Another reason therapists don't know

[John W]

The patients perception of us (PTs) having manual handling expertise is not reduced or diminished by the provision of lighter/non coercive touch. It's reduced by the explanation we provide.

I'm not sure what the relationship is between the patient's perception of our manual skill and enduring relief from the pain they're experiencing. I routinely see patients who've expressed confidence in the manual treatment they've received from various practitioners- PTs, chiros and MTs- but the method the intervention is based on is not defensible.

I'm seeing a patient now who was seeing a chiro for ART, and is confident that it cured her "psoas pain", but she continues to have pain in the hip region, although it's changed somehow, and continues to interfere with her desire to train for long distance off-road races. So, whatever the chiro explained to her about ART apparently instilled some measure of confidence in his manual skill, just not enough to completely fix the problem. I don't think the explanation for pain relief provided by an ART practitioner is defensible. It includes fairly coercive manual interventions that are heavily based on an explanation that emphasizes muscular dysfunction.

This is just the kind of "manual handling expertise perception" that we should be concerned about promoting in the culture of treatment for non-pathological pain. To the extent that more aggressive or coercive handling of the patient reinforces patients' erroneous beliefs about why they hurt, it might also reinforce passive coping strategies, which have been shown to predict increased disability.

I think the biggest mistake therapists make is that they give up too soon on educating the patient. It's hard to do, requires some "tough love", and, for those of us who rely on referrals from medical people, may threaten that relationship as well.

Shouldn't we do it anyway?

[Diane]

Yup.

"Every chronic pain patient has a brain" - Adriaan Louw.

[Evanthis Raftopoulos]

Diane and John, thank you for your responses.

While I see what you are saying, I also think that anyone could use the same/similar arguments to defend their practice, regardless of where it sits in the spectrum of 'science based'. Personally, if I'm not convinced of the plausibility and efficacy of an intervention, then I'd rather stop delivering the intervention than trying search in hopes of finding reasons to deliver it. If for a specific patient/presentation there is nothing in the context of PT practice that fits this model, then I'd rather discharge the patient to self management than entertain the patient with stories and interventions that make little sense to me in the context of 'pain resolution'. And this works fine assuming that the therapist and patient are on the same page, which IMO is not difficult most of the times assuming that the therapist takes care to provide the patient with facts and not just hopes.

Evan
PS apologies for delayed responses, currently out of country




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[Ryan A]

I'm not sure what the relationship is between the patient's perception of our manual skill and enduring relief from the pain they're experiencing. I routinely see patients who've expressed confidence in the manual treatment they've received from various practitioners- PTs, chiros and MTs- but the method the intervention is based on is not defensible.

I'm seeing a patient now who was seeing a chiro for ART, and is confident that it cured her "psoas pain", but she continues to have pain in the hip region, although it's changed somehow, and continues to interfere with her desire to train for long distance off-road races. So, whatever the chiro explained to her about ART apparently instilled some measure of confidence in his manual skill, just not enough to completely fix the problem. I don't think the explanation for pain relief provided by an ART practitioner is defensible. It includes fairly coercive manual interventions that are heavily based on an explanation that emphasizes muscular dysfunction.

This is just the kind of "manual handling expertise perception" that we should be concerned about promoting in the culture of treatment for non-pathological pain. To the extent that more aggressive or coercive handling of the patient reinforces patients' erroneous beliefs about why they hurt, it might also reinforce passive coping strategies, which have been shown to predict increased disability.

I think the biggest mistake therapists make is that they give up too soon on educating the patient. It's hard to do, requires some "tough love", and, for those of us who rely on referrals from medical people, may threaten that relationship as well.

Shouldn't we do it anyway?

This week I had a DPM (or, as Rod Henderson would say, a foot dentist) send a patient to another PT because my "picture and mirror approach" was not aggressive enough. The patient had long standing CRPS which the surgeon apparently felt would be amenable to an ankle fusion. You can imagine how that went.

Fortunately for my sanity, I had a doc refer a patient to me the next day who had gradually worsening pain and CRPS symptoms after not responding to treatment elsewhere. This is a doc I have built a good relationship with as he was military trained and has worked extensively with amputees.

My emphasis on pain science rather than the micromanagement of movement and over emphasis of mechanical factors in persistent pain regularly leaves me feeling more than a bit ostracized, but I truck on anyway.

This discussion has me thinking about this essay from Barrett. The barriers to implementing SC into clinical practice are about much more than just understanding.

[Ryan A]

Barrett, do you think the provision of passive motion by a PT necessarily prevents an ideomotoric transition from protection towards resolution?

Obviously I'm not Barrett, but I would argue it does not.

I think it was Luke Rickards who said that a decrease in mechanical deformation could be achieved by instinctive motion toward resolution, or a "lucky" passive one.

I would argue that with certain presentations of mechanical pain that we can reasonably deduce which direction of movement may reduce the abnormal neurodynamic, and thus have some success with passive movement and/or choreographed movement.

However, given the fuzz ball nature of the nervous system, it seems like the most reasonable method would be the patients own instinctive movement toward this resolution.

I personally feel, based on my interpretation of the literature and what I have noticed in practice, that fear is the key ingredient in persisting mechanical pain. This fear is often induced by the culture surrounding them, most commonly the healthcare providers they have seen in the past. Not always, but often. How many times does a concerned patient ask you if it is "ok" for them to perform a movement that is completely pain free? It happens regularly for me.

Fear seems to result in the persistence of the protective phase, which makes sense to me. Thus any approach that reduces fear of movement, whether through education, simple contact, or passive motion, is more likely to lead that patient towards resolution of their pain experience, both through the reduction of mechanical deformation, and reduction of cognitive-evaluative inputs.

[nari]

I personally feel, based on my interpretation of the literature and what I have noticed in practice, that fear is the key ingredient in persisting mechanical pain.

I agree and this point could be better promoted, perhaps.
Patients are not very good sometimes at expressing fears so the therapist may think they have none, especially if they smile a lot and make a joke or two.

Nari

[Johnny_Nada]

I think the biggest mistake therapists make is that they give up too soon on educating the patient. It's hard to do, requires some "tough love", and, for those of us who rely on referrals from medical people, may threaten that relationship as well.

My question is when can we really give "tough love?"

When will it be okay to say: Your view of pain is flat wrong. If you want to continue looking for your a tissue problem or feel the need to get fixed, I can't help you. That view is why you go to your doctor, get an image, referred to a specialist for injection, more imaging and surgery. That view is why you will continue shopping for chiropractors, physical therapists, acupuncturists and god only knows what else to validate your thoughts of something wrong. That view is why you'll be where you are in five years. When you are ready to listen, give me a call. Here's what I can tell you. I'm not selling anything. I'm hoping to help you help yourself. When you have finally decided to help yourself, give me a call. I'll leave you with one more thing (a quote I read the other day) "If you still reject pain as an output from the brain, you still view the earth as flat."

Will this ever be okay? I suspect not. It probably wouldn't be good for business….

[nari]

"If you still reject pain as an output from the brain, you still view the earth as flat."

I think the number of flat earthers is quite healthy in the world (correction: on the world)
For those dependent on referrals from MDs, it would probably be bad for your business....

Nari

[Johnny_Nada]

Can a flat earther be helped?

[Barrett Dorko]

Matt, I don't think so. This is why we use the Mothership analogy. Once someone is aboard there's little to be done.

[PatrickL]

To the extent that more aggressive or coercive handling of the patient reinforces patients' erroneous beliefs about why they hurt, it might also reinforce passive coping strategies, which have been shown to predict increased disability.

Well, to what extent do you think this is the case? I contend that the reinforcing of erroneous beliefs regarding the cause if pain is much more heavily tied to the explanation than it is the nature of the manual input.

I'd rather see a PT perform aggressive "art" like manual input with a defensible explanation than a PT performing gentle / light touch with an erroneous explanation

[PatrickL]

However, given the fuzz ball nature of the nervous system, it seems like the most reasonable method would be the patients own instinctive movement toward this resolution.

I don't disagree. My point is that, given equal parts of appropriate education and context setting, gentle non coercive touch is no more likely to catalyze a shift from protection towards resolution than passively applied movements, or conscious active movements.

[Evanthis Raftopoulos]

Bas:
"The effort required to educate the patient that "no, my special skills are not really needed for you to do this" appears to be greater with choreographed/guided movement (by us, the experts) than by auto-correct."

Ryan:
"However, given the fuzz ball nature of the nervous system, it seems like the most reasonable method would be the patients own instinctive movement toward this resolution."

As an addition to what Patrick and Josh mentioned,

I see myself supporting both of the following views in the context of encouraging movement: a. Most movement is good for you b. structured exercises are good for you. I think that both ideas can help turn on 'auto correct'. I'm not confident that we can generalize that one way is superior to another in the context of self correction. Theoretically speaking, guided movement has the capacity to register to the Neuromatrix novel (or pre pain)ways of moving which can be helpful by reducing fear avoidance and catastrophizing, and also by providing for new opportunities(movement patterns) for 'ideomotion' to occur. I still think that 'instinctive' is the wrong word to describe self corrective thoughtless movement (which seems to be how ideomotion is defined here vs. Carpenter's definition).

What do you think?




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[nari]

...and also precisely why I abandoned private practice (I was NOT the owner) after a couple of years. Too much emphasis on keeping the books as full as possible. Not enough time to think over the last pt and then the next.....

Nari

[Diane]

But the beauty of being a solo practitioner is to be able to book however you want. I see each patient for an hour, and spend a half hour between patients charting, thinking, tidying, reading.. hanging out on the internet.
Semi-retired, I can do whatever I want.