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Dynamic Chiropractic – February 25, 2002, Vol. 20, Issue 05
Dynamic Chiropractic
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Dynamic Chiropractic

Functional Reactivation: "Patient-Centered Care"

By Craig Liebenson, DC

A new and rather novel treatment has recently proven its value in the battle against acute and chronic back pain. Advice that gradual resumption of normal activities is both safe and effective has proven highly effective in spurring recovery.5,8,12,16,22,25,27 This new method now takes its place alongside other evidence-based treatments, such as spinal manipulation and medication.2,8,30 In contrast, the traditional treatment of bed rest has been unmasked as not only a prescription which lacks effectiveness, but if prolonged for more than a few days, it has been shown to produce harmful side-effects.1,2,8,9,11

Why should a treatment as simple as reassuring and reactivating advice be so effective? As every chiropractor knows, the most disabling factor for patients is their fear and anxiety.

The most powerful weapon we wield against pain is the reassurance that we can offer. Patients have pain and suffer. While pain is usually of mechanical origin, suffering is of psychological origin. When anxiety or fear-avoidance behavior are significantly involved, their identification and management are just as important as addressing spinal dysfunction in achieving successful outcomes.

While most clinicians are aware that a patient's suffering is relevant, history alone is not sensitive enough to reliably identify abnormal illness behavior.10 Questionnaires have been developed for capturing a patient's "yellow flags," psychosocial risk factors of a poor recovery.6,19,23,24 These have been shown to have very good sensitivity and specificity.

What is the Patient-Centered Model?

The emerging patient-centered paradigm focuses on the patient's symptoms, distress and disability (activity intolerances - see Figure 1).35 It is grounded in functional reactivation of the patient. This addresses not only impairments identified by clinicians, but even more importantly, activity intolerances reported by the patient (see Table 1).15

Table 1: The Patient-Centered Approach

  • Symptoms
  • Dysfunction
    • General - activity intolerances
    • Specific - i.e., joint dysfunction
  • Psychosocial - i.e., fear-avoidance behavior

Symptoms can be distressing5,16 and lead to changes in how one performs general functions, such as walking,14,31 and specific functions, such as the body's ability to respond to a sudden load efficiently.29 In turn, psychological distress, such as fear-avoidance behavior, negatively influences specific functional abilities,21,34 general functional abilities,7 and pain reporting.33 Finally, specific dysfunctions, such as poor trunk extensor endurance, have been shown to be prospectively linked to the development of acute low back pain (LPB) in asymptomatic individuals,13,26,32 and recurrent LBP in acute LBP subjects.3

The Disabling Effect of an Overemphasis on Structural Pathology

Persistent pain reinforces negative attitudes about the relationship of activity and pain. Diagnostic tests that focus on pathoanatomy are frequently ordered to find the "cause" of the pain. Unfortunately, these tests have high false-positive rates for coincidental structural findings, such as degenerative joint disease or herniated discs, and thus reinforce the patient's self-image as having a "bad" back or needing to "learn to live with it."4,17,18,20 The result is further activity avoidance and deconditioning. Unfortunately, excessive immobilization interferes with the healing and recovery process. Thus, health care professionals (HCPs) are being urged by each successive internabeing urged by each successive international guideline on back and neck pain to first perform a diagnostic triage to rule out "red flags" of rare but serious disease, then reassure patients of the benign nature of their back pain and the safety and value of gradually resuming activities.2,8,30

image - Copyright – Stock Photo / Register Mark

Are All Specific Dysfunctions Clinically Relevant?

The World Health Organization (WHO), in its International Classification of Impairments, Disabilities and Handicaps (ICDH-2),15 distinguishes "activity level" or general functional ability from "impairment in body function" or specific functional deficits. General functional ability is what the patient can do (or perceives he or she can't do!) in daily life. In contrast, specific functional deficits are found only on clinical examination, and may be related to the patient's symptoms or functional abilities. A challenge facing clinicians is to ferret out the specific dysfunctions (that are clinically relevant maladaptations) from those that are adaptive. The difficulty inherent in this task is highlighted by Mannion, who reported that functional measures accounted for only seven percent of self-reported pain, in contrast to psychological factors, which accounted for 26 percent!28 Functional measures were responsible for 25 percent of self-reported disability, while psychological factors accounted for 36 percent.

That specific functional impairments (i.e., ROM, strength) have not correlated significantly with pain or disability suggests that these dysfunctions are more likely the consequence of pain rather than its cause. Mannion suggests that motor control dysfunctions, which have largely been ignored, are the most likely specific dysfunctions causally "linked" to pain and disability (general dysfunction).28,29

Treatment

Active care approaches involving a variety of strategies, from simple advice to resume activities, and stabilization training to cognitive-behavioral approaches, have all been shown to be highly effective for reducing pain and disability. Of particular note is that active care approaches without a psychological or cognitive-behavioral component have been highly successful in reducing psychological distress accompanying pain or disability.28

Information and advice emphasizing the value of fitness and the safety of resuming activities achieved superior outcomes to advice that reinforced rest, activity restrictions and the notion that the spine was injured or damaged (arthritis, herniated disc).5 Reassuring workers and encouraging resumption of ordinary activities was superior to medication, bed rest or mobilization exercises.27 Little, et al., recently demonstrated that educational advice that encourages early exercise (not just advice to stay active) or endorsement by a physician of a self-management booklet has been shown to increase patient satisfaction and function while reducing pain.25

Indahl emphasized the importance of dispelling patients' fears when giving reactivation advice.16,16a Table 2 summarizes the key points used by Indahl for patient education/reactivation. Being too careful was emphasized as the worst form of self-treatment. Patients were instructed to take regular walks, encouraging flexibility. Prolonged static postures, such as those involving carrying objects, were discouraged. For acute pain flare-ups, patients were advised to assume these were just acute muscle spasms and to perform stretching or light activity. Patients were informed that they should not be afraid to use their backs, not to be overcautious and to try to be as flexible as possible. Patients were very satisfied with this approach and that they were taught explicitly how to perform activities of daily living.

Table 2: Specific reactivation advice, according to Indahl.

  1. Patients were informed that pain or anticipation of pain could increase muscle activation/tension and thus increase pain;

  2. they were assured that light activity would not further injure the disc or other structures, causing pain;

  3. they were informed that light activity would enhance the repair process; and

  4. the link between emotions and pain was explained.

Conclusion

The patient-centered approach is less focused on the various signs of often coincidental structural pathology, or the patient's subjective symptoms, than on the patient's dysfunction and distress. A paradigm shift from a traditional biomedical model to a biopsychosocial one has taken firm hold in the spine field. The biopsychosocial approach teaches us that the old adage "let pain be your guide"can actually reinforce illness behaviors such as fear-avoidance behavior. The more modern report of findings reassures patients that they do not have a disease (tumor, infection, and fracture), and that staying active will actually speed recovery. Learning that pain does not always warn of impending harm or damage can empower patients to remain active, avoid disability, and prevent the transition from acute to chronic pain.

References

 

1. L, Rossignol M, Valat JP, Nordin M, Avouac B, Blotman F, Charlot J, et al. The role of activity in the therapeutic management of back pain: Report of the International Paris Task Force on Back Pain. Spine 2000;25(4):1S-33S.

2. S, et al. Agency for Health Care Policy and Research (AHCPR) 1994. Acute Low Back Problems in Adults. Clinical Practice Guideline Number 14. AHCPR Publication No. 95-0642. Rockville, MD. December 1994.

3. F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine 1984;9:106-119.

4. MN, Jensen MC, Obuchowski N, et al. Interobserver and intraobserver variability in interpretation of lumbar disc abnormalities: a comparison of two nomenclatures. Spine 1995;20:1257-1263.

5. K, Waddell G. Information and advice to patients w/ back pain can have a positive effect. Spine 1999;24:2484-2491.

6. AK, Tillotson K, Main C, Hollis M. Psychosocial predictors of outcome in acute and sub-acute low back trouble. Spine 1995;20:722-8.

7. DS, Just N. Pain expectancy and work disability in patients with acute and chronic pain: A test of the fear avoidance hypothesis. Journal of Pain 2001;2.

8. Health Technology Assessment (DIHTA). Manniche C, et al. Low Back Pain: Frequency Management and Prevention from an HAD Perspective, 1999.

9. RA, Diehl AK, Rosenthal M. How many days of bed rest for acute low back pain? N Engl J Med 315:1064, 1986.

10. M, Pande K, O'dowd J, Webb J. Do first impressions count? A comparison of subjective and psychologic assessment of spinal patients. Eur Spine J 1998;7:218-223.

11. KB, Hilde G, Jamtvedt G, Winnem MF. The Cochrane review of bed rest for acute low back pain and sciatica. Spine 2000;25:2932-2939.

12. EM, Eriksen HR, Ursin H. Does early intervention with a light mobilization program reduce long-term sick leave for low back pain? Spine 2000;25:1973-1976.

13. SM, Dickenson AL. A comparison of two isometric back endurance tests and their predictability of first-time back pain: A pilot study. Journal of the Neuromusculoskeletal System 2001;9(2):46-53.

14. TM, Simmonds MJ, Etnyre B, et al. Kinematics of gait in subjects with low back pain with and without leg pain. Scientific Meeting & Exposition of the American Physical Therapy Association. Washington, DC, 1999.

15. International Classification of Functioning and Disability. Beta-2 draft. Full version, World Health Organization, Geneva, 1999.

16. A. Velund L, Eikeraas O. Good prognosis for low back pain when left untampered: A randomized clinical trial. Spine 1995;20:473-7.

16a. Indahl A, Haldorsen EH, Holm S, Reikeras O, Hursin H. Five-year follow-up study of a controlled clinical trial using light mobilization and an informative approach to low back pain. Spine 1998;23:2625-2630.

17. Jarvik JG, Deyo RA. Imaging of lumbar intervertebral disc degeneration and aging, excluding disc herniations. Radiology Clinics of North America 2000;38:1255-66.

18. Jensel MC, Brant-Zawadzki MN, Obuchowki N, et al: Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med 2:69, 1994.

19. Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychological yellow flags in acute low back pain: Risk factors for long-term disability and work loss. 1-22. Wellington, NZ, Accident Rehabilitation & Compensation Insurance Corp. of New Zealand and the National Health Committee, 1997.

20. Kendrick D, Fielding K, Bentler E, Kerslake R, Milller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ 2001;322:400-405.

21. Lackner JM, Carosella AM. The relative influence of perceived pain control, anxiety, and functional self-efficacy on spinal function among patients with chronic low back pain. Spine 1999;24:2254-2261.

22. Linton SL, Hellsing AL, Andersson D. A controlled study of the effects of an early active intervention on acute musculoskeletal pain problems. Pain 1993;54:353-359.

23. Linton SJ, Hallden K. Risk factors and the natural course of acute and recurrent musculoskeletal pain: Developing a screening instrument. Proceedings of the 8th World Congress on Pain, Progress in Pain Research and Management, Vol 8, ed. Jensen TS, Turner JA, Wiesenfeld-Hallin Z, IASP Press, Seattle, 1997.

24. Linton SJ, Hallden BH. Can we screen for problematic back pain? A screening questionnaire for predicting outcome in acute and subacute back pain. Clin J Pain 1998a:14;1-7.

25. Little P, Roberts L, Blowers H, Garwood J, Cantrell T, Langridge J, Chapman J. Should we give detailed advice and information booklets to patients with back pain? A randomized controlled factorial trial of a self-management booklet and doctor advice to take exercise for back pain. Spine 2001;

26:2065-2072.26. Luoto S, Heliovaara M, Hurri H, Alaranta H. Static back endurance and the risk of low-back pain. Clin Biomech 1995;10:323-324.

27. Malmivaara A, Hakkinen U, Aro T, et al. The treatment of acute low back pain - bed rest, exercises, or ordinary activity? N Engl J Med 1995; 332:351-5.

28. Mannion AF, Junge A, Taimela S, Muntener M, Lorenzo K, Dvorak J. Active therapy for chronic low back pain. Part 3. Factors influencing self-rated disability and its change following therapy. Spine 2001;26:920-929.

29. Radebold A, Cholewicki J, Panjabi MM, Patel TC. Muscle response pattern to sudden trunk loading in healthy individuals and in patients with chronic low back pain. Spine 2000;25:947-954.

30. Royal College of General Practitioners (RCGP)1999. Clinical Guidelines for the Management of Acute Low Back Pain. London, Royal College of General Practitioners (www.rcgp.org.uk).

31. Simmonds MJ, Lee CE 2002 (scheduled publication). Physical performance tests: An expanded model of assessment and outcome in Liebenson C. (ed) Rehabilitation of Spine: A Practitioner's Manual (2nd ed.) Lippincott/Williams and Wilkins, Baltimore.

32. Takala EP, Vikari-Juntura E. Do functional tests predict low back pain? Spine 2000;25(16):2126-2132.

33. van den Hout JHC, Vlaeyen JWS, Houben RMA, Soeters APM, Peters ML. The effects of failure feedback and pain-related fear on pain report, pain tolerance, and pain avoidance in chronic low back pain patients. Pain 2001;92:247-257.

34. Vlaeyen JWS, Linton S. Fear-avoidance and its consequences in chronic musculoskeletal pain. A state of the art. Pain 2000;85:317-332.

35. Waddell G. The Back Pain Revolution. Edinburgh, Churchill Livingstone, 1998.

Craig Liebenson,DC
Los Angeles, California



Click here for more information about Craig Liebenson, DC.

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