I have taught (clinically, not academically) a variety of students from different DPT schools and backgrounds.  More specifically, many come to me after having past clinicals utilizing McKenzie, Postural Restoration Institute, and even cookie-cutter approaches for low back pain.  The latter kills me, as written on the knee in the past, but even some of the other classification systems can be unfavorable to patient care.  Unfavorable doesn’t mean improper, but utilizes a one-way street.

Even clinical prediction rules, which claim to obtain superior functional outcomes, has not reached full potential yet. I do like the idea of subgrouping patients, but we have a long ways to go to show superior results. Fitting patients into the fantastic four of low back pain classification systems: directional preference, motor control exercises (aka stabilization), traction and manipulation may not happen, and in many cases, doesn’t happen.  Staunton et al 2010 Haskins, et al 2012 showed clinical application of CPRs is not applicable currently.  And we know that some patients do not fit into just one category, and some do not “fit” into a category at all. 

Sometimes the students can lose direction based on trying to fit the patient in their system, or a system at that.  A square peg can’t fit in a round hole.  They can have tunnel vision, or railroad track vision; while losing track of lateral thinking.  Most of the other treatment approaches utilize this model, but it gets pushed away like a runt in the litter to make up for the bigger name. The students lose reality of a more broader and successful foundation that should form the roots of the overall treatment approach.

This foundation bears no one’s name and doesn’t make money.  It has been the basis of patient care in physical therapy prior to the modern era of research and is one of those good ‘ol characteristics that should get passed down to other generations.  It is not an up and coming treatment, nor is it sexy.

It is the patient response model.  The patient response model simply utilizes the patient’s report of symptoms to assist you in classifying them into an intervention group.  Pain reproduction or reduction is typically the response of choice.  This in turn should dampen fear of movement, improvement of movement patterns and then function.  This is exactly what CPRs are intended to do, but just have not yet.  With overwhelming choices to treating low back pain, this is my foundation for intervening.  It is simple, effective, satisfying (for patients and myself) and obtains good outcomes.  If you perform an intervention and are able to obtain within session improvement, between session improvement, educate on self-management strategies and improve function while decreasing disability, then it may be the right approach for the patient.

What leads to the right approach: the patient response model. Yes, level 5 opinion and a broad approach.  But, it is supposed to be broad, it is the foundation.

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10 comments

  1. Thanks, having a Feldenkrais background, I have to agree to be prepared to let your client be the driver of their care, patient-centric without the therapist agenda as the first driver. One of my teachers said try and not always get seduced by the symptom. Consider disconfirming your first hypothesis….
    I also like working off a pleasure scale, to address other ways to define comfort and freedom of pain. Once a pain scale is offered, it sets the goal to pain relief and pain is in the agenda. How about helping clients find where they feel more comfort, in their body, with what support, at what time of day, during what kind of function…just a thought. It has worked well for me in the past with patients who have had long standing symptoms….

    1. Hey Stacy,
      Absolutely, thanks for the response. I do appreciate you offering your experience and I do agree with client being driver, but not a dictator though.
      H

    2. Hey Stacy,
      Thanks for commenting and visiting the blog!
      I’m interested in your pleasure scale. Is there more information on this that you can provide or just something that you use individually?

      H

  2. Harrison,
    Great post! I really do think that after learning and using the CPR’s they just don’t usually describe the patients I see in my practice. Especially back pain. I rarely see a patient primarily for low back pain within the first 16 days of their episode. Evidence and the CPR’s are a great way to guide treatment when a patient is similar, but as you described, the patient’s experience is really what this is all about.

    1. Hey Aaron! Thanks for responding man. Yeh, I agree, pragmatically speaking: the CPRs aren’t what I see either.

      Keep up the good work yourself on your blog. I really enjoy reading it.

      Harrison

  3. I love the patient response model, a key component of evidence-based practice. I’ve heard other great PTs like LJ Lee talk about the case study taking on a higher “level” within the world of evidence. I always get a lot of important information day to day from patient response, as well as from published case studies. Thanks for another great post Harrison!

  4. Really Patient Response Model is the ONLY way to treat patients in my opinion. Maybe 10% of the patients I have treated in my 10 years as a therapist have been a textbook patient that fits a McKenzie or lumbar stabilization protocol. Yes, you may utilize components of many different methodologies for treating pain, but you must resist the urge to get locked in to what initially works. Utilize that means as necessary but help the patient devise other means of dealing with their pain as people don’t function in one or two directions of movement. What some therapist don’t do is revisit those options that may have initially been painful and see if with modification, they can now be done. Some people simply MUST move in certain planes for work or other ADLs and unless we want to condemn them to avoiding it for life, we have to find a way to make it work. I love how you want to make sure we therapists don’t pigeonhole ourselves into one corner or the other.

    1. Hey Dan,
      Thanks for reading and responding! Your statement: “Maybe 10% of the patients I have treated in my 10 years as a therapist have been a textbook patient that fits a McKenzie or lumbar stabilization protocol” probably fits treatment to a T.

      I appreciate the honest response.
      Hv

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