Sam,

You: "My concerns lie firstly with such an obviously mechanical approach."
Me: If you mean that versus a biochemical approach (in which the mechanical aspect is if no or little relevance), I can assure you that McKenzie pays due attention to that aspect in his books! In fact, on more than one occasion in the McKenzie clinical discussion group the group came to the conclusion that a certain patient probably had a primarily biochemically determined complaint versus a mechanically determined one. 

If you mean that versus a behavioural appoach, you're in deep trouble. Not so much with me, but with the state of affairs concerning science, and therefore concerning EBP/EBM. I've extensively studied the general behavioural approach, but cannot distill a practical method that can generally be applied to patients with physical complaints. McCracken & Turk seem to share my conclusion in a recent review (1). The major problem is that 95% of the studies finding a correlation between psychosocial variables and physical pain/disability (so what's new?????) do <not> determine which comes first.

 

If you ever had one patient with a RSD, who, as in my case, was a joyful, sports-minded and socially happy women before she underwent the arthroscopy a couple of years ago, and is now in a wheelchair due to the subsequent rapidly developing RSD, with recent suicidal(!) thoughts because she could do practically nothing anymore of what she loved to do, you'll understand my drift.

 

We have to be very careful with labelling patients with (chronic) complaints as "between the ears".

 

I <fully> acknowledge the influence of psychosocial variables in (reported) physical complaints. The evidence when it comes to Workers' Compensation is <overwhelming> (2). But that is just one variable. What do we know about the others? Why is it that more elderly patients seek help for not being able to walk longer distances because of increasingly radiating LBP, and young and middle-aged patients usually tell that the LBP is the worst when they stand up, but the pain decreases when they walk a while? Where is the behaviour model that explains that, based on (if it were only circumstantial) evidence? McKenzie offers an an (at least acceptable) explanation for it, based on extensive (be it circumstantial) evidence.     

 

You: "I do think it is dangerous for a junior physio to concentrate so fully on one aspect of our practise, so early in his/her career".

Me: I'd say: we're <physical> therapists. We need to know everything there is to know about the biomedical approach. We also need to know those aspects of the psychosocial side of the story that have been established as being clearly correlated with physical complaints. I.e.: the psychosocial red or reddish flags. But that's it, for now. A behavioural therapist should know everything there is to know about the psychosocial side of the story. A behavioural therapist should also know about those aspects of biomedical aspects that have been established as being clearly correlated with behavioural complaints. The "referee" as to which patient should go where, at first, is the general practitioner. If s/he does his/her work well, <we> can focus on the primarily biomedical aspects.

 

In short: I think Ben, assuming he whole-heartedly chose the profession of physical therapist, should learn as much as possible about the biomedical approach as possible. And <especially>, should be given a workable model that has (<uniquely>) been proven to be reliable in terms of diagnosis, includes almost all subtherapies (with the last one probably to come), and can count on a large amount of circumstantial evidence to prove its validity. If we were to send him to therapist-teachers or a school that know(s) only one or two sides of the biomedical story, he will be deprived of teachers that can teach him a multi-faceted biomedical model with a logical model as to when to do what. Guru or no guru (in fact, the literal translation of 'guru' is: teacher).

 

Folks who suggest he should invent the wheel himself should by a bike. They're available.      

 

References:

1. McCracken LM, Turk DC, Behavioral and Cognitive-Behavioral Treatment for Chronic Pain: Outcome, Predictors of Outcome, and Treatment Process. Spine 2002; 27(22):2564-2573.
2. Conijn FJJ, The BPS Model. Physical Therapist's Literature Update 2001; 1(5): Editorial (www.ptlitup.com | Archive & Search | Editorial March 2001 [free]).

 

----- Oorspronkelijk bericht -----
Van: Sam Bowden
Aan: [log in to unmask]
Verzonden: zondag 26 januari 2003 9:34
Onderwerp: Re: LBP & neuro signs dilemma


Frank thankyou for your reply,

I have no wish to criticise an approach unduly (and hope that i'm not) but
simply see problems with some peoples understanding/application of the
approach( That i have experienced the same concerns with accredited PT's
concerns me even more!). There are by all accounts useful aspects in the
assessment, and I would hope that I have tried to identify them and apply
them within my own work.....

My concerns lie firstly with such an obviously mechanical approach. In
view of recent advances in understanding pain processes/chronic
pain,/influence of other factors, any approach (whether guru led as in
this case or not) that relies so heavily on mechanics would be of concern
for that matter. I appreciate that the approach attempts to (soften)be
more inclusive of other ideas...but somehow it always sounds to me like
everything else gets tagged on the end when the purist aproach doesn't
quite work?

Issues regarding Physio preferences, might I think revolve more around
considerable marketing brilliance (one of the first courses I knew about,
where you had to take parts in an order, and if you left it too long you
had to start again)! No problem with that, except it always feels that
conversion to the way is really the only way? Remember the average
practitioner qualifies, realises they weren't taught the whole truth and
nothing but the truth, and then somebody offers them a nice recipe- and
even better it has some evidence behind it....maybe this illustrates a
lack of decent research fullstop, as opposed to anything more?

I'm certainly not advocating applying hot packs, massage and some SWD OR
ignoring a McKenzie approach,but I do think it is dangerous for a junior
physio to concentrate so fully on one aspect of our practise , so early in
his/her career.

Sam Bowden