Visit Your Physical Therapist Every Six Months To Tune-Up Your Back
Meet Linda Van Dillen, PT, PhD, Associate Director of Musculoskeletal Research and Professor of Physical Therapy and Orthopaedic Surgery at Washington University in St. Louis. She received a Doctoral Training Research Grant from the Foundation in 1992 while pursuing her PhD in Experimental Psychology from WUSTL. Dr. Van Dillen’s research focuses on musculoskeletal pain problems, particularly low back, hip, and neck pain. Read on to learn more about Dr. Van Dillen, how she got her start, and what’s going on in her lab!
FPT: Dr. Van Dillen, how did you become interested in physical therapy and what led you to research?
Van Dillen: During my undergraduate education I was studying biology but I had no idea what I was going to do after graduation. And then I met a physical therapist who opened my eyes to how I could apply the basic science that I was currently learning. After three years as a biology major, I decided to change my focus. I started to take some of the background courses that were needed for physical therapy and I fell in love with the clinical sciences. I practiced for about eight years. During this time I earned a master’s degree in physical therapy. While I was in the clinic I pretty much did everything you could do as a PT. As I treated patients, I realized that as a profession we were really not based in evidence. I saw the importance of research in making decisions about how you treat patients and the benefit of knowing what the evidence is in order to give the best treatment. So I made a decision that research was what I wanted to focus on for the rest of my career.
FPT: Interesting! Evidence based practice is fundamental to the profession. How did the Foundation for Physical Therapy assist you in achieving your goals as you made your transition?
Van Dillen: I received Foundation funding to support my PhD in experimental psychology. I was impressed that I was being supported even though I wasn’t studying in a “physical therapy” program. I had purposefully stepped out of physical therapy to learn content and research skills that were relevant to physical therapy but in a discipline that I thought had a strong scientific foundation. The goal was to use the knowledge I gained during my doctoral education to ask questions relevant to physical therapy. The money I received allowed me to focus on my research and helped fund the experiments I was conducting as part of my dissertation. I am thankful that the Foundation saw the importance of training people in other sciences so that they could come back to the profession and apply that knowledge to study questions relevant to physical therapy. I was also a co-investigator on another Foundation-funded grant, and without this support, I would never have been able to go on to obtain funding from the National Institutes of Health (NIH).
FPT: Speaking of funding, what are a few of the research projects you have been involved with?
Van Dillen: Our lab is focused on understanding mechanisms contributing to musculoskeletal pain, and most of our funding has been related to low back pain (LBP) conditions. The largest project we are currently running is an R01 NIH-funded study looking at management strategies for people with long-standing LBP. We’re comparing a best evidence treatment for chronic LBP, which is providing strength and flexibility exercise, to what we are calling ‘motor skills training’. In the motor skills training condition we are targeting the activities people can’t perform due to their pain. We take the information we have obtained from our standardized examination about movements and postures associated with the person’s LBP symptoms, and we apply this information as we train people to change how they perform their activities. The goal is to reduce their pain and improve their function by getting people to learn new movement and posture strategies during daily activities.
The basis for this project came from an earlier study. In the earlier study, we found that when people received treatments for LBP that included exercise as well as a training program to try to change HOW they perform activities contributing to their LBP, they adhered more to one aspect of the treatment than the other. Specifically, they adhered more and for a longer period of time to the training program focused on changing daily activity performance rather than the exercise. The current study is separating exercise from the motor skills training to see what the separate effects are of the two kinds of treatment. We also are trying to determine to what extent people adhere to the two different kinds of treatments for LBP and how preference may affect adherence and outcomes.
Even if both treatments end up being equally effective, it will be important to know which treatment people adhere to the most and for the longest time. It is important to know if a particular treatment is an effective stimulus. It is just as important to find a treatment for LBP that fits people’s needs, and to which they can adhere so that they can manage this chronic problem over prolonged periods of time.
The other interesting finding from our earlier study was that at 6 months after the initial active treatment phase, people started to drop off in their adherence to their home program, and the change in adherence was associated with a deterioration in outcomes. In our current study, at the 6 month time point we are randomizing people to either extra treatment in the clinic or no extra treatment. The goal is to determine if people who get extra treatment at the 6 month time point do better over the long run than people who don’t. It’s similar to the model of how a dentist practices; you go in and you get your treatment and you improve, and then you come back for a checkup to tune things up, and then you get sent back out again. This really isn’t how PT practices for the most part, so we are hoping that we find something that’s effective, we find something that people adhere to, and that we find out whether little ‘tune-ups’ in the long run are going to be better for the course of the problem, rather than just waiting until somebody gets into an acute flare-up of pain.
FPT: Wow – considering that millions of Americans suffer from chronic LBP, this sounds like something from which the population would benefit! I love the idea of 6-month check-ups with your physical therapist. What is the potential impact that your research will have on the clinical population?
Van Dillen: We are hoping we find treatments that are effective for reducing LBP, but also that people with LBP are able to find a treatment or practice that they understand how to implement in order to manage their condition. Our emphasis is on giving the patient the skills to manage their condition. So your mention of a 6-month check-up with a physical therapist is spot on: this potentially offers a long term solution to handling LBP in which a physical therapist can re-visit with the patient periodically for needed adjustments, while also providing the patient with the skills and tools he needs to handle the day-to-day management of his LBP.
This model also has implications for healthcare costs. Helping the patient initially learn how to perform skills and exercises to manage their issues at home, and providing periodic assistance from a physical therapist to avoid acute flare-ups could ultimately lower healthcare costs. The model also likely can be applied to other persistent or recurrent musculoskeletal conditions.
FPT: This is a whole new way to approach the management of LBP and other chronic musculoskeletal conditions! What advice would you give to an emerging investigator as they’re beginning their career?
Van Dillen: As a research scientist, you don’t get a lot of day to day payoff or feedback as you do with patient care, so it is important to stay focused and to be very persistent. It is also important to really look at what your data is telling you and to change given that information. You should test things, not to prove that physical therapy is the be all and end all, but rather to understand how physical therapy can provide the best care for a patient. You may hypothesize something that’s not right or that’s a little off, but that’s ok. That data tells you where to go in the future. Sticking with what you’re doing and being willing to reconsider what you’re examining is important as a new researcher.
FPT: Great advice. Finally, I have to ask, what is the best part about being a scientist?
Van Dillen: I like the idea of discovering new information that could impact the care of people. I’ve been very lucky because I have good ties within physical therapy but I also have a lot of relationships with scientists outside the field who are interested in mechanisms that contribute to musculoskeletal pain. I have learned a lot from these colleagues. They have perspectives that I don’t have so I think that has been really educational and fun. I also enjoy mentoring. I like bringing on new students and taking them through the process and hoping they get as passionate about being a scientist as I am.
FPT: Thank you, Dr. Van Dillen, for taking the time to speak with us. This has been such an interesting conversation and your research holds much potential for patient care, especially in the area of prevention. We look forward to following your research and how it is implemented into practice to help those individuals suffering from low back pain.
If you’re interested in learning more about Dr. Van Dillen and her research, check out this video about her study on fox2now.com and read about her tips to alleviate back pain while standing in a recent issue of Dr. Oz Magazine!