Stikkordarkiv: Behandling

When a cause cannot be found

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Artikkel som nevner mye av problemen rundt behandling av f.eks. ikke-spesifikke ryggplager, IBS eller firbomyalgi. Dette er plager det ikke er noe tydelig årsak-virkning forhold, som ikke kan forklares med et molekyl eller anatomisk utgangspunkt som er felles for alle som har disse plagene, og hvor det ikke er noe klart skille mellom kropp og sinn.

https://raniblogsaboutcausation.wordpress.com/2014/08/14/when-a-cause-cannot-be-found/

This is not a small problem in medicine. By some estimates, such unexplained conditions amount to 30 percent of all symptoms reported to doctors, and they are linked to a 20-50% increase in outpatient costs and a 30% increase in hospitalisation.

This is, basically, what evidence based medicine means: statistical evidence from population studies are applied directly to a patient. This means that each patient is treated as a statistical average, not as a unique individual.

Rather than being dismissed as marginal, therefore, these unexplained conditions should be taken as exemplary for understanding health and disease in general.

Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change.

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Denne nevner at for å kunne kalle en behandling for «klinisk relevant» så må man kunne se en 30% forbedring fra utgangspunktet når man måler før-og-etter hos pasienten. For 0-10 skalaen som vi ofte bruker vil disse forfatterene regne en forbedring på 2 punkter som klinisk relevant. Om vi bruker 0-5 vil egentlig en endring på 1,5 være riktig, men sannsynligvis bedre å forholde seg til en endring på 2 punkter da, som blir 40%.

http://www.ncbi.nlm.nih.gov/pubmed/18165753/

Proposed MIC values are: 15 for the Visual Analogue Scale (0-100), 2 for the Numerical Rating Scale (0-10), 5 for the Roland Disability Questionnaire (0-24), 10 for the Oswestry Disability Index (0-100), and 20 for the QBDQ (0-100). When the baseline score is taken into account, a 30% improvement was considered a useful threshold for identifying clinically meaningful improvement on each of these measures.

For a range of commonly used back pain outcome measures, a 30% change from baseline may be considered clinically meaningful improvement when comparing before and after measures for individual patients.

A CLASSIFICATION-BASED COGNITIVE FUNCTIONAL APPROACH FOR THE MANAGEMENT OF BACK PAIN

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Denne beskriver et ganske så komplett opplegg for behandling og undervisning av klienter med nesten alle typer muskel og leddplager.

Klikk for å få tilgang til OSullivanIFOMPT-Oct2012.pdf

Pathoanatomical factors: F.eks. funn på røntgen og MRI, som spiller liten rolle i kroniske muskel og leddplager.

Physical factors: muskelspenning og bevegelsesmønster endres ved smertetilstander. F.eks. kjermuskulatur spenner seg mer i bevegelser hos smertepasienter.

Lifestyle factors: interessant at mat og kosthold er det eneste av livsstilsfaktorer som ikke nevnes på denne listen. Ellers er trening, stress, søvn, røyk, overvekt, m.m. med.

Cognitive and psychosocial factors: angst, depresjon, frykt, katastrofering, og særlig ideen om at (f.eks.) ryggen må beskyttes pga smertene.

Social factors: trivsel i jobb, familie, forhold, og livssituasjon.

Neurophysiological factors: endringer i hjernen, som f.eks. mindre går materie, økt hjerneaktivitet i hvile, endres kroppsbilde, mindre nedregulering av smerte.

Individual factors: mål med behandling, forventninger, grunnleggende helsekunnskap, m.m.

Genetic factors: Visse gener gir økt disponering for smertetilstander.

Jeg likte spesielt dette sitatet:

Manual therapy is only used as a window of opportunity to change behaviors where movement impairments are present.

Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials

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Denne har sammenlignet mange forskjellige behandingsformer, både aktive og passive og medikamenter, mot korsryggplager og sett at neste alle følger samme behandlingsrespons kurve.

http://rheumatology.oxfordjournals.org/content/49/12/2346.long

Overall response to treatment in clinical trials, cohorts or clinical practice, is not only influenced by the active or specific components of the treatment, but can also be influenced by various other factors. Some of these factors relate to characteristics of the pain problem (as described above), or to the patients themselves [36] such as their beliefs, expectations and experiences with other illnesses, previous episodes of the illness or with previous use of the current treatment or other treatments [37].

An important finding from our review is the large response to treatment common in all trial arms, active as well as placebo, usual care or waiting list arms. It seems ironic that we clearly have evidence for a large overall improvement in back pain symptoms in all arms of clinical trials, while more and more trials are unable to show clear evidence for the effectiveness of the active treatments.

Evidensbasert praksis i manuellterapi

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I denne artikkelen nevnes noe spesielt interessant om hvordan forventning til behandling gir 5 ganger større sjangse for et positivt resultat. Og at de som hadde positiv forventning til massasje fikk bedre resultater om de fikk massasje enn om de fikk akupunktur. Det er 3 studier som refereres til i denne sammenhengen.

http://www.sigurdmikkelsen.no/?p=1155

De som derimot hadde størst forventning til at akupunktur ville hjelpe, fikk altså bedre funksjonelt utbytte av akupunktur enn om de ble randomisert til massasje. Analysen viste i tillegg at deltakere som fikk den behandlingen de på forhånd hadde høyest forventninger til, hadde fem ganger større sjangse for et positivt funksjonelt utbytte, enn de som fikk den behandlingen de hadde lav forventning til.

1. Does how you do depend on how you think you’ll do? A systematic review of the evidence for a relation between patients’ recovery expectations and health outcomes. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC81284/

2. Patient expectations as predictors of outcome in patients with acute low back pain. http://bvsalud.org/portal/resource/en/mdl-18066631

3. Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects. http://www.ncbi.nlm.nih.gov/pubmed/11458142

Healing Skills for Medical Practice

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En svært interessant artikkel som forklarer hva som gjør en terapeut til en flink terapeut. Etter min mening har det lite med behandlingsteknikk å gjøre, men med hvordan man møte mennesker og deres problemer. Her er 8 punkter som kjennedegne flinke terapeuter, uansett profesjon (lege, kirurg, kiro, fysio, m.m.).

Klikk for å få tilgang til healing_skills_for_medical_practice-churchill-aim-2008.pdf

Do the little things

Introduce yourself and everyone on the team

Greet everybody in the room

Shake hands, smile, sit down, make eye contact

Give your undivided attention

Be human, be personable

Take time and listen

Be still

Be quiet

Be interested

Be present

Be open

Be vulnerable

Be brave

Face the pain

Look for the unspoken

Find something to like, to love

Take the risk

Stretch yourself and your world

Think of your family

Remove barriers

Practice humility

Pay attention to power and its differentials

Create bridges

Be safe and make welcoming spaces

Let the patient explain

Listen for what and how they understand

Listen for the fear and for the anger

Listen for expectations and for hopes

Share authority

Offer guidance

Get permission to take the lead

Support patients’ efforts to heal themselves

Be confident

Be committed and trustworthy

Do not abandon Invest in trust

Be faithful

Be thankful

Immediate effects from manual therapy: much ado about nothing?

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Her diskuteres hvordan et stort antall behandlingsteknikker gir umiddelbare resultater, men at disse umiddelbare resultatene ikke nødvendigvis gir langvarige og kliniske resultater. Mange blir glade når studier viser en umiddelbar bedring i f.eks. smerte etter en korsryggmanipulasjon, men vi må være oppmerksomme på at denne ummidelbare bedringen ikke alltid er en langvarig effekt. Og vi må også være oppmerksom på at svært mange behandlingsteknikker gir slike resultater. Alt fra laser til menipulering. Den ene er hverken bedre eller dårligere enn den andre.

Jeg mener vi må ta de umiddelbare effektene for det de er; umiddelbare effekter, og bruke dem for det de er verdt. Det gir et overraskelsesmoment og håp når man kjenner at smerten blir mindre og funksjonen bedre. Man kan bruke det for å vise at smerten KAN reduseres. Men ikke la de stå iveien for det som trengs for langvarige resultater, som livsttilsendringer (trening, mat, stress, søvn, osv) og livssituasjonsendringer (jobb, forhold, hjem, osv.)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3172950/

The measurable treatment effect may take many forms. Within the last few years, immediate effects of thrust and non-thrust manipulation have been shown to: improve proprioception,1 standing balance,2reduce pain,3,4 increase nociceptive flexion reflex threshold,5 thermal pain sensitivity (temporal summation),6 provide a widespread hypoalgesic effect,7 improve range of motion,4,8 alter EMG signals,9and modify sensorimotor integration.10 In fairness, the studies represented here were both mechanistic- and clinically-oriented.

But before we get too excited about these results, let’s look at literature outside main-stream manual therapy, because thrust and non-thrust manipulation aren’t alone in their ability to provide immediate measurable treatment effects.

Immediate effects have been reported with superficial heat, long-wave ultrasound, short-wave diathermy, and specific exercises.11 In addition, immediate effects have been identified using massage,12 kinesio-taping,13 passive physiological movements,14 acupressure,15,16 ischemic compression,17 thermal ultrasound,18 simple touch,19 ice massage,20 and strain–counterstrain.21 Even more notable and dubious are the immediate effects findings of improved active mouth opening after hamstring stretching,22improved hamstring mobility after suboccipital stretching,23 and improved spatial cognitive tasking after breathing through the left nostril only.24

 

We know the carry-over effect of some immediate findings (within-session changes) lead to between-session changes,26but there is little to support these changes having any effect on long-term functional outcome.26–28

 

 

Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses.

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Denne sammenligner effekten av forskjellige behandlingsformer mot isjas og konkluderer med at f.eks. manipulering, akupunktur og anti-inflammatoriske biologiske midler (renger med dette inkluderer kosttilskudd) er en bedre løsning enn opioider, hvile, treningsterapi, m.m. Den sier også at kirurgi er en god løsning generelt, men ikke for smerte.

http://www.ncbi.nlm.nih.gov/pubmed/24412033

For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture.

For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant.

The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction.

Effectiveness of myofascial release: Systematic review of randomized controlled trials

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Denne viser til en økende grad av kvalitet på studier på myofascial release, som Strukturell Integrering er. Konklusjonen er at det er god evidens for å bruke dette mot mange muskel- og ledd smertetilstander, og at denne behandlingsformen faktisk kan konkurrere med andre behandlingsformer.

http://www.bodyworkmovementtherapies.com/article/S1360-8592(14)00086-2/fulltext

Seventeen studies were with higher methodological quality and the remaining 2 were of moderate quality, which is appreciable for a relatively new approach with considerable amount of practice variations.

The results of the studies were encouraging, particularly with the recently published studies. In many RCT’s the MFR was adjunctive to other treatments and the potential-specific MFR effect cannot be judged.

Nine studies concluded that MFR may be better than no treatment or sham treatment for various musculoskeletal and painful conditions. Seven studies demonstrated that MFR with a conventional therapy is more effective than a control group receiving no treatment (3 studies), sham treatment (1 study) or with a conventional therapy.

There is evidence that MFR alone or added to other conventional therapies, relieves pain and improves function not lesser than conventional therapies studied. According to these results, MFR may be useful as either a unique therapy or as an adjunct therapy to other established therapies for a variety of conditions like sub acute low back pain, fibromyalgia, lateral epicondylitis, plantar fasciitis, headache, fatigue in breast cancer, pelvic rotation, hamstring tightness etc.

Comparison of spinal fusion and nonoperative treatment in patients with chronic low back pain: long-term follow-up of three randomized controlled trials.

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Denne nevner at 11 år etter en «spinal fusion» operasjon er det ingen forskjell på de som ble operert og de som ikke ble operert. De konkluderer med at «spinal fusion» ikke bør utføres så lenge det er andre muligheter for behandling tilgjengelig.

http://www.ncbi.nlm.nih.gov/pubmed/24200413

CONCLUSIONS:

After an average of 11 years follow-up, there was no difference in patient self-rated outcomes between fusion and multidisciplinary cognitive-behavioral and exercise rehabilitation for cLBP. The results suggest that, given the increased risks of surgery and the lack of deterioration in nonoperative outcomes over time, the use of lumbar fusion in cLBP patients should not be favored in health care systems where multidisciplinary cognitive-behavioral and exercise rehabilitation programmes are available.