Welcome
Kieran is a chartered physiotherapist, registered nutritional therapist and corrective exercise specialist who specialises in helping people in chronic pain get back to what they do best.
Kieran is fascinated to understand the causes of someone’s pain. From here he puts together a plan using physiotherapy, exercise, nutritional therapy and education to help you get back to what you do best.
Kieran is based at the Bowskill Clinic, 4 Duke Street, W1U 3EL near bond street tube station. Where patients are unable to attend the clinic he can do home appointments.
To find out more about Kieran see his bio here
To ask Kieran a question or book an appointment;
call 07830160323
email kieran@kieranmacphail.com
Uncertainty, seeking diagnosis, need for reassurance
Patients with damaging beliefs draw on past personal experiences of pain, societal beliefs, and diagnostic certainty to try and make sense of their experience (Bunzli et al 2015). When patients do not have a clear diagnosis or a diagnosis that cannot be fixed they feel fearful of damage and confused about how to ‘fix’it (Buzli et al 2015).
Participants with suffering/functional loss beliefs draw on past personal experiences of pain and seek help from healthcare professionals to control their pain (Bunzli et al 2015). Failed treatments and the repeated failure to achieve functional goals leaves patients unable to make ‘sensible’ decisions of what to do about their pain (Bunzli et al 2015).
The lack of control people feel when they lack understanding is a key contributor to “negative affect”. This is seen throughout the psychology literature with those lacking a feeling of control having higher incidence of depression.
Could this uncertainty be a significant contributor to the depression and negative psychological symptoms associated with CLBP?
References
Bunzli S, Smith A, Schütze R, O’Sullivan, P. . Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear. BMJ Open 2015; 5.
What we say to patient during manual therapy really matters.
I find the results of this paper fairly startling taken at face value (Louw et al 2017). It's very easy to have a conversation with clients and focus on developing the therapeutic alliance/ rapport etc. But this paper highlights just how important our explanation of what the proposed mechanism is. In this case a neursocience explanation (refining humunculus) of grade 2 pa mobs produced significantly greater improvement in straight leg raise compared with a hypo/hyper mobile explanation. However, there was no significant difference in pain intensity or forward flexion. Why is a whole other question!?
References
Louw, A., Farrell, K., Landers, M., Barclay, M., Goodman, E., Gillund, J., McCaffrey, S. and Timmerman, L., 2017. The effect of manual therapy and neuroplasticity education on chronic low back pain: a randomized clinical trial. Journal of Manual & Manipulative Therapy, 25(5), pp.227-234.
4 Parts to the pain experience?
Gustin et al. (2011) outlined the 4 main processes that are abnormal in chronic pain;
Sensory-discriminative
Reflecting location, quality and severity (how much and where)
Affective-motivational
Referring to feelings of unpleasantness, distress, and threat (how the pain makes you feel)
Cognitive-evaluative
Referring to the individual’s attitudes and beliefs about pain (how you feel about the pain)
Psychosocial.
How the pain effects your interactions with others.
I've found this really interesting to discuss with patients this week. For example one is feeling down and lacking motivation, although his numerical rating scales for the pain throughout his body is reducing. I talked him through this model and he stated that he felt his issues were that how he feels about his pain and how the pain effects his interactions with others were not better. Interestingly despite huge reductions in his ODI, his BDI has stayed the same. This helps us direct his treatment and my discussions with his MDT.
How about this Steve Trapp?
The ever interesting to follow Ben Cormack, discussed the use of neurological screening as step in reassurance recently. Since reading his approach to this aspect I've noticed how often I do this. Several patients this week come in very anxious about their symptoms concerned it could be something serious. But classical questioning to exclude red flags and neurological and orthopedic testing allows us to give them really good reassurance. Eg one patient with a history of cancer, he had a clearly mechanical pattern, no other red flags and thus I could give really good reassurance based on the findings and talk him through this.
I think the bio-psycho-social approach can be seen in these interactions. A good basic orthopedic approach to clear red flags and identify or exclude a mechanical cause of the symptoms (biological), this then informs and gives more credence to reassurance (psychological) and encouragement to return to normal activities (social).
Orthopedic enough Steve Trapp?
A systematic review I just published with highly "salacious" conclusions suggesting more general exercise may be better for psychosocial symptoms, whilst passive treatment and specific exercise may be better for improving pain. www.researchgate.net/publication/329442463_Physiotherapy_Management_of_Chronic_Low_Back_Pain_Pati...
Physiotherapy Management of Chronic Low Back Pain Patients with Yellow Flags: A Systematic Review
clinmedjournals.org
CLBP is the leading cause of years lived with disability worldwide and patients with yellow flags have the worst outcomes and contribute significantly to the societal cost. Clinicians are aware of the importance of yellow flags but feel undertrained to deal with them. Furthermore there is a lack of....More from Steele's group on extension training for chronic low back pain.
The highlight being a correlation between improvement in extensor strength and disability and pain.
Call me a subgrouper, but I really feel like this approach can be fantastic for some e.g. a pt that reports feeling their back is weak and wants to try strengthening it. vs a typical patient with more pain in standing where extension tends to aggravate symptoms where I would lean away from it.
www.researchgate.net/publication/322267181_Does_Change_in_Isolated_Lumbar_Extensor_Muscle_Functio...
Does Change in Isolated Lumbar Extensor... (PDF Download Available)
researchgate.net
Full-Text Paper (PDF): Does Change in Isolated Lumbar Extensor Muscle Function Correlate with Good Clinical Outcome? A Secondary Analysis of Data on Change in Isolated Lumbar Extension Strength, Pain and Disability in Chronic Low Back PainFascia alters muscle function?
Forces transmitted via fasciæ change sarcomere lengths along and across muscle fibers: a key determinant of muscle’s force production and its contribution to joint ROM. Therefore, passive intra- and epimuscular fasciæ interfere with, and affect muscle’s active mechanics substantially (Gozubuyuk et al 2018)
References
Gozubuyuk, O.B., Karakuzu, A., Pamuk, U. and Yucesoy, C.A., 2018. The role of intra-and epimuscular fasciae beyond being passive structural elements: MRI analyses indicate that they interfere with and affect muscle’s active mechanics. Journal of Bodywork and Movement Therapies, 22(4), pp.852-853.
Some updates to my thoughts on therapeutic alliance. I really think it needs to be a layered approach with education as the foundation. Autonomous patients are not always on the "best" path.
www.kieranmacphail.com/the-therapeutic-alliance-and-low-back-pain/?preview_id=2228&preview_nonce=...
Gender may be a social construct but...
Gonadal steroids can increase the number of dentritic spines in the amygdala and other regions in adult men. Furthermore in women the dendritic density varies significantly across the estrous cycle. (Rasia-Filho et al 2012). In addition rapid gray-matter changes occur across the menstrual cycle, which seems to be driven by changes in estradiol concentrations (De Bondt et al 2013). Borsook et al (2013) suggest the female brain may be “at risk” of clinical conditions, including the increased prevalence of chronic pain because of the rapidly changing pattern of dendritic complexity.
References
Borsook, D., Youssef, A.M., Simons, L., Elman, I. and Eccleston, C., 2018. When pain gets stuck: the evolution of pain chronification and treatment resistance. Pain, 159(12), pp.2421-2436.
De Bondt, T., Jacquemyn, Y., Van Hecke, W., Sijbers, J., Sunaert, S. and Parizel, P.M., 2013. Regional gray matter volume differences and sex-hormone correlations as a function of menstrual cycle phase and hormonal contraceptives use. Brain research, 1530, pp.22-31.
Rasia-Filho, A.A., Dalpian, F., Menezes, I.C., Brusco, J., Moreira, J.E. and Cohen, R.S., 2012. Dendritic spines of the medial amygdala: plasticity, density, shape, and subcellular modulation by sex steroids. Histology and histopathology, 27(7), p.985.
Last Monday I attended a really interesting event on dermatology for allied health professionals. I would strongly recommend if you see a lot of people's skin you should too. Likelihood is we will see several serious skin cancers in our careers I've already referred one, and I hope I haven't missed any but hard to know. Hard to really summarise any key takeaways as there was a lot, the gist for me is if even remotely unsure refer and preferably to dermatologist. Be especially cautious with unusual presentations on the feet and hand which patients may say have been there a while and were probably from a bang.
