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Investigations for radiculopathy: The patients’ perspective

By Clare Ryan and and Dr Lisa Roberts

Background to the study: As an advanced physiotherapy practitioner in spines, I work at the interface between primary and secondary care and radiculopathy (sciatica) is a large part of my caseload. The term radiculopathy refers to a collection of leg signs and symptoms, referred from the back, caused by compromise of a lumbo-sacral nerve root. These include pain, altered sensation and weakness. Radiculopathy differs to somatic or referred leg pain, which is caused by structures other than the nerve, such as the joint, ligament or muscle. Radiculopathy is an important condition to manage well as people can experience severe pain and poor outcomes, with at least a third reporting significant, on-going symptoms 12 months after onset.

The decision whether to request investigations for people with radiculopathy is often a difficult one. Existing research tells us that diagnosing this condition accurately, using clinical assessment or imaging is problematic .1;2;3 History taking may not clarify whether the patient’s symptoms constitute radiculopathy, examination may not exclude other causes, and investigations may not detect a structural cause. There is also concern that investigations may result in patients and/or clinicians focusing unnecessarily on largely irrelevant findings, making recovery slower4  and increasing the likelihood that patients will undergoing treatment such as injections or surgery, based on scan findings that may well not account for symptoms (and are therefore much less likely to respond to treatment).5 Whilst clinical guidelines suggest that investigations should be used only when likely to change the patient’s management,6;7 in practice a fine line exists between under and over imaging. Particular difficulty can occur when patient and clinician differ about how important investigations are to managing the patient’s symptoms, and when the reasons for patients wanting a scan may be primarily psychosocial e.g. to provide reassurance, address concerns or fears, to provide legitimisation for absence or altered activity, or for medico-legal reasons.

For this research, we particularly wanted to explore the patients’ perspective of investigations for radiculopathy and to understand how this information could be used to improve current practice. Although two existing studies have explored the perceptions of people with low back pain who have undergone investigations 8;9 these studies are more than 10 years old, do not identify the perceptions of people with radiculopathy and refer to investigations such as x-rays and myelograms, investigations now rarely used in radiculopathy. Importantly however, one of these studies8 identified that the concordance (or match) between investigation findings and clinical presentation might influence people’s experiences of investigations.

The aims of this study were to explore how people experience investigations for radiculopathy and how the concordance between clinical presentation and investigation results affects this.

Method: We interviewed people who had recently had investigations for a clinical diagnosis of radiculopathy (based on Kongsted et al’s (2012)10 criteria). We located the study in a UK, primary care, NHS, musculoskeletal service, in a spinal interface clinic.  We asked participants about their clinical diagnosis, their initial thoughts about having investigations, how the results compared with their expectations and what, if anything, investigations added to their care.

What did we find? The study included 14 participants, who had experienced radiculopathy for between 3 months and 9 years (average 13 months). Everybody who took part had been investigated using MRI. Half of the participants had investigations results that were concordant their clinical presentation (i.e. clear evidence of nerve root impingement at the level and side of their symptoms), a further 5 had potentially relevant findings (such as an annular tear or foraminal narrowing at the level and side corresponding with symptoms) and 2 had no relevant findings.

We identified three key themes about how people with radiculopathy experience investigations: accessing investigations, why investigations were wanted and the effect of investigations.

Why investigations are wanted: People wanted investigations to gain an accurate, certain diagnosis that explained the cause of their symptoms, and excluded a serious cause, such as cancer. They felt that having an accurate diagnosis would enable treatment to be more effective and would inform their understanding of their prognosis. Some patients had ben advised by another health care professional (such as their physio or GP) that a scan was the next step in their care; others needed ‘evidence’ to support claims for financial support or legitimise sickness absence. There was little evidence in this study that participants recognised the limitations of investigations.

In line with previous research, these findings highlight that people with radiculopathy want to undergo investigations to increase the certainty of their diagnosis, to help them make sense of their symptoms and prognosis, and to inform treatment decision-making. These findings are important, as the informative role of investigations is not currently recognised in clinical guidelines. There is clearly a need to better educate patients about the limitations of investigations. However, due to the limitations of other methods of diagnosing radiculopathy, we suggest that future policy considers the informative role of investigations within accepted referral criteria. To be most useful, this would require changes to the way images are reported, to focus on findings that correspond to the patient’s presentation, and to make clear where changes fit within the normal range of age-related changes, and/or are unlikely to be relevant.

Accessing investigations: Participants found accessing investigations to be slow and difficult. Whilst people wanted to access scans early in their care, they had to instead attend and fail a course of physiotherapy before they would even be offered investigations. Participants waited an average of 9.5 months to access a scan. They also found it difficult to contribute to the decision that their clinician made, about whether a scan should occur. People described finding ways to ‘play’ the system, with over half attending physiotherapy solely to gain access to a scan.

These findings present a some-what bleak picture of clinicians struggling to manage the tension between prescriptive, guideline-based care and shared decision-making, and that physiotherapy is not being offered as a choice but a required aspect of management in a series of steps rather than a coherent care pathway. The findings also reflect that practice in this study does not align with the most recent NHS England (2017) guidance7 that people with severe radiculopathy have access to a clinical specialist opinion within 6-8 weeks (NHS England 2017) (or prior to this where patients have particularly severe symptoms) and that physiotherapy is no longer required prior to investigations being undertaken. Whilst the data for this study were collected prior to these guidelines being released, they indicate the need for a shift in practice and for clinicians to ensure that their practice aligns with current evidence and clinical guidelines and that the systems are in place to facilitate this.

The effect of investigations: The third key theme was the effect of investigations. When scan findings were concordant with or potentially relevant to the patient’s clinical presentation, patients were relieved that a ‘real’ cause had been found and that it was not serious. They were able to make sense of their symptoms. In these circumstances people felt they were able to self-manage their symptoms better and to actively contribute to decisions about their care. They also felt that the results acted as a turning point, enabling decisive decision-making and for their care to move forward. People were however frustrated if a long wait to access treatment (such as investigations or surgery) followed, or when their prognosis remained unchanged.

When the scan failed to show relevant findings in this study, participants were unable to make sense of their symptoms. They felt compelled to keep searching for the cause of their symptoms and did not know where in the healthcare system to turn to next.

These findings reveal the empowering effect investigation findings can have when concordant with the patient’s clinical presentation. They also reveal how distressing it can be for patients when nothing is found on a scan to explain their symptoms. These findings suggest that as clinicians we must help to manage patients’ expectations about the possible and likely outcomes of scans (before they are undertaken). Also, so patients are not left in limbo, we must proactively support people to legitimise their symptoms, help them understand why ‘no relevant findings’ have been identified, what this means for their clinical diagnosis, and what the next steps in their care might be.

Take away messages for clinical practice

For patients with severe radiculopathy we need to:

  1. Ensure that practice aligns with the most recent clinical guidelines6;7 [NICE (2016); NHS England (2017)] so that patients have access to a specialist opinion at 6-8 weeks (following symptom onset) to discuss management options, including investigations. Physiotherapy prior to investigations should be a choice, not a requirement.
  2. Provide accessible patient information about the role and limitations of investigations.
  3. Enable patients to be involved in the decision whether to investigate. This should include asking the patient’s perspective, sharing information about the limitations of investigations and discussing the possible and likely outcomes of investigations.
  4. Be proactive in providing support and a structured pathway of care for people who have a scan that fails to identify a structural cause. This should include helping patients to make sense of the scan findings, legitimising their symptoms and outlining the care options now available

Implementing the findings into practice

I loved almost every minute of undertaking this research, finding it fascinating (and at times humbling and inspiring) to better understand the patients’ perspective. However, achieving change in practice is what it’s all about, and the most challenging aspect of this project has been using the findings to achieve impact and improve patient care.

Over the past year I’ve shared the findings with clinicians and managers and encouraged them to think about how this might affect their individual practice, and about how the systems within our service could work better. The findings resonated with staff in different ways. For some the most important message was that patients believed that investigations would provide a definitive diagnosis. They have worked harder to help patients understand why scans often don’t help with making a diagnosis. For others, what stood out was how distressing ‘no relevant findings’ could be. This has helped them to better select patients for imaging, managing patients differently when scans are less likely to identify a structural cause. For me, it’s been about always asking about and exploring patients’ preferences about imaging, educating patients about the limitations of investigations and then having the courage to negotiate.

At a service level, we’ve undertaken work to help us to identify patients with severe radicular symptoms and to improve the speed with which they can move through the musculoskeletal pathway, to a specialist (physiotherapy) opinion, imaging and where appropriate into partner organisations for treatment such as injections. We’re also in the process of putting together patient information about the use of imaging. This work is ongoing and managing patients with radiculopathy remains a challenge – both to help alleviate their (often distressing) symptoms and to align their expectations, so that they are aware that investigations are only helpful in identifying whether a structural cause for radiculopathy exists (which could be a target for treatment) and that they often fail to identify a likely cause at all.

References

  1. Van Der Windt, D. A., Simons, E., Riphagen, Ii, Ammendolia, C., Verhagen, A. P., Laslett, M., Deville, W., Deyo, R. A., Bouter, L. M., De Vet, H. C. and Aertgeerts, B. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev, 2010: CD007431. DOI:10.1002/14651858.CD007431.pub2
  2. Verwoerd, A. J., Peul, W. C., Willemsen, S. P., Koes, B. W., Vleggeert-Lankamp, C. L., El Barzouhi, A., Luijsterburg, P. A. and Verhagen, A. P. Diagnostic accuracy of history taking to assess lumbosacral nerve root compression. Spine 2014:J, 14, 2028-37. DOI:10.1016/j.spinee.2013.11.049.
  3. Tawa, N., Rhoda, A. and Diener, I. Accuracy of magnetic resonance imaging in detecting lumbo-sacral nerve root compromise: a systematic literature review. BMC Musculoskelet Disord 2016: 17, 386. DOI:10.1186/s12891-016-1236-z
  4. Webster, B., Baue, A., Choi, Y., Cifuentes, M. and Pransky, G. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine 2013: 38:1939–1946.
  5. Foster, N.E., Konstantinou, K., Lewis, M., Ogollah, R., Dunn, K.M., van der Windt, D., Beardmore, R., Artus, M., Bartlam, B., Hill, J.C., Jowett, S., Kigozi, J., Mallen, C., Saunders, B. and Hay, E.M. The clinical and cost-effectiveness of stratified care for patients with sciatica: the SCOPiC randomised controlled trial protocol (ISRCTN75449581). BMC Musculoskelet. Disord. 2017:18, 172. https://doi.org/10.1186/s12891-017-1513-5
  6. National Institute For Health And Care Excellence (NICE). Low back pain and sciatica in over 16s: assessment and management (NG59) 2016. Available from: https://www.nice.org.uk/guidance/ng59
  7. National Health Service (NHS) England. National low back and radicular pain pathway 2017. Available from: http://www.ukssb.com/assets/PDFs/2017/February/National-Low-Back-and-Radicular-Pain-Pathway-2017_final.pdf
  8. Rhodes, L. A., Mcphillips-Tangum, C. A., Markham, C. and Klenk, R. 1999. The power of the visible: the meaning of diagnostic tests in chronic back pain. Soc Sci Med 1999: 48, 1189-203.
  9. Espeland, A., Baerheim, A., Albrektsen, G., Korsbrekke, K. and Larsen, J. L. 2001. Patients’ views on importance and usefulness of plain radiography for low back pain. Spine 2001: 26, 1356-63.
  10. Kongsted, A., Kent, P., Albert, H., Jensen, T. S. and Manniche, C. Patients with low back pain differ from those who also have leg pain or signs of nerve root involvement – a cross-sectional study. BMC Musculoskelet Disord. 2012:13, 236. DOI:10.1186/1471-2474-13-236

 

 

 

 

 

 

 

 

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Exploring the effects of sustained glide on scapular and shoulder muscle activity levels: a research journey. By Dan Cury Ribeiro

I am a musculoskeletal physiotherapist, who graduated in Brazil a while ago. Now I work as an academic at the University of Otago – New Zealand. When I was an undergraduate student in Brazil, MWM had not been incorporated into the undergraduate curriculum yet. So, as a new graduate, I enrolled into one of the Mulligan Concepts workshops. When I first learned about mobilization with movement (MWM), I was impressed with the immediate reduction in pain, and improvement in range of motion observed in the clinic. But I was also intrigued and asked myself some questions … how can this technique work? What does it do? Does it have any impact on muscle activity levels? Does it matter?

I wondered “what was the mechanism underlying MWM in patients with musculoskeletal disorders?” and how that led to “pain-free, immediate, long-lasting effect”. At that time, I did not have the training to design a research project to answer these questions. A number of years later, I found myself asking that question again. This time, I was working as an academic in New Zealand. This time, I had the training and “freedom” to decide and to plan a number of research projects to gain a better understanding on what are the underlying mechanisms of MWM in patients with shoulder pain.

With that question in mind, I designed a series of research projects. To understand the underlying mechanisms of MWM in patients with shoulder pain, I thought it was important to plan studies using a step-wise approach. I planned initially laboratory-based studies, with the goal of using data from these studies to inform future lab-based studies, but also clinical trials. Adopting that strategy ensured that each new study I conducted would be informed by findings and knowledge gained from previous studies.

As a first step, we decided to conduct some studies with asymptomatic individuals and explored what was the effect of sustained glides on scapular and shoulder muscle activity levels. We conducted two studies (Ribeiro et al. , 2016, Ribeiro et al. , 2017). The first study (Ribeiro, Castro, 2016) was exploratory. We wanted to know whether it would be worthy pursuing this research question. Therefore, we monitored only four muscles (i.e. supraspinatus, infraspinatus, middle and posterior deltoid muscles) during some shoulder movements. On that study (Ribeiro, Castro, 2016), we compared shoulder abduction or elevation performed with or without sustained glide. Our findings suggested significant reductions on shoulder muscle activity levels. Motivated by our findings, we designed the second study (Ribeiro, Sole, 2017).

The first study had some limitations. We just assessed shoulder movements with and without sustained glide. We did not analysed what happens to muscle activity levels before, during and after the sustained glides. In a clinical setting, clinicians would usually assess the movement first, perform the MWM, and then re-assess. Such process was not included in our design for study 1.

The second study compared clinician-administered sustained glide with participant-administered sustained glides (Ribeiro, Sole, 2017). This time, we designed a slightly more complex study: (1) used a cross-over study design; (2) assessed muscle activity levels before, during and immediately after shoulder movement performed with the glide; (3) assessed scapular (upper and lower trapezius, serratus anterior) and shoulder (supraspinatus, infraspinatus, middle and posterior deltoid) muscles.

A cross-over study design was a really nice challenge to get involved with (from a research perspective). In cross-over designs, participants are randomly allocated to two different sequences of interventions (or experimental conditions). In our study, half of participants received the clinician-administered glide followed by the participant-administered glide; while the other half received the opposite sequence (i.e. participant-administered glide followed by clinician-administered glide). The main advantage of a cross-over design study is that participants are their own controls. This is a neat approach, as it means that between-subject variability is reduced. That results in a smaller sample size (Stoney and Johnson, 2012).

Designing and analysing the second study was exciting but also challenging. The challenges with cross-over design included: (1) the risk of carry-over effects (i.e. the effect of the first intervention are long enough to influence the measurements of the second intervention) (Stoney and Johnson, 2012) and defining the wash-out period; (3) designing and conducting the statistical analysis (this was a challenge for me as an early career researcher – may not be for others).

The challenges of carry-over effect and wash-out period were linked. Not much research had been done, particular on the effects of sustained glides on scapular and shoulder muscle activity levels. We did not find any previous study using a cross-over design and assessing effects of manual therapy on muscle activity levels. Hence, we based our decision on data from study 1. The wash-out period was set at 5 min. We did not know whether this would be enough. But had good reasons to believe it would. Turned out, 5 min was long enough, and we did not find any carry-over effect in our EMG data.

The statistical analysis. Study 2 was my first study with a cross-over design, and understanding and conducting the stats analysis was a massive learning curve. Specially because I decided to run the analysis using the R Software (as I do for all my projects). I get a lot of satisfaction and bit of frustration when using R (but will leave the joys and challenges of it for another moment). To summarize, conducting Study 2 was a massive research learning. Challenging. Really exciting journey.

Findings from Study 2 showed that asymptomatic individuals had significant reductions in scapular and shoulder muscle activity levels when moving the arm while the sustained glide was applied to the shoulder. This was especially true during the concentric phase of shoulder abduction. Findings from the second study (Ribeiro, Sole, 2017) confirmed the findings from the first study (Ribeiro, Castro, 2016). That was re-assuring and encouraging, suggesting that what we are observing in the lab is a “true” effect of the sustained glide on muscle activity levels. This will be strengthen further if another research group can replicate the same findings.

Our findings also showed that there were no differences between clinician-administered and participant-administered glide. Both conditions led to reductions on muscle activity levels. Hence, no “statistically significant” differences were found between the two experimental conditions. We did noticed, though, that the reductions in muscle activity levels were larger in the clinician-administered glide condition. We believe that is due to a more precise, controlled glide that is generated by the clinician, when compared to a less accurate, less precise glide performed indirectly by the belt. This was confirmed by participants who reported they could feel a “firmer” glide at their shoulder when the clinician applied the glide. The directions of the glides are also different (Hing et al. , 2015), and that needs to be taken into account.

Together, these studies helped us to gain a better understanding of the effects of sustained glides on scapular and shoulder muscle activity levels when pain is not present.

It is reasonable to expect that manual therapy techniques have mechanical, and neurophysiological effects on the body (Bialosky et al. , 2009, Vicenzino et al. , 2011). Based on our findings, we speculate that sustained glides might improve pain and ROM due to the following factors:

  1. Mechanical effects: postero-lateral sustained glides at the shoulder led to posterior displacement of the humerus (Ho and Hsu, 2009). This posterior displacement may affect moment arm of shoulder muscles. That may have an impact on muscle recruitment. As I wrote, this is only a speculation, with no data to support it. To assess the mechanical effect of sustained glides on the glenohumeral joint, ideally, one needs to measure the position of the humeral head with regards to the glenoid cavity with and without the glide. I do not have the research expertise on the area, but this certainly brings few methodological challenges. This mechanical effect (i.e. posterior displacement) may also affect spinal and transcortical reflex circuits that regulate excitability of motor neurons (Struyf et al. , 2015). We cannot discard the fact that the clinician’s hand provide some mechanical support to the glenohumeral joint. With this in mind, it is reasonable to think that less muscle contraction is required to provide support to the joint during shoulder movement. Together, these factors could explain why we observed reductions in scapular and shoulder muscle activity levels.
  2. Neurophysiological effects: cutaneous and proprioceptive afferent discharge and changes in descending drive to motor neurons (Bialosky, Bishop, 2009). Cutaneous afferents might inhibit and stimulate motor neurons located in the spinal cord, and can impact on motor neuron threshold and the recruitment order of motor units. This mechanism could partially explain the reductions in muscle activity levels when the sustained mobilization was applied to the shoulder. I am planning some further research to assess the effect of sustained shoulder glides on the neuro-system.We conducted studies 1 and 2 so that we could understand what happens when pain is not present. That is the “normal” response to the glide. When designing and planning a research programme, it is wise (that is my take on it at least), to undertake a step-wise approach: (1) start small; (2) conduct exploratory studies; (3) improve the design of the study by analysing data from previous studies; (4) understand the foundational mechanisms of an intervention; (5) understand how asymptomatic individuals respond to an intervention (in this case a sustained glide); (6) then move into research with symptomatic individuals.

By adopting this approach, we strengthened the research design. I improved my statistical analysis skills. We gained a better understanding of what is happening in the body when we apply a sustained postero-lateral glide on the shoulder. These knowledge can be used in future research.

Now, you may be thinking, “fair enough Dan, but patients have pain. So, what is the effect of sustained glides on patients with shoulder pain? After all, patients may respond differently to this technique”. That might be true. They might respond differently. I also ask myself that same question!

To answer your question about the effect of MWM on patients with shoulder pain, we designed our third study. In that study, we compared the effect of sustained glides with a “placebo” glide. We used a cross-over study design (again), and measured scapular and shoulder muscle activity levels. Findings are very interesting, and we hope to submit that study for publication soon.

References

Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual therapy. 2009;14:531-8.

Hing W, Hall T, Rivett DA, Vicenzino B, Mulligan B. The Mulligan Concept of Manual Therapy, Textbook of Techniques. 1 ed: Churchill Livingstone; 2015.

Ho KY, Hsu AT. Displacement of the head of humerus while performing “mobilization with movements” in glenohumeral joint: a cadaver study. Manual therapy. 2009;14:160-6.

Ribeiro DC, Castro MP, Sole G, Vicenzino B. The initial effects of a sustained glenohumeral postero-lateral glide during elevation on shoulder muscle activity: A repeated measures study on asymptomatic shoulders. Manual therapy. 2016;22:101-8.

Ribeiro DC, Sole G, Venkat R, Shemmell J. Differences between clinician- and self-administered shoulder sustained mobilization on scapular and shoulder muscle activity during shoulder abduction: A repeated-measures study on asymptomatic individuals. Musculoskelet Sci Pract. 2017;30:25-33.

Stoney CM, Johnson LL. Design of Clinical Studies and Trials. In: Gallin JI, Ognibene FB, editors. Principles and Practice of Clinical Research San Diego: Academic Press; 2012.

Struyf F, Lluch E, Falla D, Meeus M, Noten S, Nijs J. Influence of shoulder pain on muscle function: implications for the assessment and therapy of shoulder disorders. Eur J Appl Physiol. 2015;115:225-34.

Vicenzino B, Hing W, Rivett D, Hall T. Mobilisation with Movement: The Art and the Science. 1 ed: Churchill Livingstone; 2011.

Dan

Dan is a Senior Lecturer at the School of Physiotherapy – University of Otago (New Zealand). He conducts clinical research on musculoskeletal disorders, with a special interest in shoulder rehabilitation. He holds a “Sir Charles Hercus Health Research Fellowship” funded by the Health Research Council NZ. During his Fellowship, Dan will undertake a number of studies on process evaluation of clinical trials.  Please find a link to one of Dan’s articles https://www.sciencedirect.com/science/article/pii/S246878121730084X

 

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“Should I do another course?” Confidence of physiotherapists in the assessment of psychosocial factors in people with chronic low back pain

It is clear now for most primary health care practitioner, including physiotherapists, that addressing psychosocial (PS) factors is important in the management of musculoskeletal symptoms. Patients presenting with PS factors are associated with a higher risk of reporting pain (particularly chronic pain) (Hoogenndoorn et al, 2000) and these factors have an important role in the development and subsequent recovery of low back pain episodes (Andresson, 1999; Wand and O’Connell, 2008 What are the current beliefs and knowledge of physiotherapists in the evaluation of the PS factors in patients with chronic low back pain (CLBP)? Starting from this question, we looked at physiotherapists’ personal views about the BPS model and the different ways they assess and manage PS factors with patients presenting with CLBP. We focused our research on Italian physiotherapists as there was limited research into Italian physiotherapists’ views and assessment of PS factors in patients with CLB (Zangoni & Thomson 2017).

Whilst the word psychosocial is widely used in the context of physiotherapy, the meaning of this word can remain unclear. What it means is the interaction between the person and his/her social environment and the barriers that can derive from this interaction (Singla et al, 2015) and it is characterized by the combination of the individual’s cognitive, emotional and social status influencing their condition. PS factors often include negative behaviours, fear avoidance beliefs, social withdrawal, problems at work, low mood, coping strategies and faith/religious beliefs (Kendall, 1999; Overmeer et al, 2004; Innes, 2005). Current literature and guidelines for low back pain (LBP) in UK, Australia, New Zealand and Italy recommend that PS factors should be addressed in addition to traditional biomedical factors when managing patients with LBP (Negrini et al, 2004; NICE, 2016; Synnott et al,2015; Darlow et al, 2014). Although the literature and guidelines recommend the incorporation of the BPS model into clinical practice (NICE, 2016) when managing patients with CLBP, it does not seem to be translated in practice yet: activities of reasoning and practice in physiotherapy are still centered on a traditional biomedical model of care (Darlow et al, 2014; Cruz et al, 2012; Singla et al, 2015; Piccoliori et al, 2013). In Italy, we observed little evidence about the knowledge and understanding of the role of PS factors in the management of people with CLBP (Negrini et al, 2004) and the reported data underlined:

  • Lack of standardisation in the teaching of PS factors assessment
  • Resistance of general medical practitioners and physiotherapists in adopting a BPS model in their clinical practice (Negrini et al, 2004).
  • Limited research describing and explaining Italian physiotherapists’ attitudes and beliefs towards PS factors in patients suffering from CLBP.

This led us to investigate Italian physiotherapists’ personal beliefs about PS factors, the different ways they assess and manage PS factors in clinical practice and the possible deriving barriers, with particular interest in patients presenting CLBP (Zangoni & Thomson, 2017).

For those interested in research methods, this section is for you, for the others feel free to jump to the next paragraph! A qualitative research design using semi-structured interviews to collect the data was adopted with Italy-based physiotherapists, as we intended to approach experiences, interactions and beliefs, that can’t be measured in numbers. We then used a grounded theory approach to analyse and compare the data resulting from different perceptions and experiences participants had in relation to PS factors in CLBP. A grounded theory approach was selected for the study as it allows active process of collection and interpretation of data that are constructed by the researcher as a result of his/her interaction with the interviewee (Charmaz, 2016; Thomson et al, 2014). You can find more details of the study and its design here.

We found that that all of our participants demonstrated awareness about the multifactoriality of CLBP and identified PS factors as important factors to consider when evaluating and treating these patients. General recognition of social factors (family, work, social relations), stress and negative attitudes were reported by all the participants but expectations and psychological factors, including depression or anxiety, were less mentioned (Pincus et al, 2006a, b; Nicholas et al, 2011).

Although participants demonstrated some understanding of the BPS model, they did not appear to have acquired the knowledge and skills necessary to implement it in practice: they did not appear to have acquired the knowledge and skills necessary. When exploring the barriers practitioners faced in the daily practice, the struggling to apply a multidimensional approach became even more apparent. Physiotherapists discussed patients’ expectations of receiving manual treatment and feared that taking time to discuss about PS factors would be considered as a waste of time by the patients. This perceived attitude of patients lead the physiotherapists to avoid or limit the exploration of these PS factors in order to avoid the disruption of the therapeutic relationship previously established. The fear to disrupt the relationship with patients was considered by the participants an important barrier, as reflected in quotes such as:

“First of all there is a cultural barrier, I mean in their opinion if you are a physiotherapist you have to do a massage and fix their back… Sometimes patients look at the discussion as a lack of time”

“If a person is reserved, trying to talk about those aspects or analyse them in depth could contribute to his suffering, and to outdistance him from you”

Our participants demonstrated clear interest in the PS factors but they also felt they did not have the appropriate knowledge/understanding of the BPS model and of the clinical guidelines; this was another important barrier in conducting PS assessment and treatment. To assess PS factors they mainly used general questions in the form of a dialogue during the case history led by the patient. The issue is that identification or awareness of PS factors is not enough for changing patient management and outcome as active engagement in identifying the potentially modifiable factors is fundamental (Main et al, 2010; Synnott et al, 2015).

We had the feeling that the difficulties in the management of patients and the persistency of PS factors seemed to have created preconceptions about the outcome in patients with CLBP. Some of the participants believed that often only a partial recovery form the chronic state is possible:

“I expect a partial resolution… With chronic low back pain I do not consider myself so good to resolve a problem that is present from minimum 3 months in 10 sessions… My aim is to educate, train and get the patient conscious of his possibilities…

Conversely one participant stated that in some cases too much attention is given to the PS factors, diverting the attention from a possible leading biomedical cause perpetuating the symptomatology:

“In my opinion one part of chronic lumbar problems is underdiagnosed, the cause is musculoskeletal and not biopsychosocial… I think that nowadays there is an underestimation, everyone is moving towards the psychosocial aspects”

The findings of our research reflect the results of similar studies conducted in Australia and UK by Singla et al, (2015) and Darlow (2016) which found physiotherapists recognise the importance of PS factors but still tend to focus on clinical biomedical and biomechanical findings. The lack of active engagement in identifying which are the potential modifiable factors due to superficiality and missing standardization within the physiotherapy profession have to be addressed through a shift from biomedically-oriented to biopsychosocially-oriented practice. Moreover, limited education about the PS aspects in the university training and the need of additional specific training to improve the knowledge of physiotherapists in this area is needed in order to improve physiotherapists’ uncertainty about the management of the these factors.

What can we do on our own without going on another course?

Activities of mentoring in the clinical settings, improving our capacity to listen to patients to contextualise their symptoms in their social environment and gradual engagement with assessment scales of the BPS status are probably a good starting point. In regards to the assessment scales, the STarT Back Screening Tool is a simple questionnaire helping clinicians to screen primary care patients with LBP and stratify them into low, medium and high risk to develop persistent disabling symptoms.

Training practitioners to implement a BPS approach is difficult. Until recently, interventions to increase practitioners’ provision of psychosocial interventions have had little effect on patient outcomes but more recent attempts have been a bit more successful in physiotherapy. An interesting study compared the impact of BPS training and biomechanical training on physical therapy students: those who took the BPS training showed a reduction in fear-avoidance and pain impairment beliefs of patients, and an improvement of the recommendations given by students for activity and work but the biomechanical group showed opposite trends (Domenech et al, 2011). Probably good evidence that curricula need changing!

Another problem of previous training programmes was teaching content delegates already knew! It can be difficult to know which content to include: sometimes the content is not novel enough and therefore delegates learn little which has little or no impact on their practice. Finally, no studies have so far explicitly stated if their learning packages were informed by any behavioural change frameworks. Changing one’s behaviour is hard in all fields (e.g. smoking or obesity prevention) and the same challenges are faced for training programmes aiming to modify clinician’s behaviour when managing patients. We developed an 8-hour e-learning programme to train 45 osteopaths with more than 15 years to the BPS model for the management of patients with non-specific low back pain (Draper-Rodi et al, 2016). We saw that this quite short course had a positive impact on the participants’ attitudes to back pain. Participants’ perceptions of the BPS model after taking the e-learning programme were represented in three categories: not structural enough, part of existing practice and transformative. Participants found e-learning a very effective way of taking CPD: it was very easy to do whether during clinic gaps or at home and its flexibility allowed many of them to retake lessons when content was challenging. E-learning was found suitable to disseminate new knowledge to manual therapists including those in remote areas. We are currently looking at continuing research on this topic, maybe using blended learning (e-learning and face-to-face) to offer a full BPS training to manual therapists

In conclusion, the lack of active engagement in identifying which are the potential modifiable factors due to superficiality and missing standardization within the physiotherapy profession have to be addressed through a shift from biomedically oriented to biopsychosocially oriented practice. Moreover, additional specific training about PS aspects and the BPS model is needed, starting from the improvement of the university programmes on this topic and the development of an effective BPS training programme for practitioners.

Link to the full article:

Giacomo Zangoni, MSc, BSc, MHCPC, MCSP, Physiotherapist and Osteopath

Dr Oliver P. Thomson PhD, MSc, PG Cert, BSc (Hons), DO, Associate Professor

Dr Jerry Draper-Rodi D.Prof. (Ost), PG Dip, PG Cert, DO, Senior Research Fellow at University College of Osteopathy

 

 

REFERENCES 

Andersson, G.B., 1999. Epidemiological features of chronic low-back pain. Lancet 354 (9178), 581e585.

Charmaz, K., 2016. Constructing Grounded Theory. SAGE Publications.

Darlow, B., (2016). Beliefs about back pain: the confluence of client, clinician and community. International Journal of Osteopathic Medicine. 20, pp.53-61

Darlow, B., Perry, M., Stanley, J., (2014). Cross-sectional survey of attitudes and beliefs about back pain in New Zealand. British Medical Journal, 4(5): e004725.

Domenech, J., Sànchez-Zuriaga, D., Segura-Ortì, E., Espejo-Tort, B. & Lisòn, J. F. 2011. Impact of biomedical and biopsychosocial training sessions on the attitudes, beliefs, and recommendations of health care providers about low back pain: A randomised clinical trial. Pain, 152, 2557-2563.

Draper-Rodi J, Vogel S, Bishop A. 2016. Impact of an e-learning programme on the biopsychosocial model for non-specific low-back pain on experienced osteopaths’ attitudes to back pain: A mixed-methods study. Manual Therapy 25, e167-e168

Innes, S.I., 2005. Psychosocial factors and their role in chronic pain: a brief review of development and current status. Chiropr. Osteopat. 13 (1), 1.

Kendall, N.A., 1999. Psychosocial approaches to the prevention of chronic pain: the low back paradigm. Best Pract. Res. Clin. Rheumatol. 13 (3), 545e554.

Main, C. J., Foster, N., Buchbinder, R., (2010). How important are back pain beliefs and expectations for satisfactory recovery from back pain? Best Practice & Research Clinical Rheumatology, 24 pp. 205–217.

Negrini, S., Monticone, M., Chirchiglia, S., Fabiani, L., Gattinoni, F., Giorgianni, R., Giovannoni, S., Minozzi, S., Politano, E., 2004. Experience in Italy in the development and application of clinical guidelines for low back pain. Eur. Medicophysica 40 (1), 45e53.

NICE, 2016. Low Back Pain and Sciatica in over 16s: Assessment and Management.

Nicholas, M.K., Linton, S.J., Watson, P.J., Main, C.J., 2011. The “Decade of the Flags” Working Group. Early identification and management of psychological risk factors (“yellow flags”) in patients with low back pain: a reappraisal. Phys. Ther. 91, 737e753.

O’Sullivan, K., O’Sullivan, P., O’Sullivan, L. & Dankaerts, W. 2013. Back pain beliefs among physiotherapists are more positive after biopsychosocially orientated workshops. Physiother Pract Res, 34, 37-45.

Overmeer, T., Linton, S.J., Boersma, K., 2004. Do physical therapists recognise established risk factors? Swedish physical therapists’ evaluation in comparison to guidelines. Physiotherapy 90 (1), 35e41.

Piccoliori, Giuliano, Adolf Engl, Doris Gatterer, Emiliano Sessa, Jürgen Der Schmitten, and Heinz-harald Abholz, ‘Management of Low Back Pain in General Practice – Is It of Acceptable Quality : An Observational Study among 25 General Practices in South Tyrol ( Italy )’, 2013

Pincus, T., Vogel, S., Breen, A., Foster, N., Underwood, M., 2006a. Persistent back pain and why do physical therapy clinicians continue treatment? A mixed methods study of chiropractors, osteopaths and physiotherapists. Eur. J. Pain 10 (1), 67, 67.

Pincus, T., Vogel, S., Burton, A.K., Santos, R., Field, A.P., 2006b. Fear avoidance and prognosis in back pain: a systematic review and synthesis of current evidence. Arthritis Rheum. 54 (12), 3999e4010.

Singla, M., Jones, M., Edwards, I., Kumar, S., 2015. Physiotherapists’ assessment of patients’ psychosocial status: are we standing on thin ice? A qualitative descriptive study. Man. Ther. 20 (2), 328e334.

Synnott, A., O’Keeffe, M., Bunzli, S., Dankaerts, W., O’Sullivan, P., O’Sullivan, K., 2015. Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. J. Physiother. 61 (2), 68e76.

Thomson, O., Petty, N., J., Scholes, J., (2014). Grounding osteopathic research – Introducing grounded theory. International Journal of Osteopathic Medicine, 17, pp. 167-186.

Wand, B.M., O’Connell, N.E., 2008. Chronic non-specific low back painesub-groups or a single mechanism? BMC Musculoskelet. Disord. 9 (1), 1.

Zangoni, G., & Thomson, O. P. (2017). “I need to do another course”- Italian physiotherapists’ knowledge and beliefs when assessing psychosocial factors in patients presenting with chronic low back painMusculoskeletal Science and Practice, 27, 71–77.

About Giacomo Zangoni

g.zangoni@uco.ac.uk

giacommo

Giacomo is a registered Osteopath and Physiotherapist, obtaining the Master’s degree in Osteopathy at University College of Osteopathy (London) and previously the Bachelor’s degree in Physiotherapy at the University of Padua (Italy). Since 2012 he has been collaborating in Italy and now in London with sport societies and working in private clinics and rehabilitation centers. Giacomo is currently collaborating with the Research team of the British School of osteopathy on the evaluation of psychosocial factors in chronic low back pain.

About Dr Oliver Thomson

o.thomson@UCO.ac.uk

olly thomson

Dr Oliver Thomson is a practicing osteopath and Associate Professor at the University College of Osteopathy where he leads the research teaching for the undergraduate and postgraduate osteopathy programs. Oliver completed his PhD in osteopathy at the University of Brighton, Clinical Research Centre for Health Professions, where he explored osteopaths’ clinical decision-making. His research interests include clinical decision making and reasoning, professional identity and beliefs, and qualitative research and has published extensively in these areas. He is an Associate Editor of the International Journal of Osteopathic Medicine and is on the international advisory board for Musculoskeletal Science and Practice.

About Dr Jerry Draper-Rodi

J.draper-rodi@uco.ac.uk

 

Jerry

Dr Jerry Draper-Rodi is an academic clinician: he is CPD Manager and Research Lecturer at the University College of Osteopathy, chairs Oxfordshire Osteopathic Network and practises in Oxfordshire. He was awarded a Professional Doctorate in Osteopathy in 2016. His research was on the acceptability, feasibility and likely impact of a biopsychosocially-informed e-learning programme for non-specific LBP on experienced osteopathic practitioners’ attitudes to back pain. He has presented his research in numerous conferences and has published articles in peer-reviewed journals. Jerry is a reviewer for the International Journal of Osteopathic Medicine.

 

 

 

 

 

 

 

 

Blog

‘It’s like Chalk on a blackboard’ My Experiences Researching Patellofemoral Crepitus. By Claire Robertson

As a specialist in patellofemoral pain (PFP) I have been increasingly aware of the importance placed by people on their knee joint noise, (crepitus). On asking about their presenting complaint it is often the first symptom mentioned, before pain or functional difficulties. For some people there is no pain, just noise!

In an attempt to answer questions I had on this topic I turned to the literature. My initial searching revealed the unexpected finding that crepitus is an alleged Roman God of flatulence. Looking to the mammalian veterinary literature also revealed the obscure finding that eland, (a type of African antelope) use knee crepitus in displays of dominance, (Bro-Jorgensen et al., 2008). Fascinating yes, but unhelpful in my quest to better understand the crepitus experienced by people I see in clinic!  Papers on joint crepitus in key medical journals dating back as far as 1885, (Heuter, 1885) starts to shed light on this intriguing topic. Blodgett, (1902), introduced the practice of joint auscultation, (listening with a stethoscope) with great interest in this technique persisting for several decades. Early studies focused on the intensity of joint crepitus volume, and this soon progressed in to more sophisticated studies, recording frequency, wavelength, sequencing, and quality of noise, (Steindler, 1937). These studies, albeit interesting really don’t inform contemporary practice.

An absolute dearth of literature was seen for half a century until McCoy et al., (1987) investigated the prevalence of crepitus in normal subjects without pain. McCoy et al., (1987) investigated 247 symptomatic, and 250 normal knees and found that 99% of normal subjects had patellofemoral crepitus. This finding really fueled my desire researching this topic, and in particular to reach a better understand of why many people are really anxious about what, in essence is a normal finding.

I therefore firstly wrote an editorial where I posed my belief that patients were often very anxious regarding the noise in their knee, (Robertson, 2010). The response from this editorial was fascinating. Some were amused I should be discussing noisy knees, some thought it was a frivolous irrelevance, but most fed back that yes, they too had noted similar concerns about this phenomena amongst their patients.

The perception of some clinicians that this was an irrelevance to them, together with the overarching positive response of others, combined with my ongoing desire to start a line of enquiry led me to carry out the research I have published in Musculoskeletal Science and Practice, ‘People’s beliefs about the meaning of crepitus in patellofemoral pain and the impact of these beliefs on their behaviour: A qualitative study.’ I really wanted to explore what patients thought their joint cracking meant. I specifically looked at patients without osteoarthritis so that we knew the noise was not in response to joint pathology. In order to explore this previously unresearched topic I carried out semi-structured in-depth interviews, and the transcripts were then analysed for emerging themes. These, in essence were themes that came through again and again. The key themes were, belief about the noise, influence of others, and avoiding the noise .The answers to, ‘what do you think the noise means?’ were often alarming and frequently along the lines of, “my joint is wearing away”. The emergent theme of belief about the noise also revealed that for many it represented premature ageing and also brought about strong emotional responses. One 26-year-old gentleman voiced he was house hunting and he was so perturbed by the noise in his knee that he had decided to only look at ground floor properties. Just stop for a minute and reflect on that. He had a normal knee on MRI, but his belief about the noise had made him so fearful he was altering where he was going to live! The emotional response was very apparent and came through as a sub-theme of belief about the noise. One participant said, ‘It’s like chalk on a blackboard; it makes you feel a bit queasy really.’ In response to this research, in the clinical setting I now routinely ask, “What do you think it means?’ if a patient mentions their crepitus. It can be very revealing!

It is my belief that in the world of managing low back pain we are much better at exploring our patient’s beliefs and looking at fear avoidance. I would like to propose that this should be no difference in this instance just because we are looking at a symptom of noise, and in a different anatomical area.

My study also revealed that patients had tried to find a meaning for their crepitus, often through internet research, and often through asking health professionals. It is likely that in many cases the anxiety behind the meaning of crepitus is enhanced by inaccuracies and generalisations in the public domain. Internet sites such as the Oxford dictionary define crepitus as, ” A grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone.”, (Oxford dictionary). Given the evidence presented in this editorial many of these Internet sites fail to discriminate between the unusual arthritic bone-on bone crepitus, and the common fine crepitus, leading many to wrongly self-diagnose their crepitus as a sign of severe degenerative disease. It must also be noted that my research revealed patients felt unsatisfied with answers they had received from health professional regarding what the crepitus actually is. This led to patients feeling that it was dismissed as unimportant, or that the health professionals didn’t actually know themselves. Let’s just think about both of those issues. Firstly, and to be quite frank about it if something is important to the patient, it should be of importance to you as the health professional. Secondly, I think many health professionals are rather unclear about what exactly crepitus is, so I have summarized that here.

In the non-osteoarthritic knee crepitus will likely be either loud isolated cracks and pops which is either bubbles of gas releasing, (like knuckle cracking), or the patella clunking into the central portion of the trochlea, (it often feels better after this). But perhaps the noise that causes the greatest alarm is the fine grating often heard on the stairs. This was cited by many of the participants in my study as frequently commented on by family and friends, often reinforcing anxiety about the noise. It can be powerful to mention to patients the aforementioned work of McCoy et al., (1987) where 99% of normal subjects had some patellofemoral noise. It is my belief that many of the patients possibly had crepitus pre-dating their pain, but through the presence of pain have become hypervigilant to their knee and hence notice both the pain and swelling.

To return to the central issue of this blog is to inform regarding what is meaningful to patients. It is my strong belief that if people voice anxiety regarding their joint crepitus, then it should firstly be taken seriously, and secondly addressed. Wolpert, (2007, p220) aptly states that, “It is the action based on beliefs that ultimately matters.” Hence to evade the belief system of people with crepitus through lack of interest or knowledge is to fail the person and leave them vulnerable to fear-avoidant behaviour, which may further compound their initial problem. To accurately inform and reduce anxiety is conversely likely to empower and reduce the risk of catastrophizing.

Claire Robertson MSc PGCE MCSP

Consultant Physiotherapist Wimbledon Clinics

http://clairepatella.com/

@clairepatella

(06)

Please find the link to Claire and colleagues article on patients experience of patellofemoral pain

 

References

Blodgett WE. Auscultation of the knee joint. Boston Med Surg J 1902; 146: 63-6.

Heuter C Grundriss der chirurgie. 3rd ed. Leipzig: FCW Vogel, 1885.

Steindler A. Auscultation of joints. J Bone Joint Surg (Br) 1937; 19:121-36

Walter SCF. The value of joint auscultation. Lancet 1929; 1:92021

 

 

Blog

Relaunched in 2017!

Musculoskeletal Science & Practice was formerly known as Manual Therapy. We wish to inform all of our authors that the journal relaunched as the International Journal of Musculoskeletal Physiotherapy in January 2017. The journal continues to be published by Elsevier, and the Editorial team and Aims & Scope remain unchanged.