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
In some cases of chronic low back pain resolution can occur whilst the MRI looks the same. Lederman (2017) suggests this shows that repair has not taken place and in fact adaptation and alleviation of symptoms are the primary processes. However, it may be that the MRI findings were not the cause of the symptoms. To prove such an hypothesis a gold standard for patho-anatomical pain would be required such as positive discography. This disc would then have to remain positive whilst all other symptoms significantly improved.
On reviewing Lederman's process approach.
www.sciencedirect.com/science/article/pii/S1746068916300074?fbclid=IwAR1mWZc_nc_RKc_SVtTOwGQpkhO3...
A process approach in osteopathy: beyond the structural model
sciencedirect.com
The innate capacity of the body/person for self-recovery and healing is a key concept in osteopathy and the basis of clinical management for a broad r…Manipulation and Chronic Low Back Pain
Clinical prediction rules based on clusters of signs and symptoms have been proposed to identify responders to MT (Cleland et al., 2007). Flynn et al (2002) performed the following manipulation with the symptomatic side down. This was identified by pain on forward flexion, most pain on sacral sulcus palpation, the patient’s description of most painful side or a coin toss if neither of the previous provided a direction of preference!
They assessed 11 variables and found 95% success when these five conditions were met; <16 days of symptoms, >35°of internal rotation in one hip, hypomobility with lumbar spring testing, FABQ work subscale score <19, and no symptoms distal to the knee. Perhaps this could be refined further by not performing the technique if a coin flip was required. The clinical prediction rule has been validated with a follow up. (Childs et al., 2004).
Naloxone partially prevents placebo effect by stopping opioid system- old but interesting and relevant to understanding mechanism of placebo effects which influence us all.
www.sciencedirect.com/science/article/pii/0304395983902038
Partial antagonism of placebo analgesia by naloxone
sciencedirect.com
Thirty subjects were given a placebo (intravenous saline), which was described as a known pain killer, once a week for 3 consecutive weeks. Experiment…Kalauokalani et al (2001) conducted a randomized trial of 135 patients with chronic low back pain who received acupuncture or massage. Before randomization, study participants were asked to describe their expectations regarding the helpfulness of each treatment on a scale of 0 to 10. After adjustment for baseline characteristics, improved function was observed for 86% of the participants with higher expectations for the treatment they received, as compared with 68% of those with lower expectations. Furthermore, patients who expected greater benefit from massage than from acupuncture were more likely to experience better outcomes with massage than with acupuncture, and vice versa
References
Kalauokalani, D., Cherkin, D.C., Sherman, K.J., Koepsell, T.D. and Deyo, R.A., 2001. Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects. Spine, 26(13), pp.1418-1424.
Visceral Manipulation & Chronic Low Back Pain!?
Guillaud et al (2018) conducted a systematic review on the accuracy of visceral osteopathy diagnosis and treatment. The systematic review for treatment identified six studies, with four deemed high risk of bias. The two studies that were included were one on low birth weight infants with negative effects and Panagopoulos et al’s (2015) RCT of physiotherapy plus visceral manipulation or placebo visceral manipulation for chronic low back pain. This found no benefit at 6-weeks for NRS, but at 1 year there was benefit, but no change in disability and patient specific functional scale. Guillad et al (2018) scathingly conclude that there is no evidence for the reliability or efficacy for visceral osteopathy. Which is technically accurate, however, Panagopoulos et al’s (2015) findings are interesting, and surely with refining which patients respond to such an intervention there could be real benefit here. How to do this is difficult. There are huge issues. There are no gold standards to compare assessment and treatment to. These need to be identified first before assessment and treatment can be done. This is an area in its infancy that needs to be opened up to the scientific method and not cling to pseudoscientific excuses to avoid clarification in developing the most efficacious approach.
References
Guillaud, A., Darbois, N., Monvoisin, R. and Pinsault, N., 2018. Reliability of diagnosis and clinical efficacy of visceral osteopathy: a systematic review. BMC complementary and alternative medicine, 18(1), p.65.
Panagopoulos J, Hancock MJ, Ferreira P, Hush J, Petocz P. Does the addition of visceral manipulation alter outcomes for patients with low back pain? A randomized placebo controlled trial: does visceral manipulation alter low back pain outcomes? Eur J Pain. 2015 Aug;19(7):899–907.
Fuentes et al (2018) conducted an interesting four arm trial on Interferential, sham interferential, with a good therapeutic alliance and poor therapeutic alliance. Each session was thirty minutes. In the good therapeutic alliance during the first 10 minutes, each participant was questioned about his or her symptoms and lifestyle and about the cause of his or her condition. Therapists were encouraged to listen actively by repeating the patient's words and asking for clarifications, tone of voice, nonverbal behaviors such as eye contact, physical touch, and empathy. For example saying, “I can understand how difficult LBP must be for you.” The therapist then stayed in the room during the entire treatment and during the measurement of outcomes. During this time, verbal interaction between the therapist and participant was encouraged. Finally, at the end of the session, a few words of encouragement were given. In the poor therapeutic alliance group, interaction was limited to about 5 minutes during which the therapist introduced herself and explained the purpose of the treatment. Participants were told that this was a “scientific study” in which the therapist had been instructed not to converse with participants. After setting up the interferential the therapist left the room and returned 15 and 30 minutes into the treatment to be present when the tester arrived to conduct outcome assessment. Mean differences on the post intervention NRS were 1.83 cm active interferential and poor therapeutic alliance, 1.03 cm for sham interferential and poor therapeutic alliance, 3.13 cm for the active interferential and good therapeutic alliance, and 2.22 cm for the sham interferential and good therapeutic allliance. Mean differences on PPTs were 1.2 kg, 0.3 kg, 2.0 kg, and 1.7 kg respectively. Thus therapeutic alliance was more effective at reducing NRS and pressure pain thresholds than the interferential.
Pain education as recommended by Nijs and chums back in (2011). How do you do it?
First education session
The first educational sessions are suggested to last one or two 30 minutes sessions and be based around sections 1, 2 and 4 from the book “Explain Pain” (Butler and Moseley, 2003). The treatment rationale should be explained, patients should understand the mechanism of central sensitization. Therefore education of the central sensitization model relies on deep learning, aimed at reconceptualising pain, based on the assumption that appropriate cognitive and behavioural responses will follow when pain is appraised as less dangerous (Moseley, 2003).
Nijs et al (2011) suggest acute nociceptive mechanisms are explained first and are then contrasted with central sensitization processes. The education is presented verbally (explanation by the therapist) and visually (summaries, pictures and diagrams on computer and paper). During the sessions patients are encouraged to ask questions and their input should be used to individualise the information.
Home work
Patients should receive an educational information booklet about the neurophysiology of pain and be asked to read it carefully at home. Patients with central sensitization often have neurocognitive impairments, including concentration difficulties and impairments in short-term memory (Nijs et al., 2010), they can forget a number of aspects of the verbal education. Therefore providing the same diagrams and information provided in the education sessions, written information that can be read afterwards is a valuable and essential part of the intervention.
Second session
Before the second education the patient is asked to complete the neurophysiology of pain test. This is used to test the reconceptulisation of pain and guide the session. Next, the therapist discusses the existence of sensitization in this particular patient by giving the patient insight to somatic, psychosocial and behavioural factors associated with pain. This is followed by i.e. discussing with the patient how information provided can be applied during everyday situations. Nijs et al (2011) suggest this can be done with the Pain Reaction Record.
Nijs et al (2011) suggest that after these sessions, treatment such as stress education or exercise can be conducted. It should be explained to the patient how these treatments will further contribute to decreasing hypersensitivity. From then on the therapist should continually check the patients understanding and continue to help the patient reconceptualise pain where appropriate.
References
Butler, D.S. and Moseley, G.L., 2013. Explain Pain 2nd Edn. Noigroup Publications.
Moseley, G.L., 2003. Joining forces–combining cognition-targeted motor control training with group or individual pain physiology education: a successful treatment for chronic low back pain. Journal of Manual & Manipulative Therapy, 11(2), pp.88-94.
Nijs, J., Van Houdenhove, B. and Oostendorp, R.A., 2010. Recognition of central sensitization in patients with musculoskeletal pain: application of pain neurophysiology in manual therapy practice. Manual therapy, 15(2), pp.135-141.
Nijs, J., Van Wilgen, C.P., Van Oosterwijck, J., van Ittersum, M. and Meeus, M., 2011. How to explain central sensitization to patients with ‘unexplained’chronic musculoskeletal pain: practice guidelines. Manual therapy, 16(5), pp.413-418.
I think the poor Piriformis gets very unfairly blamed. So this anatomical study fits my bias nicely.
Natsis et al (2014) found of 294 limbs of caucasian cadavers examined 6.4% had anatomical variants of the sciatic nerve passing through the piriformis.
Reference
Natsis, K., Totlis, T., Konstantinidis, G.A., Paraskevas, G., Piagkou, M. and Koebke, J., 2014. Anatomical variations between the sciatic nerve and the piriformis muscle: a contribution to surgical anatomy in piriformis syndrome. Surgical and Radiologic Anatomy, 36(3), pp.273-280.
If like me you like to make a pathoanatomical diagnosis where possible and challenge yourself pre-MRI this excellent paper by Petersen et al (2017) is for you bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-017-1549-6
My notes are included below for those who want to skip the paper.
Intervertebral disc
Petersen et al (2017) found sufficient evidence for centralization of symptoms to be a sufficient clinical decision rule for intervertebral disc lesions compared with the reference standard of discography.
Facet Joint
There were no useful clinical decision rules identified (Petersen et al (2017). Although it was interesting that no centralization and no pain relief with recumbency were associated with facet joint pain.
Sacroiliac Joint
Petersen et al (2017) found the Laslett rule (Laslett et al 2003) was sufficient on its own to constitute a clinical decision rule. Laslett rule comprises, compression test, distraction test, Gaenslen’s (Patrick’s), sacral thrust and thigh thrust. However, they suggest the addition of no centralization with repeated movements and predominant pain over the PSIS as additions to improve the accuracy of the clinical decision rule.
Disc herniation with nerve root involvement
Petersen et al (2017) suggest the combination of Hancocks rule, 3/4 of corresponding dermatomal pain, sensory deficit, reflex deficit and motor weakness; with straight leg raise. In addition the use of the cross straight leg raise test was also supported, thus if lifting the contralateral leg to the painful side reproduces symptoms this is also positive for disc herniation with nerve root involvement.
Spinal Stenosis
Petersen et al (2017) concluded that a combination of the Cook rule, 3 of 5 positive out of age >48, bilateral pain, leg pain worse than back, pain during walking/ standing and relief with sitting. In addition, they suggest adding relief with flexion and improved walking with lumbar flexion.
Spondylolithesis
Petersen et al (2017) suggested a clinical decision rule could be based on manual inspection/ palpation, hypermobility and passive lumbar extension test in the elderly.
Fracture
Petersen et al (2017) were unable to produce a clinical decision rule for spinal fracture. When at least one of the following was present there was increased likelihood of fracture diagnosis but not sufficient to justify a clinical decision rule; age >70, trauma, significant use of corticosteroids. When none were present clinicians can rule out fracture with a degree of confidence.
Myofascial Pain
The very concept of myofascial pain is contentious. Petersen et al (2017) found no sufficient evidence to create a clinical decision rule. They suggest the presence of a taut band, pain on pressure of the taut and patients recognition that this is their pain as a starting point.
Peripheral Nerve
Petersen et al (2017) were unable to find any studies that had compared with neurodynamic test with a refernce standard, and thus suggest no clinical decision rule. Their suggested criteria for future studies against a reference standard are reproduction of the patients pain with two sensitising manoeuvres during a neurodynamic test. E.g neck flexion, dorsiflexion, adduction, abduction etc.
Central Sensitization
Peterson et al (2017) highlight that studies in this area are hampered by the lack of a diagnostic reference standard. Their suggested criteria are included below.
Criterion 1. Pain experience disproportionate to the nature and extent of injury or pathology, i.e. not sufficient evidence of injury, pathology, or objective dysfunctions capable of generating nociceptive input consistent with the patient’s severity of pain and disability.
Criterion 2. At least one of the following patterns present:
• bilateral pain/mirror pain (i.e., symmetrical pain pattern)
• pain varying in (anatomical) location/travelling pain to anatomical locations unrelated to the presumed source of nociception e.g., hemilateral pain, large pain areas with non-segmental (i.e., neuroanatomically illogical) distribution
• widespread pain (defined as pain located axially, on the left and right side of the body and both above and below the waist)
• allodynia/hyperalgesia outside the segmental area of (presumed] nociception. These findings are based on testing of light touch by means of a swap or cold items (allodynia) as well as testing by pin prick or pressure (hyperalgesia).
Criterion 3. Hypersensitivity of senses unrelated to the muscular system. These findings are based on a score of at least 40 on the Central Sensitization Inventory
References
Laslett M, Young S, Aprill C, McDonald B. Diagnosing painful sacroiliac joints. A validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother. 2003;49:89–97.
Petersen, T., Laslett, M. and Juhl, C., 2017. Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews. BMC musculoskeletal disorders, 18(1), p.188.
Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews
bmcmusculoskeletdisord.biomedcentral.com
Clinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in....Chronic Low Back Pain and Telephone-Based Therapy!?
O’Brien, K et al (2018) conducted a meta-analysis combining RCTs comparing telephone interventions with usual care in acute/ chronic low back pain and osteoarthritis. Telephone interventions outperformed usual care in disability and pain. These findings conflict with those of Dario t al (2017) who included studies of any telehealth intervention for patients with non-specific low back pain and found no difference between these interventions and minimalist interventions (i.e. health or non-health-related information). O’Brien et al explain this difference by suggesting Dario et al included intervetions such as email, e-communitites and web-based content. Nonethless as various different conditions were grouped together by O’Brien et al (2018) the findings are impressive but hard to make exact recommendations about, other than clearly there is utility here. For example where patients are unable to get back in face to face we should probably be doing telephone follow ups on perhaps a weekly basis, whilst reviewing programmes on a monthly basis?
References
Dario, A.B., Cabral, A.M., Almeida, L., Ferreira, M.L., Refshauge, K., Simic, M., Pappas, E. and Ferreira, P.H., 2017. Effectiveness of telehealth-based interventions in the management of non-specific low back pain: a systematic review with meta-analysis. The Spine Journal, 17(9), pp.1342-1351.
O’Brien et al (2018)
peerj.com/articles/5846/?fbclid=IwAR1qDnHegRS6nopLC5-W02tdPaP8mAcgX530NOMmfOmjJHxc75QLSnKj5CQ
peerj.com
Background Osteoarthritis and spinal pain are common and burdensome conditions; however, the majority of patients with these conditions do not receive care that is consistent with clinical practice guidelines. Telehealth models of care have the potential to improve care for osteoarthritis and spinal...
