Pot-Pourri

[Johnny_Nada]

http://www.bodyinmind.org/wp-content...d-the-bush.pdf

[Johnny_Nada]

I routinely use the ankle sprain metaphor to understand acute on-set pain after trauma (injury or surgery). I have found a small percentage (surprisingly large actually) of people I see have never experienced an ankle sprain, let alone any other trauma induced painful occurrence.

I find this group really struggles to cope with their painful condition. They struggle with any activity creating discomfort resulting from exercise and delayed on-set muscle soreness that may result.

[nari]

I have never injured myself in the sense of degree of sprain, strain or whatever. There was a brief period while working in neurorehab where I had 5 bouts of LBP. Everything was normal within 2-3 days every time.

On the other hand, I have never played sport or done risky stuff like rock climbing; so the back lash there I guess, is my lack of exposure to significant pain levels.
Which means if a serious injury occurs I may or may not cope well with it. Oh well.

[Ryan A]

Matt,

I've heard Adriaan Louw talk about a study on kids who play football being something like 20x less likely to experience pain than those who don't. I haven't read the particular study, but that makes a lot of sense and would fit in nicely with a BPS paradigm. The experience of injuries, pain, and coping with it is, like many other things, learned.

I have a patient right now who has literally never had an injury her entire life (not counting childbirth). She sustained a nerve injury at work and has some pretty gnarly but classic neuropathic pain - combining her lack of experience and knowledge of coping with an already difficult issue is making for a bumpy ride.

[Johnny_Nada]

To the dry needling crowd:

I recognize you like performing this "technique" on people. I recognize you "believe" it is truly effective for people. I recognize you can reference countless articles and anecdotes that indirectly support these factors.

So in a nutshell it looks like this:

You like it
You believe it
You reference it

Do you recognize the outcomes do not support your likes, beliefs and references?

[Johnny_Nada]

My Placebo

It's no secret i deal with cluster headaches. I've recently started using high flow oxygen to treat and abort the headaches. I'm fortunate to say it has been effective thus far. There is evidence to support its use but I still can't get over the idea it's all a placebo effect. I can't help but think I'm inhaling 'fake' oxygen. In light of the effectiveness thus far, it's hard to believe less than 15 minutes of O2 can abolish something countless medications, personal trials and neurologist recommendations didn't, and in some cases, made worse.

[Johnny_Nada]

This is wonderful!

Its stuff like this and this that make me think everyone wants a piece of the pie.

"Hey look at all those PT's paying money for stuff! How do we get some? Hey I have an idea…"

[Keith]

This is wonderful!

Its stuff like this and this that make me think everyone wants a piece of the pie.

"Hey look at all those PT's paying money for stuff! How do we get some? Hey I have an idea…"

I purposefully tried not to draw any conclusions with my posting, Matt. All I can do is make observations and wonder with open curiosity about the circumstances/evidence that would lead a respected and knowledgeable member of our little online community to change their views on a particular subject.

Further evidence that there is no group-think here.

I love this thread, by the way.

Respectfully,
Keith

[Jo Bowyer]

[YT]rkRIbUT6u7Q[/YT]

[Keith]

I purposefully tried not to draw any conclusions with my posting, Matt. All I can do is make observations and wonder with open curiosity about the circumstances/evidence that would lead a respected and knowledgeable member of our little online community to change their views on a particular subject.

Further evidence that there is no group-think here.

https://www.youtube.com/watch?v=rkRIbUT6u7Q

To rephrase my posting from above:

I could not endorse the impugning of a respected members reputation or personal ethics without additional supporting history.

While others may disagree with an individual's change in position in regards to the evaluation of research on any given topic, I find it in poor taste to call into question their integrity on open forum just because they change their mind or hold a stance that may be in conflict with, or contrary to, your own.

Respectfully,
Keith

[Jo Bowyer]

Dry needling: a literature review with implications for clinical practice guidelines

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4117383/

[Jo Bowyer]

I could not endorse the impugning of a respected members reputation or personal ethics without additional supporting history.

I could not endorse the impugning of any individual's reputation or personal ethics without gold standard evidence, respected member or otherwise. It is no secret that I have have an aversion to marketing.

[Johnny_Nada]

Keith,

Its no secret I went through one of these programs in the past. It's no secret the head guys have MBA after their name. It's no secret the courses provided are following what PT's are willing to spend money on.

Manipulation: check
Instrumented soft tissue: check
Dry needling: check
Residency: check
Fellowship: check
DPT: check
Certifications: check

[Johnny_Nada]

"At the San Diego Summit I said I felt it was unethical to deliver a treatment you had good reason to believe was placebo only" -Jason Silvernail

I've been thinking about this a lot over the weekend….

This is why I'm not a manual therapist and it's why I don't utilize passive modalities (US, needles, etc).

As a physical therapist my primary role is physical rehabilitation.

Many use modalities and suggest they/we:
"open a window of opportunity"
"press control-alt-delete"
"embrace placebo"

I know where I stand….

[PatrickL]

Matt, it sounds more to me like you know where you don't stand. Where any of us are standing in our chosen career paths is, in my view, a lot harder to define. We all speak of a "deep model", but no one can define it- except in terms of what it isn't.

As a physical therapist my primary role is physical rehabilitation.

Couldnt it be said with just as much credence, that

As a Physiotherapist my primary role is to (therapeutically) influence my patient's physiology?

leveraging a placebo response is only unethical if the explanation is withheld from the patient.

The other day I applied ultrasound to a very angry and sensitive ankle. The patient asked what the ultrasound did. I said that it is probably best explained as an "elaborate placebo generating machine"... then spent the next few min chatting about descending modulation while i painlessly maneuvered the ultrasound around. I often talk about the placebo documentary where the lady with irritable bowel syndrome participated in a study where she knowingly took inert tablets (from a bottle marked "placebo") as treatment. her symptoms improved, and I recall her saying something about "missing the pills" once the study was finished. My ankle patient walked out of the clinic with greater ease than when she walked in. She may have left wondering if it was all placebo, or if the ultrasound did "something"... but she would be wondering the same thing whether the "treatment" was education, strength training, DNM, SC, hvla, stretching etc etc etc. I dont think there anyway to totally prevent a patient from attributing clinical outcomes to something "specific" to the treatment. In the end, they like us, have to wrestle with the uncertainty of it all. All we can do is provide them with as much info as possible so that they can make informed conclusions.

As long as a treatment is safe for the patient, and its expected/hoped for effects are explained in terms of both bottom up, top down and cyclical processing, I don't see much value in taking a hard line on the various interventions out there. Inevitably, that approach, in my opinion, leads to therapeutic nihilism, where our job as PTs is to not treat patients at all.