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  • Originally posted by Johnny_Nada View Post

    As a PT, I can do things and say they are "abnormal" to justify my "doing something" but that would make me full of shit.
    I no longer risk 'the look'. There's just too much at stake. You can easily end up with 4 unsatisfied parties - a patient and his family/employer, a referrer and a physio.

    My education nowadays amounts to a single, basic concept, aided by a simple, hand-drawn diagram which takes a maximum of 5 minutes to explain. Then I repeat that single concept several times during the hands-on part of the treatment. That's if I do education at all. There are sub-groups of patients where I don't even consider it, because of the high likelihood of failure:
    • the elderly (some get it, most don't )
    • those with poor English comprehension (especially if from 2nd/3rd world countries)
    • low intellect patients
    • emotionally suppressed patients, though there's always the potential to work it in very slowly.
    • highly logical people, since they tend to maintain a rigid mechanistic world view.




    In such cases I tell them the muscle is tight and I will fix it. You have to meet them where they are. It's no fun being so indirect, but that's the way it is. Recently I had an engineer tell me his L5 facet joint was jammed. "How do you know it's your facet joint?" I asked. His response indicated this was a very rigid belief - so much so, it left me with no choice but to "unjam his facet joint". Arguing the point with a person like this only ends up in an unsatisfactory outcome. He knew better and that's all there is to it. I had to accommodate him for the sake of a good outcome.
    Last edited by EG-Physio; 05-11-2017, 02:22 PM.

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    • EG,

      I respect where you're coming from. Its the default many take. For some of the bullets you list, I too resist any form of pain education and simply promote a "use it of lose it" "rest is rust"
      "hurt not harm" approach.

      For those coming in with no physical limitations, impairments or "dysfunctions" (stupid word) looking for a menu to order from, its not one I take. I'm not a licensed healthcare professional to satisfy people or make them happy. If that was the case I'd have been a barber or hairdresser. I feel its my job to address inappropriate expectations in these situations.

      https://noijam.com/2017/07/06/callin...all-the-shits/

      I know there are many talking of "meeting the patient." I understand where they are coming from. I've "met" many before with the passive hands on approach. Having it backfire in epic fashion multiple times, I'm less likely to spend multiple scheduled appointments for someone I'm not benefitting.
      "The views expressed here are my own and do not reflect the views of my employer."

      Comment


      • Originally posted by Johnny_Nada View Post
        EG,
        ....the passive hands on approach. Having it backfire in epic fashion multiple times, I'm less likely to spend multiple scheduled appointments for someone I'm not benefitting.
        Yes, the never-ending passive joint mobilization treadmill is a horrible bore, and a complete waste of time and resources.

        This is how I see it:

        -- If the patient is afraid of movement and think their back is crumbling, then a repeated message of "hurt |=| harm" can be quite effective. It's rare that this is the sole cause of chronic pain, but we've all seen cases like this. The response is usually a quick and complete recovery. Great when it happens, but...
        -- If they are in pain because they don't have a life, then education around that aspect is fraught, because it's too confronting for most people. Everyone wants a life - sometimes it's hard to move beyond negative beliefs and perceived short-comings. On the rare occasions that psychologists help such patients, it tends to take forever and cost a lot. So I don't attempt that task.
        -- Similarly, if the patient has repressed emotional material from traumatic events earlier in life.

        So 2 out of 3 scenarios are difficult or impossible to address with education. This is why in many cases I avoid using it.

        But there is a 3rd alternative.

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        • EG,

          I see similarities in our observations. The hurt=harm message can be game changer for some folks.

          I defer for the indigent, uneducated and those with awful socio-economic-demographic lifestyles. I don't use any form of TNE. Pointing out the negatives in a life someone has little power over isn't something I find helpful. Those with major depressive, anxiety, PTSD, physical, emotional and sexual abuse histories also make the list of non-TNE education. Safe, non-threatening company is who I am for most of these folks.

          A 3rd alternative? Care to elaborate. I'd also be interested in your 5 minute explanation.
          "The views expressed here are my own and do not reflect the views of my employer."

          Comment


          • Just a variation on Moseley/Butler diagram for pain sensitization.

            Anxious movement and guarding caused the normal pain signal to move downwards over time, so that now any small movement will trigger pain (red line = faulty signal). It triggers pain even when you're miles away from the possibility of tissue damage. By moving boldly and courageously, the red line moves back to it's proper place (true pain signal). Sometimes it moves back instantly; sometimes it takes weeks.

            The 3rd alternative is the stuff I've been writing about on the EM thread. Not sure if you're into that side of things.


            x.jpg
            Last edited by EG-Physio; 07-11-2017, 06:36 AM.

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            • A nice discussion:

              https://www.youtube.com/watch?v=zDurZ3SS8NE
              "The views expressed here are my own and do not reflect the views of my employer."

              Comment


              • Muscle heads who are also doctors...great.

                Actually not bad but they seem to not fully understand that pain is generally not patho-anatomical in nature. They seem to "get" that patients tend to get a little excessively freaked out but I get the sense they fail to grasp the full complexity of the lived pain experience (psssst....it's the nervous system).

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                • Proud,

                  I think they have a decent grasp...

                  https://startingstrength.com/article/aches-and-pains
                  "The views expressed here are my own and do not reflect the views of my employer."

                  Comment


                  • I stand corrected. That's an excellent article

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                    • It's hard to know whether humanity is doomed, but when you see this...

                      https://www.youtube.com/watch?v=fRj34o4hN4I

                      Musk is probably going to have to save the world. He's doing well so far. The truck and Roadster released this week are so groundbreaking I'm lost for words. There is a word for it actually - the hook point or something. It's basically where the technology parabolic curve starts to accelerate madly.

                      https://www.youtube.com/watch?v=MPQaB8DGpVo

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                      • EG,

                        I have no idea why you posted your comment #1060 here.
                        Last edited by Johnny_Nada; 25-11-2017, 04:22 PM.
                        "The views expressed here are my own and do not reflect the views of my employer."

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                        • Currently reading the book "Waking Up" by Sam Harris. I can't help but see parallels to patients I see with his discussions of consciousness and thought.

                          What is anger? Where is it felt? Why do we let negative emotions persist longer than is necessary? How often do we have our anger interrupted?

                          We all know what its like to have our negative emotion suddenly dropped? We are depressed only to be brought to laughter. We are impatient in traffic only to be cheered by a phone call from a friend. We are able to create a new state of mind.

                          Those patients many of us struggle to help have no break in their day, life, experiences. They have lost the ability to break the cycle. Living situation, occupation, family, friends, finances, etc make it difficult to have gratitude, smile, "look on the bright side" or even identify these negative states.



                          "The views expressed here are my own and do not reflect the views of my employer."

                          Comment


                          • Thanksgiving. Something lost on many going through a rough patch in clinics.

                            https://www.youtube.com/watch?v=5tJgp48aoPo

                            Want to help your prognosis and outcome? Take this outlook.

                            "The views expressed here are my own and do not reflect the views of my employer."

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                            • Two random thoughts that are questions:

                              Does anyone have dibs on the idea of "The nervous SYSTEM" becoming "A NERVOUS system"TM?

                              Having just performed a lactate threshold test on myself I can't help but think of the evolutionary aspect of physical activity becoming painful. Given we were hunter gatherers way back when, the pain that accompanies physical exercise likely helped us continue tracking prey for long durations. Without it, our tracking would've ceased in minutes as opposed to hours and maybe days or weeks. I'm curious what others in the exercise physiology world think?
                              "The views expressed here are my own and do not reflect the views of my employer."

                              Comment


                              • How screwed we are:

                                Today...met a good old friend for coffee. We have been great friends for a while now. He's a Physician.

                                2 weeks ago he was back visiting and he came to see me because he just had an acute onset of sciatic pain (past 5 days.Pretty severe with whole leg pain really.

                                I assessed him and essentially there was not much I could do really. He was neurologically intact and found extensions did temporarily relieve the leg pain so I advised him to do these frequently and be re-assured that this would likely be short lived...get moving about and modify as required.

                                Met him toady (2 weeks latter). He tells me that he "knew something was wrong" so got desperate and "walked into a chiropractors office"

                                He was impressed:

                                "He spend an hour with me going over my entire body....he was thorough"

                                "He found the problem"

                                "My gluteus medius was weak causing my pelvis to rotate pulling my 5th vertebrae to pinch my nerve"

                                "I was skeptical but let him crack my back"

                                "I did not feel better after the first 3 sessions but after my 5th one...I started to feel better" (10 days worth)

                                "I'm not completely better but it's getting better each time I go"

                                "He expects another 2-3 sessions and it should be 100%"

                                "He told me that I probably need to see a chiropractor 2-3 X per year to keeps things lined up properly....he gave me the name of a chiropractor in my city"

                                "I would never have believed it but after that experience...there must be something to what they do"

                                Me: Smirk.

                                Him: "Oh what you think it's bullshit don't you?"

                                me: "regression to the mean (he's smart enough to understand that)

                                him " Not a chance...I had 10/10 pain and within 2 weeks it's over half that"

                                Me: yep....what do you want in your coffee.

                                Screwed.

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