First up:
‘Re-writing ‘Colonel Bogey’ – can chronic pain be forgotten’
and second up:
For any of you who like the ‘tricking pain’ idea – you’ll probabaly enjoy this book:
‘Sleights of Mind: What the neuroscience of magic reveals about our brains’ by Stephen Mackik and Susan Martinez-Conde with Sandra Blakslee. Profile Books 2011.
Hope you enjoy
Louis xx
Hi
Apologies for the rather tossy title of this post – ‘Post hoc,ergo propter hoc!’ – it was actually the title of a PPA editorial I did back in December 2006. I’ll come to ‘Pink flags’ in a moment…
I’ve posted the Post hoc editorial pdf up:
Gifford LS 2006 Post hoc, ergo propter hoc! PPA News Issue 22:3-7
The reason I’ve put it up is because David Collis posted the following…..
Healthy sceptism about predominently anatomical/biomechanical models of assessment/treatment lead me to your writing in the early 2000s and eventually attending your ‘aches and pains’ course in Tamworth 2004. Despite many influences (mainly signposted to by the somasimple crowd) it is you I credit for allowing me to see the much bigger picture in terms of pain, and that the mature organism model/neuromatrix should be applied with all patients in pain, regardless of time scales. Even though I have seen increased awareness of pain physiology over the years, it is still an approach that seems to be half-heartedly trotted out for those patients who have failed to respond to the obligatory correcting of ‘imbalances’ and pressing of sore spots.
I hope that your online presence will reach as many people as possible to help shape our profession for the future.
I would be interested in your thoughts about how you, if indeed you did, integrate manual therapy into your explanatory model/treatment? It is my experience that no matter how little percentage of your treatment time is passive treatment, then this is what the patients’ view of their treatment becomes. Explanations seem to become secondary to the “manipulation” you perform..
Thanks are not enough.
David Collis
Thanks David you’re very kind, as are many others, and you make some great points, …….and…… I hope the editorial linked above answers some of the points and questions you make! See the case histories and my reasoning comments in particular.
To me, the shopping basket approach (see last post and the three associated papers in the downloads) actually helps you to see when and how to integrate ‘passive’ or ‘manual’ therapy into the management picture.
A very very brief case history that might help follows….(but please read the post hoc, ergo… editorial first if you can!)…. What I’m trying to illustrate in the case history is how the shopping basket approach is used to lead you and the patient to the most important requirements for their problem – and that this needn’t be ‘treatment’,’manual therapy’ or ‘explanations’……
Lets take a young fit rugby player who injured his right shoulder over a year ago and hasn’t played since. In fact ‘Stuart’ has been very protective of it and only feels confident with it when swimming. He says it aches intermittently and there’s a ‘clunk’ when he rotates his arm backwards. In his shopping basket ‘compartments’ are the following:
Biomedical, Compartment 1: – No red flags, no shoulder instability on examination, but I could reproduce the clunking by doing relaxed big range floppy postero-anterior glides of the glenohumeral joint in loose packed type position of about 30-40 degrees abduction. My thoughts? – Possible labral tear… or… many shoulders clunk like this and work perfectly normally… so keep an eye on it… acknowledge…explain…. but don’t make a big deal of it…Could refer to orthopod but what’s the point until he’s got going, got it strong and seen if he can get back to rugby…. ? Tissues safe to start loading far more….yes! Tissues safe to get back to rugby once fit…. ? Proabably but lets give it a go and wait and see….
Pain mechanisms – best way of thinking is ‘Is the pain adaptive/maladaptive?’, rather than get tied in knots with nociceptive/peripheral neurogenic/central etc… So, to me, here’s a kid who’s suffered quite a nasty gleno-humeral joint strain – possibly injurying ligamentous and cartilaginous tissue and still has pain and compromised function after quite a long time period. Is this length of time reasonable? Well, considering the healing time of these types of tissues it could be…. but, he really hasn’t got going as well as he could. So, maybe some adaptive pain – the tissues are still healing/mending…. but the amount of pain is a tad on the too much side – so a degree of maladaptive in terms of the amount of pain. The biggest deal is his lack of confidence and fitness (local and general) …. see below….
Compartment 2: Psychosocial barriers? Has been told he has a ‘bursa’ problem by some local therapist who has an ultrasound scanning machine – all treatments received have emphasised go carefully, and something wrong, rather than something was wrong/injured its healing and needs normal forces through it to reach the best possible healed state….. So, he’s been activity avoidant for over a year except for swimming – which he says feels good – and he can swim hard, any stroke… including backstroke and crawl. He’s bored and fed up as Rugby is his life….he’s starting to feel he’ll never get better and won’t ever play rugby again. He has intermittent sleeping problems due to his concern about turning onto and hurting the shoulder. He’s bored out of his brains and put on a bit of flab.
Compartment 3: Disability/functional limitations. This guy had not only stopped all rugby, he’d stopped fitness training, gym, cycling, running…Plenty to start getting going with straight away.
Compartment 4: Physical Impairments… This is the compartment that most physio’s obsess about and get very possesive about…the little bits and pieces found on physical examination that we like to do manual therapy on…For example, I bet he had lots of ‘muscle imbalance’ and abnormal subtle movement anomalies…(yawn) With this lad – he had weakness in all shoulder muscles, – tested using simple grey theraband pulled and pushed in all directions repeatedly – and getting him to compare the feeling of strength/tiredness/weakness relative to doing it with his good left arm first…. By doing this he could instantly see that he was considerably weaker…. He also had full range movement, but simple ‘stiffness’ feeling at end range of all movements. Although full range his movements were tense, slow and protective. There were no signs of bursal impingement at all.
Compartment 5 and 6: General and Specific Physical fitness. – covered enough above – and needs addressing….
Compartment 7: Pain – the ache – which was around the point of the shoulder and the anterior joint line, plus increased tenderness to the tissues under the pain. As discussed a bit of adaptive due to slow nature of healing …. plus maladaptive as too much pain for length of time it’s been going on… I’m reckoning on it being helped by getting him fitter and changing his perspective on the pain – downgrading it to ‘normal’ and to not worrying about it so much. Getting going and seeing that he can get going and stronger should help his confidence… distract….etc.
So, Stuart gets my summary of ‘his shopping basket’ – I could almost ask him the answers to ‘Stuart, what have I found?’ ‘what have I put in your shopping basket of things to start working on….?
‘OK Louis you found the following:
‘I can move it well but it’s a bit stiff at the end of all ranges…. It’s considerably weaker in all directions when I make it work under load….That I haven’t kept my general fitness up or the fitness of the shoulder up and it needs this to help the final recovery phase….. That I’ve been a bit too cautious with it, especially in the last few months…. That it doesn’t look like there’s anything seriously wrong, you’ve explained what the ‘labrum’ is to me and that small tears and clicking from it are very common, but needn’t stop me from using the arm strongly…and there’s always the option of an orthopod later if needs be…..and I’m being a bit of an over-protective wimp with it…. etc….
‘Good, Stuart.. now, lets get going…… I want you to start getting a lot fitter… but start easy…build slowly at first … (I make suggestions for bike, jog/run/get going…and keep going with swimming)…. also, lets get the shoulder muscles fitter – good strong muscles that are confident and react quickly are joint protective… they need to be as strong, if not stronger than the left side… – Start with the theraband – slow at first to get confident, then build up…and if all’s going well it’ll be back to the gym, pull-ups, press-ups and so forth… I’ll monitor and guide you for a week or two…if there’s anything wierd going on with your patterns of movement later on I’ll devise some special exercises to help improve that… There’s nothing I can do about the clicking – though sometimes when people get fitter, the tone comes back in their muscles, the clicking gets less… best thing is to accept it, and not worry about it…. I’ll keep an eye on it. Next time you come in I may spend a bit of a time giving the shoulder a good loosen-up… see if we can’t help some of that stiff feeling you’re getting.
So, the next time he comes in – he’s a changed lad… he’s had the green light… I’ve told him not to get upset with the pain coming and going – that’s normal… it turns out that when it does come, it soon settles… all good… I tell him to be freer and less protective of it… Time to get down the gym… even get the boxing gloves on and thump the bag… but ‘start easy build slowly’ – a la graded exposure…. I taught him, he knows the rules… I get him doing pull ups on my pull-up bar and press-ups from his knees. Then I spend 20 mintues doing heaps of hands-on to his shouder – lots of big accessory glides in abduction and flexion, some easy stretches in all directions, lots of soft tissue into the shoulder… so that when he gets up he says… ‘ feels best its felt for a year…’
3 Weeks later he calls because I asked him to. He’s back doing rugby training and building up. It’s still clicking but it doesn’t bother him. He uses ice pack if it goes a bit grumpy. He’s positive and virtually stopped thinking about it. etc etc…
Moral of story… see the bigger picture – use a shopping basket… don’t wallow in the ‘Impairments’ compartment or some Guru’s cure all technique that only focuses on pain response… shopping basket it!!… rehab it!!…. put the whole thing in the context of normal recovery and natural history….don’t start harping on about central pain mechanisms and all the compexity of pain explaining – it’s inappropriate here… get the guy going and confident in himself again… We get so many patients at our practice who’s treatment has been over focused on tissue impairment. For example, patients like Stuart who have been told to do shoulder stabilising exercises and movement abnormality correction routines..and nothing else….Jesus… this guy can swim for 45 minutes and feels great… sure he’s ‘compensating’ but that’s because his general shoulder/arm/right quadrant are inhibited/weak… just get them going like any good hunter-gatherer would!
So, I’d like David Collis, and everyone else who has the same problem, – that the patient sees what you did to them in terms of the passive hands on as the big deal, and all the rest as a lesser side issue…. to see that it’s how you go about it… explaining the findings from the shopping basket as you go along… so the patient can see what they need to do… (as I tried to illustrate, the patient should almost be able to tell you what you’ve found, what they need to do and what you can offer..) and… that there are bits and pieces that you can do for some of the compartments too… like me mobilising his shoulder… It’s all about how you set the scene with the patient.
Now Pink flags!
They’re the opposite of ‘Yellow flags’ as you’ll see when you read the piece. Just go find your ABCDEFW yellow flags, learn them and then turn them into the exact opposite to get the best results….. and… when you’re doing your history taking/subjective and objective – look for pink flags – look for the ‘good’ signs and tell the friggin’ patient….!
When I do a physical exam I tell the patient that they’re going to do movements and I’m going to watch and they’re going to tell me…. and that I want to tell me first up what feels normal and good…. and second up what doesn’t … and that I’m just as interested in both… the good the bad and the ugly… but more the good. Get it? That’s pink.
Medicine and professions allied to medicine are by their very nature an the search for ‘bad’ and fixing bad…. all research has been done on how things go bad, how they hurt, how they stop working…. the research on natural recovery is shockingly lacking. If we knew more about recovery and the best conditions for recovery, we might just be getting somewhere… hopes, hopes…. the future is pink folks….
hope you enjoy anyway…
Big thanks to Zara Hansen for her wonderful memory of my ‘crap’, you made us really smile, Thanks Zara, and everyone who’s posted such supportive comments! xxxxx
Louis
Wo! this is going faster than I ever imagined. First up thanks to those of you who have signed up to ‘follow’ and an even bigger thanks to those of you who have posted such amazing comments.
I really wasn’t ready for this to go ‘out there’ but Adam Bjerre from Denmark found ‘me’ and left a message on the soma simple website… and off it went… I’ve thanked Adam very much but had to quickly re-tweak a few pages and realised I hadn’t quite included everyone in my story bit… particularly Ian Stevens from Dunblane and two very special American friends Bernie and Ellen Guth. I’m also struggling a bit with sorting the ‘blog’ page and all the ‘reply’ stuff… I’m getting a hand with that from time to time and trying to be a patient patient. Bloody widgets and side bars…..
Anyway, next up the 3 part series I did for the Organisation of Chartered Physiotherapists in Private Practice(now called ‘Physio First) journal: ‘In Touch’. The articles are a bit of my 2001-2003 spin on biopsychosocial/multidimensional thinking and an introduction to the ‘Shopping Basket Approach’ – The way I think and reason with patients given all the evidence base meshed with my own thoughts with regards biomedicine, healing and recovery, pain mechanisms, disability, function, impairments, fitness and the the various ways of thinking about and dealing with pain. Part 3 gives a patient example which may help!
I’ll also put up the clinical reasoning article I did with Dave Butler and a lengthy complex pain case history that was published in Mark Jones’ book ‘Clinical Reasoning for Manual therapists…. so you can see where I came from and where I ended up. When you read the case history note how Mark Jones keeps asking and harping on about bloody abdominal muscles! I love Mark to bits but he did seem to think I’d missed something with this lady… Anyway see what you think…
While on abdominal muscles, don’t forget their main function before we all went and sat down in front of computers and moved around in cars… – breathing! Panting! Shouting… Not…. tensing to pick a pen up from the floor, or doing sit-ups – unless you’re like me and have to get out of bed to have a pee 5 or more times a night….
Hope you enjoy and I really appreciate everyone who’s joined in… and made such encouraging comments..
Louis
I have now put up the full ‘McKenzie debate’ debate on the ‘Download’ page. It’s here!
I would like to point out that the Mckenzie Institute did not publish any of my material or Mick Thacker’s article in their newsletter. They only published the critiques from their own faculty and members, some of which called my stuff a ‘diatribe’. I was unimpressed but not surprised. I got what I deserve I guess, but I thought I was being pretty reasonable!
Anyway, I hope this debate can still get you thinking, – even though it was printed in 2002 over 10 years ago…. The McKenzie operation seems as vibrant and as powerful as it always was…… or is it?
After the pounding I was given back then I’d like to point a few things out…. and look, the points below are general things that re-reading the McKenzie Institute replies to my original editorial have made me think of… they could be applied anywhere…
First up: Remember, good science should set out to try and disprove a given observation or hypothesis. We should be testing to see that a given treatment doesn’t work, or that there’s no relationship between two observations, or ‘measured’ phenomena…..Start out sceptical and then if your results reject the ‘null-hypothesis’ the results hold far more power.
To me good science means that we should be sceptical about the many clinical ‘truths’ we are fed by treatment ‘gurus’ and that’s what I was and still am in the debate here.
Second, I’m interested in the common statement:- ‘no one gets worse with my treatment’! Or, ….’in all the trials we did, no cases of worsening were reported…’
When I was teaching I used to get a class of 30-40 physiotherapists on the course to raise their hands if they’d had patient’s come to them who’d been made worse by other practitioners. For example by forceful manipulation, forceful exercises, forceful end range extension, combined movements, hard pressures… even simple gentle stuff, whatever. Every time I asked this question a vast majority raised their hands. Many were keen to tell their stories. When I then asked if anyone had made any of their patients worse – hey, I was the only one to raise my hand!
My point is that patients often do get worse from seeing ‘other’ practitioners… for physio’s we like to blame chiropracters and osteopaths, but I bet if I’d asked the same question to a group of chiro’s or osteopaths I’d get the same show of hands… and they’d be blaming physio’s!! This clealy needs researching and would make a great project for someone. I’m mentioning it because in my clinical experience, not only did I make patients worse (sometimes a lot worse), I frequently observed patients who’d been made worse by others – and I mentioned this in the McKenzie editorial, because I particularly saw patients with low back pain that had become sciatica following a strict regime of McKenzie repeated movement using the extension principle.
Third, I was lambasted by the UK McKenzie Institute for equating ‘McKenzie’ treatment with extension exercises to the vast majority of the world – but this is massively born out by the numerous Youtube vids and internet articles you can very easily find (e.g.this)…. plus… the McKenzie Institute’s International Extension Award – known within the Institute as “The Bronze Lady” – is a bronze naked lady doing an extension in lying exercise….I know the method uses other movements like into flexion, side gliding in standing etc… I did the courses with Robin McKenzie himself back in the early 1980’s… but…!! ….Please make sure you read my response ‘editorial’: ‘Memes dreams and dualism, the flexion extension debate and beyond’.
You must also make sure you check out the ‘Williams’ flexion exercises for acute low back pain too.
Fourth. Researchers who look at their favourite treatment (often their major source of income) and try and prove it are not to be trusted unless they are very open. That’s why it’s always wise to check who the researchers are being paid by or who sponsors the research…….
Did you see the recent headline in the UK Daily Telegraph: ‘Antibiotics could cure 40% of chronic back pain patients….Up to four in 10 cases of chronic lower back pain could be cured by antibiotics, research has suggested…..
and then comments like….
“Make no mistake this is a turning point, a point where we will have to re-write the textbooks,” says Peter Hamlyn, a consultant neurologist and spinal surgeon at University College London, as quoted by the U.K. Telegraph. “This is vast. We are talking about probably half of all spinal surgery for back pain being replaced by taking antibiotics … It is the stuff of Nobel prizes.”
Now do a little research (Thanks to my mate Ian Stevens!) – about the authors and you find this….
A widely publicised study which claimed antibiotics could relieve up to 40% of lower back pain failed to disclose its authors’ potential conflicts of interest, it has emerged. Three authors did not state they serve on the board of a UK company that receives money to certify doctors in antibiotic therapy. The publicly-listed Modic Antibiotic Spine Therapy Academy, or MAST Academy, charges £200 ($310) to certify doctors in how to identify and treat modic back pain with antibiotics. Clinicians can alternatively take an online course for £100 ($155)….. The Danish study was widely publicised after it was published in the European Spine Journal in early May…. The authors claimed that the cause of up to 40% of lower-back pain was a common infection in the vertebrae that could be cured by antibiotics.
Many practitioners come wielding some expensive product for you to buy aswell…… care again!!
Fifth: Research that doesn’t give the results ‘wanted’ by the sponsors, drug company or Therapy Institute …. doesn’t get published, it gets binned. (That would be a good research project if it was possible to access all the research archives….) Are there any whistle-blowers out there??? It’s a trendy thing to be one….!
Sixth. Make sure you look for a part of a ‘treatment’ or ‘intervention’ related research script or paper that has a ‘made worse’ column which gives the details of how and what was worse. There’s no such thing as a treatment that doesn’t make some people worse, there’s also no such thing as a treatment that makes 100% of people 100% better either. If you see results that suggest over 70% of subjects got 70% or more better… particulalrly for human musculoskeletal pain states…. get suspicious…. Also, sometimes bad figures can be made to look good because none of us are good enough at research stats to see through it…
Seventh. As humans we tend to only listen to evidence that supports our stance or beliefs and avoid, ignore, reject, ridicule (call it a diatribe)… evidence that might challenge it. Buy and read Stuart Sutherlands’ book: ‘Irrationality’ In fact buy 2 and give one to your local Parliamentarian!
Eighth. It might just be me, but in the last 4-5 years I’ve seen far fewer patients with the ‘fear of flexion/bending’ and ‘extension made them worse’ problem. – It maybe because the population of Mckenzie therapists in this area moved out long ago, or, that the McKenzie ‘fad’ isn’t quite what it used to be here in the UK, well, here in Cornwall…. in other words, maybe clinical folk are being more ‘graded’ in their approach…like I suggested!! Certainly the heavy- manipulating bone-setters, chiropracters and osteopaths seem to have virtually vanished and given way to far more gentle techniques..!.
Points done.
I was genuinely sorry to hear of Robin McKenzie’s death recently. He was a great character, teacher and promoter of movement and self management – which was very refreshing back in the very passive therapy orientated days of the early 1980’s when I attended his early courses.
I think this ‘debate’ material, or stuff like it, should be mandatory reading for all McKenzie/physio/manual therapy courses. I do have some further thoughts on the ‘centralisation’ phenomenon – but I’ll save that for another time! There’s also a need for a discussion on this ‘mechanical pain’ thing too. Arghhh!
Anyway, good luck and enjoy! Remember, it’s fine to criticise, but do it nicely, no spitting! I just want to get everyone thinking and using rational science.
Louis Gifford June 2013
Thanks to all of you who find this site and have a look around. Take what you want, read, maybe even study…. and hopefully enjoy.
Over the coming weeks I will be posting more and more of my published work up. Any requests please leave them here and I’ll see what I can find in my archives!
I’m not entirely sure if blogging is 100% my scene as I’ve viewed a few that are a bit sickly and they’re ‘it’s me’, ‘make me money’ and ‘sell my products’ centred, but others that I’ve thought, hey, great to access this person’s stuff so easily and be able to have a discussion with them too…. they enjoy their work and want others to…. That’s how I’d like this place to be. Of course, anyone who thinks and writes wants others to read their stuff, otherwise, what’s the point.
It’s been about 25 years now since I started out wondering what pain was really all about and getting better answers. I’ve had a good trip and I’m trying to get my ‘book’ finally out although time is pressing for me a bit now.
Over the years I’ve had a lot of requests for my writing from overseas and abroad – and realised that a great deal of it rests in hard to get and hard to find places, much of which is no longer available. Of course, the internet makes access so much easier. So, here it is.
Look, one of the main reasons I ended up filling my head with pain related stuff was because I wanted better answers for my patients when they asked awkward questions.
Like…
‘Louis, one day I was absolutely fine, I went to bed fine, slept fine and then woke up hardly able to move my neck…..the pain was down my arm… I can’t think of anything that might have caused it… what do you think is going on…?
Or,
‘One day the pain was in my right arm, then it went, then 2 days later it was in my left arm…. the Dr can’t explain it, can you?’.
Or the classic awful question to some ghastly problem you haven’t a clue what’s going on…… ‘How long is this going to take to get better?’ In the old days I’d say something like…. ‘er, that’ll be easier to judge after a couple of treatments’….. and hoped that they forgot to ask you again…
…. and there are better answers, a lot better answers!
More soon!
Thanks,
Louis.
louisgiffordachesandpains 