Dear Di, Kevin,
Here's a few ref's re- recovery from an acute episode of LBP.
1. 70% of LBP patients recover within 2/52 with 90% recovering within 4-6/52. Institute for clinical systems integration - Health care guidelines, acute LBP, 1998.
2. 50% of nerve root pain patients recover within 6/52. Royal College of GP - Clinical guidelines for the management of acute LBP, 1997.
Regards
Michael
>>> "kevin reese" <[log in to unmask]> 03/05/00 09:57pm >>>
Dear Di
Thanks for your response and there are some very interesting issues which you have raised.
Firstly the 90% figure, on what evidence are you basing this. I have seen a BMJ report that suggests 60% recovery rate in 6/52 are there others?
Secondly the NHS in which I work, has waiting lists which mean that I only treat the chronic in your definition. I do not overtly use psychosocial techniques but yes of course an experienced physio will have home grown councelling skills if they are remotely empathetic.
Why does a syndrome that has gone chronic automatically taken on a psychological emphasis. Could it not simply be an unresolved musculoskeletal problem?. I have lost track of the number of patients I have treat with manual therapy, who have had pain for many years and got a good result in a short period of time.
Of course any physio worth their salt will not persist with a treatment strategy which only has a very temporary effect, but why do you think this suggests a psychological approach is needed and not another manual/rehab therapy approach?. Perhaps it is not extrinsic just an intrinsic we have not come to terms with.
Also no physio worth their salt would not advise/empower/give specific stragies to help with a syndrome. This is not peculiar to the biopsychosocial model and has been kicking around physio for years. I am surprised you feel physios are either not doing this or blindly persisting with ineffective treatments. No one I know does.
So basically if we are so far off the mark, please explain with evidence not opinnion. I have re read this and it sounds curt, and I don't mean to, I just don't know how I can re-phrase.
Regards Kevin
-----Original Message-----
From: acthydro1 <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Date: 05 March 2000 00:11
Subject: Re: spinal psychology
Jill & Kevin
I agree completely! Why is it only for the spine that chronic pain or
patients that don't seem to improve immediately as a result of our treatment
that we automatically assume that it must be psychological?
>> Jill, I think that you've missed the boat here. It is widely accepted that approximately 90% of people presenting with spinal pain will improve within 2 - 6 weeks. The types of patients that do not improve (ie have chronic spinal pain), I think can basically be divided into two groups.
1. The group who over time have increasing difficulty "coping" with the constant pain and as a result of this pyscho-social factors play an important part in pain management and learning to deal with the condition ie:
problems due to a change of roles in the relationship; feelings of reduced self-esteem due to not being able to carry out their normal role in family life whether that be caring for the family or as primary income earner; societal pressures or perceived pressures. These feelings of anger; depression and withdrawal can have a very real effect on central processing areas (Central sensitisation refer D. Butler) and pain perception.
2. The group who have had psychosocial factors pre-existing in their lives eg past history of depression; problems with teenage children; hate their jobs; financial pressures; unhappy marriages ...and the list goes on...
I thinK that if you look carefully at those patients of yours presenting with chronic pain (of any desription ie spinal or otherwise)..you will find that these issues are either there or becoming increasingly prevalent. I do not think that anyone is saying that they have a "psychological" problem meaning that it is all in their heads and yes they do require our skills as Physiotherapists but we also have the opportunity to talk to them about how other things affect pain perception and how it is important that if there are other issues that they think may be affecting their ability to cope that they would be better to talk to someone who is qualified in this area.
This is an important part of taking control and "ownership" of their condition and moving to an acceptance that there are things that they can do to assist making their lives more manageable.
We know very
little about the spine, so instead of trying other treatment methods or
referring the patient to another practitioner who may try another approach,
we automatically lay the blame to the patient, i.e. not compliant, is under
too much stress, isn't following PT's advice, or has some underlying
psychological issues that must be addressed. Could it be (dare I say it)
that we tend to say anything to our patients except the truth- maybe we
don't exactly know what's going on, why they're not responding to our
treatment, that maybe we just don't know?
It is important not to blame the patient and I do not think that the majority of physios that truly understand and work with chronic pain patients would ever do that!
As physiotherapists (speaking from my perspective), we are not pop psychologists and should not let psychological issues be in the forefront of our minds every time we evaluate a new back
patient just because they're back patients.
No we are not psychologists but we are often in a position where we can identify if there are other issues going on that may be affecting these patients coping mechanisms because we spend a lot more time with them than their doctors and we have an important role in assisting with this by referring on if necessary or bringing it to the attention of the patient and their GP. (It is very important when discussing issues like this that the patient understands the link between extrinsic factors (ie psychosocial) and intrinsic factors (their injury and processing areas)
? If we're so fast to jump to non-mechanical
conclusions, we could easily miss many of these problems (I know firsthand
that this happens).
This is a tricky one...the nature of spinal pain is so complicated that often a "mechanical cause" cannot be found and even if it can eg bulges on MRI, may not necessarily be related to injury. I know that the majority of patients that I see are of the Non-specifc variety. It is likewise in these situations to ensure that we use our skills to assist the patients to understand that back pain is very complicated and can involve many strucures and just because a "cause" cannot be found that it does not necessarily exist.
How many patients with other pathologies at other joints do we treat,
knowing the patient is fairly non-compliant & has other issues, etc, and yet
our patient still gets better? This should tell us something.
Yes it tells us that they probably would have got better anyway ie part of the large percentage that do with our intervention and there probably wasn't a large neurogenic component to their problem.
Please have a read of David Butlers; MOBILISATION OF THE NERVOUS SYSTEM if you want more technical info. Research is continuing and physios are at the cutting edge. How about getting on board!
All the best
Di Howell
Physiotherapist
Canberra
Australia
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