Patients gave me cards. They hugged me. They shared my pain.

We weren’t provider and patient at that point; we were equals. They met me in my darkness.

All I can do is return to their darkness. It comforts me to know that you could meet there, too, so that we can climb our mountains together.

Is the McKenzie Method any good?

McKenzie: You’re all I ever needed /
So tell me what to do now?

What do you think about the McKenzie method? Also known as Mechanical Diagnosis and Therapy, the McKenzie method is popular and influential.

But is it any good?

This issue of Physio Weekly addresses some recent research findings on spinal pain, with some interesting implications for physios.

Let Me Show You a Few Things

If MDT is new to you, then here is a quick and dirty rundown. MDT is a classification system that divides patients into four groups.

  1. Posture syndrome is caused by “mechanical deformation of soft tissues or vascular insufficiency” which comes from prolonged positional stresses. The way to alleviate pain for this syndrome, as MDT suggests, is to correct the posture.
  2. Dysfunction syndrome is caused again by “mechanical deformation” of structurally impaired soft tissues, though this time pain only presents at end range movement. Movement is therefore impaired in one or more directions, though pain should subside when the patient is not at the end range movement in question. Treatment for this syndrome involves the goal of remodeling tissue.
  3. Derangement syndrome is allegedly the most common of the syndromes, and is associated with a mechanical obstruction of the affected joint. For derangement syndrome, one goal is to find the directional preference, which may or may not centralize symptoms. There may be irreducible or reducible derangements; irreducible derangements occur when no loading strategies decrease, abolish, or centralize symptoms, whereas reducible derangements find loading strategies that decrease, abolish, or centralize symptoms. Anterior derangements have a directional preference for flexion, and posterior derangements prefer extension.
  4. Other. The other category includes pathologies like cancer, cauda equina syndrome, spinal fracture, infection. This category also includes “chronic pain syndrome,” post-surgical pain, ankylosing spondylitis, spinal stenosis, and pelvic girdle pain, among others.

As Long As I’ve Got My Suit & Tie

One of the most important scientific questions to ask about a classification system is whether the system is reliable. In other words, will two clinicians be able to agree on how to classify the same patient? If not, then the system isn’t of much use in my opinion.

Garcia et al. (2018) put this question to the test in a JOSPT systematic review. The authors evaluated 12 studies of spinal pain. The authors found acceptable inter-rater reliability with respect to classifying pain into syndromes and sub-syndromes in low back pain, but only when performed by clinicians who were either credentialed in MDT or had the MDT diploma. There is conflicting evidence of inter-rater reliability with respect to identifying the centralization phenomenon or directional preference in low back pain, and there is mixed evidence for inter-rater reliability for any aspect of evaluation of neck pain or thoracic pain.

I’m not sure what to make of these findings, because on one hand it’s a decent advertisement for taking more courses in MDT in order to get credentialed, but on the other hand, reliability is only one aspect. Does it actually lead to better outcomes?

Another recent JOSPT paper, this time a meta-analysis by Lam and colleagues, tested this questions for low back pain. The authors extracted data from 11 studies of acute and chronic back and neck pain. In acute low back pain, there was no difference in pain resolution or disability between MDT and other physical therapy interventions overall. In chronic low back pain, the authors concluded that MDT offers an advantage over “exercise” alone with respect to disability (not pain), and was not more effective than a combination of manual therapy and exercise.

Baby bye, bye, bye?

I believe that it is vital to address some interesting aspects of the studies included in this meta-analysis.

First, some of the studies included only patients that fit within the derangement subgroup, and others included only patients that fit within the 3 mechanical syndromes (not the “other” category).

Second, some of the control groups were poorly defined, or poorly dosed, such that it may be unfair to say that MDT outperformed “exercise.”

Third, the control groups were not tailored to patients, whereas other paradigms such as treatment-based classification, movement system impairments, the STarT Back approach, or cognitive functional therapy all offer tailored treatment.

One of my primary concerns about systems like MDT is — well — how mechanical it is. Low back pain has a strong psychosocial component, and a recent study by Lam and colleagues identified some interesting information about patients with chronic neck pain.

The study found that patients could be sorted into derangement, dysfunction, posture, and other subgroups at a rate of 74.4, 2.4, 1.2, and 20.7 percent respectively. I’m blown away by how rare the dysfunction and posture subgroups are.

The study also examined the prevalence of central sensitization and psychological distress, with findings that a whopping 62% had central sensitization (defined as >= 40 on the Central Sensitization Inventory). Importantly, 64.7% of the derangement group also had central sensitization, and 38% of the sample had a combination of derangement, central sensitization, and kinesiophobia. The authors conclude that merely classifying patients into their respective MDT subgroups may miss crucial characteristics of patients.

What’s your conclusion? If you have experience with MDT or other classification systems, then we would love to hear from you on the Facebook group, or on Twitter — just use the hashtag #physioweekly.

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

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Nocebo and the Power of Words

Words Will Never Hurt Me… Or Will They?

Words matter. It’s amazing how often patients share stories about how other providers have explained their condition in horrific terms. “Your arthritis is terrible” or “your back is a mess.”

The “placebo” effect is well-known, but its counterpart, the “nocebo” effect is just as strong (if not stronger), and perhaps even more relevant for the healthcare industry. When patients are told that something will hurt, then it will likely hurt, whereas without this verbal suggestion, there is often much less pain. Many studies have been conducted related to drawing blood and/or giving injections, finding a strong effect of verbal suggestion on increased pain with the stimulus.

In this issue of the Physio Weekly, we discuss the role of our words in the clinic.

Sticks and Stones

I can’t imagine the thought of healthcare providers looking at imaging and suggesting that patients should be in pain because of their imaging. If you’ve spent any time researching imaging studies with respect to pain, then you have surely found how images aren’t stellar at predicting pain.

In this month’s issue of JOSPT is one of my favorite papers ever , written by Stewart and Loftus. In the paper, the authors make the case for changing the words that we use in order to avoid creating harm. Stewart and Loftus argue that many biomedical terms reinforce negative beliefs, and the authors provide some alternative options instead of common terms that we hear or say in the clinic. For example:

Instead of “wear and tear,” say “normal age changes

Instead of “damage,” say “reparable harm

Instead of “trapped nerve,” say “tight, but can be stretched

Instead of “bulge/herniation,” say “bump/swelling

Instead of lordosis or kyphosis, say “the normal curve in your back

I am often the one to interpret imaging findings for patients, because even though they are provided the radiologist’s impression, the jargon is overwhelming. The alternative phrases above are some ways to translate the imaging findings into non-threatening terms.

When More Treatment Isn’t Better

What happens if we suggest to patients that their bodies are messed up and that we need to correct everything? What if we explain that if we use some gadgets to mend their imperfections, and yet we only to arrive at a disappointing outcome for the patient?

I’m afraid that when we explain symptoms in terms of pathology, then we may contribute to overmedicalization and even harm to patients. The STarT Back Trial is one study that offers evidence that some patients don’t really need much treatment; they just need to know that it’s okay to move, to exercise, and to keep working. In the trial, physios in the group using the STarT Back tool provided only 1 session of treatment to those who score as low risk for poor prognosis, whereas the physios provided an average of 5 visits to those not in the group using the STarT Back tool.

Despite these differences in number of visits, the patients’ outcomes were not significantly different between the groups. This finding tells me the value of reassurance, encouragement, and education when prognosis is good.

When Words Hurt

Healthcare providers, though, could do something entirely different: They could look at how patients move or how their joints move and say something like, “No wonder you’re in pain, I see some problems with you.” What’s the possibility that such an assessment could actually create more pain? The research about nocebo responses is fascinating, and I believe that this 1-page paper about nocebo should be required reading for anyone who works with people in pain. As the paper mentions, merely suggesting that something could be painful actually leads to people experiencing pain.

I’ve been choosing my words a bit more carefully after seeing this research. What about you?

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

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The 5 A’s for Behavior Change and Weight Loss

We Need to Change

If you have ever quit smoking or lost a lot of weight, then you know how hard it is to change your life. You wouldn’t be alone in feeling that your doctors didn’t care about your struggle… or perhaps even judged you.

The healthcare industry is clearly having a difficult time with overweight and obesity in America. It’s estimated that more than half of today’s children will be obese by age 35.

What can we do about this?

Starting the Conversation

Physios have the time, resources, and knowledge to be leaders in promoting weight loss. When I started practicing, I was afraid to even discuss nutrition or patients’ weight. Patients would often mention their desire to lose weight or, alternatively, their skepticism that their weight has anything to do with their pain. I was never the first person to bring up the topic.

But not anymore. 

I work with many patients who want to lose weight in order to manage their osteoarthritis. One of my favorite questions toward the end of my subjective interviews with patients is this: “Are there any other goals that you have that we haven’t talked about?” 

This is usually where our meaningful conversations about weight loss happen. But sometimes I felt uncomfortable with knowing what I should say or how I could steer the conversation without offending yet still offer something valuable to patients.

The 5 (or so) A’s

The 5 A’s method is based on the transtheoretical model of behavior change. This method helps to provide some guidance on how we can approach these conversations.

The 5 A’s model has evolved, initially designed for smoking cessation but recently adapted for obesity management. The 5 A’s as they relate with weight loss are ask, assess, advise, agree, assist, and arrange. (I know, that’s actually 6 things. More on that in a minute.)

Definition: Asking the patient about habits, behavior patterns, weight, nutrition, and readiness for change.

  • “How do you feel about your diet?”
  • “How do you feel about your exercise routine?”
  • “What goals do you have related to your health?”

Definition: Assessing the patient’s BMI, waist circumference, quality of diet, physical activity status, psychosocial factors, environmental milieu.

  • “What challenges have you faced with trying to lose weight?”
  • “How does your family feel about your goal to lose weight?”
  • “It sounds like we can try to increase your physical activity.”

Definition: Giving clear, specific, and personalized behavior change information, which includes health risks and benefits.

  • “If you were to lose 5-10% of your body weight, then the odds are that you would feel less pain in your knees.”
  • “Losing weight is a fantastic way to lower your blood sugar and blood pressure, which could help you to live longer and to feel better.”

Definition: Collaboratively selecting appropriate treatment goals and methods based on the patient’s interest and willingness to change.

  • “It sounds one goal could be to lose 20 pounds over 6 months, which would be 1 pound per week. How do you feel about that plan?”

Definition: Aiding the patient in achieving goals that were established together, by teaching skills, providing confidence, and supplementing with other medical treatments when necessary (e.g., pharmacotherapy).

  • “What barriers do you foresee with your goal to eat fewer carbohydrates?”
  • “What are some things to tell yourself when you don’t feel like exercising?”
  • “What are some ways that you can feel more supported by your family in this journey?”

Definition: Scheduling follow-up contacts, adjusting the treatment plan as needed, and providing referrals for specialists when appropriate.

  • “I’m going to give you a phone call in two weeks to see how your plan is going, and please let me know if you have any issues along the way.”
  • “Because you’d like some specific meal plans, I’m going to refer you to a registered dietician for assistance.”

Our Map to Change

The 5 A’s model has been adapted by different organizations, with some choosing to use “agree” and others choosing “ask,” and so on, but I think all are important.

Here’s the problem: This list might trick you into thinking this process is linear. I don’t think it is. Sturgiss and van Weel provide a beautiful image for how we can use this strategy while taking a patient-centered approach, assuming a strong therapeutic alliance.

This image below from their paper provides a lot to consider. What if a patient isn’t ready to discuss weight loss? What if they know what to do but want more assistance? The authors provide us with a roadmap for the ongoing mission of achieving a healthier world.

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

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Risk and Resilience in Pain

Resilience Despite Pain

Wellness is bigger than the absence of illness. One of my problems with the healthcare industry is that the predominance of the biomedical model leads us to treat pathology rather than actually promoting and reinforcing health.

I mean, do we even deserve the term “healthcare” anymore?

Here’s where it gets worse: Under a purely biomedical approach, when find pathology, we make assumptions about the relationship between pathoanatomy and symptoms. Then we start patients on a path of trying to eliminate pain in the face of scary radiographics and MRIs. Patients then interpret their condition as higher risk for pain; they might think that it will only get worse. Sometimes providers even feed into this and actually tell the patients that they will get worse. I’ve heard the stories, just as you have.

We need a different approach for pain.

Theories of Resilience

We need to focus more on resilience, not just risk.

Goubert & Trompetter (2017) wrote a perspective titled, “Toward a science and practice of resilience in the face pain,” which is the focus of this Physio Weekly. The authors present convincing evidence that positive outcomes are just as important, if not more important than negative outcomes. Physios can learn from this, as we are just as likely as other providers to look for what’s going wrong instead of what’s going right.

There are three perspectives that provide some direction for how we can foster resilience with patients. They are the psychological flexibility model, broaden-and-build theory, and self-determination theory.

Flexibility Programs

The psychological flexibility model assumes that negative experiences like fear and pain are not pathological in nature by themselves. Of course these things can get in the way of our goals.

As this model suggests, our best path toward recovery involves accepting things as they are, yet disengaging from negative thoughts and feelings. Instead, we can determine what goals are important to our values, and then figure out how to meet those goals despite our problems.

If you use the Patient Specific Functional Scale, then you’re probably inclined to think this way already. But this also shifts how I think about our interventions. Should we try to chase pain away, using the kitchen sink if necessary, or should we pursue the patient’s goals in life despite pain?

This is the approach of Acceptance and Commitment Therapy (ACT) and one way to use these concepts is to use a values-based goal setting sheet so that you and your patients can work together to determine the higher objective — and then how to get there.

Strength Training and Self Mobilizations

Barbara Frederickson and colleagues developed the Broaden-and-build theory which emphasizes the role of positive emotions and thoughts in growth. If you’re more positive, then you are more likely to be active and to pursue your goals. Of course, those in pain are frustrated, but the Broaden-and-build theory suggests that we can induce positive affect in others. How can we do that?

A recent trial for knee osteoarthritis shows how we can use positive psychology interventions to decrease negativity — and even decrease pain. One easy exercise to use from the protocol is the “3 good things” exercise. For this, write down three good things that happen each day, and include explanations for why they were successful.

The Self-determination Theory suggests that humans have basic psychological needs for autonomy, competence, and relatedness. We want to feel free to choose what they want to do; we want to feel good at what we do; and we want to feel connected to one another. Physios have the opportunity to help patients to meet these needs in ways that almost no other healthcare providers can. We spend enough time with patients to develop real intimacy, and we can reinforce patients enough so that they feel successful.

I’ve wondered about how we can grant patients autonomy in treatment — whether it’s choosing how to exercise or even choosing interventions. How does this fit into high value care when the patient wishes to receive a modality that may be “low value”? Should patients decide when they follow up, rather than a prescriptive twice per week for six weeks?

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

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Cognitive Behavioral Therapy for Fibromyalgia

Going Mental With Fibromyalgia

Do you ever feel like a psychologist in the clinic? Pain affects so many aspects of life, and some days I am navigating emotions, thoughts, and behaviors much more than I am assessing joint mobility or muscular function.

Fibromyalgia is one condition that can be overwhelming at evaluation because the patient might say that “everything hurts” or that they would like to see why they hurt in their neck, back, shoulders, hips, and knees. If I were to systematically evaluate and treat each joint as if the pain is purely nociceptive, then I would be overwhelmed… and possibly misguided.For fibromyalgia, there is evidence that psychological treatments — and cognitive-behavioral therapy in particular — are more effective than active controls for pain, disability, and negative mood. But what is cognitive-behavioral therapy, and how does it work?

What is Cognitive Behavioral Therapy?

Cognitive-behavioral therapy is hard to define, but typically involves attempts to change thoughts, modify unhelpful behaviors, and/or introduce self-management strategies. There isn’t a universal definition, though typically it is a structured intervention used by mental health practitioners.

Cognitive-behavioral therapy often tries to encourage “skills” that help with managing pain or improving the quality of life despite pain. Some skills include progressive muscle relaxation, cognitive restructuring, mental imagery, goal-setting, and activity-rest cycling.

Activity-rest cycling is one skill that I find especially helpful for those with fibromyalgia. If the patient feels that they “overdo” something often, then perform a thought experiment about how taking some rest breaks might prevent a flare or allow the patient to do even more of the activity than just trying to power through.

As we discussed in the first newsletter about fibromyalgia, pain modulation doesn’t work the same way in fibromyalgia, might make intermittent rest much more valuable in painful moments.

Be Present, CBT-style

To make things complicated, there are many “third-wave” cognitive-behavioral strategies that incorporate other frameworks such as Acceptance and Commitment Therapy (ACT) or mindfulness-based strategies.  I think ACT and mindfulness are valuable additions to psychological interventions because of their goal to bring more attention to the present moment and to emphasize that we should try to find aspects of our life that we can control without preoccupying ourselves with what we can’t control.

If you’re interested in exploring some of these strategies, then I would first encourage you to reach out to a psychologist friend or to find one for your referral network, and see if they can mentor you.

Next, check out Psychology Tools for many free handouts and resources that are useful for patients with these types of treatments. Using these strategies are at the heart of psychologically-informed physical therapy.

How CBT Changes Thoughts and the Brain

Many physios understandably think we should stick to exercise as our treatment. As we discussed last week, exercise is effective for fibromyalgia. So why notstick with exercise without struggling through psychobabble?

Here’s how I see it…

Exercise is often our product in order to allow patients to meet their ultimate goals. Psychological treatment is kind of a customer service line for when the product isn’t working. In many cases, exercise might seem too dangerous or painful for patients, or perhaps patients are struggling with stress or sleep or weight loss and these other factors are interfering with the thought of exercising. Psychological intervention can troubleshoot these problems by providing coping skills, modifying behaviors, and addressing unhelpful thoughts.

In fact, one RCT using fMRI suggests a possible mechanism for how CBT can lead to decreased pain. A group of patients with fibromyalgia who participated in CBT showed reduced resting-state connectivity between the S1 area and anterior/medial insula after treatment. Moreover, this reduction in connectivity correlated with reductions in pain catastrophizing, which was also significantly decreased in the CBT group compared to control. Therefore, this study suggests not only the role of catastrophizing in mediating the effects of CBT on pain but also the possible biomarkers of these effects.

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

And if you want more posts like this one delivered to your inbox, consider subscribing. Subscribe to stay on top of the latest research, develop your professional skills, and improve your patients’ outcomes.

Treating Fibromyalgia With Exercise

Everybody Get Up: Treating Fibromyalgia

Two weeks ago we covered the diagnostic criteria and some of the pathobiology of fibromyalgia. All of that isn’t so helpful without strategies for treating fibromyalgia or widespread pain in general. This week and next week will focus on evidence for treating fibromyalgia.

Oh, and what happened to last week’s Physio Weekly? We have been on vacation, but to make up for it, here is a free tool to help with diagnosing fibromyalgia based on Wolfe et al.’s 2016 criteria. Even if you aren’t in the position to medically diagnose, it’s helpful to know when patients meet the criteria.

Just Work That Body, Work That Body

In the clinic, I have heard patients offer a wide variety of knowledge of how to manage fibromyalgia; some mention that only gabapentin has helped, and others have noticed that certain types of exercise is helpful, and some are surprised to hear that anything can help at all. What does the evidence say?

There are many interventions that are unimpressive for fibromyalgia. Based on Cochrane reviews, whole body vibration and acupuncture offer no benefit beyond sham interventions, and the evidence is insufficient to support or refute transcutaneous electrical nerve stimulation (TENS). The evidence for myofascial release therapy is not sufficient to support its use for chronic musculoskeletal pain in general.

Recent practice guidelines offer conflicting advice. Still, the non-pharmacologic interventions with the greatest evidence are exercise and cognitive-behavioral therapy. Exercise takes many forms, and it’s challenging to determine whether one form of exercise offers more pain relief or improved function compared to other forms.

Aquatic exercise, land-based aerobic exercise, and resistance exercise all seem to offer meaningful improvements in pain and function.

In the clinic, though, it’s sometimes hard to sell exercise when it hurts. One reason that exercise might hurt more, like we discussed last issue, is that pain modulation is sub-optimal with fibromyalgia.

This means that you might find more success with low-intensity exercise, at least to start, when working with those with fibromyalgia. Even walking short distances can be a place to start, and using a graded walking program is one way to blend exercise with cognitive-behavioral strategies. In fact, one trial found positive effects with just brisk walking for 20-30 minutes per day.

As for resistance exercise, even body weight resistance, if sessions are at least twice per week and for 40-60 minutes, appears effective for reducing pain and improving function.

Here’s Your Chance, Do Your Dance

There are other ways to exercise, too, of course. Tai chi is one example. I love tai chi, though I usually only offer it when patients mention that they’ve heard about it.

This Youtube video is one that I share, because it’s easy, relaxing, and not as corny as other exercise videos. Tai chi postures are difficult to put onto a handout because of the “flowing” nature of postures, rather than the “start here and end there” movements of resistance exercise.

Yoga, on the other hand, is more accessible than tai chi. (My three-year-old son says that I look like a bug when I do tai chi, but he says that I look I’m exercising when I do yoga.) In fact, this randomized trial found that yoga postures were more effective for treating low back pain than traditional physiotherapy exercises. Yoga with Adriene is an easy starting point for beginners.

We’re Gonna Take It Into Overtime

Exercise is the bread and butter of physiotherapy. But is it good enough on its own for fibromyalgia?

I don’t think so. What happens when patients simply don’t want to exercise? What if patients are so afraid of movement that they don’t even want to shop at the big stores? What if patients are so stressed about their pain that they’re having trouble sleeping? What if there is evidence for central sensitization?

Next week will highlight some of the components of cognitive behavioral therapy, which adds significant value to the treatment of fibromyalgia and other persistent pain syndromes.

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

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What Is Fibromyalgia?

Fibromyalgia: The F Word

When I was a student it was interesting to see how other therapists would treat widespread pain.

A clinical instructor of one of my classmates said you can’t really expect anyone with fibromyalgia to get better. Another therapist said that whenever we see someone who says that they have fibromyalgia, then we should suspect malingering. Wha…?

What do you think? Is fibromyalgia real? And can people with chronic widespread pain improve? Buckle up — this Physio Weekly brings the science.

Help! I Need Some Diagnosis

There is no gold standard for diagnosis of fibromyalgia, though in 2016 the American College of Rheumatology updated the criteria for fibromyalgia. A patient satisfies the criteria if they meet these four criteria:

  1. Widespread pain index (WPI) >= 7 and symptom severity scale (SSS) >= 5 OR WPI of 4-6 and SSS >= 9. (More on this alphabet soup below.)
  2. Generalized pain, defined as pain in at least 4 of 5 regions, must be present. Jaw, chest, and abdominal pain are not included in generalized pain definition.
  3. Symptoms have been generally present for at least 3 months.
  4. A diagnosis of fibromyalgia is valid irrespective of other diagnoses. A diagnosis of fibromyalgia does not exclude the presence of other clinically important illnesses.

To score the WPI in criterion 1, note the number of body areas in which the patient has had pain in the last week. The body areas are organized in the five body regions that are used to define “generalized pain” in criterion 2 above.

  • Region 1 is the left jaw, left shoulder, left upper arm, and left lower arm.
  • Region 2 is the right jaw, right shoulder, right upper arm, and right lower arm.
  • Region 3 is the left hip, left upper leg, and left lower leg.
  • Region 4 is the right hip, right upper leg, and right lower leg.
  • Region 5 is the neck, upper back, lower back, chest, and abdomen. Count the number of areas across all regions to score the WPI.

Next, scoring the SSS first involves rating the severity of the symptoms of fatigue, waking unrefreshed, and cognitive symptoms from 0 to 3 (0=no problem and 3=severe). Then the SSS includes additional points for the presence of headaches, abdominal cramps/pain, or depression (1 point each). The maximum scores of the SSS is 12. Take your WPI and SSS scores and see if they satisfy criterion 1 above.

At this point, diagnosing fibromyalgia is just about as complex as filing taxes.The brief approximation would be to see widespread pain of over 3 months with additional symptoms of fatigue, poor sleep, headaches, and/or depression within 6 months.

Imaging All the People 

Studies using MRI testing have found differences between those diagnoses with fibromyalgia and those without fibromyalgia. Those with fibromyalgia havedecreased gray matter in the anterior and mid-cingulate and mid-insular cortices. Hippocampal volume is also reduced in those with fibromyalgia, which would offer a neurobiological explanation for cognitive deficits and memory problems, like the “fibro fog.

Researchers study pain modulation via concepts such as temporal summation and conditioned pain modulation. Temporal summation is a phenomenon where repetitive noxious stimuli amplify the pain experience. Conditioned pain modulation (CPM) is an occurrence where the application of conditioning stimulus to one area of the body can allow greater tolerance of pain in another area of the body.

One example of CPM is the application of a blood pressure cuff on one arm as a conditioning stimulus, while a heat stimulus is applied to the hand of the other arm. Someone with “good” pain modulation would show a decrease in pain with this paradigm.

recent meta-analysis found that endogenous pain modulation functions differently for those with fibromyalgia. They found a 68% relative difference in temporal summation between those with fibromyalgia and those without, with an effect size of 0.53. Similarly, the authors found a 65% relative difference in conditioned pain modulation between those with and without fibromyalgia, with an effect size 0.57.

Tomorrow Never Knows

So what? Fibromyalgia involves the central nervous system. The etiology is still unclear, but it appears that it’s not a purely musculoskeletal condition, and clinicians who get caught in the trap of performing special tests on every painful joint might create more frustrations than solutions.

What do you do when a patient says, “By the way, my shoulders hurt and my neck hurts and my hips hurt too. What can we do about all of those?” Now you have several examinations on your plate, probably with less time than normal because of how persistent pain affects so much of life. In my experience, this is where the “low tech examination” comes in handy: screen for motor neuron dysfunction, test for mechanical changes to pain to ensure a musculoskeletal component, and go easy on special testing if pain is widespread, for the sake of rapport and avoiding flaring up patients.

But what can we do about fibromyalgia? Lots. The next Physio Weekly will focus on treatment of fibromyalgia and chronic widespread pain.

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

And if you want more posts like this one delivered to your inbox, consider subscribing. Subscribe to stay on top of the latest research, develop your professional skills, and improve your patients’ outcomes.

Lateral Hip Pain and My Trigger Word

“It’s Just the Bursitis.” Or is it?

Do you have trigger words in the clinic? I know I do. One of mine is “bursitis.”

I get a little miffed because I anticipate determining that it’s not just bursitis (if at all), which makes for an interesting discussion with the patient. The hip is tough to evaluate, though, which is why this Physio Weekly is dedicated to lateral hip pain.

Putting Bursitis to the Test

What are the odds of a patient having bursitis? That’s tricky.

In a study of forty patients with unilateral hip pain, researchers performed MRIs for both hips. Of the symptomatic hips, the largest proportion had a combination of bursitis and gluteal tendon pathology, not just bursitis.

But here’s the funny part: Out of the 40 hips with no pain, 22 of them had radiographic bursitis. The prevalence of bursitis was the same for the hips with pain and without pain. 

By the way, three of the 40 patients had no pathology in either hip. …What would you say to them?

A Hip Precautionary Tale 

In the recent issue of the Orthopaedic Physical Therapy Practice magazine, there is a fascinating case report about a patient who underwent surgery for gluteus medius tendon rupture. The patient injured her hip after slipping on ice and falling on an outstretched hand. Two weeks after her fall, she consulted an orthopaedic surgeon. The surgeon’s diagnosis? Trochanteric bursitis.

The patient participated in physical therapy for 4 weeks without benefit, then received a cortisone injection with only slight benefit, and took ibuprofen as needed.

Eight months after the initial injury, she returned to her physician with increased hip pain, and the physician ordered an MRI. The MRI revealed gluteus medius tendinosis with small partial thickness tearing and no evidence of trochanteric bursitis. The gluteus medius tendon was surgically reattached, and the patient participated in a second round of physical therapy. The patient got better.

What would have happened if the orthopaedic surgeon or first physical therapist could have detected the tear? Probably a faster recovery, less suffering, and lower costs to the patient.

The authors of this case report present five special tests that were not performed initially and could have yielded a more informative evaluation in the clinic. Here are the tests in order of the easiest to most difficult. The first four are all with the patient lying on the uninvolved side, and the last is in standing.

  1. Isometric hip abduction test: (sensitivity: 80%, specificity: 71%). The patient performs isometric hip abduction without any external resistance. Reduced abductor contraction and/or increased pain indicates a positive test for gluteus medius tendinosis.
  2. Resisted abduction(sensitivity: 73%, specificity: 46%). With the involved leg in abduction and slight extension, the examiner applies moderate resistance against the involved leg. Elicited weakness is positive for greater trochanteric pain syndrome, specifically tendon involvement.
  3. Ober’s test: (sensitivity: 41%, specificity: 95%). The examiner brings the involved led into adduction and allows it to fall toward end range. Restricted range and/or pain provocation is positive for iliotibial band tightness or trochanteric bursitis.
  4. The hip lag sign: (sensitivity 89%, specificity: 97%). The involved leg is passively brought into abduction, slight extension, and internal rotation. The patient is asked to hold the position, and a positive test occurs if the patient’s foot drops 10 cm or more and indicates gluteus medius tear.
  5. The single leg stance test: (sensitivity: 23%, specificity: 94%). The patient stands on the involved leg for 30 seconds with minimal hand support of the examiner. A positive occurs if patient is unable to lift the uninvolved leg off the ground or is unable to maintain the position for 30 seconds, and indicates gluteus medius tendinosis.

Put This in Your Gluteal Folder

The odds are that when you see lateral hip pain, you will be seeing gluteal tendon pathology without actual tear. So what do you do?

A randomized trial published this year found that a combination of exercise and education outperformed corticosteroid injections or no treatment at 12-month follow up. For your exercises, think heavy and slow, using bridging, squatting, band sideslides, and sidestepping. The patients started with a daily HEP of 1-2 sets of each exercise, only 5-10 repetitions but between somewhat hard and very hard RPE depending on patient’s response to loading.

Looking for more? The authors’ protocol is free. By the way, sidestepping is a solid gluteus medius exercise, but the stance leg’s gluteus medius is actually loaded more than the gluteus medius of the moving leg.

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

And if you want more posts like this one delivered to your inbox, consider subscribing. Subscribe to stay on top of the latest research, develop your professional skills, and improve your patients’ outcomes.

Is Positive Behavior Change a White Whale?

Behavior Change: Fact or Fiction?

Physical therapy practitioners promote behavior change.

We ask patients to exercise more; we educate patients about the type of activities to do (or to avoid). We might even talk about diet, weight loss, smoking, stress, and sleep.  I feel that patients care way less about the anatomy & physiology and instead care way more about how they can make changes in their lives.

If you’re like me, then you have noticed how hard it is to change attitudes and behavior. You might also relate with how hard it is to change habits or to make dramatic changes for the sake of your own health. This is where we have so much to learn from psychologists about health behavior change — the focus of this Physio Weekly.

Turn and Face the Strange.

There are many health behavior theories. The goal of these theories is to try to predict and understand health actions so that we can try to promote healthier actions. Health behavior theories are subtly different from each other, but they usually address three major constructs:

  1. Attitudes — the appeal and consequences of certain behaviors.
  2. Social norms — how other people view behaviors and how often others actually engage in those behaviors.
  3. Self-efficacy — how well one can complete the requirements to engage in behaviors.

Health behavior theories address these three constructs because of what’s called the intention-behavior gap. The intention-behavior gap is the discrepancy between someone’s plans for their behavior and their actual behavior. In fact, intentions to perform a behavior explain about 50% of actual behavior. 

In other words, whether or not someone increases their physical activity is only halfway explained by their intentions to do so.  

I see this all the time in the clinic, and you probably do too. The usual intention-behavior gaps that I see are related to exercise and diet. Most people want to walk more and to eat better, but it’s hard to change.

Train in Vain? 

One of my biggest fears about clinical practice is the possibility that people don’t really change. If we can’t change behavior, then much of our efforts are in vain, right?

A recent meta-analysis found strong evidence that we can facilitate change. The authors examined the effects of interventions based on health behavior theories, including social cognitive theory, the transtheoretical model, the theory of planned behavior, and others. The study examined many health behaviors such as physical activity, smoking cessation, getting vaccinated, and dietary changes.

The study found that interventions that intended to change attitudes, norms, or self-efficacy actually do change both intentions and behavior. Since this meta-analysis analyzed only longitudinal designs, this study provides experimental evidence of the causal role of changing beliefs in order to change behavior.

Our efforts are not in vain. In fact, perhaps without our encouragement, many of our patients wouldn’t make it through.

Stronger Than Yesterday

So how can we encourage change?

One meta-analysis of experimental studies shows the value of monitoring progress toward goals. Merely tracking and reflecting how we are doing increases our odds of success. This is liberating for healthcare professionals. Rather than lecture about the importance of changing diet or exercise, what would happen if we merely ask patients to monitor their diet or exercise?

In the clinic, one of my favorite ways to encourage monitoring is printing a blank calendar for the current month or an achievement worksheet so that patients can track their activity and place the paper somewhere as a reminder. For those who are more technologically inclined, use apps like Google Keep or Wunderlist.

When it comes time to review progress with patients, are you the “tough love” type or the “warm and fuzzy” type? One recent study shows the importance of positivity when reviewing progress. The researchers assigned two groups to think about their eating choices.

One group reflected about only “good” choices and the other group reflected about only the “bad” choices. One week later, the group that focused on the “good” choices reported stronger intentions to eat healthy food, and the “good” choices actually felt like they were closer than the “bad” choices group to achieving their goal of healthy eating.

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

And if you want more posts like this one delivered to your inbox, consider subscribing. Subscribe to stay on top of the latest research, develop your professional skills, and improve your patients’ outcomes.