Pot-Pourri

[proud]

I'm not willing to simply capitulate to that societal bias without making my case. Sure would be helpful, though, if my PT colleagues didn't sabotage my efforts by filling patients' heads full of nonsensical crap about why they hurt.

But at least I think anyway...the EIM crew justify dry needling and manipulative procedures by suggesting that they then explain pain in a manner consistent with the science.

So to them...they would argue that what you stated does not apply to them.

And I'll own my thoughts on this....I think they are wrong and actually undermining what science is informing us by embracing placebo they way they seem to want to.

[John W]

So to them...they would argue that what you stated does not apply to them.

No argument from me on that point, proud. Given the amount of programming devoted to pain neuroscience at the big professional conferences these days and the prominent role that many of the residency faculty play at the conferences, they have to at least be conversant in the relevant literature. Unfortunately, like you, I think they make the science conform to what they're selling. It's not that hard to do because there are still quite a few gaps in our understanding. My personal choice is to err on the side of being less coercive/invasive and more conservative in the way I treat my patients.

I'm a member of a very small minority.

[Barrett Dorko]

John,

I would say that it's a shrinking minority. We aren't the salesmen or marketers some are.

[Johnny_Nada]

I respect Bronnie for her courage and willingness to talk about the idea that pain may not settle.

I have yet to hear ANYONE say this on a stage, at a CEU course or under any situation where they are a paid speaker. Some (more paid speakers/presenters) even talk about their discontent with the term "pain management."

https://healthskills.wordpress.com/2...uction-divide/

If we accept pain as an multifactorial output, like love, how do we treat love? At best we can influence it, maybe manage it. In the end, the individual experiencing it has to manage, cope, deal, and live with it.

[Barrett Dorko]

Johnny,

What I've asked many people when speaking of certainty (like this) is:

Ever try to talk somebody else out of being in love?

I have the sense that many, many people being able to make money out of selling a method or idea they are never asked to defend don't because they aren't asked to.

[Josh L]

Understandable post. The following quote in the link resonated a bit.

"Is it about our feelings of powerlessness?"

I typically struggle to have these discussions with those with distal symptoms (i.e peripheral neuropathic involvement).

Many times from my experience, symptom modification techniques only provide short term relief. I try to have discussions to set expectations for prolonged recovery. Most instances, patient's continue to experience some symptoms at discharge. Despite education regarding recovery, limitations of surgery, and the wonderful healing power of time for some, patients are still looking for more.

On top of that, PCP's/surgeons consistently make patients' aware of various options such as surgery, injections, and various meds for this patient population.

Thus, I find it hard to have discussions of coping, management, and acceptance despite limited efficacy of several prescribed interventions for this patient population.

Pain management and coping discussions are likely not going as successful as they should to reduce unnecessary healthcare spending in today's current medical system.

But it is likely what most need.

Tricky discussions to have with some as a young clinician.

[Johnny_Nada]

To me, this should garner a lot of attention and discussion...

http://www.apta.org/PTinMotion/2017/5/EthicsinPractice/

Why are we only talking about "energy therapy?"

[John W]

Why are we only talking about "energy therapy?"

Because it's an extreme example of indefensible care that the vast majority of PTs can agree is blatantly unethical.

I can just hear the needlers: "Look over there at that crazy PT waving her hands over the patient and charging 'manual therapy' for it. She's only got one- two at the most- legs of the EBP stool accounted for. What a joke."

Incidentally, last year this course was approved by the Louisiana State Board of PT, but I complained to the Board and now it's no longer listed as an approved course.

I asked the Director, How can you approve a course that explicitly refers to treating "energy meridians" while at the same time allowing PTs to dry needle because it "does not rely upon the meridians utilized in acupuncture and other Eastern practices"? This was the response: "The use of meridians in treatment of physical impairments has been well-documented in both eastern and western medicine." So, you see, as long as even the most ridiculous idea is "documented" somewhere- preferably in something that calls itself a "journal"- then it's immediately considered legitimate and "evidence-based."

I appreciate Dr. Kirsch bringing this up, but she's just giving the CAM peddlers cover.

[Ken Jakalski]

I recently heard someone use the metaphor for little kids and pain. When they haven't slept, are hungry, stressed out, etc and bump their nose, they cry like crazy. When they are happy, with friends, in a playful environment and bump their nose, its no problem. When mom and dad react in a scared way, they too react in a scared fashion (crying).

This reminds me of Barrett's repeated point about context. Exited football players will bang their helmets, slap each other on the back, etc. yet under different circumstances these same kinds of behaviors would be painful.

[Johnny_Nada]

I've listened to and read countless podcasts and articles of so-called "experts" talking about injury prevention in youth. I've seen countless kids and parents in the clinic with "injuries" sustained while participating in athletics. So here are some random thoughts. I've discussed these before but here goes one more time.

Random thought #1
Injury prevention tactic:
DO NOT PARTICIPATE IN COMPETITIVE SPORTS.
If you compete for long enough and at a high enough level, you will get hurt. You will have pain. You may require surgery. It may be life changing and altering with long term consequences. Of course injuries may occur while playing on a playground, riding a bike or jumping on a trampoline. Of course the incidence of multiple concussions, ACL tears, shoulders injuries etc just don't seem to occur to kids NOT playing competitive sports. Admittedly, I'd have to look at the evidence. (like I said these are random thoughts without citations).

Random thought #2
If you do not choose #1, then my opinion is we should change our culture from one of

"I don't want my kid lifting weights until he/she is done growing"

to

"I don't want my kid playing competitive sport until he/she is done growing. I want my kid to develop their strength and conditioning, while remaining a kid. After this base period, then I want my kid to participate in sport when their body has a sufficient level of strength developed to tolerate the enormous loads/stresses sport applies. Then I want a coach that cares more about fostering my kid to their potential long after they leave said coaches' team."

[Barrett Dorko]

I wouldn't argue with any of this Johnny. We're going the other way though.

The rejection inherent to other things (like, for instance, theater, marching band and any creative activity) may be just as bad as injury though.

Good thing that some understand life and suffering are pretty much concurrent.

[FrustratedNewGrad]

I've listened to and read countless podcasts and articles of so-called "experts" talking about injury prevention in youth. I've seen countless kids and parents in the clinic with "injuries" sustained while participating in athletics. So here are some random thoughts. I've discussed these before but here goes one more time.

Random thought #1
Injury prevention tactic:
DO NOT PARTICIPATE IN COMPETITIVE SPORTS.
If you compete for long enough and at a high enough level, you will get hurt. You will have pain. You may require surgery. It may be life changing and altering with long term consequences. Of course injuries may occur while playing on a playground, riding a bike or jumping on a trampoline. Of course the incidence of multiple concussions, ACL tears, shoulders injuries etc just don't seem to occur to kids NOT playing competitive sports. Admittedly, I'd have to look at the evidence. (like I said these are random thoughts without citations).

Random thought #2
If you do not choose #1, then my opinion is we should change our culture from one of

"I don't want my kid lifting weights until he/she is done growing"

to

"I don't want my kid playing competitive sport until he/she is done growing. I want my kid to develop their strength and conditioning, while remaining a kid. After this base period, then I want my kid to participate in sport when their body has a sufficient level of strength developed to tolerate the enormous loads/stresses sport applies. Then I want a coach that cares more about fostering my kid to their potential long after they leave said coaches' team."

While I know the FMS has been found to be pretty useless in predicting injuries, don't you think that certain motor patterns could contribute to increased stress on certain structures leading to injury in athletes? Do you believe there a therapeutic value in changing these motor patterns? While the literature certainly says strength and chronic loading is protective against injury, there isn't much on quality of movement.

I watch my colleagues work on "motor control" daily with athletes and I can't help to think most of it is useless, but not all of it.

A colleague did a presentation of the SFMA and while some of it sounds logical, the whole basis behind it is the certain motor dysfunctions indirectly lead to stress of certain structures and pain. Research is scarce on the subject.

[Josh]

Do you believe you can change motor patters in 60 min a week?
Do you believe changing how a person lunges in your office will change how they catchall a football on the sideline, land after a layup, make a catch in Centerfield?
What part of the FMS translates to a pitcher opening their lower body up too soon with too great of an elbow flexion angle at release?
How long do you need to train a new pattern to ensure those new tissues being loaded, have been loaded enough to handle the demands of a game, season, etc.

I think most of the science supports training a specific skill if you want to improve a certain skill, but I'm not an expert here.

[Johnny_Nada]

While I know the FMS has been found to be pretty useless in predicting injuries, don't you think that certain motor patterns could contribute to increased stress on certain structures leading to injury in athletes? Do you believe there a therapeutic value in changing these motor patterns? While the literature certainly says strength and chronic loading is protective against injury, there isn't much on quality of movement.

I believe there is merit to coaching a skill that improves performance of a skill (swim stroke, golf swing, shooting a basketball, performing a snatch etc). Do certain movements load structures more or less? Sure. There are plenty of biomechanicals studies for that. Does changing a movement reduce symptoms. Sure, but does it change the load so much to make a difference or actually change how someone moves in the long term? Maybe?

I think too many forget our impressive ability to adapt to loads and stresses encountered in our lives.

And for heaven's sake, can someone, please oh please define "quality of movement?" As "movement specialists" I'd like to think the physical therapy profession could define this.

[FrustratedNewGrad]

Do you believe you can change motor patters in 60 min a week?
Do you believe changing how a person lunges in your office will change how they catchall a football on the sideline, land after a layup, make a catch in Centerfield?
What part of the FMS translates to a pitcher opening their lower body up too soon with too great of an elbow flexion angle at release?
How long do you need to train a new pattern to ensure those new tissues being loaded, have been loaded enough to handle the demands of a game, season, etc.

I think most of the science supports training a specific skill if you want to improve a certain skill, but I'm not an expert here.

60 minutes a week? Probably not but that's why we give our patients a home exercise program. If I'm not mistaken, we're not really changing a motor pattern but introducing a new one and with continuous reinforcement it becomes the dominant motor pattern. The old one is still there but is used less and less as the new one taught becomes the go to pattern for the patient. Will the patient revert back to the old pattern? Maybe, but I don't think teaching them a new pattern is useless.

Can we change the way someone lands after a layup? Going back to motor learning I would say that is why we introduce random practice vs. blocked practice. Sure then can land without dynamic valgus in the clinic when you cue them to. Can they do it when not cued in the middle of a game? I think we can design programs that incorporate random practice. No?

Runners can change their running form. The most common is to change their cadence. Many studies show for those with PFPS, it can reduce pain. Yes structures adapt but what about changing motor patterns to reduce load or redirecting that load on structures that are inherently more load resistant?