In episode 202 I'm bringing the conclusion of my interview with Dr. Craig Leibenson. He shares some of the primary elements he includes in his evaluation, some ideas on symptom presentation and patient-described lesion behavior, how we can further become the point person to treat musculoskeletal disorders sooner in the episode of care and more. This week on MCF!
De-emphasizing pathological labels
Craig talks about the importance of making our patients aware of coincidental MRI findings, and that a lot of asymptomatic people can have positive findings on MRIs. He stresses the importance of educating patients that, even if they have symptoms and positive findings on MRI, it is possible to recover.
Craig shares his perspective on the limitations of clinician’s ability to give a specific diagnosis in low back pain patients, especially those who do not have red flags and/or nerve root involvement. He thinks it is important to re-assure patients that all the “scary stuff” is out of the window and the prognosis is excellent. He basis his assessment on the rehab giants including Robin McKenzie; and does a movement assessment to find out which are the painful movements, more precisely those that peripheralize the symptoms, then secondly drawing from Gray Cook and Functional Movement Systems (FMS) to find movements that are at their worst for stability and motor control. He assesses the fundamental movements patterns of squat, push, pull, lunge and carry on day one and on subsequent visits to re-assess.
He believes in preaching “Hope” to his patients and draws onto the research to state that giving positive feedback to patients is important, especially in presence of “yellow flags” where you do not want to re-enforce the already catastrophizing beliefs of the patient by giving a bleak outlook. He relies on McKenzie method and focuses on active treatment, centralization phenomenon, making patients independent in self-management to treat his patients especially those with yellow flags and lauds Robin McKenzie as a behavioral medicine specialist.
To summarize his mantra, “It is about control, not cure”.
Cause and Effect
Educating patients to relate activity to symptoms that specifically are the cause of symptoms and not have erroneous beliefs of activities that they might think are the cause of their symptoms. Craig spends a lot of time educating his patients about effects of faulty posture and draws his information from original research of Alf Nachemson (loading of spine with different positions: the findings of which conclude that sitting has more load than standing and standing and bending forward has more load than normal standing on the spine). He feels that sedentary lifestyle is baked into our culture and our focus should be on educating patients about the effects of sedentary lifestyle and at the same time, working on their fitness so that they do not have the ill-effects even after bouts of sedentarism. Craig believes that it is important to invest in activity to build resiliency of our tissues.
Craig does not believe in depending on imaging for management of his patients. He reserves use of imaging in certain cases like trauma or those who have not responded to his treatment after about 2 weeks. He believes that imaging can cause a fragile mindset in patients and hence likes to delay the use when patients can be successfully managed conservatively.
Craig feels that there is a disconnect in the pain science field with respect to the nuances of patient management. He thinks that people are poisoned about being told that they need to keep their spine in neutral and some people avoid flexion at all costs and they are doing a dis-service to themselves and perpetuating their problem, because at some point it stops being a protective mechanism. He agrees that during the phase of acute derangement, when pain peripheralizes with flexion, it is possible to alter pain behavior by teaching these patients to maintain neutral lordosis. He refers to research studies by Long and Donelson and validity of directional preference paradigm; and believes that is the concept of stabilization. He references to McGill’s Big 3 stabilization exercises, Folsom stabilization (Dennis Morgan, DC and Michael Moore, PT), and Australian Queensland Approach, and that their concept of stabilization is also about maintaining lordosis not only in sagittal plane but also in the transverse plane like in the Bird Dog position, McGill curl up position and the side plank positions. He is of the opinion that, McGill’s stabilization approach and McKenzie’s concept of postural control have a lot of similarities in concept.
He feels that it is important to avoid labeling patients, especially those with poor self-efficacy/yellow flags by telling them that there is instability in their spine and worsening their catastrophic behavior. His assessment includes determining if patients are able to maintain a neutral spine with their ADLs. If they are unable to maintain a neutral spine and spike their pain with activities, his management focuses on teaching them how to maintain a neutral spine. He believes that it is important to avoid early morning flexion in the acute phase for early recovery, but does not believe that his patients need to avoid early morning flexion throughout their life. Advice should be different at different phases of recovery, and individual to each patient depending on their activity level. He believes that there is a time and place for everything, and it is important to avoid over protective behaviors by giving the right advice in the right context.
End of the Day
It is important to consider the merits and limitations of all the different approaches that are out there for management of the spinal pain. There is a certain level of uncertainty to all approaches and at the end of the day, it is all about outcomes and results. The goal is to know what the patient wants, what are the patient’s concerns, and trust and empathy between the patient and clinician. The best way to gather all this information about the patient is taking a very effective history.
To Become the First Line of Care for Spine Patients
Craig thinks that us rehab specialists (chiropractors and/or physical therapists) need to load our patients quicker and need to give patients their due credit for being resilient. We need to slow cook their fitness which will get more people onboard. He feels that a lot of people have experienced that a trainer has helped them more than an MD or a rehab specialist and we need to turn this tide towards us.
Link to abstract for Alf Nachemson study: https://journals.lww.com/spinejournal/Abstract/1976/03000/The_Lumbar_Spine_An_Orthopaedic_Challenge.9.aspx
Links to abstracts of studies on directional preference:
Long 2004 and 2008
Donelson 1990, 1991