Conversation

between @CraigLiebenson and @aaron_kubal.

a month ago

Craig Liebenson@CraigLiebenson

I’m constantly challenged by all of youngsters & by our failure to stem the tide of musculoskeletal disability & sedentary lifestyles. What can we do better to inspire change & educate people why opiates, surgery & endless “fix it” approaches aren’t the sustainable solution?

Aaron Kubal@aaron_kubal

What turned me off most from the ‘fix it’ approach was when I realized how damning it can be for the patient’s ability to take ownership of their condition. It is not well understood at an institutional level the repercussions of noceboing people and only treating passively

Craig Liebenson@CraigLiebenson

Building self-efficacy is crucial to sustainable resilence. In an era of ⬆️ musculoskeletal disability & #ncds motivating lifestyle change is paramount for #healthylongevity @_Tyson_Beach @jeubanksMD @M_Stamatakis This is not only about MSP but #healthspan

Craig Liebenson@CraigLiebenson

gets it. This is why we don’t pursue a “fix it” strategy. Passive care is low value. @JanHartvigsen @CGMMaher @RachelleBuchbin @MaryOKeeffe007 We may use passive care but less than most DCs & PTs realize.

Craig Liebenson@CraigLiebenson

From #ros 1st edition by #vertmooney revolutionary figure in Orthopedics. Helped promote #functionalrestoration emphasizing the sports medicine approach for everyone. Crucial distinctions between between physical & psychological deconditioning were assessed & addressed

Craig Liebenson@CraigLiebenson

1996 #ros of course based on Waddell/Main 1983, 1984, ##1986, Mayer/Gatchel 1985

Craig Liebenson@CraigLiebenson

Self-efficacy. @PeteOSullivanPT @PainRevolution #firstprinciplesofmovement Reassurance & Reactivation

Craig Liebenson@CraigLiebenson

“use education to facilitate active management approaches (targeted exercise therapy, physical activity & healthy lifestyle habits) reduce reliance on passive interventions”  http://dx.doi.org/10.1136/bjsports-2018-100488  @jpcaneiro @DrChrisBarton @kieranosull @JanHartvigsen @ewa_roos @PeteOSullivanPT

Craig Liebenson@CraigLiebenson

“Physiotherapists, for the most part, tend to approach the management of chronic low back pain on the premise of a biomedical model of disease, with treatment focus on a physical pathology and on addressing the symptoms and physical impairments.”

 http://www.sciencedirect.com/science/article/pii/S1836955317300693 

Craig Liebenson@CraigLiebenson

“Healthcare professionals’ attitudes and beliefs have been shown to influence adherence to guidelines for low back pain, such that a healthcare professional with a biomedical treatment orientation and high fear avoidance beliefs is more likely to show poor adherence”

Craig Liebenson@CraigLiebenson

“there is a need to reframe the way we care for non-traumatic persistent and disabling musculoskeletal pain conditions, by aligning the management of such conditions with the principles underpinning the management of other chronic conditions: strong clinical alliance,...

Craig Liebenson@CraigLiebenson

“Reframed in this manner, patients would no longer be led to expect a ‘magic’ manipulation or other passive approach to ‘cure’ their condition, & this in turn may reduce stress and burnout experienced by many clinicians who are unable to deliver on such unsubstantiated promises.”

Craig Liebenson@CraigLiebenson

“Interventions such as manual therapy, pharmacology and injections, when provided, should be seen as an adjunct, and their risks and benefits must be considered and honestly communicated.”

Craig Liebenson@CraigLiebenson

“... education,..exercise and lifestyle (sleep hygiene, smoking cessation, stress management, etc) in order to build the individual’s self-efficacy to take control and ultimately be responsible for their health.”

 https://analytics.twitter.com/mob_idsync_click?slug=1wsRw3dCA1&idb=AAAAEICAfZgTIfEhIeNg9sFgpbMgfrVcpp1FMZZPGar9Zhgq_8ik6FiMKGXPYNNUGBWz7NUsWi13viG7re68RMB5bQY-euAwAj8v0EDKQ0Gdq5AYn6YcxNOmL4aa2S84uuEBojxtetTgeP1pOCl_6_b76HH6UfFW&ad_tracking=true&tailored_ads=true 

Craig Liebenson@CraigLiebenson

“A whole of community approach to education will require partnership with influential agents of change. They need to have skin in the game and see a commercial benefit of facilitating recovery rather than simply facilitating treatment.”  https://bjsm.bmj.com/content/53/10/588 

Craig Liebenson@CraigLiebenson

Why Uncertainty?
❇️ our approaches are not finished developing yet 
❇️ people relapse
❇️ people are not ‘fixed’
❇️ long term follow-up data are incomplete
“this reflects I think my commitment to science and my own lack of conviction that I really understand stuff” L Moseley

Craig Liebenson@CraigLiebenson

“A revolution in understanding of LBP is truly required but we need a
whole of community approach to make it happen. Considering the reluctance of our field to truly rethink the problem of LBP,..

Craig Liebenson@CraigLiebenson

“... we might do well to aim our education directly at the masses—harness their collective strength to shift the conversation, & clinical practice, around LBP.”

Craig Liebenson@CraigLiebenson

Lorimer @PainRevolution #painrevolution

❇️ We over-worry people
❇️ We need to reassure people
❇️ We think there is a huge amount of unnecessary and in fact iatrogenic care going on

Our goal is to provide a - 
❇️ “sensible application of contemporary science”

Craig Liebenson@CraigLiebenson

“Millions of people across the world are getting the wrong care for low back pain...Protection of the public from unproven or harmful approaches to managing LBP requires that...

Craig Liebenson@CraigLiebenson

“... governments and health-care leaders tackle entrenched & counterproductive reimbursement strategies, vested interests, and financial and professional incentives that maintain the status quo..”
 https://www.theguardian.com/commentisfree/2018/mar/22/back-pain-drugs-scans-fixes-treatment-lancet 

Craig Liebenson@CraigLiebenson

“..it is increasingly clear from scientific studies that most of the treatments offered across all professions are nowhere near as effective as we once thought...

Craig Liebenson@CraigLiebenson

“... the decision to seek treatment can - when the pain does not resolve quickly - leads to people with LBP being referred for a vast range of costly, ineffective and sometimes harmful tests and treatments.”  https://www.rte.ie/brainstorm/2018/0130/937071-all-you-ever-wanted-to-know-about-back-pain/ 

Craig Liebenson@CraigLiebenson

“We propose adoption of the so-called positive health concept as the overarching strategic approach to the prevention of long-term disability from low back pain...

Craig Liebenson@CraigLiebenson

“... Positive health, as proposed by Huber and colleagues, is “the ability to adapt and to self-manage, in the face of social, physical, & emotional challenges”.

Craig Liebenson@CraigLiebenson

“..This term encompasses a much broader idea of health than simply absence of disease and its emphasis on medicalisation & cure.”  https://onlinelibrary.wiley.com/doi/full/10.5694/mja17.01152 

Craig Liebenson@CraigLiebenson

“Quick fixes promoted in the media seem like a helpful avenue for LBP. There is always a new pill, device, gadget, cream, lotion, exercise craze promised to be the next cure for LBP.

Craig Liebenson@CraigLiebenson

“...miracles promise the person w: LBP that they need not put in any effort to help themselves and say they need somebody else to fix their pain for them...these "quick fixes"...distract people from..approaches that would be more helpful, like sticking with their exercise plan.

Craig Liebenson@CraigLiebenson

“A mere 6.8% physiotherapists were aware of the WHO-recommended level of adult PA... Novice PT's (5 > years of experience) knew significantly more about adult PA recommendations (P < 0.05) than did the more senior physiotherapists.
 https://www.sciencedirect.com/science/article/abs/pii/S2468781219300815 

Craig Liebenson@CraigLiebenson

“Loss of muscle mass is generally gradual, beginning after age 30 and accelerating after age 60. Previous longitudinal studies have suggested that muscle mass decreases by 1.0-1.4%:year in the lower limbs.”
 https://www.ncbi.nlm.nih.gov/pubmed/31343601/ 

Craig Liebenson@CraigLiebenson

We hold people back by pathologizing normalcy. @benedsmith @MattLowPT  https://podcasts.apple.com/us/podcast/muscle-medicine/id1425627401?i=1000464106786 

Craig Liebenson@CraigLiebenson

So much about science that I’m lucky I learned when studying philosophy of science.

Craig Liebenson@CraigLiebenson

#BrianNord
“I think the principle element of science is actually failure.”

 https://youtu.be/CkG-E3v21_4 

Craig Liebenson@CraigLiebenson

“The way I look at science is I want to fail as fast as fast as possible. I want some ideas to fail as fast as possible so I can move on to the next one. Or by some kind of fortune this idea survives all my tests. That’s what science is - surviving tests.”

Craig Liebenson@CraigLiebenson

“We’re trying to disprove ourselves

These failures are highly productive because we’re still learning

The failures we are seeing in science are some of the most productive I can imagine.”

Craig Liebenson@CraigLiebenson

To me this humility #bealearnitallnotsknowitall is key to growth #failuretolerance

Craig Liebenson@CraigLiebenson

 https://urbanwellnessclinic.com/dr-craig-liebenson-first-principles-of-movement/ 

“The social is more important than the bio & psycho
I realize now how blind I’ve been”

Craig Liebenson@CraigLiebenson

“Does move well really matter as much as I learned from Pr Janda, I taught or Gray Cook teaches. I would say it doesn’t matter as much as social determinants of health”

Craig Liebenson@CraigLiebenson

“I’m guilty of training people to over-correct. I think it makes people fragile.”

Craig Liebenson@CraigLiebenson

“The ultimate social constraint is the tyranny of the visit. It’s not just about good manual therapy & rehab. The clinic or visit itself because of the social contract (leads) people expect you to fix them.”

Craig Liebenson@CraigLiebenson

If the real movement problem is something that requires confidence, self-efficacy & independent functioning rather than somebody fixing you then in the clinic setting you’re hamstrung. I’m shocking myself again. I can’t believe I said it. It wouldn’t have made sense to me before.

Craig Liebenson@CraigLiebenson

The first principle is reassurance. The tyranny of the clinic tells us that the environment of the interaction drives people to want things that aren’t necessarily good for them.

Craig Liebenson@CraigLiebenson

Follow the science reassurance & reactivation. Most people are trying to fix it..., we’re not pathologizing. @PeteOSullivanPT is saying we are. We are making people feel sick. “I have a tight QL...” who’s been giving people this idea. I’ve been.”

Craig Liebenson@CraigLiebenson

When people are vulnerable they over-interpret the “don’t do this” messages.
Spine sparing strategies..of course mechanically they are right. But how much does mechanics influence pain.
Self-efficacy influences pain more than the mechanics does...

Craig Liebenson@CraigLiebenson

...Mechanics is important but maybe not as important as the social or the psycho. The Social - the trust & confidence - bridges the gap between the bio & psycho.




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