Treat the cause not the symptoms??? Wheres the evidence to back up this in relation to physical therapy
“He who treats the site of pain is lost”
People may or may not recognize the above quote. The phrase seems to be flown around a lot or at least paraphrased one way or another amongst physical therapists. It’s actually a saying from a well known practitioner of rehabilitative medicine Karl Lewit. So let’s get things straight, are we truly lost if we just treat the site of pain? Let’s find out.
First of all, because pain is such a complex subject It’s going to be impossible to answer definitively whether the above statement is completely true or not so I’ll be specific, illustrating for the argument with 4 examples of specific conditions. The reason I’m going to be so specific here is because I’ve heard over and over again about how “ We treat the cause not the symptom or we assess the whole body not just the part that hurting you “ it’s very easy to paint a picture with a big brush but the devil is always in the details, which I’ll attempt to cover.
Rub my Tummy and help my Back: by rubbing I really mean visceral manipulation. It is something people may not have heard of before and involves the manual manipulation of viscera to reduce body pain. Hold on a second?
Despite what the textbooks show, organs are not static but move throughout the day with respiration and under the demands of general activity. Our organs are encased by connective tissue (fascia) and Its theorized that if the viscera(organs) are “immobile/not moving properly” due to unhealthy constrictions of the fascia, pain can refer to other distant regions of the body. First described by the researcher Pottenger in 1905, it was explained that dysfunction in an individual organ is not felt directly over that specific viscus but is referred and felt in areas supplied by the skeletal sensory nerves of that viscus( Pottenger 1905 ). Due to this specific manipulation can open up these fascial restrictions restoring the viscera to their natural function reducing pain. Some leading practitioners in visceral manipulation include Jean Pierre Barral who has some publications on this type of treatment and authored numerous books: link - https://www.barralinstitute.ie/books-and-products/
It might sound wacky to think that pain can be referred from the organs but let’s look at the literature. In a recently published study in BMJ, there were marked improvements in low back pain disability with fascial manipulation of the kidney ( Tozzi 2012 ). Another study showed that visceral manipulation of the colon increased the pain pressure thresholds of patients who were subjected to deep palpation at the lumbar region.( King 2013 ). This is interesting and definitely calls for more directed research so when your back hurts maybe get somebody to give your kidney or colon a rub!!!
Cause and Effect: we know all events have a cause and effect. There are similar situations that can occur in the body on a Joint by joint basis. It’s important to realize that the point of pain or “pathology” might not always be the part that needs fixing, it may simply be a reaction to dysfunction elsewhere. A Dysfunction in muscle length/strength or even poor motor control may contribute to injury away from the point of initial dysfunction. These dysfunctions can occur along a kinetic chain , where a dysfunction at one end may affect another segment distal to it. The “kinetic chain” theory refers to a group of synergistically acting muscles that produce and respond to movement. As always the body’s movement is never a compartmentalized or isolated process but a complex interaction of individual parts.
While chronic pain syndromes have a significant element of psychology, sporting or high load injuries are more mechanical affairs which can illustrate the kinetic chain concept. Sports injuries are known to re-occur and could explain how treating the pain with site specific stretching/strengthening fails to treat the underlying biomechanical inefficiency and prevent the injury from re-occurring again. Pain that persists is common in sports which is why it begs a large discussion ( Almekinders 1994 ) .
ITB BAND SYNDROME: This is an extremely common injury for runners. It occurs on the lateral side of the thigh along the iliotibial band of connective tissue. A lot of conservative treatment so far has focused on specific stretching but recent emerging research suggests strongly that the hips have a large role to play in treatment and prevention and may explain why strength deficits in the hip abductors are commonly reported in patients with the condition ( Fredicson 2000 ) But what have the hips got to do with the knee?? Well, during running and particularly during the landing phase if the hip drops laterally (as viewed from behind) it can place an increased amount of tension on the dense connective tissue of the It band. This repetitive shortening and lengthening of the dense connective tissue can cause friction and become irritated eventually resulting in pain.( Lavine 2010 ) The drop in the pelvis is very common in patients with the pathology and is thought as a primary driver to this condition.( Noehren et al. 2006 ) To improve the faulty biomechanics a neuromuscular re-education of the body is necessary as well as various other strengthening excercises directed at the hip.
So when your knee’s hurting from running, don’t just rub it strengthen your hips and keep them level!!!
PPF or patellofemoral pain: It is an injury that’s very common in sports and other activities involving general activity of the lower legs and is exacerbated during movements such as sitting, squatting, running and other motions. ( Lomée 1999 ) Research has unanimously confirmed that biomechanical changes at the leg and hip can increase the likelihood of injury. These changes range from Motor control deficits to poor muscular strength/length, it’s thought these changes alter knee mechanics which predispose the knee for injury, by way of excessive loading on the tissues( Waryasz 2008 ) So far research has focused mainly on the segments above the knee but little has focused on the lower limb, the bit that has, has popped up some interesting findings.
1. shortness at the gastrocnemius was found to increase the chances of PPF developing, It was theorized that shortness here caused poor bio-mechanical adaptions further up the kinetic chain( Macrum et al. 2012 )
2.There is a direct link between excessive foot pronation and flat footedness and an increased risk of PPF. It’s believed they also cause poor biomechanical adaptions at the knee complex ( Barton et al 2010 )
What to take away??? Keep them calves flexible and make sure you don’t walk like Donald duck!
Elbow pain elbow conditions most commonly occurs around the medial or lateral epicondyle and are conditions referred to as golfers and tennis elbow respectively. The pain can spread down the arm but is concentrated at the medial and lateral side of the elbow. Most treatment especially found over the internet has focused on site specific stretching and strengthening which has produced results in pain reduction but no more than doing nothing at al ( Smidt et al. 2002 ) A common standard approach of physical therapy is direct treatment at the elbow, including ultrasound, mobilisation and deep friction massage. ( Bisset et al. 2005 ) Still to this day a lack of convincing evidence exists that conventional physiotherapy management is effective at treating elbow pain ( Smidt et al. 2003 ). It’s possible this ‘site specific’ approach of physiotherapy has grown out of the widespread belief that Elbow conditions involve some sort of inflammatory process. It sounds good but Due to the lack of histopathological evidence the theory has been refuted ( Potter 1995 ) While in some cases changes can occur at the tendon they are degenerative changes not inflammatory ones( Doran 1990 ), and in the case they do occur they occur infrequently and only in the minority of patients who eventually resort to surgery ( Nirschl et al. 1979 )
If we perhaps shift our understanding that this debilitating condition has less to do with specific damage at the tendon and shift our focus elsewhere, there might be some answers further away from the elbow.
The shoulder complex could contribute to elbow pain and some research studies suggest that elbow pain isn’t an isolated condition but one that is closely linked to the shoulder. To begin, patients experiencing elbow pain often have accompanying shoulder discomfort and thoracic pain ( Berglund et al. 2008 ), Trigger points may also lie in the shoulder region, which have been shown to contribute for the condition of elbow pain, Its reported they’re often present in those with elbow conditions ( Travell 1999 ).
Don’t think that was enough, It gets even deeper, patients with lateral tendinopathy were found to have increased spinal cord excitability, specifically in the upper cervical nerves .( Lim et al. 2012 ) It’s thought the higher excitability of the nerves in the upper trunk change the nociceptive pathways and decrease the pain thresholds of patients. Another study examined the effect of cervical manipulation on a group of patients who previously failed to respond to conventional rehabilitation for lateral elbow pain. The response was positive, and an immediate reduction in pain levels followed after the manipulation of the neck( Vicenzio 1996 ) Other studies findings are also consistent with this( Gunn 1976 )( Fernandez 2008 )There have also been correlations made between shoulder mobility and lateral elbow pain. In One research study it was found that patients with LE had diminished shoulder mobility. following a MWN to the elbow, The patients shoulder mobility improved drastically ( Abott 2000 )
The exact explanations for the complex connection the cervicothoracic region and elbow have has yet to be fully elucidated, it is clear that the connection is strong and the emerging evidence is exciting which in my opinion calls for more investigation. It’s imaginable that both regions would influence one another as they share innervations from the spinal cord and a lot of soft tissue connections. It could even be possible that pain is merely perceived at the elbow but actually originates from the cervicothoracic region. This is based on the theory of somatic referral, or the pain convergence theory, (basically a misinterpretation of the brain where the pain is coming from( Bogduk 1994 )
Hamstring Strain: Hamstring injuries are a common occurrence in sports such as football , rugby and sprinting .( Foreman et al. 2006 ) In profession football hamstring injuries account up to as much as 10 percent of the total recorded injuries and higher in others.( Hawkins 2001 ) According to the literature one of the best predictors of concurrent injury is a previous hamstring strain/injury.( Orchard et al 1997) In fact in most sports re-occurrence rates are high ( Crosier 2002 ) and In Australian rules rugby the fact is quite evident, with 1/3 of the players returning from previous hamstring injury sustaining another one early on.( Orchard and Seward 2003 ). With re-occurrence rates being so high it could suggest that previous treatment to the hamstring needs to be re-evaluated and a further evaluation into the factors that contribute to re-occurrence.( Hoskins 2005 ) One of the first lines of treatment in Hamstring injuries? you guessed it focused hamstring excercises. The most famous being the Nordic curl , an eccentric excercise to strengthen the hamstrings which in many studies has proved effective in rehabilitation( Askling 2006 ) but in others not so much.( Gabbe 2006 ). So let’s take a look elsewhere, here are three studies that call for some curiosity.
SIJ joint: The Si joint is made of two Ilia and a sacrum. the two hip bones( Ilia ) sit either side of the suspended sacrum and During movement the two Ilia move in conjuction with the lower limbs. In high level sports it’s not uncommon for the pelvis to become slightly misaligned causing SIJ dysfunction and altering biomechanics of the body in some sort of way ( Brolinson 2003 ). In reference to Hamstring strains, It was found that patients peak hamstring strength increased greatly following an SIJ manipulation ( Sinacore 1989 ) The restoration of normal muscle tone is clearly important in the case of Hamstring Injuries. Research suggests previous injuries to the hamstrings in patients alters the onset of muscle activity in the biceps femoris and results in an earlier activation which has been theorised to cause more strain in the muscle since the load is not shared equally.( Sole et al. 2014 ) An earlier onset in the activation of the biceps femoris in patients with SIJ dysfunction has also been confirmed. (Hungerford 2003 ) Thus it’s clear that the SIJ if out of alignment needs to be corrected for a full recovery of the hamstrings to take place.
Spine/Hip pathology: There have been strong correlations made between an increased number of hamstring injuries and older age ( Orchard 2001 ) Its understood that degenerative changes of the spine specifically at the L5/S1 nerve root occur more heavily than the rest of the structures of the spine and it’s thought impingment of the nerves here could be a significant factor leading to reccurent injury ( Orchard 2004 ) Interestingly , there have also been studies conducted that show there are sports players who present with the same symptoms of a normal hamstring strain but fail to show any subsequent muscle damage on MRI imaging, Negative imaging on the MRI for hamstring strains can be as high as 42 percent in some cases.( Verall 2014 ) It’s thought these outliers may also have a spine or hip related dysfunction that mimics the pain of a hamstring injury.( Woods et al. 2004 ) Other studies even suggest that sciatic nerve entrapment could contribute to the reoccurring condition.( Puranen 1988 )
Pelvis: As we all know the pelvis is like a bucket holding a lot of water. Most of the time it’s balanced and water doesn’t fall out either end. But in some cases it can tip under ( posteriorly ) or over the top (Anteriorly ) . What has this got to do with hamstring injuries? Well it’s possible that the increased curvature of the spine or an excessive lumbar lordosis could increase the chances of hamstring injury, this excessive posture was positively correlated with the injury ( Hennesy 1993 ) A more recent study demonstrated how an increased lordosis could put excessive tension on the biceps femoris and sacrotuberous ligament.( Panayi 2009 )
Will post references really soon
Caolan here. Im a curious man to say the least and as an enthusiastic enrolling physiotherapy student. I have felt the need to share my thoughts and conclusions on the topic that is pain. Its something that will effect us all. Above all its very mysterious, misunderstood and complicated one and Im here to figure out more.