Is Pain in the Brain?

I finally leaped into the 21st century and discovered I can post specific YouTube videos on my blog. This is an excellent lecture from the University of California on the origins of pain. Dr Basbaum is as sharp as they come on this topic and this is a very entertaining and informative lecture on pain science. I hope you are able to get something out of it!

Physical capacity and low back pain: Is there a connection?

We frequently advise patients that having strong trunk muscles and better lumbar mobility are important strategies to prevent future episodes of LBP. These types of recommendations go a long way to emphasizing autonomy versus dependence in managing this common musculoskeletal problem.

However, emerging evidence has spawned some serious questions and criticisms of our current paradigm regarding exercise and low back pain. For example, we still don't have a clear picture as to whether specific exercise programs or just activity in general is more effective at preventing LBP. We have even less specific guidelines regarding key exercise parameters such as volume or intensity of activity.

A recent systematic review in Pain raises even more difficult questions regarding the relationship between LBP and trunk strength, endurance, or mobility. After all inclusion criteria were met, the authors reviewed 24 articles. Relevant findings provided some very interesting food for thought.

• Trunk muscle strength and low back pain: Thirteen quality studies and four low-quality studies met the inclusion criteria and were reviewed. The authors found inconclusive evidence to support a specific relationship between trunk muscle strength and low back pain.

• Trunk muscle endurance and low back pain: Eight high quality studies and four low-quality studies were reviewed. In this case, there is strong evidence that there is no relationship between trunk muscle endurance and risk for LBP.

• Trunk mobility and low back pain: Seven high-quality studies and one low-quality study were reviewed. There was inconclusive evidence connecting lumbar mobility and low back pain due to conflicting results.

It should be acknowledged that there are some significant methodological limitations within this systematic review. There was substantial heterogeneity between many of the studies which should prompt the reader to cautiously interpret the results. However, as we are often keen to site evidence to support our interventions, we must all be prepared for the eventuality that our current paradigm may not be as rock-solid as we think.

Exercise will continue to be a significant part of my plans of care in the management of low-back pain. I doubt this will change dramatically, but systematic reviews like this have me looking even harder for the best available theoretical and clinical evidence to support my approach. Until next time!

H HAMBERGVANREENEN, G ARIENS, B BLATTER, W VANMECHELEN, P BONGERS (2007). A systematic review of the relation between physical capacity and future low back and neck/shoulder pain Pain, 130 (1-2), 93-107 DOI: 10.1016/j.pain.2006.11.004

Are you CPR Certified?

Fortunately I'm not talking about through the Red Cross. As important as this life-saving skill is, it may be just as important to understand the nature of a more trendy form of CPR in the world of rehabilitation science: The Clinical Prediction Rule.

Prescriptive clinical prediction rules on topics such as lumbar manipulation, traction, and even anterior knee pain have emerged recently in our rehabilitation literature. The fact these reports exist underscore the fact that we are actively engaged in evolving into an evidence-based profession. However as has been recently and contentiously bantered on more than one discussion forum, as evidence builds it will become even more important for us to understand how to interpret and utilize this evidence in the most appropriate manner. In the case of such a potentially powerful tool as a CPR, we need to have a very clear understanding of its potential uses and possible pitfalls.

To this end, I would like to suggest two articles. The first is by Childs and Cleland published in our PT Journal in 2006. It provides excellent insight into the utility, establishment, and validation of a clinical prediction rule. The second article is actually an editorial in the Journal of Manual and Manipulative Therapy titled "The Potential Pitfalls of Clinical Prediction Rules". It is authored by Chad Cook, the editor-in-chief of JMMT, and provides a good overview of the potential misuses of a CPR.

Clinical prediction rules have been around for quite some time and have significant utility in a variety of clinical settings. They will no doubt be powerful allies in our quest for strengthening our clinical decision making. However, the most appropriate use of the CPR will occur with its judicious application and not blind allegiance. Whether we embrace it or not, the age of evidence-based medicine is upon us and is here to stay. Using evidence-based medicine with a clear understanding of what it truly is (and isn't!) will allow us to continue practicing the science of physical therapy without the trappings of becoming an automaton.

Instead of relying on my synopsis, I eagerly invite you to read these articles for yourself with the hope you will use them in the most appropriate manner for your patients. Enjoy!

Childs, J.D., Cleland, J. (2006). Development and Application of a Clinical Prediction Rule to Improve decision making in physical therapist practice. Physical Therapy, 86, 122-131.

Cook, C. (2008). Potential Pitfalls of Clinical Prediction Rules. Journal of Manual & Manipulative Therapy, 16(2), 69-71.