nual thrapy_EB approach_2007_chapter 1 summary

CHAPTER 1 Orthopedic Manual Therapy 11 Coping Strategies During their discussion of coping strategies, DeGood and Shutty132 distinguish three distinct fields of inquiry. These include (1) specific beliefs about pain and treatment; (2) the thought processes involved in judgment or appraisal; and (3) coping styles or strategies. Schultz et al.133 report mat effective treatment to improve coping strategies re- quires accurate distinction between chronic pain and a chronic pain syndrome. Theoretically, the most effective treatments designed to improve coping strategies should in- corporate both psychological and physical components and require intervention by an interdisciplinary team. Generally, early treatment of pain syndromes may improve employ- ment-related outcomes, but even those with longstanding syndromes generally improve dramatically.134 Improve- ments in coping include the use of a biopsychosocial model. A biopsychosocial model assumes an interaction between mental and physical aspects of disability, assumes that the re- lationship between impairment and disability is mediated by psychosocial factors, and that beliefs about illness/disability are as important as illness. Presence of a chronic pain syn- drome strongly suggests mat medical interventions (in- cluding surgery) may not be effective.134 Prior to physical improvements, separate psychological interventions may be necessary for reducing back pain incidence.135 SUMMARY OF BENEFIT FROM MANUAL THERAPY Methodology designed to measure the strength of evi- dence of selected interventions is essential to determine the strength of a study. Subsequently, the "Levels of Evi- dence" outlined by the U.S. Clinical Practice Guideline for Acute Low Back Problems in Adults.136 Table 1.5 out- lines the parameters to determine the "Levels of Evi- dence" used within this chapter. TABLE 1.5 Methodological Guidelines Outlined by the U.S. Clinical Practice Guideline for Acute Low Back Problems in Adults Category Description 1. Strong evidence: Level A Includes interventions deemed either effective or ineffective with strong support in the literature as determined by consistent findings/results in several high-quality ran- domized controlled trials or in at least one meta-analysis. 2. Moderate evidence: Includes interventions deemed either effective or ineffective with moderate support in Level B the literature as determined by consistent findings/results in one high-quality ran- domized controlled trial and one or several low-quality randomized controlled trials. 3. Limited/contradictory Includes interventions with weak or conflicting support in the literature as evidence: Level C determined by one randomized controlled trial (high or low quality), or inconsistent findings between several randomized controlled trials. 4. No known evidence: Includes interventions that have not been sufficiently studied in the literature in Level D terms of effectiveness and no randomized controlled trials have been done in this area. Summary • The placebo effect could potentially explain some of the pain reduction benefit associated with man- ual therapy. • It is difficult to design a study in which an effec- tive and comparable placebo sham is used during manual therapy intervention. • Treatments that consist of manual therapy tech- niques routinely display better patient satisfaction scores than other non-manual therapy related methods. • Manual therapists may improve the likelihood of meeting patient expectations secondary to the na- ture of the physical intervention. • Failure to meet patient expectations is associated with poor patient satisfaction. • Anxiety, fear, depression and anger are common emotional components that may alter a manual therapist's outcome. • A manual therapist may reduce the anxiety associ- ated with unknown symptoms. • Fear is commonly associated with decreased movement and trepidation of re-injury. • Depression co-exists with numerous other vari- ables; all which can lead to poor patient outcomes. • Anger and outcome are poorly understood, yet there does appear to be a relationship between higher report of pain and increased anger. • Coping strategy is reportedly a reason why some disorders progress to chronic pain syndrome. • There is little evidence to suggest that manual therapy intervention will decrease the progression to chronic pain syndrome. • Purportedly, a biopsychosocial model should demonstrate effectiveness in treating patients with chronic pain syndrome. 12 CHAPTER 1 Orthopedic Manual Therapy TABLE 1.6 An Overview of the Effectiveness of Selected Manual Therapy Methods Using the Methodological Guidelines Outlined by the U.S. Clinical Practice Guideline for Acute Low Back Problems in Adults Static stretching for temporary increase in ROM in symptomatic subjects Manipulation for temporary increase in ROM in symptomatic subjects Mobilization for temporary increase in ROM in symptomatic subjects Manually assisted movements for temporary increase in ROM in symptomatic subjects Mobilization leads to a neurophysiologic change associated with joint-related movement Manipulation leads to a neurophysiologic change associated with joint-related movement Mobilization or manipulation has the capacity to alter pH levels and alter central sensitization properties Manual therapy methods have the capacity to alter psychologically-oriented conditions such as fear, anger, anxiety, or depression Manual therapy methods improve the coping capacity of the chronic pain sufferer Strong Moderate Evidence Evidence / / / / Limited/ Contradictory Evidence / / / No Known Evidence / / Table 1.6 outlines the cumulative findings behind the science of manual therapy. Each conclusion is based on the strength of the studies, whether the findings were pos- itive or negative, and whether any evidence exists to sup- port potential use. Static stretching yields strong evidence of benefit for asymptomatic subjects but limited evidence for sympto- matic patients. It is worth noting that the word "temporary" is used, since most studies, mobilization and manipulation included, only investigate short-term findings. Manipula- tion and mobilization both present moderate beneficial evi- dence for ROM gains and neurophysiologic changes. The studies fail to provide strong evidence based solely on the strengths of the individual studies. Whether manual therapy provides pH or central sensitization changes or psychologi- cal alterations is essentially unknown. Overall, the science behind manual therapy is promising. As research improves we will have the opportunity to better decide which meth- ods and what type of patient impairment are best associated with positive outcomes. Chapter Questions 1. Identify the three hypothesized effects of manual ther- apy and describe the scientific evidence that supports their suppositions. 2. Compare and contrast the cumulative findings associ- ated with static stretching, manually assisted move- ment, mobilization, and manipulation. Outline the weaknesses of the research and areas that would strengthen the aggregate findings. 3. Outline the different forms of neurophysiologic effects of manual therapy. 4. Describe why meeting patient expectations is often considered as important as patient outcome when ad- dressing patient satisfaction.