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  • Power of expectation

    Posted by Christophb<script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,29,9,59,0), dfrm, tfrm, 0, 0, 0, 0)); </script> (Member # 3884) on 29-11-2005 16:59<noscript>November 29, 2005 09:59 AM</noscript>:

    I've been thinking about this in light of a few patients I’ve seen and in relation to the torture threads. As I've been working more and more with simple contact and other more neuro-modulatory treatments of pain, there has been some resistance to the new concepts, especially by people who have already had previous experience with PT and had been moderately successful. The interventions they expect to help them (deep pressure to change the connective tissue and vigorous stretching and strengthening), are rarely offered by me and I try my best to offer them a less aggressive way to treat their symptoms. The problem is this, it seems that if they expect those torturous treatments to help, the other things I offer seem to have no or minimal effect. I have been trying my best to be objective but it is hard to know if it is the wrong treatment or their expectations of what I'm "supposed" to offer fall short. Then I came across this in the paper today Expectation and placebo. I wonder if it is wise in those cases to play up to their expectation? I was also thinking about this in relation to gamma, would a more coherent gamma increase the power of this effect? I'm thinking of this in relation to it not working with people with Alzheimer’s... just wondering.

    Chris
    <hr> Posted by Gil Haight (Member # 691) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,29,12,3,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 29-11-2005 19:03<noscript>November 29, 2005 12:03 PM</noscript>:

    Chris,
    Your recognition of the importance of expectation (and therefore doubt) is very important in any model employed by PTs. A major challenge for me daily is to proceed with the same confidence in the presence of an ostensible doubt. Occasionally these patients are the ones who experience the most profound surprise and that makes it most worthwhile as I believe the "surprise" is as good as it gets in our line of work. The problem is it shouldn't have to be so difficult. I also feel the very value of this forum is to develop a consensus of opinion of the whys and hows and therefore relieve this dilemma.
    I do have a question for you and the others that may be relevant to SC. Do those pts. who do not recognize a difference feel any different to you ( after a change) than those who experience + results?
    Gil
    <hr> Posted by SJBird55 (Member # 3236) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,29,12,52,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 29-11-2005 19:52<noscript>November 29, 2005 12:52 PM</noscript>:

    I always try to play up to their expectations. The power of effective communication and negotiating is definitely handy. I do believe that some of what we do really is a game. Just as Barrett likes to bring up poker, generally, for us to be effective there is an aspect of being able to read patients and play the game of selling our view to them.
    <hr> Posted by Barrett (Member # 67) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,29,13,10,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 29-11-2005 20:10<noscript>November 29, 2005 01:10 PM</noscript>:

    Gil,

    I think you have to give the patient something to look at if at all possible, aside from what they may tell you they feel. Maybe this is why I emphasize the resting posture of the hip so much. Any patient can see this in themselves. I say, "Nobody comes to me looking like this," as I show them what I want. Chris has found something that explains why this helps.

    "Playing up to their expectations" makes no sense. The therapist is supposed to guide them toward rational care, not just do whatever their neighbor's nephew told them happened to his girlfriend when she went to therapy. No matter how much anybody wants or expects heavy pressure from me, I won't do it because it makes no sense.
    <hr> Posted by Christophb (Member # 3884) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,29,13,36,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 29-11-2005 20:36<noscript>November 29, 2005 01:36 PM</noscript>:

    Recognizing expectations exist can be helpful. I typically don't give in to them but try to do a little education regarding reasonable care and treatment options. I will try to change to a method that makes sense to them and makes sense given all the relevant literature and my understanding of the nervous system and pain. Sometimes I'm just not a good "fit" far a patient, but I’m learning that can be ok, but hard on the ego.

    Gil,
    I occasionally get people who give me blank stares and confused looks when I ask about characteristics of correction; I usually try to do a pre-test/post-test of some sort (whether is checking the hip or having them perform some movement that was previously painful). If this still doesn’t connect with them I just start hitting my head against a wall repeatedly until they leave.

    Chris
    <hr> Posted by nari (Member # 2772) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,29,14,26,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 29-11-2005 21:26<noscript>November 29, 2005 02:26 PM</noscript>:

    Chris, I can easily understand what your frustrations are with the "fit" principle.
    I don't think we should give in to their expectations, but if we try to understand where they are coming from, it might ease the head- banging.
    It is the same story many GPs face - "my neighbour was given this ..medication..and she's fine now, can I have it too?"
    Patients' terms of reference usually come from friends, neighbours, TV and pulp magazines. That is a hard meme to deal with. In a way, it is a bit of a sell; we 'sell' our convictions that this or that model works best.
    If we go with the "toolbox" mentality, we might still get praise and adulation because "the PT tried so hard to fix me up" after twenty different 'tools' were pulled out of the bag. That makes for nice relationships, perhaps, but does not do the profession much good, nor our long term reputation/ego/whatever...

    Some patients just do not 'gel' with us. Their expectations are too strong about what they believe they need. Unfortunately they will wander off to find a PT who follows their wishes; but that at least preserves our sense of honesty.

    Expect to win some, lose some. At least you might be giving those who "don't get it" something to think about afterwards.

    Nari
    <hr> Posted by SJBird55 (Member # 3236) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,29,15,31,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 29-11-2005 22:31<noscript>November 29, 2005 03:31 PM</noscript>:

    When you play up to someone's expectations, that doesn't mean you do every little detail the person wants - you spend time to know their expectations and come up with a plan that seems to mutually fit both you and the patient. I think that people do value that caregivers are interested in their expectations. Also, with discussing the expectations, it is a perfect time to alter their expectations so that they are met. Sometimes it is a give and a take. Sometimes I do have to disagree with an expectation, but I tend to negotiate what I believe to be a better option after an agreed upon period of time.
    <hr> Posted by nari (Member # 2772) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,29,16,38,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 29-11-2005 23:38<noscript>November 29, 2005 04:38 PM</noscript>:

    Fair enough. That sounds perfectly reasonable.
    <hr> Posted by Jon Newman (Member # 3148) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,29,19,13,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 30-11-2005 02:13<noscript>November 29, 2005 07:13 PM</noscript>:

    Gil I need you to clarify your question a little before I can answer it.

    Thanks

    jon
    <hr> Posted by KAK (Member # 4130) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,29,20,4,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 30-11-2005 03:04<noscript>November 29, 2005 08:04 PM</noscript>:

    I agree. I think a mutually acceptable treatment plan is ideal and for the most part I’ve had little trouble finding this with my patients. When it comes to asking for their input into the treatment plan I am surprised how often I hear, “You’re the boss.” I’ve learned to read this as an expression of their confidence in me, but I’ve never been comfortable with it. I usually counter with something like, “Ultimately you are the boss since it is your body” and I encourage them to take an active part in their treatment by providing feedback and feeling free to make suggestions. I educate them and try to include them in the decision making process.

    I’ll never forget an elderly cervical patient (severe pain) who came to me her second or third visit and said one of her friends (from the senior center) told her it was important to see a therapist who does manual therapy. He apparently talked manual therapy up and she was convinced that this was the answer. She asked if I did manual therapy. I had already incorporated manual techniques in her treatment, but this visit I’d say “this is manual therapy” when ever I would do mobs. I didn’t play up to her expectations, but played into them, if that makes sense? She came back her next visit with no pain. I was thoroughly convinced that it was a large part placebo. I’m pretty sure the expectations of effectiveness of manual therapy and the neuromodulation from touch eased her pain. I know I didn’t “fix” anything with the gentle techniques I used.

    Now if only I could only be as convincing as the gang from the senior center!
    <hr> Posted by nari (Member # 2772) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,29,22,20,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 30-11-2005 05:20<noscript>November 29, 2005 10:20 PM</noscript>:

    KAK

    A thoughtful post - and by any definition of the word "fix", that is what you did. Placebo certainly, because that is unavoidable in any amicable encounter with a patient, and talking to the CNS as well. That comes under manual therapy, and it makes good sense and management.
    At least that's how I look at it.

    Nari
    <hr> Posted by SJBird55 (Member # 3236) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,30,5,58,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 30-11-2005 12:58<noscript>November 30, 2005 05:58 AM</noscript>:

    When we test/retest someone and we know there is a difference, but the patient doesn't realize or own up to a difference, I always assume it is because 1) they aren't in tune with their bodies 2) they expect larger obvious differences 3) that little test/retest situtation doesn't correlate in the person's mind as something of value and doesn't make sense to them.

    So, Chris, don't argue or get frustrated. Instead, what I tend to plant in their brain.... things like, I think you're going to notice an overall improvement in getting in and out of bed... I think you're going to notice that it is less bothersome getting up from a chair... I bet it's going to be easier to take off or put on your shoes. Since I've already used functional tools, I know where the person had problems and if I believe that somewhere what I just observed should carry over into function where the person had difficulties, I merge my local joint or movement findings into some activity. I always joke and tell them that they'll know - they can report back to me next time. People are always very hesitant to be of the attitude of "wow, yeah, this is great..." and I always assumed it was because they had problems for whatever period of time and definitely won't commit on the spot to improvement. It's kind of like a new pair of shoes, they want to try the change out.
    <hr> Posted by Diane (Member # 1064) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,30,11,54,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 30-11-2005 18:54<noscript>November 30, 2005 11:54 AM</noscript>:

    Chris, I recommend that you just keep plugging along. You'll eventually find your own best way to communicate to people what you intend, what they might expect, how it works.

    We all have to learn how to do that regardless of what techniques we are offering.

    The point of PT is to help people be in their bodies better, not just 'make the body' better. At least, I've always thought that was the case.. Seems to me that causing more nocioception doesn't exactly help. Well, maybe masochists.. athletes... you could always pass such people on.
    <hr> Posted by paulpt (Member # 5125) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,30,12,36,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 30-11-2005 19:36<noscript>November 30, 2005 12:36 PM</noscript>:

    I have found that evidence based practice is a useful tool for setting forward expectations.
    <hr> Posted by Christophb (Member # 3884) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,30,12,57,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 30-11-2005 19:57<noscript>November 30, 2005 12:57 PM</noscript>:

    Didn't anyone see the humor in the banging head imagery? I have no intention of stopping what I am doing, refining it... definitely. Regarding pre-test post-test things, I seem to get more joy out of hearing people say they feel different (especially when they look confused saying it), don't always get the same feeling if they say they feel better. With feeling different I suspect there is some learning taking place... with just pain reduction, there seems to be no reason to grow/learn and understand what just happened.

    Chris
    <hr> Posted by nari (Member # 2772) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,30,14,0,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 30-11-2005 21:00<noscript>November 30, 2005 02:00 PM</noscript>:

    I think we missed the head-banging humour...

    A good point about the difference between 'better' and 'different'; anyone can feel better after doing anything to them that isn't nociceptive, but to say they feel different suggests you are on the right track towards raising the awareness thing.

    Some folk just aren't aware enough (as Diane says, not good at being better in their bodies)...and they might have to give themselves much longer.

    Alzheimer's, SC and reduced gamma activity...now that is an interesting thought.


    Keep going as you are. At least you know you cannot do anything of a nociceptive nature, unlike most of PT practice.

    Nari
    <hr> Posted by SJBird55 (Member # 3236) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,30,14,50,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 30-11-2005 21:50<noscript>November 30, 2005 02:50 PM</noscript>:

    LOL Chris, I didn't miss it. There have been plenty of various issues that my head continuously bangs against a wall about. I won't mention any names. [IMG]wink.gif[/IMG]
    <hr> Posted by Gil Haight (Member # 691) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,1,10,12,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 01-12-2005 17:12<noscript>December 01, 2005 10:12 AM</noscript>:

    Jon,
    Thanks for the interest. I'll to clarify. My point has to do with the concept of "the release" or what has been referred to more appropriately by Barrett and others as " a softening". This phenomenon is always what I'm after. My question is do we as therapists achieve this in successful and unsuccessful pts. alike. Do difficult pts. feel( from the therapists point of view) any different than successful ones. In other words, is the hang-up a difficulty achieving the softening or an interpretation/perception of it.
    I believe it is the latter.
    Gil
    <hr> Posted by Jon Newman (Member # 3148) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,1,13,1,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 01-12-2005 20:01<noscript>December 01, 2005 01:01 PM</noscript>:

    Gil,

    I agree with you that I have had patients who, to my mind, demonstrate softening but do not necessarily perceive it themselves. On occasion I'll have those patients compare and contrast the sensations of isometric and resistive exercises to that of ideomotion. Usually they are easily able to see how frank ideomotion is "softening" in nature.
    My non-successes do seem to be non-successes for much more complicated reasons than not perceiving a particular characteristic of correction although failure to note these does seem to be correlated with a denial (by the patient's account) of these characteristics. I think I need to be more diligent in tracking this.

    jon
    <hr> Posted by nari (Member # 2772) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,1,15,19,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 01-12-2005 22:19<noscript>December 01, 2005 03:19 PM</noscript>:

    Gil
    I think definitely the latter - perception of softening is rather subtle in nature, and really only perceived by patients after a passive massage, etc.

    I think they do not associate 'softening' easily in the environment of a PT's rooms; the association with tension (read muscle strengthening, etc) is a strong one. (Pun unintended)

    It is so easy for us to feel what is happening dermally and subdermally that it can be hard to accept the patients sometimes can't compute the same way as we do.

    Nari
    <hr> Posted by Jon Newman (Member # 3148) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,4,15,45,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 04-12-2005 22:45<noscript>December 04, 2005 03:45 PM</noscript>:

    Here's the abstract to a hot off the press article from Spine

    link
    <hr> Posted by nari (Member # 2772) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,4,17,52,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 05-12-2005 00:52<noscript>December 04, 2005 05:52 PM</noscript>:

    Shows that expectations from patients don't match reality; the surgeons may or may not have given realistic information; or the patients simply did not listen to that information if it was given...

    Nari
    <hr> Posted by Gil Haight (Member # 691) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,5,11,36,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 05-12-2005 18:36<noscript>December 05, 2005 11:36 AM</noscript>:

    Jon,
    Your example of comparing the consequences of SC to other forms of movement is perfectly reasonable. I have done similar things with patients and have found it to be valuable. I have not found protracted discussions about the importance or origin of ideomotion to be particularly therapeutic. I think it is unusual if your pt. were to follow with " I wonder how that happens".
    I guess that brings up the question of what does the patient need to know to get better. As far as SC goes, I think the essential point is that a type of movement (unintentional or unwilled) exists that produces remarkable pain relief. Why patients would not be interested in this surely cannot be simple. On the other hand why should are pts.
    be different than our colleagues. Certainly expectations, as in “this is not what I was looking for”, are a part of it.
    We over think this stuff. What is valuable in my opinion is that this movement exists, that it can be experienced if allowed and that it leads to profound pain relief. Simply put, the greatest obstacle to the effectiveness of SC, is a failure or reluctance to be impressed by a process much different than that which was expected prior to treatment. I believe it is “the allowing” that is most troublesome. Giving up the need to gain mastery over our bodies is apparently a difficult task.
    Gil
    <hr> Posted by Christophb (Member # 3884) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,11,5,12,45,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 05-12-2005 19:45<noscript>December 05, 2005 12:45 PM</noscript>:

    [Certainly expectations, as in “this is not what I was looking for”, are a part of it.]

    Yes, it would seem that anyone actively looking for pain relief outside themselves would be very disappointed with SC. I found some comfort in this:

    When we touch another we enter a place where we may or may not be welcomed, and this is not entirely dependent upon our approach or intent. Others have their own agenda, and may not find something in us with which they can resonate. – Barrett Dorko “As Two Rivers Meet”

    I certainly don't resonate with everybody, and SC doesn't resonate with everybody, and on days when both don't resonate... oh boy, good times, good times.

    Chris
    Last edited by bernard; 29-12-2005, 06:03 PM.
    Simplicity is the ultimate sophistication. L VINCI
    We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances. I NEWTON

    Everything should be made as simple as possible, but not a bit simpler.
    If you can't explain it simply, you don't understand it well enough. Albert Einstein
    bernard
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