I have had a pretty hectic week in all fairness and writing this blog has become quite therapeutic to help me find time for me (which is so important whether you are qualified or student, don’t burn yourself out!). So all of my checks have now gone through so I am now officially employed by UHB! I spoke to my manager yesterday to confirm a start date which is now MONDAY!!! Scary times. Now if that wasn’t scary enough my first rotation is on critical care!! (better get the respiratory books out!) I am very lucky because as a student I worked in the same area so at least I have some idea of where things are. One thing I will be doing is writing down some of the keys things like ABG’s, contraindications and indications for certain treatments as I know that in a new environment sometimes your mind can go completely blank so better to be prepared. I also did this as a student which was useful if I was quizzed by an educator. The things I included were:
- blood gas values
- Normal HR, BP, MAP values etc…
- auscultation sounds
- mini neuro assessment
- contraindications for suction
- contraindications for manual techniques
- contraindications for manual hyperinflation
- weaning protocols
- decannulation protocols
- Areas of the brain
- Manchester Mobility Scale.
This is not an extensive list but it really helped me during placement. Alternatively you can now get mini pocket books from Flipio which has the same sort of things in a published book. See link below:
I am very excited to get started so I will update you on how my first day goes !!
So last weekend I was running Seth O’Neil’s LBP: Using Sub classification to Achieve Better Patient Management course. The course gave a great insight into LBP classification which could be implemented into practice. I am going to talk about some of the stuff I took from the course . However,because it is my interpretation I will try to reference some of the main sources if you want to learn more as I think I need to go away and read around the topic myself to get a wider understanding. A great place to start would be to listen to Kieran O’Sullivan’s podcast on chronic LBP http://physioedge.com.au/pe-022-chronic-low-back-pain-with-dr-kieran-osullivan/ and the Pain Education Group website. Obviously this is not the only way to treat Lower back pain as there are many other theories but is good to attend courses so you can make an informed choice.
So as pre course reading we were given 2 papers one by Fersum et al 2012 and the other by O’Sullivan 2005. The reasoning behind classifying back pain is similar to any joint, we wouldn’t necessarily treat an OA ankle the same as an inversion sprain? So if we could why would we not classify a patient’s specific LBP problem to help direct our treatments? It is little bit more complicated than that but a good place to start is what pain mechanism is causing the patient’s pain?
So in this case we are going to look at three:
- Nociceptive/Mechanical Pain
- Peripheral Neuropathic Pain
- Centrally Mediated Pain
Nociceptive Pain is from activity in tissues such as muscle, joint, skin ans viscera and can be classified by pain which is local, sharp/dull, normal aggs and eases (mechanical), predictable, antalgic pattern, absence of dysesthesias i.e. pins and needles or numbness.
Peripheral Neuropathic Pain is caused by a primary lesion or dysfunction in the peripheral nervous system. Symptoms include dysesthisa, allodynia (pain on non-painful stimulation), hyperalgesia, dermatomal pain and aggs and eases in line with neural tissue. eg. CRPS, Pain generated from the nerve. Physiology of a nerve can generate pain.
Centrally Mediated Pain is caused by a primary lesion or dysfunction in the central nervous system this can be seen from diffuse/ non anatomic areas of pain on palpation. It may be unpredictable, pain disproportionate to the nature of lesion, strong association with maladaptive psycho-social factors. e.g. fibromyalgia
A great way that Seth explains chronic pain to his patients’ is by stating:
“Firstly your pain is real!! If you can imagine doing a crossword everyday for a year- you get very good at it. This is because your brain gets bigger and creates more neurones in this area due to repetition. Therefore if your brain constantly receives pain signals your brain learns to feel pain better and becomes hard wired. So we need to think of strategies we can use to retrain your brain.”
or you can try this video how to explain pain:
There are many classification systems however this event was focused on O’Sullivan Classification (CB-CFT). Through the Fersum et al study the CB-CFT approach had far superior results compared to normal physio (MT + Exercise).With AQP affecting MSK services in the UK it is vital we have statistics to back up our treatment effects. To begin patients should be screened using either the StartBack or Oreobro tool (these also have mobile apps). These tools allow us to see who needs secondary intervention i.e pain team and it also helps with prioritising patients. One of the biggest risk factors for chronic back pain is psychological screening. One outcome measure which can be used to monitor LBP is the Oswestry Disability Index (which can be downloaded for free on if you search on Google).
The O’sullivan Classification addresses whether Back pain is:
- Specific or non- specific
- maladaptive or adaptive
- movement impairments vs control behaviour
To understand this you might want to read: Diagnosis of classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Peter O’Sullivan 2005.
When assessing a patient why is it that some of us ignore passive movements of the spine whereas if we were looking at a knee joint this would not even cross our mind? So if we don’t assess passive movement of the spine how do we know whether the problem is a movement disorder so loss of movement or a control disorder full ROM but painful. It is is difficult to explain this with out providing images but please refer to the resources available.
Movement Impairment Classification- Management
- education- regarding pain mechanism
- reduce fear
- CBT approach
- restore movement impairment
- graded movement restoration
- graded pain exposure
- functional restoration
- normalise movement behaviour
Control Impairment Classification- Management
- Education- regarding pain mechanism
- Cognitive behavioural motor control
- pain control
- retrain faulty postures and movements
- self control of pain
- functional restoration
- normalise movement behaviour.
So at large the treatment should be direction specific, control or movement specific and should take into account psych profile.
This post is more to create awareness of the classification as I am aware I need to clarify some of my knowledge so I can further implement this approach into my practice. I think as a new graduate it is difficult to reason through some of these processes without actually getting the chance to assess patients in an MSK setting on a regular basis. One thing I will be trialing will be looking at passive movements to see how this affects my clinical reasoning in practice.
Seth was a fantastic teacher and he had great feedback from the course. Seth is one of the key Physiotherapists on twitter and his feed attracts a lot of UK and international physios so it is well worth a follow @Seth0Neill.
Some other useful resources below are:
- Physioedge podcast
- BJSM Podcast
- Various other podcasts
Comments are welcome especially if it involves discussion around Sub-classification of LBP or tweet me @LCphysio
Thank you for taking an interest.