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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6032_Библиотеки_им_академика_М_И_Перельмана
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Figure 5
Photograph of a patient performing a neurodynamic
tensioner exercise in which tension is directed at the distal
component of the nervous system by kicking the leg straight out while
simultaneously directing tension at the proximal aspect of the nervous
system by looking downward.
Summary
To achieve the best outcome for patients with spine pain, it is vital to
properly classify the dominant pain mechanism to guide patient education
and therapeutic exercise. These interventions vary based on the risk group
and subgroups within each risk group. The identification of the proper risk
group for spine pain allows ease of categorization into one of the five pain
mechanism and exercise subgroups. This classification helps direct patient
education and the selection of the correct dosage of therapeutic exercise.
Key Study Points
The PMCS, MDT, and TBC classification systems aid in determining the
correct dosage of the conservative care interventions of patient education
and therapeutic exercise.
Patient education about the dominant pain mechanism as it relates to the
exercise subgroup promotes better understanding of and compliance with
the conservative care intervention.
Therapeutic exercise for patients with LBP should be considered like a
“movement pill,” which requires understanding the correct dosage
(intensity, frequency, and type of exercise).
Pain mechanism education and prescriptive therapeutic exercise for LBP
can be summarized into the following five pain mechanisms and exercise
intervention subgroups: (1) nociceptive mechanical inflammation pain
mechanism and directional preference, (2) nociceptive ischemia pain
mechanism and remodel tight and weak tissues, (3) nociceptive ischemia
pain mechanism and restore function, (4) central sensitization or affective
pain mechanism and gradual exposure to fearful and pleasurable activities,
and (5) motor/autonomic pain mechanism and sensorimotor retraining.
Annotated References
1. Vos T, Flaxman AD, Naghavi M, et al: Years lived with disability (YLDs) for 1160
sequelae of 289 diseases and injuries 1990-2010: A systematic analysis for the Global
Burden of Disease Study 2010. Lancet 2012;380(9859):2163-2196.
This systematic analysis for the Global Burden of Disease Study reported that the main
disease contributors were mental and behavioral disorders, musculoskeletal disorders,
and diabetes or endocrine diseases. The leading causes of years lived with disability
(LBP, major depressive disorder, iron-deficiency anemia, neck pain, chronic obstructive
pulmonary disease, anxiety disorders, migraine, diabetes, and falls) were approximately
the same in 2010 as they were in 1990.
2. Matsumoto M, Okada E, Ichihara D, et al: Prospective ten-year follow-up study
comparing patients with whiplash-associated disorders and asymptomatic subjects using
magnetic resonance imaging. Spine (Phila Pa 1976) 2010;35(18):1684-1690.
3. Matsumoto M, Okada E, Ichihara D, et al: Age-related changes of thoracic and cervical
intervertebral discs in asymptomatic subjects. Spine (Phila Pa 1976) 2010;35(14):1359-
1364.
4. Moseley GL: Teaching people about pain: Why do we keep beating around the bush?
Pain Manag 2012;2(1):1-3.
A clear and direct relationship does not exist among pain, nociception, and tissue
damage. Pain is multifactorial and broadly fits within the following three categories:
prioritization, meaning, and transmission/processing. Evidence shows tissue pathology
does not equate to chronic pain. The goal is reconceptualization of pain before it
becomes chronic pain.
5. Sembrano JN, Polly DW Jr: How often is low back pain not coming from the back?
Spine (Phila Pa 1976) 2009;34(1):E27-E32.
6. Nijs J, Apeldoorn A, Hallegraeff H, et al: Low back pain: Guidelines for the clinical
classification of predominant neuropathic, nociceptive, or central sensitization pain.
Pain Physician 2015;18(3):E333-E346.
Low back pain is a diverse condition that includes nociceptive, neuropathic, and central
sensitization pain. The pain classification system for LBP is focused on these pain
mechanisms and should be considered an addition to classification systems and
diagnostic procedures.
7. Kolski MC, O’Connor A, Van Der Laan K, Lee J, Kozlowski AJ, Deutsch A:
Validation of a pain mechanism classification system (PMCS) in physical therapy
practice. J Man Manip Ther 2016;24(4):192-199.
The authors provide validation that peripheral components of pain can be classified and
the PMCS can be implemented into clinical practice. The study used cluster analysis;
97% of the patients were classified.
8. Fritz JM, Cleland JA, Childs JD: Subgrouping patients with low back pain: Evolution
of a classification approach to physical therapy. J Orthop Sports Phys Ther
2007;37(6):290-302.
9. Clare HA, Adams R, Maher CG: Reliability of McKenzie classification of patients with
cervical or lumbar pain. J Manipulative Physiol Ther 2005;28(2):122-127.
back syndrome: Identifying and staging patients for conservative treatment. Phys Ther
1995;75(6):470-485, discussion 485-489.
examination and intervention of lumbar disorders. Sports Health 2011;3(4):362-372.
LBP is a common athletic injury resulting in missed play time. The TBC system allows
the clinician to reliably classify the athlete’s condition and apply the optimal
intervention, with the potential to reduce lost participation time, disability, and pain.
Ther 1997;10(2):86-95.
judgments and criteria associated with mechanisms-based classifications of pain in
patients with low back pain disorders: A preliminary reliability study. J Man Manip
Ther 2010;18(2):102-110.
2000.
‘peripheral neuropathic’ and ‘central’ mechanisms of musculoskeletal pain: A Delphi
survey of expert clinicians. Man Ther 2010;15(1):80-87.
Thomas Land Publishers Inc, 2015, p 194.
The authors select elements from two medical classification systems to create one
useful and comprehensive guide for pain classification. An integrative approach to pain
classification and practical guidance to the approach of diagnosis and treatment are
presented.
Davis Company, 1973, p T-62.
booklets to patients with back pain? A randomized controlled factorial trial of a selfmanagement booklet and doctor advice to take exercise for back pain. Spine (Phila Pa
1976) 2001;26(19):2065-2072.
Limited success of a program for back pain in primary care. Spine (Phila Pa 1976)
1996;21(3):345-355.
educational book change behavior and reduce pain in chronic low back pain patients?
Spine J 2004;4(4):425-435.
neurophysiology and fear avoidance in people with chronic pain: A point in time,
observational study. Physiother Theory Pract 2016;32(4):271-276.
Patients who are more knowledgeable about the neurophysiology of pain exhibit less
fear avoidance. Clinically, education can decrease fear avoidance and may be an
effective strategy to decrease disability in patients with chronic pain.
during an education intervention in people with chronic low back pain. Eur J Pain
2004;8(1):39-45.
trial: General practitioner-supported leaflets may change back pain behavior. Spine
(Phila Pa 1976) 2002;27(17):1821-1828.
Waikanae, New Zealand, Spinal Publications, 2003.
pain: The actual and perceived ability of patients and health professionals to understand
the neurophysiology. J Pain 2003;4(4):184-189.
for the management of musculoskeletal disorders and injuries of the extremities: A
systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa)
Collaboration. J Can Chiropr Assoc 2015;59(4):349-362.
Little is known regarding the effectiveness of structured patient education concerning
musculoskeletal disorders of the extremities. Two studies found that education used
alone may be less effective than other interventions in patients with persistent lateral
epicondylitis and patellofemoral syndrome.
studies in the United States and internationally. Spine J 2008;8(1):8-20.
trial of exercise for low back pain. Spine (Phila Pa 1976) 2004;29(23):2593-2602.
and centralization: A useful tool for front-line clinicians? J Man Manip Ther
2008;16(4):248-254.
trained faculty. J Manipulative Physiol Ther 2006;29(8):637-642.
and directions of preference. Man Ther 2008;13(1):75-81.
and centralization in patients with low back pain. J Orthop Sports Phys Ther
2011;41(1):22-31.
Findings of this study suggest that classification by pain pattern, directional preference,
and centralization can improve the ability of a therapist to provide a short-term
prognosis regarding function and pain outcomes. Directional preference and
centralization should be considered independent classification variables. Level of
evidence: Ib.
preferences. Kinésithérapie, la Revue 2014;14(145):36-44.
A high rate of derangement was found in the lumbar spine based on the McKenzie
classification. Extension was the most prevalent directional preference, followed by
lateral movement and flexion. Derangement was confirmed in 90% of cases, and
directional preference changed in 26.5% of cases. Level of evidence: II.
Waikanae, New Zealand, Spinal Publications, 1990.
low back pain: Revision and update. Phys Ther 2016;96(7):1057-1066.
Use of the TBC system reduces disability and pain. The first level of classification is to
determine if physical therapy is appropriate for the patient. The second level of
classification determines the severity of the patient’s condition and resulting disability.
The third level of classification divides patients into four subgroups to direct treatment
selection—manipulation, stabilization, specific exercise, and traction.
directional preference and functional and pain outcomes in patients with neck pain. J
Orthop Sports Phys Ther 2014;44(2):68-75.
Directional preference and centralization were associated with improved functional
outcomes in patients with neck pain. Neither centralization nor directional preference
was associated with pain outcomes.
preferences. 2015. Available at:
https://www.researchgate.net/publication/286875499_Neck_Pain_Prevalence_of_McKenzie%27s_Syndrome_and_Directional_Preference
Accessed June 5, 2017.
The authors investigated the prevalence of centralization of pain and directional
preference in patients with nonspecific neck pain and directional stability over time. A
high rate of derangement syndrome was reported, with the classification confirmed 9 of
10 times. The directional preference changed in 41% of the cases. Level of evidence:
III.
physical therapists for patients with low back pain. J Man Manip Ther 2007;15(1):42-
49.
chronicity in acute patients. J Rehabil Outcomes Meas 2000;4(2):31-40.
recurrent low back trouble, in Yeomans SG, ed: Application of Outcomes Assessment to
Clinical Practice. New York, NY, Appleton & Lange, 2000, pp 437-447.
management for low back pain with current best practice (STarT Back): A randomised
controlled trial. Lancet 2011;378(9802):1560-1571.
LBP is a worldwide problem. A stratified and a nonstratified management model were
compared. The results of the study show that the stratified approach has a general health
benefit and cost savings.
for low back pain in family practice (IMPaCT Back): A prospective population-based
sequential comparison. Ann Fam Med 2014;12(2):102-111.
Family practice use of stratified care for patients with LBP resulted in improvement in
patient disability and a reduction in time off from work without an increase in
healthcare costs. The mean time off work was 50% less and there was a 30% decrease
in sickness certification in patients managed with stratified care compared with those
given typical care.
tool for orthopaedic physical therapists: Results from the Optimal Screening for
Prediction of Referral and Outcome (OSPRO) Cohort. J Orthop Sports Phys Ther
2016;46(5):327-343.
Assessment of yellow flags in outpatient therapy clinics is feasible. A yellow flag tool is
a multidimensional tool that can be used to screen pain-associated psychological
distress. Further research is needed to compare the results to risk assessment tools for
treatment monitoring.
Chapter 12
Manual Medicine and Spine
Care
Samuel A. Yoakum, DO John M. Lavelle, DO
Abstract
Spinal manipulative treatment is a frequently used option for patients with
acute or chronic low back pain. Understanding the variety of treatment
techniques and the appropriate selection of patients is important for the
successful use of osteopathic manipulative medicine. When used by the
spine specialist or orthopaedic practitioner, manual medicine can provide a
safe and beneficial treatment option.
Keywords: nonsurgical options; nonsurgical spine care; spinal
manipulation
Neither of the following authors nor any immediate family member has received
anything of value from or has stock or stock options held in a commercial company
or institution related directly or indirectly to the subject of this chapter: Dr. Yoakum
and Dr. Lavelle.
Introduction
The topic of spine care is exceedingly broad, largely because of the variety of
problems that can result in a patient seeking care. A substantial amount of
care provided for the spine is related to the nonspecific diagnosis of low back
pain, as well as its equally vague associated diagnosis of neck pain. In the
setting of serious spinal disorders, which can be traumatic, degenerative, or
pathologic in nature, a theoretically finite number of presentations and
causative agents exist, most of which can be paired with an appropriate
workup and a range of reasonable treatment options. However, given the
breadth of entities potentially responsible for axial low back pain or neck
pain, particularly any chronic or subacute variety, the overworked
practitioner may simply add the semispecific, virtually all-encompassing term
“musculoskeletal” to the diagnosis. Irrespective of specialization in the spine,
any practitioner who evaluates patients with such musculoskeletal problems
recognizes the vast number of patients with subjective discomfort caused not
by fracture or neurocompression disorder, but rather by one of many potential
muscular, soft-tissue, or articular dysfunctions. These issues are quite
frequently included in the realm of manual medicine, and have been for many
years.
Origins of Osteopathic Medicine
Osteopathic medicine was introduced in 1874 and based on several central
tenets: structure and function are interrelated, the body has self-regulatory
mechanisms (such as homeostasis), and the body is one interrelated unit;
rational treatment of patients should consider these tenets. None of these
concepts is particularly radical and would be considered reasonable by most
physicians. The first students of osteopathic medicine learned to examine for
dysfunction within the plasticity of the structure of the body, and when
appropriate, sought to resolve the dysfunction and help reestablish
homeostasis. This goal was accomplished by using one of many techniques
classified under the general term manipulation. Manual medicine has been in
use longer than American systems such as osteopathy, which regarded
manipulation as an augmentation of medical treatment, or the more widely
known chiropractic approach, which presented a complete alternative to
medical care. These systems predominate in western medicine, and over time
influenced greatly the day-to-day practices of physical therapy and massage.
Osteopathy in the Literature
Although a cursory PubMed search using terms such as “spinal
manipulation” and “manual techniques” combined with “low back pain” or
“spine pain” will result in thousands of citations, studies of sufficient size,
breadth, and levels of blinding are limited. Some studies offer insight into the
potential effectiveness of the use of manual medicine in spine care. A 1999
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