Treatment Effect of Postural Awareness Exercises in Patients with Chronic Neck Pain

Treatment Effect of Postural Awareness Exercises

Numerous studies of patients suffering from chronic neck or back pain have focused on the elements of safety or the effectiveness of clinical interventions in subjects, but a recent study conducted by the Department of Complementary and Integrative Medicine in Essen, Germany highlights the effects of intentional postural awareness on neck discomfort and symptom-related anxiety instead. The results of the 12-week study—which compared the baseline and outcome indicators of small control groups—suggests that the development of body awareness through Tai Chi (or yoga) and neck exercises significantly improve levels of pain intensity and physical function in patients.

Though previous studies had established a connection between postural awareness and a reduction in pain intensity, the new study focused on the varying factors that may have been involved in the improved condition. By utilising the Mantak Chia variation of Yang style Tai Chi and rehabilitative neck exercises designed to stretch and strengthen the neck and core, the study’s instructor introduced interventions that would increase body awareness in the subjects and subsequently reduce their neck pain. Both control groups received instruction on guided imagery, proper breathing, isometric and dynamic mobilisation and posture awareness, as well as basic information on the ergonomics of movement. Participants of both study groups were asked to be aware of their body posture and to adjust it as needed throughout the lesson and at home, when needed.

Subjects Claim Multiple Benefits

The subjects were assessed at the beginning of the study and again after 12 weeks to determine their: level of pain intensity, psychological distress, life stress, sensitivity to the body’s stimuli, postural awareness and control, and connectedness between body and mind. Both control groups reported to have benefitted substantially from increased postural awareness and claimed to experience a “widened” awareness of parts of the body that had previously gone unnoticed. Additionally, the subjects claimed to have found their focus actively turning toward their body postures at home and that they found themselves correcting their stances while walking, sitting, and standing. The participants uniformly claimed to feel better able to affect their own levels of pain and well-being by using the techniques they had learned to observe and modify their posture.

Finally, the subjects in the study found their anxiety levels reduced in accordance with the levels of improvement in pain intensity. The results here indicate a direct correlation between chronic pain and anxiety, whether causal or due to the discomfort. It is apparent anxiety influences chronic pain and vice versa. One may conclude that better health outcomes can be achieved when anxiety levels are moderated through awareness of posture and state-of-being. Being aware of posture is one step in gaining postural control, which reduces the incidence of falls and improves levels of pain, balance, muscle tone and movement. Training a patient with neck pain to recognise and adjust posture for optimum health and wellness is a positive and empowering step in the healing process and may yield psychological as well as physical benefits.

Mindfulness-Based Stress Reduction – The Mechanics in Mindfulness

mechanics, chronic low back pain, mindfulness

Mindful Mechanics

How to best treat chronic pain is an important study. In a recent article published in the Journal of the American Medical Association, three types of treatment strategies implemented resulted in different outcomes in those with chronic lower back pain.

They were:

  1. Mindfulness-Based Stress Reduction (MBSR)
  2. Cognitive-Behavioural Therapy (CBT)
  3. Usual Medical Care

What they found after randomly selecting participants with chronic low back pain into the respective groups was both the Mindfulness-Based Reduction and the Cognitive-Behavioural Therapy outperformed the Usual Medical Care groups.

The MBSR approach was modeled after a book called: Full Catastrophe Living (Revised Edition): Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness

which includes (Section 1. Paying attention):

1 You Have Only Moments to Live

2 The Foundations of Mindfulness Practice: Attitudes and Commitment

3 The Power of Breathing: Your Unsuspected Ally in the Healing Process

4 Sitting Meditation: Nourishing the Domain of Being

5 Being in Your Body: The Body-Scan Meditation

6 Cultivating Strength, Balance, and Flexibility: Yoga Is Meditation

7 Walking Meditation

8 A Day of Mindfulness

9 Really Doing What You’re Doing: Mindfulness in Daily Life

10 Getting Started in the Practice

If you look at the headline and the summary of this research paper, you might be inclined to think the best way to treat chronic low back pain in through the mind. However, if you closely dissect the MBSR strategy there are mechanical strategies throughout the approach. This includes Yoga, Tai Chi and breathing. These are all mechanical and a careful reader must not dismiss the mechanics within the results.

There is a growing movement that mechanics does not matter, but we have to be diligent in our attention to the mechanics ‘within’ these mind-body interventions.

 

 

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Fostering Postural Interoceptive Exercises to Help Reduce Neck Pain

posture, awareness, pain, spine model

In a recently accepted Level 1 evidence publication (Jan 31, 2017), a study looked at how postural awareness can make an impact on non-specific neck pain. Non-specific neck pain usually indicates that there isn’t  any pathological problems. Moreover, this usually indicates a degenerative problem associated with the intervertebral discs and/or facet joints.

In their study (Does Postural Awareness Contribute to Exercise-induced Improvements in Neck Pain Intensity? A Secondary Analysis of a Randomized Controlled Trial Evaluating Tai Chi and Neck Exercises) seventy-five subjects were randomly allocated to two groups: a Tai Chi group and conventional neck exercise group. After a period of 12 weeks, neck pain VAS measures decreased significantly in both groups.

The authors speculated that postural awareness played an important role in the positive outcomes.

Postural awareness can be a challenging concept to encourage especially when patients do not know the reason to do so. Dynamic Disc Designs models allow the practitioner to explain why posture is important. This fosters postural awareness through education rather than a dictatorship approach.

Interoceptive consciousness often begins with an understanding of how changing posture can change the stresses on the internal spinal structures.

Whether you are trying to motivate postural interoceptive awareness or explain why certain neck exercises are important to the patient, our models help connect the reasons at to why.

“ Your models have re-established the vital importance of the doctor / client communication relationship, dramatically bridging the gap for both to have a common understanding of the condition, the process ahead, and the targeted outcomes towards health and wellness for life. Simply perfect.” Barry Kluner DC

Postural awareness begins with an understanding of how the spine works. Our viscoelastic models show patients the effect of load and time dependent compression. Changing the angles of the endplates can significantly improve ones posture and the reduction of pressure on sensitive tissues. Teaching a patient as to WHY to improve their posture is a key to helping them reduce their pain.

 

How to improve patient outcomes using spine models

Spine Patient Education, Patient Centered, Education

Spine models are excellent tools for improving patient engagement and outcomes. They make it easy for the patient to understand their condition and the proposed treatment plan better. However, like any tool, they can also be used in a way that can hold back patient improvements. This is a guide for how to use spine models to their full potential in your treatment plan, while avoiding the nocebo response.


Models and effective treatment

Most of your patients have a fairly limited understanding of spine anatomy. The mechanisms of their pain or discomfort are a mystery to them, and they come in need of a fix. The best treatment, however, isn’t the one that simply reduces or manages the pain. It’s the one that also explains how the treatment is done.

A few years ago in Economics, an excellent paper was published by Daniel Hausman called ‘Why look under the hood’. In it he put forward a similar point; if you’re testing out a used car then a test drive isn’t enough, you need to look under the hood at what is underlying the car’s performance to know what might happen in the future. His point was that it’s important to understand the mechanisms underlying a phenomenon to fully get to grips with it.

We can’t show a patient under the hood without invasive surgery because the body does not have a hood to open. However, we can show them with a model that represents the inside, so they can understand the mechanisms contributing to their pain. This will allow them to clearly see and engage more with their treatment plan. It also may allow them to feel confident in reporting new developments in their condition.

How to incorporate models in your treatment plan

Here’s a way to incorporate this explanation into your treatment plan.

  1. Watch the patient move, observe their posture and facial expressions. Notice their symmetry and how they get up from a chair. This will help add context to their personal account of their condition.
  2. Ask the patient for their narrative. Their account of their history and when the pain or discomfort started is your second piece of evidence.
  3. Touch where the patient is experiencing discomfort and feel whether there are any tissue abnormalities. Notice how they react to your touch.
  4. Assess their condition based on these three evidence points, and develop a treatment plan. Communicate what is causing their condition with the appropriate spine model, and how the treatment plan empowers the patient to reduce their discomfort.

Watch Stuart McGill’s use spine models in his explanation here:

Avoiding the nocebo response

Michael Sullivan’s landmark paper, on catastrophizing and the nocebo response, showed that spine specialists need to be careful in how they communicate a patient’s condition. Using negative, pain-focused language can negate the benefits of treatment and leave the patient feeling unable to improve their condition.

A growing trend is seeing specialists criticising spine models as contributing to catastrophizing. They argue that spine models which show defects encourage patients to associate their pain with a physical, unchangeable condition – hampering treatment. While this is certainly possible, any tool used inappropriately can cause unwanted effects. Spine models only contribute to the nocebo response when used incorrectly and under a poor practitioner.

Models should be used empower and educate the patient, not scare them. The specialist must make it clear that the treatment plan will work and use spine models to demonstrate why. Models only contribute to catastrophizing when they exaggerate and embellish the pain causing aspects of their anatomy.

At Dynamic Disc Designs we take great care to ensure our models are the most anatomically accurate on the market, and only represent spine defects appropriately to aid the specialist.

We welcome feedback from specialists in how we can further support them to avoid the nocebo response. Get in touch here with your suggestions or tell us how you incorporate models into your treatment plans.

7 Principles for Effective Patient Engagement

Patient Engagement for Spine

Dr. Jerome Fryer (Chiropractor) cuts to the chase and shares his success in clinical practice and the best ways to engage patients. Beyond the scripting and mundane approach to marketing yourself, pay close attention to a patient’s needs right at the outset. Engaging will ensure compliance and Jerome Fryer shares his 7 principles to his clinical success.

The secret 7 

  1. Pay attention Early.Watch your patient move. Observe with close attention how a patient presents in the waiting room or observe how they get out of the chair and make early observations about the behavior. This lets the patient know you are paying attention. It sets the stage that you are engaged.
  2. Tie in history.Whether the history is fresh, like the observations you’ve identified in getting to the treatment room, or whether it was when the patient felt the injury onset with a particular movement….tie it in to the exam! Even if you are not too sure exactly on the pain trigger, set out a differential, and communicate the anatomical structure(s) that is likely injured.
  3. Touch the patient’s area of complaint.This is a no-brainer but so often I hear that doctors and other therapists do not even touch the area of complaint. Chiropractors, for example, like I am, are doctors who use their hands. SO USE THEM. A patient is asking you to figure out the anatomical problem so investigate the area.
  4. Tell the patient what you are doing.This is another common-sense thing to do but is often not done. If you are checking the ligaments of the knee, say “I am checking the ligaments of your knee”. A patient wants to know what you are doing. Use your voice to communicate.
  5. Ask if this hurts.The best orthopedic tests are the simple ones. That is, “ does this hurt? ” This is especially helpful when investigating posterior to anterior pressure of the spinous processes (and inter-segmental tissues) of the spine. Too often are doctors concerned about what they feel. More important is what the patient feels. This is a direct way to engage and let the patient know you have found a sensitive tissue and you are paying attention.
  6. Treat the Tissue.If you have found something sensitive in the area of chief complaint, treat the area of chief complaint. Even if you do not have a full understanding of the patho-anatomical lesion, do your very best in developing a plan and communicate that plan. You don’t have to be 100% correct but let your patient know what your plan is. Don’t be afraid of failure and be honest.
  7. Share your findings and plan.There is no better way to communicate than to use a dynamic model to help patients clearly see and observe the tissue. I have been using Dynamic Disc Designs Corp. models for 9 years and when a patient can see where and why it hurts, it is the best way to get the patient engaged with the treatment plan. Compliance also goes way up for home care exercises.

 

Jerome Fryer BSC DC is a practicing chiropractor that is focused on improving outcomes. He has developed dynamic models to help the patient understand clearly not only the cause of their pain but also the strategies to decrease it.

Validation and Invalidation: Your Patients and the “Nocebo Response”

Nocebo Response

No doubt you’ve heard of “the placebo response”. But how about “the nocebo response”? Much research has been done about now an inert pill, when presented with positive conditioning and expectations, can be as effective as the real thing, but not nearly as many studies have been conducted in regards to the nocebo effect, where the mere suggestion of negative association with a pill or procedure brings on negative side effects.

But the word “nocebo” doesn’t just refer to experiences with medications and treatments. Recently, a pair of doctors at the University of Southampton and University of Exeter Medical School in England penned a journal article entitled: “Bad is More Powerful than Good: The Nocebo Response in Medical Consultations”, which profiled how patients could get worse due to “sham interventions” and other interactions that elicit a negative response from them.

In particular, Drs. Maddy Greville-Harris, PhD, and Paul Dieppe, MDb, focused not on nocebo responses that came from negative information about medication side effects (about which some study has been completed) but, rather, the role of negative communication between doctor and patient in generating a nocebo response in a healthcare setting.

The researchers believe that doctor-patient communication and the way it plays out can significantly impact the outcome of a course of therapy. Based on their studies and on previous research, the authors concluded that the nocebo response can happen when the patient responds negatively to the conversation(s) they have with their healthcare provider.

Among the key components in the nocebo response are the concepts of validation and invalidation, the authors opine. Validation refers to the communication of understanding and acceptance while invalidation means the opposite, that is, non-acceptance and non-understanding. This is a bit different than empathy; a doctor can be empathetic and show feelings of warmth and kindness but may not portray acceptance and understanding on an intellectual plane (rather than an emotional one).

It’s important to note that, in this article and others similar to it, it’s often determined that while validation is wonderful and gives the patient confidence to move forward, the damaging effects of invalidation tend to be more powerful than the uplifting effects of validation. In other words, bad is more powerful than good, the authors note, or the power of bad human interactions are stronger than that of good human interactions.

Confused? It’s actually simple. The negative things you say to a patient will do more harm than the positive things will do good. Hence, Greville-Harris and Dieppe conclude that it is better for the medical professional to concentrate on NOT invalidating the patient rather than simply focusing on empathy, understanding, and validation.

In tests conducted to support this dissertation, consultations with patients at a pain management clinic were observed and then the observer’s observations were reported. After that was completed, semi-structured interviews were conducted with the patients (5 women with chronic pain issues) and the four consultants. The interviews were played back in order to discuss validation and invalidation.

In many cases, patients identified feelings of being “dismissed” by their physicians and “disbelieved” due to the comments by their healthcare providers. Many believed that the doctors did not “invest in them” nor did they “show insight into their condition”.

The authors described the scenario:

“Patients described feeling hopeless and angry after invalidating consultations, feeling an increased need to justify their condition or to avoid particular doctors or treatment altogether. Although the sample was small, these findings are in line with previous work. Thus, invalidation during consultations may elicit powerful nocebo responses in patients that have so far not been adequately researched.”

Furthermore, the researchers concluded the physicians think they are validating their patients by being empathetic and compassionate when, in fact, those reactions could be eliciting the wrong response from the patient. Many see such emotional responses as condescending or patronizing and lead the patient to believe that the doctor doesn’t take stock in the severity of their condition. In addition, a doctor who says “there is nothing wrong with you” when the patient is clearly experiencing pain makes the patient feel like their complaints are less than legitimate.

So, the question all medical professionals must ask themselves is if they are validating their patients or simply pacifying them during their conversations AND, more importantly, if their conversations are invalidating. Are you providing “lip service” or having a real, legitimate discussion with your patients? Do they leave your office knowing that you not only care about their condition and are sorry for their pain but also that you understand their concerns and can address them professionally and through proper patient education? Or do they walk away feeling belittle and confused?

Patient education is a huge part of the picture. For spine specialists, tools like Dynamic Disc Designs’ (ddd) many lumbar and cervical models demonstrate a true knowledge of your craft AND offer the chance for the patient to grasp some of that knowledge as well. After a consultation that includes a frank discussion and spine education using the fully-movable, highly-detailed spine models made by ddd, patients are satisfied that their concerns are validated and that you can offer more than a pat on the back and a “I hope you feel better soon”.

By educating patients with Dynamic Disc Design models, you can strive to eliminate the nocebo response, instead providing a consultation that “validates” your patient and prompts them to return to you for treatment.

 

Source: http://www.amjmed.com/article/S0002-9343(14)00798-0/abstract

Making Sense of Lumbar Ablation

Lumbar Ablation

Lumbar ablation (or radiofrequency ablation) is a commonly used procedure performed by pain specialists. It is a pain-relieving option for many individuals who are dealing with debilitating lower back pain. The electromagnetic waves used in this procedure work to create heat energy, which is then delivered to the nerves that carry pain impulses, destroying the nerves of the medial branches and relieving the pain.

Why use lumbar ablation?

By addressing these pain-carrying nerves, spine interventional pain doctors can provide a patient with a longer stretch of pain relief than that which would be offered by other procedures such as injections or even nerve blocks. Chances are that the patients you’re considering for treatment with radiofrequency ablation have already received treatments that may have included steroid injections, facet join injections, or some sort of sympathetic nerve block. If the patient had only very temporary pain relief from those, you can offer them the possibility of a longer stint without pain by using the lumbar ablation, perhaps as long as a year.

Many types of conditions respond well to radiofrequency ablation. These include spondylosis, chronic spinal pain, post-surgery spine pain, and post-traumatic pain from accidents that include injuries such as whiplash or seat belt-related injuries.

Lumbar ablation involves inserting a thin needle or radiofrequency cannula, guided by live x-ray, near the nerves that are to be addressed. Once the cannula is determined to be in the correct position, electric current passes into the surrounding tissues and the target nerve is destroyed. The procedure is fairly short and generally painless. (Patients can be given a mild sedative if necessary but deep sedation will not be used.)

Of course, that’s the short explanation. While not every patient wants to know all the particulars of the procedure you’ll be performing, many individuals prefer to know what will happen during ablation. Knowledge eases their mind and reduces anxiety or panic. An explanation of the procedure (and its results) by you – their doctor – will help them recognize that this is the right thing for them.

To do this, it’s time to pull out your spine models. Hopefully, you own a well-crafted, fully-movable 3D model such as the ones made by Dynamic Disc Designs (ddd). These unique models are the best available for explaining procedures such as lumbar ablation.

With the use of models like ddd’s popular Medial Branch Model, doctors can begin by demonstrating the patient’s facet pain condition and how it affects the spine, and then can proceed with an explanation of how the ablation will help. With this ultra-detailed model, spine specialists can also talk about neo-innervation and demonstrate the reasons for chronic pain and how the ablation will assist in its relief from the facet joints. The patient can hold this pliable model in their hands and move the parts, allowing them a better understanding of what’s causing their discomfort because they can literally “see” the spine.

Dynamic Disc Designs offers a variety of lumbar models, all highly-detailed yet simple enough for the layperson to understand. Models may be purchased individually or in a bundle, according to the needs of the specialist. (Discounts apply when models are purchased in multiples.)

From chirohub.com:

“This awesome product has passed all of our tests and impressed us across the board.  We feel very confident in awarding the Dynamic Disc Model the Official ChiroHub Seal of Approval.”