Entering Chaos

[Barrett Dorko]

We don't completely trust the word of an economist or weatherperson. And as is said in this video:

It's hard to get people interested in Plan B when Plan A seems to be working so well.

Carol Lynn likens this message to something I wrote in 2004:

It seems no longer possible to expand any clinic or private office without turning it into a place where only training is available, and creativity is a foreign concept.

Like the Internet, therapy has become something our practice was never meant to support. In order to make it “fit,” well, look around at the way it's practiced.

I'm not sure this can change now. There's a sense of the chaos that confronts us, and many therapists prefer it weren't there.

[Barrett Dorko]

Is there something linear about our patient's response to intervention when we're trying to relieve their pain?

Am I missing something?

Does it make sense to suggest that there's a chaotic system within that therapists simply deny?

[caro]

And now this.

[Barrett Dorko]

Great replies.

Tomorrow's blog post will deal directly with the manner in which we explain something as complex and unpredictable as a painful complaint.

Clinical prediction "rules," in fact, prediction in general, seem to exist in opposition to reality.

Imagine that.

[nickmPT]

Something that stands out in my mind greatly during my internship. I was a heavy user of thoracic/lumbar/sacral manipulation. A patient came in the afternoon and his Dx was 'backache.' Looking through his MHx as we had EMR, I saw that he hadn't reported back pain for the past 1-2 months and that he was seeing the neurologist for drop foot.

During the interview, I questioned him how it all happened, he reported that he would usually go see a DC when he would have a backache, with no problems. This incident started the same, just a simple 'backache' after he was done working out. No apparent red flags, no pain radiating down past his knees, etc. The DC manipulated him and the pain didn't go away, when he returned 2 days later, the pain was about the same and the DC manipulated him again. Next day, he couldn't lift his foot or big toe (drop foot and drop toe!).

Why it stands out in my mind, is that he is someone who would most likely fit a CPR for lumbosacral manipulation (acute, low fear avoidance, no sx distal to knee, most likely one could find 'hypomobility' in a segment). It really made me question the validity of the CPR in general. If I could potentially harm someone with a treatment based on the CPR, what good is it?

[Barrett Dorko]

Nick,

I think Jason wrote something about CPRs in the past that might shed some light.

Really, weren't these a manifestation of denial?

[nickmPT]

Really, weren't these a manifestation of denial?

What do you mean?

[Barrett Dorko]

Simply that CPRs were invented to predict even further that which couldn't be predicted in the first place.

The problems inherent to prediction in a chaotic system is what's being denied.

[nickmPT]

Simply that CPRs were invented to predict even further that which couldn't be predicted in the first place.

The problems inherent to prediction in a chaotic system is what's being denied.

True.

It also seems that the CPR's purpose was a standardization of care of sorts. Using choreographed movements and specific manual techniques to treat different kinds of injuries/pathologies ala the way a physician would treat bacterial infections with antibiotics. Yet as you say treating the chaos that is pain, as I'm learning more about, is generally not as simple as applying the correct maneuver.

It would seem that our profession would do well to learn more of how the talk therapies operate rather than imposing some sort of artificial standardization based upon movements and techniques.

What do you think?

[Barrett Dorko]

I think it's a dying profession. This is just one reason why.

[nickmPT]

I think it's a dying profession. This is just one reason why.

Tell me how you really feel.

I assume you talk of PT in general. What would replace it? Something good, bad, or ugly?

[Evanthis Raftopoulos]

I think we have to acknowledge that the patients' values and beliefs (deriving from the society and culture that they live in) regarding rehabilitation and pain can be strong predictors of expectations and therefore outcomes of specific interventions. If one expects massage, manipulation and strength training in PT (See here), then good luck with anything else (I guess you better be charismatic and convincing if trying something else). It seems to me that CPRs predict patient beliefs regarding interventions more than anything. I would like to know the patient expectations and past experiences with specific interventions prior delivering the intervention. CPR studies are distorted by patient and practitioner bias, therefore, useless in my opinion when applied in individuals with variable expectations and cultural/societal backgrounds than those in the studies.

[Evanthis Raftopoulos]

Somehow my first and last sentences seem to contradict, either that or I haven't sorted out my thoughts properly (not uncommon). I guess this is my left brain still trying to make sense of the chaos.

Sincerely,

My left brain

[Barrett Dorko]

Nick,

I don't think it will be replaced in my lifetime. Its transformation from what I knew it to be is already complete.

Unless and until therapists have an incentive to know more and practice appropriately, well, I guess I'll always have something to bellyache write about.

[nari]

I think it's a dying profession.

Once upon a long time ago, what physiotherapists did with patients was unique. Nobody else came close.
Now competition is fierce and persistent from fitness instructors, trainers, OTs, LMTs, kinesiologists, chiropractors, osteopaths....and others.

I think all of these practitioners have every right to update, extend their curriculi and widen their horizons. Don't get me wrong. But here the perfect opportunity is wide open to us to get in on the pain horizon and run with it, leaving others behind to some extent and it is being largely ignored.

If as a profession, we continue with the same old, same old... then I agree totally with Barrett.
PT will not survive.

Nari