Chronic Pain Disappointment

I don't know about the rest of you, but I do tend to read some of the non peer-reviewed stuff.  Some of it is a good read and does make me think.

But... did anyone read that article in the PT Magazine on Chronic Pain Management?  We've got a LONG, LONG way to go if the person that is President of the Orthopaedic Section's Pain Management Special Interest Group is quoted within a journal published I assume by the APTA listing off frequent physical therapy interventions provided to the patient population within the chronic pain category when to my knowledge there is zero to minimal evidence for the effectiveness of those interventions!

I mean, do we look the other way?  Or do we call up Kleinkort and nicely ask him what the heck he's doing?  The article stated a $100 billion lost productivity a year... do I dare ask if Kleinkort and those that practice like him are contributing to that figure AND contributing to the cost of treatment too?  What the heck is Primal Reflex Release?  Sit tight and listen... I can do a Primal Scream!  That's a release too... probably didn't solve the whole issue though.

It's just a sad state of affairs when the leaders leading maybe are good leaders but are actually terrible examples.  (I don't know Kleinkort and I've never met him, so he may be a good leader or he may not be, but I do know he's a terrible example of how we should be practicing.)  What message does a supposed leader send to members when the leader is a rotten example who we should emulate?  Or quote some different quote... maybe he said something else of better value that would help all of us be better at evidence-based practice?

Maybe I was the only one shocked and disappointed by what I read.  The politics in our association are pushing for autonomy and direct access and evidence-based practice... so why include those Kleinkort comments in an article within a journal published by the APTA and sent to APTA members?  Logically, I would think that if there is a push to move forward, well, if I were making decisions, I'd make darn sure that anything I produced subtly addressed or blatantly addressed the issue, but I would not allow for any inkling of anything that didn't smell of autonomy, direct access or evidence based practice OR if I did allow for say something like Kleinkort's comments, well, I'd somehow address the contradiction.

Comments

[Britt Smith]

Selena,
I haven't read the PT Magazine article and I Don't know Kleinkort. The chronic pain 'thing' is a very interesting and difficult problem for everyone. I like to think, from my limited understanding of research on chronic pain, the problems become more of a neurological problem or better still a neuro-psychological phenomenon. The Jarvik et al article from Spine this year (Spine 2005;30:1541–1548) found that depression had the highest hazard ratio, predictive of future episodes of LBP when compared to imaging finding (including disc herniation and nerve root contact (the latter close to same same H.R.).The evidence, I think, points toward a multi-disciplinary approach. Anyway, we know this is the tough stuff, once the nervous system/mind become the main 'source' of pain, or perception of pain. The nervoussystem may not be a 'black box', but its at least a 'merky aquarium'!!!! Here is where the 'the magic' starts. Perhaps a treatment based on 'Primal reflexes' or 'muscle
activiation technique' or some other approach (PNF, NDT etc) may have some clues to improvement with this group, along with meds., counseling, and certainly behavior modification.
My cautionary thought on condeming these intervention is there is potentially useful technique and practice with these fringe interventions.
James Paget (1814-1899), who said in BMJ, 1867, Cases that bonsetters cure:
“Few of you are likely to practice without having a bonesetter for a rival; and if he can cure a case which you have failed to cure, his fortune will be made and yours marred... Learn, then, to imitate what is good and avoid what is bad in the practice of bone-setters." ”

Sir Robert Jones (1858-1933) also said: "“We should mend our ways rather than abuse the unqualified. Dramatic success in their hands should cause us to inquire as to the reason; it is not wise or dignified to waste time denouncing their mistakes for we cannot hide the fact that their success is our failures.”

Paget & Jones were responding to criticism of manipulation, particularly by lay-persons, which now is a practice strongly defended and advocated on these web-pages.
I am alarmed by the various 'marketing' aspects of most of these approaches, offering a 'quick fix', which I have never experience with chronic pain patients, and frank lies about 'evidence' of effectiveness:
'The most effective form of therapy in the history of healthcare!" [A direct quote from John Barnes' pamplet], These proponents need to bring the 'goods' (Thanks, Rob) on the evidence and Kleinkort needs to be a part of that if he advocates an approach. Thanks,
Britt

[Larry Benz]

Selena and Britt: Excellent comments and insight. As a profession we can't have it both ways as you point out. I can give you another example (even at the risk of a lot of scoffing). Anodyne. A great example of "stickiness" factor and "tipping point" working for a population that has both real pain and real chronic pain-neuropathy. Does it work? Don't really know but I can tell you that everything new works on chronic pain patients for a short period of time (as long as it is new and revolutionary!). It is my understanding that the fact that everything new works for short periods of time is in fact somewhat diagnostic of the chronic pain mentality.

Yikes, more new reflexes to learn and this is just after I learned that the reflex hammer can be therapeutic if pounded under the chin.

[Selena Horner]

We honestly can't have 100% EBM for every single patient, especially for the patients in chronic pain. I know we can't. (There isn't enough evidence yet.) But, there has to be some honesty in rationalizing the use of interventions. The days of doing interventions and saying they are effective without any type of proof need to be over and done with. Kleinkort's main interventions that he utilizes - laser, myofascial release, craniosacral therapy and that reflex thing... if we do a search, well, for patients with chronic pain laser, myofasical release and craniosacral therapy are not effective or have very little effect. So, I'm left thinking, why? Why are you doing those interventions and what effect are you really getting? (Combined with, do you really know what effect you may be achieving?) Nothing is known from what I could find on the reflex thing. But... the writer of that article could have asked about outcomes. The writer of that article could have asked about change in function or return to work. The writer could have searched and commented on effectiveness (or lack thereof) of those interventions.

When does the time come where some heart to heart discussions actually occur? There may be good in primal reflexes or whatever, but at some point clinicians need to be held accountable and should be required to show some sort of proof of effectiveness. As a profession, I don't believe we can have conflicting messages ongoing. We're either going to move forward with professional accountability, autonomy and EBM or we're not, but there has to be consistency. The talk has been talked, but you can't talk the talk without walking it. Action is what implements change.

[Jason Silvernail]

Well, this is a big part of the pain of being in an imperfect world.
We just don't have a 100% answer for everything. As Britt mentioned, there may be some value in some of these interventions in terms of biologic plausibility (myofascial and craniosacral for example). Of course, if they do work, they don't work for the reasons (nonscientific) that the pracitioners give, but there is some plausibility to them in terms of known physiologic effects (stretch-activated skin receptors, ideomotor movement, etc). The question for the evidence-based practitoner is how much of our practice is driven by biolgic plausibility and common sense, and how much only if there's a supportive RCT?

I don't believe we can, with a straight face, pillory John Iams and Barrett Dorko on one post, and then defend craniosacral, myofascial, and primal reflex whatever(John Iams' product) on the next post. Where's the consistency there?

We all know there is an art as well as science to this profession, and BOTH too much art and too science indeed make Jack a dull boy. Or perhaps a less effective boy?

On a lot of these interventions, the important part, I think, is the way they are marketed and explained to patients. If someone is using the tools of myofascial release couched in terms of freedom of movement and ease of active rehab, that's one thing. Ridding people of their past memories (or whatever Barnes is saying these days) is quite another. Perhaps Kleinkort (who I don't know, either, and for all I know may be a very responsible, competent therapist) is using some of these tools while also emphasizing things with biologic plausibility and some evidence, such as graded activity programs, cognitive-behavioral treatment, and pain physiology education? If so then perhaps he's advancing EBP while taking advantage of other interventions at the same time.

We talked about Active Release Technique /Graston /ASTYM a while back on the blog, and we had many therapists here supporting those approaches, even while admitting that the jury was still out and much of the support for their use was in basic science and biologic plausibility. How is that any different from myofascial release, and how is it better than Dorko's "Simple Contact" which has biologic plausibility and a deep model of explanation to support it?

I think "the devil's in the details" on these things, and the way things are presented to patients probably means more than the actual techniques used. Kind of like manipulation that way. :)

I read somewhere recently that the number of interventions for a given problem is inversely proportional to the knowledge of it, and chronic pain treatment seems like a perfect example of that.

Where do we draw the line on evidence for our interventions? After favoring those with high level evidence, the only thing left is biologic plausibility and clinical judgment. Kind of makes it hard to be too harsh on Kleinkort, or anyone else who regularly treats a population for which no clear answers exist in the evidence.
J

[Selena Horner]

Jason, the difference between the active release technique conversation that was posted and anything you read on simple contact and that reflex thing is the fact that those doing the active release technique were mentioning the studies they were involved with. I believe there is merit in attempting to do some sort of study to help substantiate claims or help define a population that the intervention may be of benefit. Ultrasound has biologic plausibility, but is it effective for everything?

I don't believe that RCT is the only type of evidence that helps make decisions. At the minimum, a case series is a nice start. There isn't enough funding for everyone to be doing RCT, but I'd think that a case series would be a reasonable start in the right direction. So, what's the rationalization for Kleinkort not being involved in a case series to support his approach in light of what has been found in research regarding those key interventions he uses at a high frequency? Granted, that is a question that I've individualized to him because it's just an example from what we all can read in PT Magazine... but that question can be posed to more than just him. From your last post, we can put Barnes, Iams and Dorko in for Kleinkort. Take it a step further, and reality is, since your statement regarding the number of interventions and it's inverse proportion to the amount of knowledge known about the condition is true, maybe each and every one of us mainly treating the population of patients with chronic pain have the same responsibility so that better informed decisions can be made by all.

[David Penn]

Well, there is certainly great dialogue here regarding less proven or unproven interventions. My take on it is that the lack of evidence for an intervention does not suggest evidence against it. Many of your strategies or multi-modal anyway. What harm is there in integrating the best evidence with biologically plausible evidence? For those of you who have been practicing PT for greater than 2 days, know that non-evidenced based strategies have helped many patients in one form or another. If I think back 10 years ago, what evidence was there for lumbar stabilization? It made sense to use intuitively and,hey, if it's good enough for Joe Montana then it good enough for my patients. What they didn't tell you was the Mr. Montana was also getting injections for pain relief that enhanced his ability to play ( according to B. Biondi,PT- personnal interview). Most of us did not bat an eye to incorperate this "biologically plausible" approach into our daily practice. And guess what, even with little to no science on who would benefit, dosage or frequency, this approach got a considerable amount of patient better.

The bottom line for the hard nosed EBP practioner should be based on results that we get with our patient. I applaud all of you how have the time, energy,skill, and resources to devote to research. The time is now to merge clinical real world practice with the often times sterile environments that produce research.

For all of the hard working clinicians out there that are getting postive outcomes with interventions that have very little research, partner with a leader in the field of research and share your success through case studies.

On a side note: Joe Kleinkort is a friend of mine and I have seen him treat patients with a multimodal approach with the integration of best practices. He also seems to have a working knowledge in the alternative and complimentary methods such as LASER etc. I have asked him to look at this post and give us some insight as to his thoughts and ideas regarding this "lesser accepted" approaches to the treatment of chronic conditions.

[Selena Horner]

I'd be interested in what Kleinkort had to say. All I really picked up in that article with his comments was the bulk of frequently used interventions which either a) have been found to be ineffective or minimally effective for that population when I've researched them or b) very little to nothing found on their effectiveness. It also concerns me that the majority of his quote focused on listing very passive interventions. I remember some generalized findings from the Ohio Project on outcomes (that never did get published), but passive treatments seemed to lead to poorer outcomes.

When I compared Kleinkort's quotes with Russell Foley's quotes, Foley's quotes seemed more evidence-based to me.

[David Penn]

I have not read this article yet but hopefully I will go online this weekend and take a look. Agreed that passive treatments exclusively are not ideal even in the chronic population. Although, if you have ever had that one patient that would not do anthing because of pain often times one needs to validate those issues and provide a conduit to activity which may be things like LASER or TENS or whatever that allows them to start moving towards an activity-based program.

[Dr. Tom Watson DPT PT Diplomate American Academy of Pain Management]

Dr Penn shows his lack of understanding and knowledge regarding pain physiology,pain treatment and management. If he would check of the British medical journal-BMJ- July, 2000 he will find that only 15% of all things that we do in medicine are scientifically validated and 85% have no scientific validation yet they've worked for years. The use of laser therapy has over 2000 double blind studies with positive outcomes. The work that John Iams PT FAAPM does, produces tremendous results with very little residual pain for the long term and is based on scientific principles. The practice of "do no harm" is used in pain management and as it continues to work we continue to use it. I have done pain management for 32 years and use CAM treatments. NO drug company or other major company will pay for multiple double blind studies to validate my
treatments. But, if it is reproducible by many of my colleagues in pain management and "does no harm" and the effects last for many years and why shouldn't we continue to do it? The physiological actions of SSRIs and SNFIs re not understood and we're really don't know how they work yet the drug companies continue to push them because they do have an effect with chronic pain patients. Does this mean we should ban all drugs because we don't know how they work? Does this mean we should ban all physical therapy techniques that we know works, have a track record of positive affects, but have no double blind studies to validate them , that we should abandon them? Pain management is a creative proceess,because not all pain patients are the same . We need to address each patient as individuals and it must, I repeat, MUST be a multi- disciplinary team approach for the treatment of these patients aand for the best outcomes.
Dr. Penn, when you have more than 30 years of experience in treating pain patients as each of us, Dr. Joe Kleincourt PT PhD DAAPM, John Iams PT FAAPM and I do, and we are all board certified by the American academy of pain management among 60 physical therapists that are board certified, then you can dice us for our treatment and knowledge of chronic pain patients. Our results speak for themselves.
Please come to our PAIN SIG sessions at CSM or attend the American Academy of Pain Managements annual conf. Buy the text book 7th edition of Weiner’s Pain Management, a practical guide for clinicians, check out chapter 18 Physical Therapy and Pain Management. I wrote it. Please educate
Yourself in the areas of pain management , become an expert as the 3 of us are, then you can CONSTRUCTIVELY criticize us.
Dr. Tom Watson PT DPT MEd
Diplomate American Academy of Pain Management

[Jason Silvernail]

Dr Watson-

I believe Dr Penn was supporting your point in this debate, not the other way around.
I also believe Selena's point about evidence existing at several levels, not all of which are at the RCT level, and for which all of us have a responsibility to support, is valid.
I appreciate your perspective on this issue, however, and you certainly speak more firsthand than many of us do, thanks for your post.
Jason.

[Dr. TomWatson]

My apologies to Dr. Penn, he did support us. My comments shoudl have been directed to Mr. Benz, Ms. Horner and Mr Silvernail.
This is my 1st blog. Both Dr. Kleinkort and John I
ams have been friends of mine for many years.
Sorry Dr. Penn

[John Childs]

Tom:

None of us have anything against practitioners using interventions for patients with chronic pain when sufficient evidence is not available to accurately guide decision-making. The problem is in the 'over the top' marketing efforts, as referenced in recent post regarding John Iams. These claims are absurd. He may be a very nice guy, but he is not Einstein until he shows the data.

John

http://blog.evidenceinmotion.com/evidence/2005/10/john_iams_garba.html

[Selena Horner]

Dr. Watson,

I hear your frustration with my view and maybe a bit of anger and defensiveness.

You may have 30 years of experience, but years of experience hasn't been proven to correlate to "expert." A study with physicians as subjects and a study of physical therapists as subjects did not find that more experience equates to "expert." In the PT study by Resnik and then qualitatively by Resnik and Jensen, interestingly enough, even specialty certification didn't always equate to "expert." I found that interesting because logically one would assume that the greater the number of years of experience then the higher the probability the person would be an "expert." So, probably most of us made a logical assumption, but that assumption has been proven wrong.

Iams and Kleinkort may be your friends, and it is normal to defend friends. My comments and beliefs really aren't directed to them as a person, but more toward their practice patterns - and that would mean to me their choices and their actions of the interventions that they choose to use in high frequency.

I really think that the days of arguing effectiveness of interventions based on years of experience and verbal reportings of "tremendous results" without any numbers or proof to support the claim are no longer acceptable.

The "do no harm" belief is good, but I'd challenge that it needs to be taken one step higher to "efficient and effective" also.

I have educated myself on pain management. An interdisciplinary approach is the best approach for achieving successful outcomes. Patient education is a very important component. Cognitive behavioral therapy seems to be an important factor. Identifying psychosocial issues and addressing them has importance. Exercise has a definite role. I found very little on laser being effective for patients with chronic pain. I found no evidence of effectiveness for craniosacral therapy. I couldn't find anything on that primal reflex deal.

I'd be interested in the results Kleinkort achieves or if you practice in the same manner, even your results. Personally, I haven't found any supporting evidence in my searches that would substantiate effective outcomes with the approaches Kleinkort was quoted to be utilizing at a high frequency. Maybe you can explain the rationale behind the high frequency of passive treatments? Maybe I'm not reading the same things as you and I'm missing something that I'm not aware of? I'm willing to change my view if I'm misinformed. If you're willing, share some evidence to head me in a different direction if what I've learned is in error.