Thursday, February 27, 2020

Does what we “say” to our patients impact how our patients move and recover?

Image from Canva

The answer may seem obvious. Yes! What we say does have an impact.  But let us take a closer look at how this plays out clinically.  As part of our clinical education, we learn what to say or what not to say.  I remember learning how to perform a posture exam; with a few mutterings and inflections like “oh,” “wow,” “hmm,” and occasionally “uh.”  I realized for the sake of learning, I was just rattling off impairments left and right.  Never was there not a “forward head posture with a kyphotic thoracic spine with rounded shoulders and bilateral abducted, downwardly and medially rotated scapula, etc.”  As one can see, the list of predicted impairments goes on and on. Plenty of information for us to dictate to our mentors, write down and test, making for a lengthy yet thorough examination.  At some point, a patient might ask “Are you going to explain what that means,” “Is it bad?” or just have a worried expression on their face.  Of course, we would say “all will be explained at the end of the examination.” 

Enter the DIMs vs SIMs conundrum we just created for the patient.  Here’s a brief explanation of DIMs and SIMs from Butler and Mosely’s Explain Pain: Supercharged.1 DIM stands for “Danger in Me.”  This simply put is your brain’s way of concluding that there is sufficient evidence of danger to create pain.  Conversely, when we find enough evidence to indicate that things are safe, we will not protect using pain, and all is well.  This is called “Safety in Me.”  DIMs and SIMs in short.  As people, we look for the evidence in the things we hear, see, smell, touch, taste, do, and say; our thoughts, beliefs, places we go, people in our lives, and things happening in our bodies.  

Explain Pain, Supercharged

Returning to our clinical example, we can see how we have added to our patient’s interpretation of DIMs / SIMs just by doing our work. The practice of doing our postural assessment and only highlighting what is not ideal can lead to the patient creating DIMs about their condition.  Instead of calling out “excess lumbar lordosis and anterior pelvic tilt”, we may make the following alternative statements:
-       “Your shoulders stack really nicely above your pelvis.  We may benefit from working on the balance of muscles around your pelvis and hips.”
-       “This alignment can be changed with some training.”

In this way, the patient knows they have to do some work but it is not negative.

Communication about alignment

The question for the clinician then becomes, do you ever think about how you do your work and how it is perceived by your patient?

Therapeutic alliance is best defined as the relationship between the provider and patient.8  A warm, friendly, and reassuring interaction has been shown to improve outcomes instead of an impersonal or uncertain interaction.2  The two main factors to create a therapeutic alliance are the patient’s ability to forge a bond and the clinician’s ability to present themselves as caring and sensitive in the treatment encounter.5  Remembering our patient example, it is imperative to think about the words we use to explain and cue our patients to put them at ease with our process of examination and intervention. Some phrases that I utilize are,
- “Yes I have seen this before and this is fixable”
- “you are saveable”
- “help me understand.”

These interactions are especially important when we are trying create a relationship that educates, inspires and empowers them to change how they move.  

Now that we have established it is important what the patient thinks of us, does it then matter what the clinician thinks?

Let’s examine this question.  According to Cook et al 2013, therapeutic equipoise is simply defined as the clinicians expectations and treatment approach preferences.3  So now we have to consider not only the thoughts and perceptions of our patients, but also that of ourselves.4  Because of this, clinicians will favor different treatment approaches and provide interventions enthusiastically and with the expectation of certain success; thus impacting our clinical outcomes.6  To come back to our patient example, it comes down to what we say, how we say it, and also how much we believe in it.  All of these variables will have an effect on our interventions and outcomes.  The next time you’re in clinic and you try that movement correction to externally rotate and elevate the scapula during shoulder elevation and it does not change their symptoms, stick with it and do not lose that enthusiasm; if you keep trying and explain your rationale for what you are attempting to do for your patient, they might surprise you and “move without making it hurt.”  Teaching and learning new movements can be tough for both clinician and patient.  With some practice in how we work and how our patients perceive our words and cues, we can create the right formula to link the movements.

Choosing our words and cues wisely is important because health care professionals have an influence on what patients take from our encounters.  Darlow et al, in his study in 2013, explored the formation and impact of attitudes and beliefs among people experiencing low back pain. Participants in the study were often given messages by their that the spine needed to be protected.  The explanatory model that insufficient muscle strength results in a more fragile spine can be impactful.  Example statements by participants were: “Basically, all I’ve been told to do by my physios is to work on my core,” or “I’ve been tested by various different physios and Pilates, and apparently my core is ridiculously weak.”

Image from Canva

 Conversely, other clinicians in the study provided education about the importance of movement with positivity and with reassurance.  The impact of this message became quite powerful for a participant with a 6-year history of episodic back pain.  “I feel that I should keep moving and keep doing things as much as possible…I mean going to bed definitely doesn’t help it.  So, I’ll keep active.”  Another participant reported: “Lots of reassurance from the [doctor]…made me feel like, “don’t panic, this is OK, you’ll be fine.  It’s not the start of something thing awful.”7

Bottom line: what we say and how we say it can have a profound effect on our patient’s confidence and anxiety levels.  It’s not always easy, though. Sometimes the right words or cues are hard to find.  We may not get the desired outcome the first or fifth time when learning a new approach.  Learning, changing and growing is difficult, especially during our busy work schedules. Stay present and think about your communication to your patients because the more you practice, the easier it gets to help those movements link!

Ernie Linares is a board-certified Clinical Specialist (OCS) in Orthopaedic Physical Therapy and a Fellow of the American Academy of Orthopaedic Manual Physical Therapists (FAAOMPT). He is also a Movement Links and Dynamic Neuromuscular Stabilization (DNS) certified practitioner. He currently works as a clinical specialist at the Kaiser Permanente Woodland Hills facility and as Guest Lecturer in the Physical Therapy Department at California State University, Northridge. Ernie also serves on the American Board of Physical Therapy Residency and Fellowship Education as an Accreditation Services Committee Member.

1.    Moseley, G. L., & Butler, D. S. (2017). Explain pain supercharged. The clinician’s handbook. Painos. Australia: Noigroup publication. Liite1(1), 1.
2.    Di Blasi, Z., Harkness, E., Ernst, E., Georgiou, A., & Kleijnen, J. (2001). Influence of context effects on health outcomes: a systematic review. The Lancet357(9258), 757-762.
3.    Cook, C., Learman, K., Showalter, C., Kabbaz, V., & O'Halloran, B. (2013). Early use of thrust manipulation versus non-thrust manipulation: a randomized clinical trial. Manual therapy18(3), 191-198.
4.    Cook, C., & Sheets, C. (2011). Clinical equipoise and personal equipoise: two necessary ingredients for reducing bias in manual therapy trials. Journal of Manual & Manipulative Therapy19(1), 55-57.
5.    Ferreira, P. H., Ferreira, M. L., Maher, C. G., Refshauge, K. M., Latimer, J., & Adams, R. D. (2013). The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Physical therapy93(4), 470-478.
6.    Witt, C. M., Martins, F., Willich, S. N., & Sch├╝tzler, L. (2012). Can I help you? Physicians' expectations as predictor for treatment outcome. European Journal of Pain16(10), 1455-1466.
7.    Darlow, B., Dowell, A., Baxter, G. D., Mathieson, F., Perry, M., & Dean, S. (2013). The enduring impact of what clinicians say to people with low back pain. The Annals of Family Medicine11(6), 527-534.
8.    Kegerreis, S. (2010). Mechanisms and Management Of Pain For The Physical Therapist. journal of Orthopaedic & Sports Physical40(10), 668-669.

Wednesday, January 15, 2020

Calling all movement experts!!!.…….have you read this treasure trove of an issue? JOSPT Special Issue- June, 2019

JOSPT Special Issue

June, 2019

If you are interested in Lumbopelvic Motor Control it’s a great resource that synthesizes past literature, reflects on where we have been, and where we might look to the future. This issue presents several clinical commentaries. I have chosen one of interest and the following blog references key points and provides reflections on my own practice.

Motor Control Changes in Low Back Pain: Divergence in Presentations and Mechanisms
JH Van Dieen, PhD, NP Reeves, PhD, G Kawchuk, PhD, LR Van Dillen, PT, PhD, PW Hodges PT, PhD, DSc MedDr, BPhty (Hons). JOSPT. 2019;(49)6:370-379.

I think most of us can agree, from our understanding of the theory and literature on motor control (Propositional Knowledge), from our clinical experience (Experiential Knowledge), and from our own personal experiences (Personal Knowledge)1,2, that individuals with low back pain (LBP) move differently than those without LBP. These 3 types of knowledge, described by Higgs and Titchen, guide our clinical decision making and shape our clinical pattern development. The interesting point of this current article and one that has not been so explicit in my own mind, is that it brings to light that we don’t really understand the why behind these changes in motor control in patients with LBP……..yet!

The neuromuscular system has a variety of strategies to carry out particular tasks, and having options is thought to keep our system balanced and healthy. Yet, this variability may also be one reason why there are so many different presentations of impairments related to LBP, thus making it difficult to match the correct intervention. Which brings us to the need we have as a profession to be able to categorize patients with LBP.

The identification of subcategories of LBP is how we organize and make sense of varying presentations in order to provide the most relevant intervention. I have better outcomes when I utilize categorization systems, such as the Movement System Impairment Model, Mechanical Diagnosis and Therapy (McKenzie), Motor Control Training, the Integrated Systems Model (Diane Lee and the concept of regional interdependence)3, and Janda’s Upper and Lower Crossed, and Layered Syndromes4,5.

In this clinical commentary by Dieen et al., the authors present an interesting new thought in this arena, one that may provide an overarching perspective on motor control changes in the presentation of LBP, though there is much work to be done to develop and validate this concept. This concept describes two possible phenotypes, either a Tight Control System or a Loose Control System. More on this later, let’s take a brief look at the evidence that is currently out there.

When considering motor control of the trunk in individuals with and without LBP, two areas have been commonly studied; trunk muscle activation patterns and trunk movements.
Changes in trunk muscle activation and muscle morphology have been observed in patients with LBP compared to those without LBP. Muscle activity has been shown to increase, decrease, demonstrate no change, activate early, and/or activate late. I think you will see some familiar patterns presented here.

Motor control changes with LBP
Lumbar extensors  -

or or no change
Transverse abdominis (TrA) and lumbar multifidus (LM) -
late activation
Abdominal muscles -
no change and early activation of oblique muscles
Muscle activity -
delayed onset or delayed offset with different intensities of recruitment
Multifidus -
muscle fiber changes Type I to Type II,
muscle atrophy, fatty infiltration
*indirectly changing lumbopelvic motor control

Dieen et al., offer possible reasons for the variability found in the literature and include the following: variable strategies to accomplish tasks, differing environments in which tasks are performed, the type of muscles recruited, as well as methodological differences such as how data were collected through intramuscular or surface electromyography (EMG).

The literature surrounding alignment, posture, and trunk movement presents differences in patients with LBP compared to those without LBP. Do you recognize these findings?

Changes in alignment, posture, or movement with LBP
lumbar flexion
postural sway, with or without balance impairments
posterior pelvic tilt
Slower trunk movements with dynamic tasks
lumbar extension

or variability of trunk movements with bending and/or gait
flattening of lumbar spine
coupling of pelvis/thorax with gait
No changes in alignment
precision of control of trunk posture, movement, and force production

Like muscle activation patterns, changes in trunk alignment, posture and movement are different in individuals with LBP compared to those without LBP and studies also demonstrate inconsistent findings. Another issue to consider when facing the inconsistency between study results is whether motor control variability is due to intraindividual responses (within one individual) and/or interindividual responses (between individuals), thus adding another layer of complexity when analyzing study outcomes. In addition, differences in study methodology may limit study comparisons and small sample sizes may affect the validity of study outcomes.

In summary, Dieen et al. state changes in motor control are evident with LBP, are not consistent, are not seen in all patients, and in the end such changes may not be explained by a single factor. As a means to help sort out some of these different responses, the authors highlight two concepts that have been previously considered; identify the underlying mechanism for motor control changes (for example is it a strategy in response to pain/injury or a consequence of pain/injury) and identify the particular mechanical consequences of such changes.

The inconsistencies and multi-factorial nature of the findings in the literature can be confusing and potentially overwhelming. In addition to summarizing existing rationale to help explain the differing results in motor control changes seen in patients with LBP, Dieen et al. present a new concept described as “tight control and loose control phenotypes” that may help to explain the diverging responses in the literature. These phenotypes are presented on a continuum, and could explain the two ends of the spectrum as well as the middle ground where little or no changes in motor control are seen (see diagram below).

Let’s take a closer look at the two proposed phenotypes.  Both may have purposeful short-term effects, but may also have more detrimental effects in the long run.

The Tight Control Phenotype
In this scenario, muscle activation increases resulting in trunk stiffening, decreased trunk movement, increased control, and less variability of movement (or need for finely tuned anticipatory trunk reactions). This could present as a slight change in local muscle activation, to co-contraction of multiple muscles, or to a complete avoidance of a particular task. In the short term, this may “protect” the system but over the long run this may lead to increased spinal loading and less options for movement. In essence, these individuals avoid excessive movements.

The Loose Control Phenotype
In this scenario, muscle activation decreases resulting in reduced tissue loading from the larger muscles that may exert compressive forces on the spine, less control of trunk posture and movement with potentially larger variations in movement. This reduced control of the spine at both mid and end ranges, creates the potential for increased tissue strains and pain. In essence, these individuals avoid excessive muscle forces.

……, both scenarios can lead to abnormal tissue loading around the spine but due to different mechanisms, thus it makes sense that intervention approaches would need to be different to address the system impairments at hand.

Also, consider that these phenotypes could be present in a system at the same time, so a mixture of approaches may be needed.

Considerations for intervention approaches
We could start by asking if a tight or loose control phenotype is at play and is it in the early stages after an injury or in the later stages with more potential for negative impacts on the system?

Tight control phenotype
If your patient/client is avoiding movement, moving en bloc, or has a stiff quality to their movements consider a tight control system. Goals may be to reduce excitability and co-contraction, or “dial down overactive muscles”:

·      Utilize Janda’s theory of tonic muscles4 (phylogenetically older muscles8) to identify possible effects of a tight control phenotype
·      Assess and retrain breathing patterns
·      Post-isometric relaxation4 to overactive muscles
·      Facilitate the antagonists of the overactive muscles
·      Unloading techniques for the spine:
o   PT places hands on lateral sides of rib cage and lifts upward to unload the lumbar spine (in patients with a “compressed lumbar spine” this can relieve symptoms)
o   Supine with pillow under knees or hooklying
o   Quadruped7
o   Modified quadruped7 – standing and leaning on table with weight bearing through forearms
o   Lumbar self-traction in sitting (hands on arm rests and straighten elbows allowing trunk to hang with gravity)
·      Increase movement gradually, in non-threatening ways
·      Encourage variability of movement and movement in multiple planes
·      Graded exposure to avoided activities

Loose control phenotype
If your patient/client demonstrates excessive movements or aberrant movement patterns such as excessive lumbo-pelvic rotation, hinging or shearing at a specific segment consider a loose control system. Goals may be to increase excitability, or “facilitate underactive muscles”:

·      Utilize Janda’s theory of phasic muscles4 (phylogenetically younger muscles8) to identify possible effects of a loose control phenotype
·      Identify and retrain aberrant movement patterns
·      Identify the weak link in the chain and retrain that muscle or group of muscles
·      Facilitate inhibited or weak muscles in the chain4
·      Post-isometric relaxation to the antagonist of the inhibited or weak muscle(s)

Therefore, intervention approaches may be completely opposite depending on the phenotype that is presented or dominant.

As participants in the Movement Links Seminars and certification courses, physiotherapists have experience in looking for these divergent patterns. Through a structured exam, we look to identify aberrant movement patterns, muscle imbalances (muscles that need inhibition and muscles that need facilitation), the cause(s) as well as the source of symptoms, and develop an understanding of the relationship between impairments that are key to understanding the patient’s movement dysfunction. The end result of such a specific exam is to be able to identify specific movement impairments and their contributing factors and then provide specific interventions.

Dieen et al. state that the concept of these two phenotypes need further development and validation before they can be translated into guidelines. This development process needs to include validation of assessments related to these two phenotypes that can identify specific patterns to be treated, provide targeted intervention approaches, with the goal of improved outcomes. As such, it could be an interesting time for clinicians to write case reports utilizing tight and loose control concepts, possibly offering some support for or insight into directions for future research studies encompassing these two phenotypes.

All of you awesome clinicians out there, this is where you shine – grab a resource for writing case reports and give it a shot!

Tracey Wagner is an Assistant Professor at Samuel Merritt University teaching musculoskeletal courses and is working on developing a part-time clinical practice and her line of scholarship in the area of movement science. She is a DNS Certified Practitioner, as well as a Movement Links Certified Clinician and Instructor. She moved to the beautiful Bay Area after a 17-year career working for Kaiser Permanente Woodland Hills, serving there as a clinical specialist, mentor, and educator.   Tracey has been published in the Journal of Orthopaedic and Sports Physical Therapy (JOSPT) for a case report on muscle imbalances of a professional triathlete and received the California Physical Therapy Association’s 2010 Clinician Research Publication Award.

  1. Higgs J, Titchen A. Propositional, professional and personal knowledge in clinical reasoning. In: Higgs J, Jones M: Clinical reasoning in the health professions. Oxford: Butterworth-Heinemann; 1995.
  2. Higgs J, Titchen A, Neville V.  Professional practice and knowledge. In: Higgs J, Titchen A, eds. Practice Knowledge & Expertise in the Health Professions. Oxford: Butterworth Heinemann; 2001:3-9.
  3. Hides, JA, Donelson R, Lee D, Prather H, Sahrmann SA, Hodges PW. Convergence and Divergence of Exercise-Based Approaches That Incorporate Motor Control for the Management of Low Back Pain. J Orthop Sports Phys Ther. 2019;49(6):437-452.
  4.  Page, P, Frank, C, Lardner R. Assessment and Treatment of Muscle Imbalance The Janda Approach. Human Kinetics 2010.
  5. Morris CE, Greenman PE, Bullock MI, Basmajian JV, Kobesova A. Vladimir Janda, MD, DSc: tribute to a master of rehabilitation. Spine. 2006;31(9):1060-1064.
  6. JH Van Dieen, PhD, NP Reeves, PhD, G Kawchuk, PhD, LR Van Dillen, PT, PhD, PW Hodges PT, PhD, DSc MedDr, BPhty (Hons). Motor Control Changes in Low Back Pain: Divergence in Presentations and Mechanisms. JOSPT. 2019;(49)6:370-379.
  7. Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis MO: Mosby Inc. 2002.
  8. Kolar P et al. Clinical Rehabilitation. 1st ed. Prague, Czech Republic: Alena Kobesova, Rehabilitation Prague School;2013.