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  • #76
    Matt, just to make sure I’m following your point, your definition of physical rehab = exercise prescription only? Also when you say placebo are you talking strictly in the context of 1.passive inputting (pt is resting) and 2. accelerating pain resolution? Are you completely against the idea of offering the pt some form of temporary relief (non invasive) while telling the patient that it is only temporary ? I personally tend to tell patients everything is most likely temporary when it comes to pain relief, even benefits of therex. However, when that happens (relief), I think it is reasonable for the patient to argue or feel strongly that the PT helped towards pain resolution, even just a little bit. btw this happened to me as well when a friend was helping me with something minor. I think it's normal. What if let's say we know for sure that an established intervention did not help at all towards accelerating pain resolution but the patient finds some value in it, even if it's just psychological benefit and experience/care/support. In you opinion, is it unethical to continue delivering it for a few sessions? This is an interesting topic and I'm not saying that you are right or wrong, I'm just trying to understand your thought process and how you practice brother.
    -Evan. The postings on this site are my own and do not represent the views or policies of my employer or APTA.
    The reason why an intellectual community is necessary is that it offers the only hope of grasping the whole. -Robert Maynard Hutchins.

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    • #77
      Originally posted by PatrickL View Post
      Inevitably, that approach, in my opinion, leads to therapeutic nihilism, where our job as PTs is to not treat patients at all.
      fair point Patrick, we could construct an argument that for many conditions exercise prescription for speedy recovery is just placebo and perhaps unethical to see the patient after the eval. Personally, I'm ok with telling a patient we are waiting for the pain to go away and in the meantime let me show you some really cool exercises. This is better for your health than resting all day.
      -Evan. The postings on this site are my own and do not represent the views or policies of my employer or APTA.
      The reason why an intellectual community is necessary is that it offers the only hope of grasping the whole. -Robert Maynard Hutchins.

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      • #78
        I think the practice variation is fine as long as the patient is informed of the science behind the intervention (placebo, modulation, stars aligning [jk], etc.).

        I find for my own personal bias, demonstrating that they are in fact strong (through various movements or exercises), the part is okay and they can continue to progress themselves in a graded manner helps with the acceptance of the situation. Some are better at accepting than others and you will never be 100%.
        Nicholas Marki, P.T.

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        • #79
          Evan,
          I had a feeling you'd be commenting

          My view of physical rehabilitation: movement and/or physical activity. Exercise prescription may be a part. For me it is admittedly the largest part. I view exercise prescription as a more structured, intentional use of physical activity to improve upon fitness factors such as strength, endurance, or functional deficit

          Regarding placebo:
          The use of passive modalities such as ice, heat, ultrasound, diathermy, TDN, skin scraping, rubbing body part etc with the suggestion of providing greater benefit than time or sham is what I speak of. It's why, when asked by patients, I suggest they use what they like at home and figure out if they think it benefits them. Their call, nothing is better than the next.

          I agree a patient may feel the therapist was the reason for improvements if pain resolution occurs (my bias/opinion says PT's with egos promote this for business sake and self fulfilling reasons) That said, I hear people say their chiropractor helped after their car accident; 3 visits per week for 6 months...

          Am I against providing a short term reduction in pain? Not at all.

          Do I think it is unethical to provide an intervention a patient desires? No. Do I do it? No. (remember it wasn't my quote ) That's a funny topic: just a few years ago I recall the EBP people being totally against providing interventions based on patient expectation or preference. Those same people have done a 180 to "leverage placebo" and expectation to maximize outcomes...
          I may not be as smart as most people, but I'm sure as hell not as dumb....
          "The views expressed here are my own and do not reflect the views of my employer."

          Comment


          • #80
            Originally posted by mrupe82 View Post
            just a few years ago I recall the EBP people being totally against providing interventions based on patient expectation or preference. Those same people have done a 180 to "leverage placebo" and expectation to maximize outcomes...
            It's a fascinating turn really. I know when I took the manipalooza in 2010 there was NO mention of non specific effects. However I have read several things from that crew since that tend to suggest they embrace placebo.

            In actuality, the direction our profession (Physical Therapy) should be heading is this way:

            1) Recognize that by and large any manual handing that isn't painful and tends to feel "good" is likely a step in the right direction

            2) Recognize that some things we do to patients are by their very nature noceboic and thus undercuts any short term placeboic effect we may wish to have gleaned (I would suggest the more invasive ones have a tendency to be the ones with the most profound placebo short term...while at the same time carry the most likely to be noceboic in the long term by there very nature). Thus....a bad idea.

            3) Recognizing that essentially we spend our day balancing placebo and nocebo (I just don't believe anymore that much of what we do has any true specific effect on tissues...mesoderm anyway)....we should be identifying what placebo tool gets the most juice for the squeeze....without eliciting the evil twin (nocebo). I just don't believe you can jab a needle into someone and have them walk away understanding that no...nope...they do not have "trigger points"...it was all an elaborate placebo.

            I honestly believe that any attempt to deceive in order to glean the wonderous placebo effect is a bad idea in the long term. And by being vague with what exactly you are doing....you are being deceptive.

            Like I've said...man oh man I'd love to be in the examination room with any of those EIM guys while the jam a needle into someone to see how they explain things. I'm pretty sure it isn't like this:

            "Okay Mr. Jones, I am going to insert this needle into you and I honestly have no idea what tissue I am aiming for or what it actually does. In fact...no one actually does in the greater research community but some people seem to feel better after it so I think I might go ahead and give it a shot on you. Oh...and by the way, there are documented cases of injury with this technique but we believe those to be quite rare...although the data on that is sparse. Can I go ahead?"

            There are two quotes that applies to this placebo/nocebo balance:

            Oh what a tangled web we weave when first we practice to deceive
            and:

            It's hard to get someone to understand something when their salary depends upon the not understanding it
            So long as we have clinicians who fully understand the significant role of non specific effects yet find ways to maximize the effect in less than honest ways....they serve to undermine every other honest clinician.

            I like the way you explain ultrasound for example Mathew...but so long as there is some clown down the street willing to give a more glorious explanation...and maximize the placebo effect...you end up being the chump.

            This house of cards our profession is building (fighting for manipulation table scraps, glorifying TDN etc etc)....will not end well.

            It's quite shameful actually.
            Last edited by proud; 12-05-2015, 08:30 PM.

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            • #81
              proud,

              Perhaps "jam" isn't the right word. "Insert" would probably a more judicious choice, though "jam" might be as accurate. At the courses on dry needling I just don't think the word "jam" is ever used.

              Yea, "insert" is much, much better.

              Otherwise, a great post.
              Barrett L. Dorko

              Comment


              • #82
                from here

                An overlooked factor when using TNE:

                "Requirement 2: Only patients dissatisfied with their current perceptions about pain are prone to reconceptualization of pain 16-18

                This implies that therapist should question the patient’s pain perceptions thoroughly prior to commencing pain neuroscience education. Even though their pain perceptions lack medical and scientific validity, patients are often satisfied with them. In such cases, it is necessary to question whether the patient can think of other reasons / underlying mechanisms for their pain rather than lecturing about pain mechanisms. It makes no sense to impose concepts and certain behaviours if the patients does not comply with them or believe in it. As long as the theories remains counterintuitive for the patient it will not be retained and integrated with attitudes and beliefs2. This form of “deep learning” is only possible when the learner is motivated 19.

                Therefore, before initiating pain neuroscience education, the therapist should lead the patient towards a situation where the patient doubts his or her current pain perceptions. This fits in the model of “stages of change” 20 in which the therapist should try to transfer the patient from the precontemplation stage (not ready) to the contemplation and even the preparation stage.

                A patient in the precontemplation stage is not open-minded to new theories and a therapist is unlikely to be able to convince such patients to reconceptualise their pain. This may even have adverse effects. It is primordial to let the patient reflect on his own perceptions, in order to create doubts about these."
                I may not be as smart as most people, but I'm sure as hell not as dumb....
                "The views expressed here are my own and do not reflect the views of my employer."

                Comment


                • #83
                  I find it to be a matter of negotiation and debate even with patients who have a scientific background. I then have to prove to them in situ that perceived pain can be modulated, if it doesn't happen within two or three sessions I lose them, no one wants to throw good money after bad.
                  Jo Bowyer
                  Chartered Physiotherapist Registered Osteopath.
                  "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi

                  Comment


                  • #84
                    Hi Matt,
                    My view of physical rehabilitation: movement and/or physical activity. Exercise prescription may be a part. For me it is admittedly the largest part. I view exercise prescription as a more structured, intentional use of physical activity to improve upon fitness factors such as strength, endurance, or functional deficit
                    To my understanding that’s what most if not all PTs do for the most part as well. Chiropractors and massage therapists do more manual rx overall than anything else. That is the general expectation of the public as well.

                    The use of passive modalities such as ice, heat, ultrasound, diathermy, TDN, skin scraping, rubbing body part etc with the suggestion of providing greater benefit than time or sham is what I speak of.
                    But temporary relief from nagging pain =/ just placebo (We also have to define placebo effect now, we can't know how much of descending modulation is from just expectation and how much is other contextual factors and MT parameters). It does happen predictably for many people during MT.Some people value temp relief A LOT and some are willing to spend a lot of money for it. If the provider is comfortable providing a little bit of that I don't see a big problem. If the provider is not comfortable doing that I totally understand. I try to explain that it tends to create dependency and it can get expensive. But we are all consenting adults and we are free to make choices.
                    It's why, when asked by patients, I suggest they use what they like at home and figure out if they think it benefits them. Their call, nothing is better than the next.
                    I do the same but I know that it’s not exactly the same. The contextual factors are much different.
                    -Evan. The postings on this site are my own and do not represent the views or policies of my employer or APTA.
                    The reason why an intellectual community is necessary is that it offers the only hope of grasping the whole. -Robert Maynard Hutchins.

                    Comment


                    • #85
                      Originally posted by Evanthis Raftopoulos View Post
                      Hi Matt,
                      To my understanding that’s what most if not all PTs do for the most part as well.
                      I wish I could agree. I've had 5 students over the last 2-3 years. 0% have been satisfied with their exercise coursework. The physical therapy curriculum for exercise is sad (that's me being kind). I'd take the knowledge of a bachelor's degree in exercise science from an NSCA focused program before any PT schooling. I see many experienced clinicians getting further and further away from physical rehabilitation. The public I see reports having "physical therapy" many times. They typically speak of wands and buzzy machines.

                      If more physical therapists asked "what is it you have difficulty doing?" they'd be more inclined to focus on returning the individual back to the task.
                      Last edited by Johnny_Nada; 14-05-2015, 04:25 AM.
                      I may not be as smart as most people, but I'm sure as hell not as dumb....
                      "The views expressed here are my own and do not reflect the views of my employer."

                      Comment


                      • #86
                        Our therapeutic exercise for orthopedic conditions was lacking. Most of it was education of various techniques and minimal was actual graded loading/exercise. I remember a lot of transverse abdominal stuff. I got more education of graded loading working through injuries with athletic trainers and my own gym trials and tribulations.
                        Nicholas Marki, P.T.

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                        • #87
                          I recently listened and read some blurps about fear and return to sport after ACL injury. As someone that fractured their tibia with an ORIF in a skiing accident I could be called fear avoidant. I have not returned to skiing and have no future plans to. Am I fear avoidant or do I understand the act of skiing provides zero survival purpose and only exposes me to harm?

                          Is an athlete wrong for being fear avoidant if it does not provide a means to survival.

                          I say not at all...
                          I may not be as smart as most people, but I'm sure as hell not as dumb....
                          "The views expressed here are my own and do not reflect the views of my employer."

                          Comment


                          • #88
                            Originally posted by mrupe82 View Post
                            I wish I could agree. I've had 5 students over the last 2-3 years. 0% have been satisfied with their exercise coursework.
                            In my opinion exercise prescription knowledge (and confidence in delivering this info) is mostly based on expertise but not from official certs/schooling. I’m still learning a lot. What students learn is rehab and exercise principles and some post op protocols. This is good enough to get people started. It's not necessarily the students/PT's fault if the patient is not responding to specific exercises/parameters. Nevertheless, the student that has good background knowledge/experience in exercise/athletics is ahead of the game.
                            -Evan. The postings on this site are my own and do not represent the views or policies of my employer or APTA.
                            The reason why an intellectual community is necessary is that it offers the only hope of grasping the whole. -Robert Maynard Hutchins.

                            Comment


                            • #89
                              I think the difference between manual therapy from a massage therapist and a physical therapist is one will do what you ask and the other will do what they think is right.
                              I may not be as smart as most people, but I'm sure as hell not as dumb....
                              "The views expressed here are my own and do not reflect the views of my employer."

                              Comment


                              • #90
                                5 years of observation as a physical therapist. Many may disagree…

                                -Evidence based practice was and is still the buzzword. If 'evidence based' is placed in front of something, you can make money selling (tricking people) it.

                                -the term 'clinical reasoning' means justifying what you do with your own bias and beliefs.

                                -Manipulation was and still is a buzzword.

                                -Physical therapists still try to fix and alter body parts. Multifidus, TVA, hip abductors, ultrasound imaging, deep neck flexors, VMO, lower traps, rhomboids, middle trap to name a few...

                                -Physical therapist still rub people thinking they are doing something to alter tissues

                                -Physical therapists were and still like naming/diagnosing stuff

                                -Critical thinking is still scary and avoided

                                -This profession will continue finding tissues to push, prod, blame, stick, rub and nocebo-ize.

                                -People still have pain...real pain...and it's not getting better…but hey we're safer and cheaper...

                                -Outcomes are a buzzword (cover-up). Patient satisfaction is what owner's really want. Outcomes aren't paying the bills, people walking in the door are.
                                I may not be as smart as most people, but I'm sure as hell not as dumb....
                                "The views expressed here are my own and do not reflect the views of my employer."

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