Douleur chronique – Francais

Pourquoi votre douleur persiste? – Une lettre pour mes patients qui souffrent d’une douleur chronique (partie 1)

 

Tout d’abord, je n’aime pas utiliser le terme chronique. Ce terme laisse entendre que la douleur restera à jamais… mais la plupart du temps, ce n’est pas le cas. D’ailleurs, qu’est-ce que « chronique » signifie? Ce terme est sujet de débats même au sein des professionnels de la santé. Est-ce une douleur qui dure plus de trois mois? Six mois? Une douleur qui durera à jamais?

nevada-chronic-pain.jpg

*Douleur chronique : Un des problèmes de santé les plus sous-estimés dans le monde aujourd’hui

 

 

Je n’aime pas le terme chronique. Je préfère employer le terme persistant. Ce terme suscite moins la crainte et laisse place à l’espoir. Il est juste. Il nous indique que votre douleur persiste, mais ne nous indique pas qu’elle ne s’améliorera pas.

 

Si vous avez éprouvé ou si vous éprouvez de la douleur pour une certaine période de temps, vous avez probablement déjà fait appel à plusieurs professionnels de la santé. Vous avez peut-être consulté un chiropracticien, un médecin, un chirurgien orthopédique, un ostéopathe, un physiothérapeute, un acuponcteur… et la liste ne s’arrête pas là.  Vous avez aussi probablement déjà entendu plusieurs hypothèses différentes tentant d’expliquer votre douleur et pourquoi elle persiste. Un os? Un muscle? Quelque chose qui ne se trouve pas à la bonne place? Un mauvais alignement ? Certains croiront même que votre douleur n’est pas réelle ! Tous ces thérapeutes ont aussi, sans doute, réussi à soulager votre douleur… par contre, ces effets ne perdurent pas et votre douleur revient toujours.

 

En ce moment, votre douleur perturbe sans doute votre vie sociale, vos émotions et votre appétit… Comme si ce n’était pas déjà assez, plusieurs personnes pourraient même croire que vous faites semblant d’avoir mal ! Mais ce n’est pas le cas

 

Maintenant, laissez-moi vous dire plusieurs choses. Votre douleur est réelle et votre condition physique peut s’améliorer.

 

La première étape est la compréhension. Beaucoup d’études prouvent que la compréhension du mécanisme de douleur diminue la douleur.

 

(Pour les thérapeutes, l’étude originale en anglais : a systematic review)

 

Mais ce n’est pas qu’une recherche! J’ai eu beaucoup de patients avec une douleur persistante. Certains éprouvaient de la douleur pendant plus de 10 ans!!! Et nous avons pris du temps pour discuter, partager et comprendre. Je leur ai expliqué ce que j’apprête à vous expliquer… Et j’espère que ceci vous aidera autant que ça les a aidés.

 

Le mécanisme de la douleur

Il existe deux types de douleur : la douleur nociceptive ou centrale.

 

Une douleur nociceptive est souvent accompagnée d’une douleur aigue. C’est une douleur qui s’associe avec du dommage tissulaire comme une fracture, un ligament déchiré, une hernie discale pour en nommer quelques-uns. Heureusement, chaque tissu se régénère à leur propre rythme. Le temps de guérison d’une fracture est d’environ six semaines, celui d’une hernie discale peut remonter jusqu’à six mois… Mais ça guérit! Donc si vous voyez des anormalités sur votre radiographie ou dans votre examen d’IRM, ne paniquez pas! La plupart du temps, elles ne s’associent pas avec la douleur… De plus, la plupart du temps, ces anormalités vont disparaître avec le temps.

 

La douleur centrale est une douleur associée avec une hypersensibilité du système nerveux et se présente souvent avec des douleurs persistantes. Il est important de bien comprendre ceci.

 

Regardez ce diagramme.

pain mechanism

*Douleur, cerveau; voie ascendante, voie descendante; moelle épinière, corne dorsale, ganglion de la racine dorsale; nerf périphérique; blessure, nocicepteurs périphériques

 

Ici, une personne a reçu une coupure à la main. Une nociception (un message de danger) est envoyée au cerveau. Une fois arrivée, le cerveau décidera s’il crée ou non la douleur en tenant compte de différents facteurs (pas seulement la nociception!) à Ceci est très important à comprendre!

 

Prenez, par exemple, une personne qui marche sur un clou de fer. Croyez-vous que ça sera douloureux si :

 

  1. Elle était en train de faire son jogging du dimanche.
  2. Elle est poursuivie par un dangereux lion qui veut la manger.

 

… La douleur est évidemment plus ressentie dans la première situation… peu importe la quantité de tissu endommagé. Ceci peut s’expliquer par le fait que la nociception (le message de danger – l’alarme pour le tissu endommagé) peut être modulée par le siège, ou dans notre jargon, le « système nerveux central ». Un petit message peut être amplifié ou atténué par le système nerveux central. Quand les messages sont amplifiés, nous disons qu’il y a une hypersensibilité du système nerveux (principalement une douleur centrale).

 

Un petit message de danger peut alors provoquer une très grande réaction.

 

Ceci est particulièrement vrai avec les douleurs des membres fantômes, un phénomène dans lequel les personnes ressentent la douleur dans un membre amputé ou manquant. Ici, il n’y a pas de message de danger et une douleur est encore présente. (Très intéressant si vous y êtes intéressé : https://www.youtube.com/watch?v=ySIDMU2cy0Y)

Alors, cela signifie-t-il que votre douleur n’existe pas? NON! Votre douleur est réelle! C’est juste que votre douleur est moins associée à un tissu endommagé… mais plutôt liée à une hypersensibilité du système nerveux. C’est un mécanisme qui ressemble beaucoup au mécanisme de la mémoire… quand nous apprenons le piano par exemple. Dans un sens… vous gardez en mémoire la douleur. La douleur se créée plus facilement.

Comme Dumbledore dit: “Of course it is happening inside your head. But why on earth should that mean that it is not real?” 

“Evidemment que tout est dans le tête. Par contre, pourquoi est-ce que ceci implique que ceci n’est pas réel??”

Inside-your-head

Comprendre ce mécanisme est la première étape vers la guérison. La compréhension de celui-ci entraîne une diminution de l’hypersensibilité du système nerveux. Les prochains articles porteront plus sur ce que votre thérapeute et vous peuvent faire pour traiter cette condition.

Maintenant, n’ayez crainte de poser des questions! Vous DEVEZ comprendre ceci.

En conclusion :

  1. La douleur est RÉELLE.
  2. Vous pouvez améliorer votre condition.
  3. La nociception (messages de danger ou tissu endommagé) n’est pas nécessaire ou suffisant pour créer la douleur.
  4. La douleur est créée à 100% par le cerveau, que ce soit une douleur aigue ou persistante.
  5. Le savoir est un pouvoir. Plusieurs recherches indiquent que la compréhension du mécanisme de la douleur diminue l’hypersensibilité du système nerveux central.

Enfin, voici un vidéo pour vous aider à mieux le comprendre :

 

J’espère que cela vous a aidé.

Votre physiothérapeute,

Olivier Lam

Review of a study- Cervical traction

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Fritz et al. (2014) did a fairly recent RCT on effectiveness of mechanical traction in patients presenting with cervical radiculopathy.

A previous study done by Raney showed that cervical traction was associated with more benefit if patients present with 3 or more of those 5 following factors: (1) Peripheralization with ROM of mobs of low cervical spine. (2) positive shoulder abduction sign [place 1 hand on the head and wait 30 second… if pain decrease, it’s (+)], (3) positive neck traction test, (4) positive ULNT, (5) 55 or older

Based on Raney study, Fritz et. al (2014) did a stratified RCT comparing 3 groups: (1) Exercise alone, (2) Exercise with mechanical traction, (3) Exercise + overdoor traction as home exercise program.

Results:
(1) Disability and pain significantly lower in the group with mechanical traction even after 6 and 12 months!
(2) Regardless of symptoms described by Raney, patients still could benefit from cervical traction

Limitation of this study:
(1) Couldn’t blind the therapist/ patient
(2) Number of treatments were up to 10 in 4 weeks
(3) High drop out… so low internal validity
(4) Selection bias… so low external validity

My thought on this:
A tool to consider for neck pain patients. (probably has more of a psychosocial effect)

Short term decrease of pain increases therapeutic alliance and decreases perceived threat. Also since it’s not blinded, the therapist beliefs will have an impact on the patient’s outcome…

 

Reference:
http://www.jospt.org/doi/pdf/10.2519/jospt.2014.5065

Is a centralizing pain always discogenic?

So I was listening to a podcast the other day (http://www.mechanicalcareforum.com/podcast/49) and the question came up to me… Is a centralizing pain always discogenic?

…I agree that, most of the time, a pain that goes down the leg is from the disc.

Here are a few studies that supports this:
Centralizers are more likely to be discs. http://www.ncbi.nlm.nih.gov/pubmed/9160470
Tissue origin of pain: http://www.ncbi.nlm.nih.gov/pubmed/1826546
(e-mail me if you don’t have access to the full study)

herndisc-BB

But I don’t agree when someone says that a pain that centralizes is always a disc.

Let me explain. (Keep in mind it is theory… and it can still change… however, I think it’s the best model so far that can explain many weird things that we see in the clinic…)

Pain is created at the level of the brain… always. We all have a map of the body in the brain. It’s called the homunculus. No brain, no pain.

penfield-homunculus1.jpg

Which means that there is a representation of a lumbar disc in the brain.

When a disc is injured, it will send nociception (a danger message to the brain) and the brain decides whether it creates pain or not.

If the brain thinks it is worth creating the pain, then a neurotag of pain will fire. Pain will then emerge with the creation of that neurotag.

img_48471.jpg

A neurotag is a combination of many neurons that fire together to create an experience. For example, when you bend forward, your premotor cortex fires, you might get a visual representation of you bending forward, or maybe a visual representation of one of your friend who suffered excruciating pain and went through surgery… or maybe it could be all the things that your therapist told you about your disc squeezing you nerve in the back and that you should completely avoid bending forward or your back will explode!? All those things will wire together to create the neurotag of pain. It creates pain.

Now, if a pain persists, this neurotag is created more easily. A great metaphor that I like is one from Adriaan Louw.

The angry neighbor analogy:
When your home alarm system goes off, your neighbors might notice it… but if it shuts down pretty quickly, nothing really happens…

Now imagine that your alarm system goes off every single day and stays open for many many hours. Or imagine that it doesn’t even close down! Well your neighbors are going to start to get irritated. It might wake them up more often… They might start to complain a little more!

The same thing happens when your pain has persisted for a while. Once one of the neurons (part of the neurotag) starts firing, the others will fire way easier than it should!

music-noisy_neighbour-compromise-comprimise-compromising-noisy_neighbours-dpan1315_low.jpg

Therefore, if a patient comes with pain radiating down the leg with a hypersensitive central nervous system, I would say that there is a good chance that we should look beyond the disc model! Normal pressure on the disc can now create pain that mimics a “discogenic” type of pain. A pain that is able to centralize and peripheralize –> Even if the disc is completely healed.

Let me give you an example of a patient that completely changed the way I treat patients. It’s one of those patients that I will never forget.

Case study:
That patient worked in a restaurant and got injured lifting heavy food from the floor (with a slight rotation of the lumbar spine). Pain started in the lumbar spine and radiated down the leg. She started worrying a lot and got very stressed because it was her business.

On the first day: already presenting with signs of centrally sensitized nervous system (I did not know back then) (to identify central sensitization: here). Pain radiates down the leg. Pain centralizes with repeated extensions, and peripheralizes with flexion. She had no improvements other that short relief of pain with the directional preference exercise.

One day, after reading a bit more on chronic pain and pain science, I tried a few things. I asked her to lie down, relax and think about different things.

  • Think about bending forward: Ayyy! I can’t. It’s painful
  • Think about bending forward… on vacations: it’s okay, not too bad
  • Think about bending backwards repeatedly: Pain centralizes
  • Think about being at the restaurant (where you got injured): Pain peripheralizes

INCREDIBLE!!! The most interesting patient I have ever had! The neurotag of pain, in this case, was created just by thinking (possibly the prefrontal cortex)!!

This patient taught me many things that I thought I should share with you:

  • Mechanism of pain MATTERS. The pain was a predominantly central pain (even if there was nociception)
  • I failed. I probably should have addressed the hypersensitive central nervous system sooner
  • I got focused too much on “reducing” a derangement… whatever that means
  • I kept a patient for too long. Should have discharge way earlier. I created dependence
  • Very little is known in physiotherapy

 

 

I hope that this post helps you understand the wonders of neuroscience and pain.

 

Hvorfor bliver du ved med at have smerter? – Et brev til mine patienter, som lider af kroniske smerter.

Here is the Danish version of my recent post:

“Why does your pain persist? – A letter to my patients suffering from chronic pain (part 1)” (link)

A big thank to Kasper Thornton for the translation!

 

Hvorfor bliver du ved med at have smerter?
– Et brev til mine patienter, som lider af kroniske smerter.

Først og fremmest, så hader jeg ordet kronisk. Ordet “kronisk” lyder som om at smerten vil vare evigt … men heldigvis ved vi, at det ikke er sandt. Men hvad betyder ordet ”kronisk” egentlig? Det er et ord, der selv i sundhedssektoren skaber stor debat, for hvordan defineres en ”kronisk tilstand”? Er det en smerte, der varer mere end 3 måneder? 6 måneder? En der varer for evigt?

Jeg kan ikke lide ordet kronisk. Jeg foretrækker at bruge ordet længerevarende eller vedholdende. For mig skaber netop de ord mindre frygt og efterlader håb – frem for skræk og rædsel. Desuden mener jeg, at det er mere præcise ord at bruge. Det fortæller blot, at din smerte har varet længe, men fortæller IKKE, at den vil vare evigt.
Hvis dine smerter har varet ved i noget tid nu, så har du sikkert konsulteret en masse forskelligt sundhedspersonel. Du har sikkert konsulteret din læge, måske en kiropraktor, en ortopædkirurg, en osteopat, fysioterapeut, akupunktør eller en af de utallige andre titler, der findes i denne branche.

 

Min gæt er, at du har søgt dem for at få svar. Svar på hvorfor det er, at du har ondt – hvorfor dine smerter bliver ved. Mit gæt er også, at du har fået mere end én forklaring. Nogle mener, det er en knogle, andre en muskel, et ledbånd, noget der sidder skævt og skal rettes på plads eller måske har nogle endda har fortalt dig, at dine smerter ikke er ’rigtige’/ægte!

Fælles for dem alle er , at du sikkert har fået en kortvarig lindring af symptomerne, men at de efter tid blot vender tilbage til samme niveau som tidligere.
Din smerte påvirker nu muligvis dit liv i en sådan grad, at det går ud over dit sociale liv, dit humør, din appetit, din lyst til at være aktiv. Mange mennesker omkring dig tror måske, at du ”faker”/lader som om, at du har ondt – men jeg er her for at fortælle dig, at det gør du ikke!
Lad mig fortælle dig et par ting. Din smerte er reel, og din tilstand kan heldigvis forbedres.

Det første skridt på din rejse mod en bedre og sjovere dagligdag er viden. Der findes nemlig en enorm mængde forskning, der viser ,at alene forståelsen af de mekanismer, der forårsager smerter, vil være med til at dæmpe den oplevede smerte.
Men det handler ikke kun om forskning. Jeg har haft en masse patienter igennem behandlingsforløb,  som stod præcis hvor du gør nu – men længerevarende smerter, som ikke er blevet bedre i lang tid – jeg har endda mødt folk, der har haft smerter i mere end 15år!

 

Fælles for mine patienter er, at jeg har brugt en masse tid på at lytte, tale, udvise forståelse og fortælle og forklare. Jeg har forklaret dem det, som jeg i dette brev ønsker at fortælle dig – og så er mit håb, at det vil hjælpe dig, ligeså meget som det har hjulpet dem.

 

 

 

 

 

Der er 2 hovedtyper af smerter: Nociceptive smerter og centrale smerter.

Nociceptive smerter er ofte til stede ved akut opstået skade/smerte. Det er en smerte, der er forbundet med vævsskade. En brækket knogle, et overrevet ledbånd eller en diskusprolaps for at nævne et par eksempler.

Det gode er, at alle væv har en helingstid. En brækket arm er ca. 6 uger om at hele, et ledbånd 4-5 måneder og en prolaps kan være op til 6 måneder om at hele … Men de heler!

 

Så hvis du er blevet scannet – det være sig røntgen, CT-scanning eller en MR-scanning og lægerne fandt såkaldte ”abnormaliteter”, så skal du ikke være bange! I langt de fleste tilfælde er der ingen sammenhæng mellem de fund, der er gjort og dine smerter – og selv hvis der er, så ved du nu, at de heler på maksimalt 6 måneder. Faktisk er ”abnormaliteter” på scanninger helt normale. Som det bl.a. kan ses på nedenstående graf, så har 40%(!!) allerede i 20’erne (!!) degeneration (det som vi kender som slidgigt). Heldigvis er det altså ikke 40% af alle i 20’erne, der har smerter i lænden. Der er altså ingen sammenhæng mellem det, vi kan finde ved en scanning, og det vi mærker og føler.

 

Mike Stewart, en anerkendt engelsk smertespecialist, sammenligner MR scanninger med at tage din velfungerende bil til Ferraris bedste super-bil-værksted og give dem en uge til kun at gennemgå din bil. Du afleverede en bil, der virkede upåklageligt, men tror du, de vil kunne finde nogle ”fejl”?

 

En anden måde at anskue det på, kunne være med denne metafor; Din computer går i stykker, og vi får samlet 10 af verdens bedste IT teknikkere. De får din computer til rådighed men må ikke tænde for den – de må kun kigge ind i den, ind og se på ledningerne, chips, og hvad der ellers er i en computer. Tror du, de vil kunne finde fejlen? Selvfølgelig ikke – de aner ikke, hvad der sker inde i ledningerne og hvilke fejlslutninger, der kan ske her. Prøv at erstatte computer med din krop og ledninger med dine nerver og tænk over scenariet igen.

MRI
Den centrale smerte er en smerte, der er forbundet med et overfølsomt nervesystem og er ofte til stede ved længerevarende smerter. Forståelsen af denne del af smerteteorien er essentiel for dit forløb.
I dette scenarie kunne man forestille sig, at man havde skåret sig selv i fingeren under madlavningen. Nociception (et fare-signal) sendes via nerverne i fingeren ind til rygmarven og herfra op til hjernen. Når beskeden ankommer til hjernen, er det hjernen, der afgør, hvorvidt signalet er vigtigt nok til, at der skal skabes smerte. Hvorvidt det vil skabe smerte afhænger af mange forskellige faktorer og ikke blot nociceptionen – altså det, at hjernen modtager et faresignal. Det er helt afgørende at forstå, at din hjerne altså træffer et valg baseret på en lang række oplysninger og ikke blot skriger ”SMERTE” hver gang, den modtager et nociceptivt signal/faresignal.

 

For at sætte det i kontekst så findes der faktisk findes utallige rapporter fra soldater, der beskriver, at de er blevet ramt af skud men først opdager og oplever smerten, når de er i sikkerhed. Dette kan forklares ved, at hjernen under kampen har vurderet, at det var mere vitalt for soldatens overlevelse, at han kunne flygte fremfor at opleve smerte forbundet med skuddet. Det er ofte først når soldaterne er i sikkerhed i en bil e.l., at de rent faktisk opdager ,at de er blevet ramt. Ret vildt, ikke?

 

Man kunne også forestille sig en helt almindelig hverdagssituation:

Du går en rolig søndagstur inde i byen. Da du skal krydse vejen, overser du kantstenens højde og vrider derfor om på din ankel. Vil det gøre ondt? Ja(!), selvfølgelig vil det gøre ondt.

 

Men hvis vi nu ændrer konteksten en smule, og historien nu er sådan her;

 

Du og dit barn går en søndagstur inde i byen. Da I skal krydse vejen, er du uopmærksom i et øjeblik og dit barn begynder at gå over vejen uden at kigge sig for. Idet du træder ud efter barnet, vrider du om på din ankel og ser samtidig, at en bil er på vej imod dit barn. Vil det i denne situation gøre ondt i din ankel? Mit bud er nej.

 

Og hvordan kan det nu lade sig gøre? Lad mig prøve at forklare.

 

I begge tilfælde vrider du din ankel. Der sendes i begge tilfælde et nociceptivt signal fra nerverne omkring din ankel op til rygmarven og herfra videre til din hjerne. Denne proces er ens i begge scenarier. Forskellen er at der i senarie 2 er indsat et element, hvor hjernen må vurdere, hvad der er vigtigst: Din skade til anklen eller dit barns sikkerhed/vel og vel. I denne situation vil hjernen selvfølgelig vægte dit barn langt højere, end at du skal ligge et par dage ekstra i sengen på grund af øget skade til anklen. Derfor vil du ikke umiddelbart mærke nogen smerte, da hjernen er i ”overlevelsestilstand”. I scenarie 1 er der ingen omkringliggende fare eller omstændigheder, som hjernen skal tage stilling til, og derfor vælger hjernen den mest hensigtsmæssige løsning og vælger, at du skal mærke smerte. Grunden til at du skal mærke smerte er for at passe på din ankel og tage hensyn, så du ikke øger vævsskaden mere end højst nødvendigt.

 

For at komplicere sagen endnu mere; når det nociceptive signal (faresignalet) bliver sendt til hjernen, så kan dette faresignal/farebesked ”ændres”/”redigeres” undervejs, idet signalet passerer igennem rygmarven. Videnskaben ved nu med sikkerhed, at faktorer som dårlig søvn, negative forventninger til forløbet, angst, urolighed, depression, stress samt negative overbevisninger omkring skaden alle giver mulighed for at ”skure op” for signalet. Derfor vil hjernen modtage et forhøjet faresignal fra rygmarven, og derfor vil smerteresponsen være stærkere/højere end det, som skaden i vævet egentlig bør retfærdiggøre.
Betyder det så, at dine smerter ikke er ægte?! NEJ! Dine smerter er 100% ægte. Det, jeg siger er, at dine smerter højst sandsynligt har mindre at gøre med en skade i kroppen og meget mere at gøre med et oversensitivt nervesystem. I Harry Potter filmene siger Albus Dumbledore på et tidspunkt følgende:

 

“Of course it is happening inside your head. But why on earth should that mean that it is not real?”

 

Nerverne og hjernen bliver gode til det de træner. Så hvis vi øvede os i at tale fransk i 1 år, så ville vi blive bedre til fransk. På samme måde er det med smerter. Når hjernen og nervesystemet konstant er i beredskab, så træner hjernen evnen til at føle smerte, og derved skal der mindre til, at du føler smerte.

Din forståelse af denne mekanisme er første skridt på din vej til at behandle smerterne – for som beskrevet tidligere, så har forskning igen og igen vist, at forståelse er en uhyre vigtig faktor på vores vej til ’recovery’.

Så for at opsummere det hele så:

  • Dine smerter er rigtige – og ingen skal fortælle dig, at det er noget du opdigter/overdriver
  • Du kan få det bedre igen
  • Nociception (faresignal) er ikke nødvendig eller tilstrækkelig til at skabe smerte.
  • Smerte er 100% af tiden skabt af din hjerne. Uanset om det er akut smerte eller en mere vedvarende form for smerte.
  • Viden er magt. Mange undersøgelser viser, at forståelse mekanismen bag ​​smerte, formindsker følsomheden af ​​nervesystemet.

 

Jeg håber dette har øget din forståelse for smerters kompleksitet, og jeg håber, du har fået mod på at kæmpe videre på vejen mod en mindre smertefuld hverdag.

 

Dine fysioterapeuter,

Oliver Lam & Kasper Thornton

 

*Dette brev er oprindeligt skrevet af Oliver Lam, på engelsk og efter aftale oversat af mig med en række ændringer samt tilføjelser.*

A letter to a freshly graduated therapist (part 2 – Classification models)

Now that you know the basics, we can get slightly more specific with classification models. These are classifications used in physiotherapy. Keep in mind that whatever classification you use, it should help you refer when needed. We have to understand that we can not treat everything.

I am biased. I believe that classifying patients leads to better outcome and that it is the future of physiotherapy. Hopefully, I will convince you to think the same way.

classification_sorting.gif

In university, I was taught to direct my treatment based on the physiotherapy diagnosis. It felt incredible to believe that I was able to diagnose! It felt incredible to think that I was able to differentiate between a bursitis, a rotator cuff tear, a herniated disc, a hypomobile joint and an instability! Each diagnosis had a slightly different treatment! A herniated disc likes traction. A bursitis benefits from ultrasound. A rotator cuff you check motor control of the scapula and drop some deep tendon friction to realign the fibers. A hypomobile joint you give ROM and throw some massage. It felt great! Too bad a few weeks after my graduation, I realized that physiotherapists weren’t reliable at giving a pathonanatomical diagnostic. This leads to poor evidence regarding effectiveness of physiotherapy. It frustrated me. Take for example low back pain. Even after thousands of randomized control trials, there is still no consensus on the best diagnosis and/or treatment!

Let me explain. The tools we use to diagnose aren’t reliable:

Let’s push it further. Let us assume that those tests were reliable… Let us assume that somehow we were able to identify that someone has a disc herniation or an instability. How do we even make sure that it is the cause of their pain? To what do we compare them to? MRI? X-Rays? We can’t.

Here is the reason why:

VOMIT Poster 2014 SAMPLE

Most asymptomatic people (never even had pain in their life) present with abnormalities! This leads to the question: “Is their pain really due to the herniated disc? Or was the herniated disc already present?”

So… Most of the time, we can’t give a patho-anatomical diagnosis, it does not guide our treatment, and it can even lead to wrong treatment approaches.

This is why many researchers got interested in classification models.

Preliminary researches show that classifying patients leads to better outcome (and yes, I cherry pick my studies and I am biased. Make your own opinion):

Mechanical Diagnosis and Therapy (Low back, knee)

Jeremy Lewis (shoulder)

O’Sullivan classification (low back)

Treatment based classification (neck, low back)

Mechanism-based classification (just theoretically)

Theory: http://www.manualtherapyjournal.com/article/S1356-689X(12)00081-1/abstract  . And theoretical treatment matched to the centrally sensitized subgroup: Pain education helps

I believe that more research is needed but that we have enough evidence to start classifying our patients into homogenous subgroups based on their clinical presentation. Each of them would benefit from a specific treatment…We also have enough evidence to stop worrying as much as before about pathoanatomy.

I believe that classifying patients before we treat them will lead to better outcome. This will then (finally) result in more conclusive researches supporting physiotherapy treatments.

I hope this helps.

Olivier Lam

Why does your pain persist? – A letter to my patients suffering from chronic pain (part 1)

Therapists are welcome to link this post to their patients suffering from chronic pain.

First of all, I hate the word chronic. The word “chronic” sounds like the pain will last forever… but most of the time, it doesn’t. Furthermore, what does chronic even mean? The word creates debates even within healthcare professionals. Is it a pain lasting more than 3 months? 6 months? That will last forever?

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I don’t like the word chronic. I prefer using the word persistent. The word persistent is less fear mongering and leaves hope. It’s more accurate. It only tells us that your pain has persisted, but doesn’t tell us that it will last forever.

If you have had pain for a while now, you probably went to see a lot of healthcare professionals so far. You might have seen a chiropractor, a doctor, an orthopedic surgeon, an osteopath, a physiotherapist, an acupuncturist… and the list goes on. All those might have given you a different reason for why your pain persists. A bone? A muscle? Something out of place? Some might not even believe your pain is real! All those might have given you a slight relief of pain but it comes back.

Your pain might now affect your social life, your mood, your appetite. Many people might think that you fake it, but you don’t.

Now let me tell you a few things. Your pain is real and your condition can improve.

The first step is understanding. A huge amount of research shows that understanding the mechanism of pain decreases pain.

(For the therapists, the actual research, a systematic review)

But it’s not only research! I have had a lot of patients with persistent pain. Some have had pain for more than 10 years!!! But we spent time talking, sharing and understanding. I explained to them what I am about to explain to you…  And hopefully this will help you as much as it helped them.

Mechanism of pain:
There are 2 main types of pain: Nociceptive pain and Central pain.

A nociceptive pain is often present with acute pain. It’s a pain that is associated with tissue damage. A fracture, a ligament tear, a herniated disc for example. The good thing is that all tissues have a healing time. A fracture takes around 6 weeks, a bad herniated disc can take up to 6 months… But they HEAL! So if you see abnormalities on your X-Ray or MRI, don’t freak out! Most of the time, they are not associated with pain… and if they are, those abnormalities will heal.

The central pain is a pain that is associated with hypersensitivity of the nervous system and is often present with more persistent pains. Understanding this is crucial.

Look at this diagram:

pain mechanism

Here, someone cut his hand. Nociception (a danger message) is sent to the brain. Once it arrives to the brain, the brain will decide whether or not it will create pain depending on many different factors (not just nociception!) –> This is crucial to understand!

Take for example, someone that walks on an iron nail. Do you think it will be painful if:

  1. He was casually doing a Sunday run
  2. He is followed by a dangerous lion that wants to eat him

… Well the pain will obviously be more intense in the first situation…. Regardless of the amount of tissue damage. This is explained by the fact the nociception (danger message – signal for tissue damage) can be modulated by the headquarter, in our jargon, the “central nervous system”. A small message can be amplified or decreased by the central nevous system. When the messages are amplified, we say that there is a hypersensitivity of the central nervous system (predominantly a central pain).

A small danger message can then create a big response.

This is especially true with phantom limb pains, a phenomenon in which amputated people feel the pain in their missing limb. Here, there is no danger message and there is still pain (Amazingly interesting if you are interested: https://www.youtube.com/watch?v=ySIDMU2cy0Y)

Now does it mean your pain is not real? NO! Your pain is real! It’s just that your pain is probably less linked to a tissue damage… but more linked to a hypersensitivity of your central nervous system. It’s a mechanism that is very similar to the mechanism of memory… when we learn piano for example. In a sense… you get a memory of pain. Pain is created more easily. As Albus Dumbledore once said:

“Of course it is happening inside your head. But why on earth should that mean that it is not real?”

Inside-your-head

Understanding this mechanism is the first step towards treating it. Understanding it decreases the hypersensitivity of the central nervous system.  Future posts will focus on what you and your therapist can do to treat this condition.

Now, feel free to ask questions! You MUST understand this.

In conclusion: 

  1. Pain is REAL.
  2. You can improve
  3. Nociception (danger messages or tissue damage) is not necessary nor sufficient to create pain.
  4. Pain is 100% created by the brain. Whether it’s an acute pain or a more persistent type of pain.
  5. Knowledge is power. Many researches show that understanding the mechanism of pain, decreases the sensitivity of the central nervous system.

Finally, a video to help you understand it even more:

I hope this helped,

your physiotherapist,

Olivier Lam

 

A letter to a freshly graduated therapist (part 1) – The Basics

This post if for young therapists that freshly graduated and other interested therapists.

First of all, congratulations, you just graduated. Enjoy this moment, you have worked hard and probably deserve it.

Now there is a few things I want to tell you…

First of all, physiotherapy is the most amazing profession! You get to learn and help people on a daily basis. People trust you and love you for what you do and you can’t help but feel rewarded… This reward, however, comes with a price. It comes with responsibility.

You have the responsibility to go out there, spend time to read, learn and especially UNLEARN. If I have one thing to tell you, it’s to stay humble and skeptical. We are still in the dark ages of physiotherapy… very little is known. Don’t take what you have learned so far for granted…Quotefancy-3331-3840x2160.jpg

For example, allow me to expose a few lies you might have learned from physio school (with awesome blogs that you should follow. The real reference are via those blogs. Don’t take it for granted and go read the actual research until you trust the authors..)

  • You can’t stretch a fascia. Here are 2 great blog posts that completely changed the way I treat patients.

http://www.greglehman.ca/2012/10/26/fascia-science-stretching-the-relevance-of-the-gluteus-maximus-and-latissimus-dorsi-sling/

https://www.painscience.com/articles/does-fascia-matter.php

  • Palpation is rarely reliable… and often, when you use it, it can lead to a misdiagnose and a wrong treatment. When I learned that, I felt relieved. I didn’t need 20 years of experience to be able to accurately palpate… no one can (although some still think they can).

https://thesportsphysio.wordpress.com/2014/05/05/diagnostic-palpation-is-it-a-skill-an-art-or-an-illusion/

  • Most of your treatments don’t change the mechanics, the anatomy nor replace anything… You can’t break down scar tissues… Manual therapy probably only has a neurophysiological effect

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775050/

 

There are many more weird things in physiotherapy like: ultrasound, muscle energy techniques, dry needling, etc… which might be clinically useful but which all have outdated/ wrong theories on why they work.

There are a lot of approaches out there and I encourage you to understand a bit of all of them and to keep an open but critical mind… However, whichever approach you use, stick to the basics, and keep it simple stupid.

Know the basics. Start with that. Many systems share the same principles. Whether they call it “Quantification of mechanical stress” from Blaise Dubois courses on running injuries, “gradual exposure”, “Reset, reinforce, reload” from Gray Cook’s SFMA and FMS courses, or “postural correction + avoidance” from the McKenzie approach, it’s all the same thing.

My favorite way of describing it goes to Greg Lehman (http://www.greglehman.ca/):

Calm Shit Down, Build Shit Back Up. 

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Calm shit down by:

  • Reassurance
  • Use symptoms modifications whether it’s:
    • McKenzie’s directional preference
    • Mulligan technique
    • Jeremy Lewis algorithm for shoulder
    • Relaxation for patients with sensitized nervous system
  • Calm shit down often

Build shit back up with:

  • Creativity, variety, exercise
  • Functional meaningful exercise for your patient

I hope that this post helps some of you freshly graduated physiotherapists. Future posts will focus on what continuing education I think is worth taking and why I believe classification systems are the futur of physiotherapy.

Olivier Lam

 

Teaching ignorance

In physio, there are so many gurus that know it all! There are so many theories that explains everything… When we graduate, we have the belief that we can treat anything…

For example, when a doctor tells us “this patient has a lumbar sprain”, we laugh at it because we have the strong belief, based on our education, that this patient has a L5 Right Z-joint hypomobility in extension because of his lack of strength in the right gluts…

The physio education (at least the one that I received) spends too much time giving far-fetched answers rather than questioning and challenging our own biases.

Ignorance is what drives me… It is the thing that made me fall in love with physiotherapy… and there is nothing wrong about it….

Don’t trust everything those guru say. Don’t join the dark side.

Stay alert, stay skeptical. Whatever treatment or system you use… THINK.

There is no one-size-fits-all…

yfoo8

Ignorance creates questions… and questions are the answer to ignorance…

 

How do we identify central sensitization?

How do we identify central sensitization (CS).. in the clinic?

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The first important step is EXCLUDE neuropathic pain. Neuropathic pain characteristics include:

  1. History of lesion or disease of the nervous system
  2. Evidence from diagnostic investigations to reveal an abnormality of the nervous system
  3. Pain/sensory dysfunction neuroanatomically logical
  4. Often burning, shooting, and pricking. N.B: Neuropathic pain does not exclude the possibility of have CS

The second step is to determine if persistence is mainly due to CS or from peripheral nociceptive input.
There are many criteria:

  1. DISPROPORTIONATE:
    Pain is disproportionate to the nature and extent of injury (e.g. in patients with OA, radiological findings show little to no association with pain severity. Furthermore, many studies show an association between OA and CS.
  2. DIFFUSE:
    Diffuse pain (Mirror pain is not always due to bilateral disc herniation… I would argue extremely rare)
  3. AFFECTS OTHER SENSES
    Hypersensitivity of senses unrelated to MSK system (Increased pain with weather, heat, cold, chemical substances, stress, TENS, etc…). It could potentially affect odors, smell, sound, and sensitivity to bright light. To assess this, therapists are encouraged to use the Central Sensitization Inventory (0/100). A score of 40 or more indicates possible sensitization.

N.B. 1 = CS may “dominate the clinical picture and modulate the transition to chronicity”. This is why it is crucial for clinicians to identify patients presenting with it…(different from chronicity!)

N.B. 2 = There is a difference between adaptive peripheral sensitization (following an acute injury, the CNS becomes sensitize to further protect the area) and maladaptive CS (that we need to identify).

Hope it helps you guys!

Reference:
Nijs – Applying Modern Pain Neuroscience in Clinical Practice: Criteria for the Classification of Central Sensitization Pain