What's old school?

We were asked a question about why we thought that speaking in pathoanatomical and biomechanical terms was a bit old school. With this being both a topical and important conversation, we wanted to share our response as a mini-blog. :) 

Our position that pathoanatomical and biomechanical reasoning is a bit old school is based on the evidence used to test these models and their limited ability to guide treatment interventions that improve clinical outcomes. For example, in the lumbar spine, we are able to conclusively identify the specific tissue or pathology at fault about 10 to 15% of the time and typically these conditions would include radiculopathies, inflammatory, conditions, fractures and cancers. I would argue that this is when pathology is important – in situations where we can identify and screen for those 10% of cases where patients have a medical pathology that requires further medical intervention. Equally important to physiotherapy practice is the ability to understand when the evidence identifies that our clinical tests and subjective questioning has limited utility in identifying a pathology and/or treatment. Sometimes using tests and historical questions that have limited utility can lead our reasoning astray and serve as red herring. Our traditional assessment that includes palpating for specific mobility deficits that guide our identification of tissue lesion or limited movement has limited support in the research1. Even if these findings were well supported in the literature, would it matter? There is evidence that demonstrates a limited ability to focus our treatment to a specific segmental level2. Furthermore, it would appear that from both an outcome and a neurophysiological perspective, specificity of manual therapy is both not required and unobtainable3,4. 

So where does this leave us? I don’t think we need to throw the baby out with the bathwater and doesn’t mean that our treatment interventions, at a glance, look all that different. What has changed is the reasoning behind choosing to implement manual therapy and, more importantly, the language used with patients regarding their diagnosis and why manual therapy is being used. Idealistically, I would use a system where we could reliably identify a specific pathology that leads to a specific treatment intervention that improves clinical outcomes but at this point it would appear that we are far from this and that the use of a model like this may give the clinician a false sense of security in their diagnosis. There is a risk that the use of a pathoanatomical model in the cases of mechanical low back pain leads to clinicians to provide patients with labels and language that create negative health beliefs and perpetuate fear and disability.  “Words That Harm and Words That Heal”5discusses the impact of clinician language on patients pain experience while this article by Lo et al discusses the changes in Australian Aboriginals beliefs secondary to exposure to Western based care of low back pain6. What has also changed is that our model for the assessment and treatment of patients has increased to include the biopsychosocial realm and its importance in the patients pain experience and prognosis. Things such as fear avoidance beliefs and pain catastrophizing have repeatedly been identified as impacting patients outcomes7,8and there is research to identify that we can include interventions such as education and graded exposure9,10.

With respect to the comment “Isn't this what the rehabilitation sciences were originally based on - empirical observations and anatomical understanding leading to testing and the 'evidence base'”, you are right that this is the starting point for research. We live in a dynamic time with medical literature being published at an extraordinary rate. Research will continue to answer questions and often for each question answered, two new ones will arise. Failure to keep up with these changes from a clinical perspective can lead to suboptimal treatment and from a professional perspective the risk of becoming obsolete. 

Finally, as was brought up, the “Art” of physiotherapy is fascinating. There is growing evidence that this art is likely not based on our use of a specific technique but rather the way with which we interact with our patients11, both clinician and patient expectations of treatment12,13 and an understanding of these factors and their implementation into clinical practice could serve to help improve patient outcomes.

We would very much be interested in people's thoughts regarding our response and would encourage you to discuss them with us on one of our social media platforms. We’d be particularly interested in any evidence you have that supports a pathoanatomical diagnostic model that demonstrates its use leads the clinician to a specific treatment that provides superior outcomes. We are always interested in thoughtful discussion!

1.    Spinal motion palpation: a review of reliability studies. J Man Manipulative Ther 2002;10:24-39. 

2.    Beffa R, Mathews R. Does the adjustment cavitate the targeted joint? An investigation into the location of cavitation sounds. J Manipulative Physiol Ther 2004;27:e2.

3.     Chiradejnant A, Maher CG, Latimer J, Stepkovitch N. Efficacy of ‘‘therapist-selected’’ versus ‘‘randomly selected’’ mobilization techniques for the treatment of low back pain: a randomized controlled trial. Aust J Physiother 2003;49:233-41. 

5.    Bedell SE, Graboys TB, Bedell E, Lown B. Words that harm, words that heal. Archives of internal medicine. 2004 Jul 12;164(13):1365-8.

6.    Lin IB, O'Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM. Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ open. 2013 Jan 1;3(4):e002654.

7.    Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. The spine journal. 2014 May 1;14(5):816-36.

8.    Wertli MM, Eugster R, Held U, Steurer J, Kofmehl R, Weiser S. Catastrophizing—a prognostic factor for outcome in patients with low back pain: a systematic review. The Spine Journal. 2014 Nov 1;14(11):2639-57.

9.    Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. The Clinical journal of pain. 2004 Sep 1;20(5):324-30.

10.  George SZ, Fritz JM, Bialosky JE, Donald DA. The effect of a fear-avoidance–based physical therapy intervention for patients with acute low back pain: results of a randomized clinical trial. Spine. 2003 Dec 1;28(23):2551-60.

11.  Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, Rashiq S, Magee DJ, Gross DP. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Physical therapy. 2014 Apr 1;94(4):477-89.

12.  Cook C, Learman K, Showalter C, Kabbaz V, O'Halloran B. Early use of thrust manipulation versus non-thrust manipulation: a randomized clinical trial. Manual therapy. 2013 Jun 1;18(3):191-8.

13.  Myers SS, Phillips RS, Davis RB, Cherkin DC, Legedza A, Kaptchuk TJ, Hrbek A, Buring JE, Post D, Connelly MT, Eisenberg DM. Patient expectations as predictors of outcome in patients with acute low back pain. Journal of general internal medicine. 2008 Feb 1;23(2):148-53.