Another reason therapists don't know

[Jo Bowyer]

Obviously, the least invasive form of care out there is treatment over the phone.

I have started several of my dizzy patients over the 'phone, with CH, discussion of red flags, reassurance and advice re graded exposure to movement. One came in this morning for examination. Although she has vestibular neuritis, there is a positional component and she consented to a Dix-Hallpike test with immediate follow through to an Epley manouver with good effect. It was pretty horrible for her and she was distressed and sweaty afterwards, but felt much better within minutes.

She commented on how much better she felt following the 'phone call and the added bonus of being able to chat to our receptionist, who is a few months down the line with a similar presentation.

[Josh]

John thanks for correcting me on Barnes and MFR, I apologize.
Diane, How much do I have to learn/read to understand my patient's specific unconscious preferred movment? I'm not sure I could learn enough to consistently, accurately, reliably ever understand that!


Bas, I would say that pain ed followed by movement is the best we have right now. If the patient expects to improve quicker with manual therapy, that has proven to be beneficial. I don't think we need to claim we can tap into a patient's unconscious and remove a culturally suppressed desire to move, through touch anywhere, to resolve mechanical pain. By adding this, which is something we can never study or falsify or validate, we are not decreasing the convolution in my opinion.

John what if ginger replaced SPB with defensive motor output? Why is asking for evidence or statistics a bad thing now, when countless times you quote statistics supporting your case against other forms of treatment?

Barrett because I question your method doesn't mean I need to spend more time studying and reading to understand the differences between care and treatment. It also doesn't mean I don't appreciate context and its power. It means I am skeptical of the method.

Direct question (John and Barrett): Why is SC necessary? Is there evidence of effectiveness over other forms of manual therapy?

[Evanthis Raftopoulos]

Evan,

Obviously, the least invasive form of care out there is treatment over the phone. I'm not suggesting that our words accomplish nothing either. .

Good point, I was thinking more in the spectrum of procedures/techniques that require physical presence and doing something in addition to conversing. Perhaps we can also say that doing nothing is the least invasive and sometimes best option for the patient.

Diane,

I disagree.
Reiki is invasive, abusive even, to the cognitive domain. It does not encourage self-efficacy. It's a totally operator-model, a-scientific/anti-scientific, so-called treatment.

I agree, that’s why I said physically invasive. Now what if Reiki was combined with neuroscience education and education about the importance of self management (like other passive interventions)?

[Bas Asselbergs]

Hi Josh.

Why is SC necessary? Is there evidence of effectiveness over other forms of manual therapy?

I know you did not ask me, but I want to say: no, SC is NOT necessary nor are there outcome studies on it.

Pain education and motion are essentials in SC as well - "followed by movement" is applicable to ideomotion.
And ideomotion is self-corrective, fits neurophysiological standards and knowledge.
I do not think we claim to tap into subconscious - it is an explanation that fits observation and is consistent with known phenomena. Nothing is ADDED - something is explained deeper.

Josh, how would you explain the "movement" part from your first sentence? What movement, and how does it help the patient?

[Josh]

I guess the movement I would use would be volitional, conscious.

[Diane]

Diane,
I agree, that’s why I said physically invasive. Now what if Reiki was combined with neuroscience education and education about the importance of self management (like other passive interventions)?

I still DIS-agree.
It's not physically invasive (not as much as ortho treatment, at least..), it's psychologically invasive.
Why would you want to combine it with anything?

Maybe I should ask you what you think "Reiki" is, exactly - your definition please.

[Bas Asselbergs]

I guess the movement I would use would be volitional, conscious.

Why would that be more parsominious or "better" than non-conscious, self generated motion?
And what (or who) would determine the direction, amplitude, and speed of that motion?
Can you see that this actually requires MORE theoretical constructs and parameters?

[Jo Bowyer]

Diane, How much do I have to learn/read to understand my patient's specific unconscious preferred movment?

What Bas said (I know you did not ask me!)

We studied movement as first year students and outside of class were encouraged to look at it at every opportunity. Some of us didn't see the point and a few became movement nerds and continued to look at it and feel it at every opportunity throughout our working lives, I along with others have queued up at a party to put my fingers on the front of an opera singer's neck as she hit the high notes. If I am taking a case history from a mother who has brought in an infant who won't let the family and sometimes the neighbours sleep at night, said infant is held by my left arm while my right is taking notes so that I can get a sense of what is going on.

Palpatory pareidolia? Absolutely! and probably a good percentage of visual pareidolia as well.
The dance of examination and treatment is highly subjective.

The doctors I work with refer to me for opinion, which is all I as a manual therapist can give.
They may choose to send the patient for investigations based on that opinion or look at outcome measures from a requested 'trial of physiotherapy'. A patient might go back to the doctor and say that they feel better when there is no discernible change in previous test results.

I try to keep myself up to date and I hope that my explanations are accurate in so far as they can be. What I actually do isn't.

[Jo Bowyer]

it's psychologically invasive.

I rather liked it. I had a nice lie down for half an hour, while they got on with whatever they were doing and I felt very relaxed afterwards, no PTSD in my case, but I wasn't listening to what they were saying.

[Diane]

Diane, How much do I have to learn/read to understand my patient's specific unconscious preferred movment? I'm not sure I could learn enough to consistently, accurately, reliably ever understand that!

Yes you could.

You can read, can't you?
See diagrams? Develop systematic thoughts?
You can do it, I know you can. You simply apply yourself.

[Diane]

I rather liked it. I had a nice lie down for half an hour, while they got on with whatever they were doing and I felt very relaxed afterwards, no PTSD in my case, but I wasn't listening to what they were saying.

Physically it doesn't invade, but never make the mistake of asking them what they are doing mentally. :sad::thumbs_do

[John W]

John what if ginger replaced SPB with defensive motor output?

What if pigs could fly? I don't understand the question.

Why is asking for evidence or statistics a bad thing now, when countless times you quote statistics supporting your case against other forms of treatment?

I don't understand where in my comment above you got the idea that I think asking for evidence or statistics is a bad thing. In fact, what I said was:

You seem to want some statistical confirmation that a therapist is able to promote or catalyze a patient's own instinctual tendency for correction, and there's nothing wrong with that. However, if that's the case, then your comparison of SC to all the other methods above makes not sense at all.

I then tried to explain why you're asking the wrong question. You seem to have the DPT version of EBP blinders on- or at least you are presenting the same behavior that I often witness in young DPT students and graduates (and not a few well-known clinical research leaders in our field).

Consider the term "prior plausibility". I suppose it's worthwhile to consider the question, "Prior to what?" May I suggest that plausibility should come prior to spending limited, valuable research dollars and brain power on outcomes studies that lack a plausible theory? The "prior" part is very important, and it's routinely ignored in the physical therapy research community.

I think it's ok for practice patterns to drive some research questions, but there should be a transactional relationship between the lab and the clinic. However, in our field, clinical practice has dominated the transaction. There's not nearly enough quality research driving practice. Look how limited an impact Moseley, Butler and Louw's research into pain neuroscience ed. has had on practice. On the other hand, clinical popularity of spinal manipulation and dry needling have driven a lot of research despite the fact that they lack prior plausibility. Not only does educating patients about pain make loads of sense (i.e. it's plausible), we have very high quality evidence showing that it is clinically effective. Yet, this is not being widely taught in DPT programs, nor is it being used with any regularity in PT clinics.

I think taking a step back and looking at the broader context of our current predicament in the physical therapy profession would help you to understand this better.

[Josh]

Bas, With conscious, volitional movement the patient is gaining locus of control, reducing fear, attending to what they are doing. This seems better to me than unconscious movement.

Of course the patient directs speed, amplitude, and direction....unless anesthesia is involved.

[advantage1]

Evan said:

I agree, that’s why I said physically invasive. Now what if Reiki was combined with neuroscience education and education about the importance of self management (like other passive interventions)?

To quote Jo you would still have to hit the metaphorical mute button to block out the explanatory poo. What you describe above is manual therapy with neuroscience education and self management. Also, by calling the manual techniques Reiki, you give the patient the impression that energy is being chanelled as well as any other poo poo idea that goes with it.

[Jo Bowyer]

If the patient with balance problems I worked with this morning had been attending to what she was doing, she would have fallen. My purpose was to set her up for instinctive movement and then feed back what she did.