Warm body with a license

[Barrett Dorko]

This morning I drove an hour south of my home in order to evaluate several patients. It's a way of making money and I realize that this is life for many therapists.

I'm a warm body with a license – nothing more.

No wonder so few want to talk about it.

[gollygosh]

Yeah, I know how that feels.

[nari]

I'm a warm body with a license – nothing more.

I can understand that emotion, but I do not think it is accurate and I would dare say there are others here who might think something along similar lines.

I went to a lot of courses over 20 years but the only ones that ever made good sense were Butler's, yours and what I have read of Moseley's work.

[Barrett Dorko]

Nari,

I should have indicated that it was the person employing me that thought this - not me.

It was a gloomy department with a poster of "the muscular" system on one wall. A similar poster showing "the skeletal" system was on the floor.

Uh-oh.

I treated one man who had been told to "use" his arm after his fracture had healed though he continued to have pain distantly from the site of the injury. I explained this and enhanced his resting posture markedly. Another patient initially said that her pain never altered with position though later she told me that pillows help a lot. I made a wonderful connection, she reported a distinct reduction in pain.

I doubt I'll ever see her again.

[nari]

Whew. Silly me, thinking it was you without thinking further...

In the health clinic where I worked for three years there were five posters on the wall, all the classic body posters, but the one showing the nerves was sort of shoved down one end and nearly hidden by a cupboard.When I removed it to prime position without compromising the others, it was valuable for TNE. Then I retired.

When I dropped in to chat with the replacement physio whom I knew quite well, I asked about what happened to the nervous system poster. "Oh", she said "it is the least useful one so I took it down."

It is probably still down, and stuck in a cupboard.

[Barrett Dorko]

This movement of the posters interests me for obvious reasons.

When the schools alter their approach, when somebody in charge reads something, perhaps this will change. The problem is, Johnny Manziell and Cuba Gooding Jr. are waiting to be shown the money.

Maybe I should just keep my mouth shut.

[John W]

I recently completed a 4-month PRN contract at a corporate-run PT clinic. I was mostly seeing other PTs' patients, so I encountered a steady stream of people lamenting their leg length inequalities, sacral torsions, and core weakness. After seeing a guy with bilateral "tennis elbow", the OT, CHT lectured me on the effectiveness of skin scraping- that 90% of his patients had a positive response. He knew that I had been critical of the method but apparently felt like I needed to hear about his amazing results anyway.

During those 4 months, I saw no evidence whatsoever that the information on pain science being touted at professional conferences, including AAOMPT and CSM, is filtering through to the average outpatient orthopedic PT. This particular large corporate rehab company seemed to be impervious to this growing body of evidence. This company has hundreds of clinics across the country with several hundred therapists working for them. Yet, no substantive change in practice based on a sound clinical reasoning process had occured- if anything, things looked worse to me with PTs transitioning from the relatively innocuous "plug-in placebos" of yester-year to tools that scrape and penetrate the skin. This is why the PT profession added a year of schooling to become a "doctoring" profession?

I'm looking forward to being surrounded next weekend in San Diego by like-minded therapists who see how off-course we've gotten in treating painful conditions. I want to believe that this will be the start of something- some kind of real change.

[Barrett Dorko]

John,

I agree whole-heartedly with your assessment of the situation.

I'm far less optimistic regarding the effect of all our efforts in San Diego.

The world of PT is run by those gesturing like Johnny Manziel.

They don't actually do this of course.

[Keith]

I recently completed a 4-month PRN contract at a corporate-run PT clinic. I was mostly seeing other PTs' patients, so I encountered a steady stream of people lamenting their leg length inequalities, sacral torsions, and core weakness. After seeing a guy with bilateral "tennis elbow", the OT, CHT lectured me on the effectiveness of skin scraping- that 90% of his patients had a positive response. He knew that I had been critical of the method but apparently felt like I needed to hear about his amazing results anyway.

During those 4 months, I saw no evidence whatsoever that the information on pain science being touted at professional conferences, including AAOMPT and CSM, is filtering through to the average outpatient orthopedic PT. This particular large corporate rehab company seemed to be impervious to this growing body of evidence. This company has hundreds of clinics across the country with several hundred therapists working for them. Yet, no substantive change in practice based on a sound clinical reasoning process had occured- if anything, things looked worse to me with PTs transitioning from the relatively innocuous "plug-in placebos" of yester-year to tools that scrape and penetrate the skin. This is why the PT profession added a year of schooling to become a "doctoring" profession?

I'm looking forward to being surrounded next weekend in San Diego by like-minded therapists who see how off-course we've gotten in treating painful conditions. I want to believe that this will be the start of something- some kind of real change.

I am in a hurry to burn through a bunch of Medbridge courses this month to meet the demands of my state CEU mandate - which is funny considering that I likely put more time and energy into learning than 99% of my fellow state licensed PTs - but travels to Montreal to meet Diane, to Manhattan to meet Barrett, SD to witness 3 days of education (not to mention the reading, writing, advocation, etc)...none of it counts.

At the end of last week, I spent 5 hours (of an online course) listening to a therapist discuss their approach to PT. The gentleman knew his pain science well and spent the first 2 hours of the course laying down the foundation for neuromodulation of pain through non-threatening input - then proceeded to get out a scraper and gently stroke the skin (no redness or bruising) in an effort to neuromodulate. That was it - there was no other evidence provided for its use other than 'neuromodulation'. And if one form of neuromodulation doesn't work, that is okay, try another type of neuromodulation. Keep scraping, compressing and pulling in different places and different directions until there is finally a difference pre- and post- test. Then have them exercise through the newly available ROM.

While I appreciated the neurocentric explanation, the obvious ability of this (or any) presenter to simply frame their treatment as non-threatening and to have a neuromodulatory effect is going to eventually border on pseudoscience - if we aren't already there.

This morning I worked with a patient with a history of manic depression with suicidal/homicidal ideations who recently lost a loved one. Her chronic leg pain from a botched LSp surgery 30+ years ago was worsened as she wept, uncontrollably. I held her hand in mine and listened. 20 minutes later, her pain was reduced and she was no longer upset. It occured to me that I should teach a course on Strategic Hand-holding In Therapy Environments. It should take some time, but with some good web-design, a strong presence online and a few choice, well-crafted testimonials about patient satisfaction - I can see this becoming something.

[YT]CF7OnW4XDck[/YT]

I think I may have stepped into something here.

Respectfully,
Keith

[PatrickL]

While I appreciated the neurocentric explanation, the obvious ability of this (or any) presenter to simply frame their treatment as non-threatening and to have a neuromodulatory effect is going to eventually border on pseudoscience - if we aren't already there.

i agree keith. I have suggested this before, in the throws of one of those long ect/meso threads and it wasn't so popular... i guess it wont be popular now either... but I think that for all the hard work done to produce science based methods for treating pain, the science that we at ss hold up most dearly appears to boil down to;

• provide non threatening sensory/discrim input
• provide novel sensory/discrim input
• don't provide a noceboic treatment narrative/context

Those are some pretty vague parameters for a science based approach to manual therapy. It leaves scope for lots of variation in method(s) that are essentially equally "scientifically defensible". In other words, i dont see that i'm practicing anymore defensibly when I utilize a gentle skin stretch technique, than when I apply a heavy, perpendicular force into some body part or when i apply some sort of traction load to some other body part.

Inevitably, someone will package a con-ed program that claims to provide novel and non threatening sensory/discrim input (while minimizing risks to self efficacy and minimizing nocebo) for the purpose of reducing sensitization, and thus relieving/resolving pain. The method used to achieve this could utilize any number of gimmicky tools like scrapers. The problem (as i understand it) is that it wouldnt actually be pseudoscientific... it would qualify as a science based method.

What this suggests to me is that the science we use to deconstruct what has been done to date, is not particularly useful for helping us decide how to proceed... except that it helps us to change in some other direction.

The way forward looks very unclear to me. Given equal parts of satisfactory knowledge of pain science across a groups of PTs, the difference between a pseudoscientific clinical encounter and a science based clinical encounter could be as subtle as a missed opportunity to demonstrate empathy towards the patient, or an unchecked moment of paternalism by the therapist.

It suggests that if there is a chasm between the interactors and operators, truly bridging it requires much more than knowing lots about pain science. I'd much rather the next generation of PTs utilize a variety of neurocentric approaches (with various tools, devices that appeal to specific populations) in an interactive fashion, than a generation of PTs who carry out the most risk averse methods (DNM, SC) in a bastardized operator fashion.

[Keith]

i agree keith. I have suggested this before, in the throws of one of those long ect/meso threads and it wasn't so popular... i guess it wont be popular now either... but I think that for all the hard work done to produce science based methods for treating pain, the science that we at ss hold up most dearly appears to boil down to;

• provide non threatening sensory/discrim input
• provide novel sensory/discrim input
• don't provide a noceboic treatment narrative/context

Those are some pretty vague parameters for a science based approach to manual therapy. It leaves scope for lots of variation in method(s) that are essentially equally "scientifically defensible". In other words, i dont see that i'm practicing anymore defensibly when I utilize a gentle skin stretch technique, than when I apply a heavy, perpendicular force into some body part or when i apply some sort of traction load to some other body part.

I would respectfully add one item to your list (although it's antonym, if there were one, would itself be a nocebo) -

• offer a deep model

The problem with a deep model at this time is that the science is so shallow. The black box of how neurologic processing works is so expansive, almost anything can (with only a little effort required) get thrown in.

I have worked quite hard over the last few years to "get it", and I understand a lot more than I did, but the cognitive dissonance is more challenging now than it was when I first introduced myself here. I hoped that I could continue to learn and learn, but eventually we (collectively, as info seeking therapists) bump into the same issues over and over again - modest effect sizes (at best) when we compare interventions. Meanwhile I continue to opine online about how each individual is a complex unique organism with varying motivational/affective 'components' to their self-matrix, yet we continue to look (ironically) to RCTs for what should guide our practice. Sure, some look promising, but after we mash them up in some systematic reviews we are basically informed that if we follow the bulleted items above (and master interpersonal skills and equipoise), we are going to maximize our outcomes.

Anyone can learn this shit in a weekend course - and they should. [If you are lurking, get a ticket to San Diego and learn all the foundational elements you need to know about therapy and the management of pain in 3 days - then find a plausible system that includes pre- and post- test to implement]. The fact that we sit at our computers every day and talk about this is beginning to amaze me. Not 'everything' works, but many things do. We can debate whose history fuels whose reasoning process, but the fact of the matter is that we all throw shit into a black box, providing a variety of sensory/discriminitive input and watching/feeling with curiosity to see what will come out. Nothing more. If we don't derail the patient with nocebo and empower them along the way, we have done our job.

The only thing that we have left to hang our hats on is locus of control. Which intervention arms the patients with the greatest control? Which context places the most ability within the patient? Hands off is likely best in this regard...BUT...there is a tremendous opportunity to change (for a brief time) the patient's experience if we place our hands on them and use the tools (HPSG) that evolution has given us to help the patient move a little farther a little more comfortably. So we weigh the importance of one versus the other.

We have come so far, and advanced greatly beyond the alternative or complimentary-types (e.g. MFR), but they are riding our coat-tails to a neuro-explanation...and the science has not yet taught us enough yet to keep our coat-tails from getting caught in the all of the dust and dirt kicked up behind us.

Respectfully,
Keith

[Keith]

The posting above reflects why some of my more recent postings on my own blog have focused on how I interact with my patients. I seems that as we move toward EBP and reimbursement squeezes us from all directions, continuing education is being forced to provide the student/enrolled with an efficient list of what to do, but there are few classes (DNM and SC as notable exceptions) that inform therapists HOW to be with their patients. Such approaches are decidedly more humanistic and empathetic in their approach.

I think my next project (this spring/summer) is to create a repository for stories/yarns to be submitted by patients and therapists alike to try to slowly redirect the conversation from "what was done" to "how care was provided."

My hope is that stories of interaction, shared among different disciplines, may remind a few folks out there that the best way to "help people" is to remember that they are people.

Respectfully,
Keith

[PatrickL]

keith, i ve been thinking about adding a tab on the frontpage of my website for storage of metaphors/stories for understanding/deconstructing and then reconstructing commonly held view about common diagnoses. perhaps our projects will overlap and we can share content?

Interesting you mention coat tails... i was just listening to a famous (in australia) song by You Am I called Berlin Chair. https://www.youtube.com/watch?v=KQOKF-sST8k

If half of what I'm saying, of what I'm saying is true
Will you rub my head, make it all shiny and new?
And you drag my coat tails, drag my coat tails down
and I'll be the only cold assed king around.
If you wait I'll give all my aches to you.
Take the chance, to ignore what you're going through?
My cold hand is there for you to take
(If you leave, can I fall down)
I'm your Berlin Chair, won't you lean on me 'til I break.

I'll ignore each golden, dragging kiss you can give.
On the blankest face that you ever had to forgive.
If you see my fallings, see my failings through.
I'm the re-run that you'll always force yourself to sit through.

If you wait I'll give all my aches to you.
Take the chance, to ignore what you're going through?
My cold hand is there for you to take
(If you leave, can I fall down)
I'm your Berlin Chair, won't you lean on me 'til I break.

Well you're too late. You're too late.
You're too late.

[PatrickL]

The problem with a deep model at this time is that the science is so shallow. The black box of how neurologic processing works is so expansive, almost anything can (with only a little effort required) get thrown in.

i agree. to me this points to the extent to which the deep model is just a guess... i still dont think Ive seen anyway clearly articulate what the deep model is that is espoused by SS mods/members. Is there a consensus view? Can it be stated plainly?

There is something about the distinction between a model and a "deep" model that gets my BS detector humming. The purported "depth" seems to say to me "i dont have evidence for this model, but I'm pretty sure its right... and even if its not, i gotta hang my hat somewhere"

[PatrickL]

I just found this in the notes on my iPad from July 2012. I can't remember if I wrote it or copied it from somewhere.

A deep model of understanding
Mine is science based, in that it is born from solid reasoning, established biological/physical laws, and experimental evidence
Pain is an output of brain
Nociception and tissue damage are not irrelevant, but neither are sufficient (i.e there is no pain unless brain says so) or necessary for a pain experience.
When the primary complaint is pain, the treatment of pain should be primary
Reductions in pain result from decreased threat to the nervous system.
Decreases in threat result from cognitive/evaluative/motivational/affective/exteroceptive/interoceptive inputs that are novel and non threatening
These inputs can be provided by a PT, and have little to with specific skill aspect of "manips, mobs, releases, massage etc" and more to do with the unique manner in which the client and therapist interact.
The therapist who can 'tap in' to a wide range of clients will likely be a more effective PT
This has more to do with reading people, interacting, reacting, providing a context than any specific skill set


A deep model guides you, gives you something to cling to while navigating the uncertainty of conflicting evidence or theories. It directs your assessment of plausibility

Perhaps it's more accurate to describe the deep model as a set of guiding principles?