In the care of back pain patients

In our first blog we gave you a short introduction to the subject functional paradigm. In this second blog we zoom in on the importance of the functional examination especially in the care of back pain patients.

Functional examination is about movement. But movement varies and is complex. Our simplistic observations may mislead us to handy solutions. So we must be aware of the most common misinterpretations:

1. What we view as weakness may be muscle inhibition.
2. The weakness in a prime mover might be the result of a dysfunctional stabilizer.
3. Poor function in an agonist may actually be problems with the antagonist.
4. What we view as tightness may be protective muscle tone, guarding and inadequate muscle coordination.
5. What we see as bad technique might be the only option for the individual performing poorly selected exercises.

We must realize that pattern identification is very important because the human brain uses patterns instead of isolated muscle and joint activity to create practical perception and behavior regarding movement.

The whole is greater than the sum of its parts
In conclusion we can say that a whole movement pattern is greater than the sum of its moving parts. But do we choose to focus on movement patterns and correct that, hoping the whole movement pat tern will adjust on it own? Or alternatively, do we look at the whole pattern and first address the problem as a whole, letting the fundamental forces within the pattern normalize naturally? In some instances managing the small parts of a movement is beneficial. A great example of the pattern versus the part phenomenon happens when a person sprains an ankle severely and then limp long after healing. The brain writes new software, the limp, to work around a temporary problem.

The checklist
This is the part Gray Cook comes in. He believes that a systematic checklist is necessary to tell us when there’s a deviation or inconsistency. Cook: “When there’s an inconsistency in the way you’re built and in the way you move, we need to baseline the way you move if we’re going to make further predictions.” We don’t want to confuse this with another protocol or assessment. Gray wants us to look at this as a tool that allows you to treat every patient and problem individually. It gives us the possibility to be more thorough at our already-thorough work. It gives the information you need to know whether the patient has an isolated problem or has a regional interdependence or other dysfunctions.

Movement patterns and functional examination should be our starting point and ending in our work. At the outset, we screen and assess patterns before parts and only then do we judge the parts within the most limited patterns as primary problems.

But what’s next?
But what’s next? After functional examination of the patient, do we know what advice to give and how to reactivate the normal activities of the patient? The great thing about the checklist is that it can be applied across the board. We can find the key weak link or painless dysfunction and from that point improving the quality of the motor pattern with the right exercises. Because we need to set goals and challenge people in doing the right exercises so they are motivated.

According to Craig Liebenson, and other pioneers in the functional paradigm, next to a thorough functional diagnosis, you have to identify a patients functional goals and functional means (e.g. mechanical sensitivities and abnormal motor control). Treating each patient, as an individual with his or her own set of goals is key and the beginning of a patient centered approach of self-care management.

Patient goals and self-care management
We can conclude that the management of back and neck disorders has been revolutionized by recent scientific evidence to a self-management strategy. This strategy of self-care management as part of the functional paradigm focuses on the patient’s functional goals rather on only treating the pain. Goal setting should be mutual and related to activities deemed important to the patient. At the end it is all about reducing pain of the patient or make him tolerant for the pain so he or she can resume normal activities.

Exercises should therefore not only be about reducing pain by strengthening condition and being fit, but more about the psychological challenges of achieving goals without being restrained by pain. Limitations at a personal level (activity tolerance) are both emotionally and physically barriers to a successful recovery of the patient.

How does this work? Craig Liebenson is claiming the following: “ Patients seeking care for back pain apparently have two major goals:

• To receive information about how to manage their symptoms;
• And to receive advice about how to resume normal activities.”

Reactivation advice about the safety of resuming normal activities is the single most important key in self-care management.

What we have learned about Functional Paradigm
So, what have we learned? The single most important key in the functional paradigm is that there is no one-size-fits-all solution for treating and preventing (lower) back pain. Clients, patients and fitness professionals have varied medical histories, exercise experiences, goals, mindsets, occupations and specific tolerances to stress, relationships, diets and medications. Each of these contributes significantly to the client’s overall makeup or their likelihood to be healthy or their chances of experiencing (chronic) pain. Therefore it is important that each client is treated as an individual no matter what tool or checklist you are using to do so.

In our next blog we will discuss three additional common myths about preventing lower back pain and a look at the solution to each of the myths.

Craig Liebenson and Gray Cook are coming to the Netherlands in October and are part of the European Functional Movement Summit 2013. Visit our website regularly. More details will follow soon!