Pot-Pourri

[Johnny_Nada]

Bias disclaimer:
As a physical therapist I suggest exercise to everyone I see; with or without pain.

For many the primary complaint is pain and those in the rehab profession want to 'treat' pain. Unfortunately, we have to accept this pain may not subside and might persist.

In either case, exercise is very important. A nice article by anoop. I always like his reviews.

http://www.exercisebiology.com/index..._older_adults/

[Johnny_Nada]

To go with anoop's write up…

http://www.thennt.com/nnt/strength-a...elderly-falls/

[Diane]

".. people reporting greater pain-related interference were less likely to be employed" ~ Bronnie Thompson. Her blogpost, WHEN MEDICATION SIDE EFFECTS GET IN THE WAY OF LIVING LIFE.

[John W]

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

I've got to address this because this argument has exasperated me on more than a few occasions, and it's made frequently by people for whom I have great respect. First of all, let me unequivocally state:
The fact that treatment from a physical therapist is safer and less expensive than many other options is unassailable. The data on this is overwhelmingly in favor of treatment by a PT for everything from "meniscal tears" in knees to chronic low back pain.

Ok, so I'm acknowledging that those who make this argument are correct that it is not technically a tu quoque. However, if we want to assign an accurate logical fallacy to this argument, then I think it would be "hasty generalization" or simply a generalization error. Just because PT is safer and cheaper on an individual case basis doesn't mean that it is safer and cheaper for a patient to be seen by PTs in general within the health care system writ large. That's not to say that there may be certain exceptions to the general rule, particularly in certain settings-such as the military- where incentives are not so skewed, where treatment from a PT is indeed, on balance, safer and cheaper than biomedical approaches to common MSK problems.

There are a series of inter-related facts which support an argument that treatment by a PT, in general, is worsening the problem of chronic pain not helping to ameliorate it. For instance, there is evidence in the scientific literature (Reme et al, 2009) that treatment from a PT increases indirect costs associated with a LBP episode due to increased sick leave utilization. Given the way we suspect most PTs interact with LBP patients, the tendency to medicalize the condition and increase health care utilization, while also providing inaccurate explanatory models that tend to maintain a fear avoidance state and promote catastrophizing, is a valid premise. The study by Fritz et al (2007) showing the extremely low rates of adherence to "active care" guidelines for patients with LBP (~40%) supports the contention that the majority of PTs are providing more passive care and probably utilizing inaccurate explanations based on a narrow and incomplete biomedical/biomechanical model, i.e. they are "JointHeads, DiskHeads, FasciaHeads and/or MuscleHeads". Finally, a large scale analysis of outcomes data by George et al found a correlation between depressive symptoms and poor outcomes for patients seeking treatment from a PT for an MSK-related pain problem. Looking deeper into the data, one sees that the outcomes for the average patient receiving care from a PT were marginal, at best, with the level of pain and disability upon discharge remaining rather high, particularly for patients with depressive symptoms. Since depression has been highly correlated with anxiety and chronicity of MSK-related pain, it follows that treatment from a PT is often associated with little improvement in anxiety, and therefore may in fact contribute to chronicity.

The totality of the evidence, then, in my view, suggests that treatment from a PT, in general, is part of a cyclical problem in modern health care systems where perverse incentives perpetuate a tendency to medicalize, over-treat, and indeed mis-treat patients with benign MSK-related problems.

I'm eagerly awaiting an argument that proves me wrong.

[Diane]

John, I think you really nailed it.
The more we try to impersonate doctors (by being too biomedical/over-utilization-prone), the less effective we are.
The more we move to biopsychosocial ways of dealing with pain problems, lighten up our physical treatment, and encourage movement, the more effective we are.
Exercise is the magic pill for not just pain but almost EVERYthing, and we are the dose experts on that.

[John W]

Thanks, Diane. I left out one of the big "dots" that I've often referenced in the past, which helps to complete this picture of medicalization that PTs, in large and significant measure, contribute to. The MINT trial clearly showed the relationship between a poor expectation of outcome after a whiplash injury and delayed recovery. To the extent that PTs promote passive care and inaccurate explanations for pain, they contribute to low expectations of recovery from common injuries. This behooves PTs from a purely business standpoint, but the overall impact could very well be the general worsening of chronic MSK-related pain. The data don't lie.

Again, the overall picture is one of PT contributing to the problem of persistent pain, not ameliorating it. Indeed, our frequent and sustained contact with patients suggests that our role is highly impactful, and the outcomes data suggest that we very well may be making the most vulnerable- and expensive- patients worse.

[Chunk]

The totality of the evidence, then, in my view, suggests that treatment from a PT, in general, is part of a cyclical problem in modern health care systems where perverse incentives perpetuate a tendency to medicalize, over-treat, and indeed mis-treat patients with benign MSK-related problems.

I'm eagerly awaiting an argument that proves me wrong.

I couldn't agree more

[Mikal Solstad]

Might one argue that, from a socio-economical view, if our interventions lead to the patient thinking "what the hell, there is nothing wrong with me, I don't need therapy, this shit I can clearly do on my own", this is the absolute best result we could have hoped for?

[Jo Bowyer]

Might one argue that, from a socio-economical view, if our interventions lead to the patient thinking "what the hell, there is nothing wrong with me, I don't need therapy, this shit I can clearly do on my own", this is the absolute best result we could have hoped for?

It does lead to new referrals, self payers don't like to think that they are being ripped off. Unfortunately there are plenty out there peddling the message that every niggle needs investigation by a body mechanic.

[John W]

Might one argue that, from a socio-economical view, if our interventions lead to the patient thinking "what the hell, there is nothing wrong with me, I don't need therapy, this shit I can clearly do on my own", this is the absolute best result we could have hoped for?

Mikal, I think there will always be a place for sensible social grooming among humans, and also a need for physical rehabilitation based on scientific principles.

What we're doing now is neither sensible nor scientific.

[Josh]

What shall we do with the most vulnerable of patients at high risk for developing chronic disabling msk conditions? I'm not asking to be a smart a$$. But if we see these high risk pts and tell them the "truth" and send them on their way. They will seek out more scam because they offer hope as they peddle their bs.

[John W]

Josh,
I don't mean to sound curt in my answer, but we treat them.

Is there not a unique body of knowledge that we possess to effectively, conservatively and invaluably provide to patients with persistent pain?

This is the whole reason that SomaSimple exists.

[Barrett Dorko]

John says:

This is the whole reason that SomaSimple exists.

It seems so to me as well.

[proud]

It is my estimation that so long as the almighty $$$$$$$$$$$$$$$$$$ gets in the way of professional integrity....patients are screwed.

I follow a few blogs and even attended a huge multiple day "mosh pit" of supposed leading experts in the field.

Frankly....I was struck by how well laid out the course was (just the most organized and professional appearing course I have ever attended)...yet...completely devoid of critical thinking.

I was shocked and disappointed by this.

But certainly not surprised. Cash is king and none of this will change until the day the chickens come home to roost. Economics 101 will tell you this day is not too far off.

No worries though...those who cashed the cheques will be perfectly fine...

If you are a younger Physiotherapist (say under 45)....you should be alarmed by this.

[John W]

proud,
I might put it at under 40, but then again, I'm an eternal optimist. :angel: