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PT TV 6: The Future of Manual Therapy (2)

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  • PT TV 6: The Future of Manual Therapy (2)

    This thread is a repository for the transcription I'm doing of the recent broadcast, The Future of Manual Therapy, starring Joe Brence, John Ware, and Tim Flynn, featured in this thread.

    Here is the program. I will add posts with bits of the transcript, as each topic is explored. When it's done, I'll post a pdf of the entire transcript.

    [YT]UYpv4_QxEWQ#t=0s[/YT]
    Diane
    www.dermoneuromodulation.com
    SensibleSolutionsPhysiotherapy
    HumanAntiGravitySuit blog
    Neurotonics PT Teamblog
    Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
    Canadian Physiotherapy Association Pain Science Division Facebook page
    @PainPhysiosCan
    WCPT PhysiotherapyPainNetwork on Facebook
    @WCPTPTPN
    Neuroscience and Pain Science for Manual PTs Facebook page

    @dfjpt
    SomaSimple on Facebook
    @somasimple

    "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

    “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

    “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

    "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

    "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

  • #2
    INTRODUCTIONS

    The Future of Manual Therapy Dec 12 2012
    http://www.youtube.com/watch?feature...pv4_QxEWQ#t=0s

    Host: Alex Scioli
    Guests: Tim Flynn, Joe Brence, John Ware

    Alex: Welcome everyone to PT TV - this is episode 6. Today we have a very hot topic, we’re talking about the future and direction of manual physical therapy. Today I am joined by some of the industry’s top experts. If you could all around and introduce yourselves for the people watching. We’ll start with you Joe.

    Joe: Sure. My name is Joe Brence. I’m a physical therapist from Pittsburgh Pennsylvania. Alex graciously asked me back after discussing IT band syndrome and potentially the clinical illusion of IT band syndrome a couple weeks ago. I’m a manually trained physical therapist through the Maitland Australian seminars, I’m also currently in the fellowship program, Sports Medicine of Atlanta. I discussed this topic with Alex a couple weeks ago - she thought it would be good, so here we are.

    Alex: Terrific. John would you introduce yourself?

    John: Sure. My name is John Ware, I’m a PT, from the faculty practice at LSU Health Science Center New Orleans. I completed my fellowship in Orthopaedic Manual Physical Therapy from the Gulf Coast Manual Physical Therapy Institute back in ‘98 and then I completed my hours for fellowship in 2004. I’m primarily a practicing clinician but I do do some teaching in the DPT program at LSU.

    Alex. Terrific.

    Tim: My name’s Tim Flynn. My practice is in Fort Collins Colorado, Colorado Physical Therapy Specialists. I’m in clinic one day a week, I have a faculty appointment at Rocky Mountain University of Health Professions in Utah where I teach the professional level students as well as the doctoral PhD program students, and I’m also involved in Evidence in Motion, and we have both fellowship training residency and transition DPT training. My background is predominantly musculoskeletal orthopaedic manual therapy - I’ve been a fellow for about 11 years - my background though was I trained more from an osteopathic background in the 80’s and early 90’s, and my research has kind of taken me different ways, when some of the answers we got didn’t really fall in line with what the models suggested.
    Diane
    www.dermoneuromodulation.com
    SensibleSolutionsPhysiotherapy
    HumanAntiGravitySuit blog
    Neurotonics PT Teamblog
    Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
    Canadian Physiotherapy Association Pain Science Division Facebook page
    @PainPhysiosCan
    WCPT PhysiotherapyPainNetwork on Facebook
    @WCPTPTPN
    Neuroscience and Pain Science for Manual PTs Facebook page

    @dfjpt
    SomaSimple on Facebook
    @somasimple

    "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

    “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

    “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

    "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

    "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

    Comment


    • #3
      QUESTION 1: "What do you think the future and direction of manual physical therapy is"

      (CONTINUED: )

      QUESTION 1: "What do you think the future and direction of manual physical therapy is?"
      Alex. Terrific. So clearly we have some experts with us today, and with that said we’re going to jump right into it. So the landscape of manual physical therapy is changing a lot from its inception to today. So our first question is, what do you think the future and direction of manual physical therapy is, and underneath that I guess, physical therapy in general. Start with you Joe.

      Joe: From a research perspective, I think we’ve seen a shift in our understanding of the mechanisms behind manual physical therapy. There’s this huge influx in and increasing of our understanding of pain science in the last several years, which has taken us from say more of a musculoskeletal base to more of a neuromusculoskeletal physical therapy.. I see the future of manual therapy incorporating more of a pain science understanding and neuromusculoskeletal understanding. I know it’s definitely a hot topic right now: there may be a little bit of a divide between some manual therapists out there but we can’t ignore the science - we can’t ignore what we’re understanding in relation to the brain’s involvement in what we do to our patients. When we put our hands on our patients and palpate them, and you know mobilize them or manipulate them, we used to always think that it has this profound effect on the joint, and we ignored the skin and the brain. And I think that the future of manual therapy’s going to involve looking at the skin and the brain.

      Alex: John, your thoughts?

      John: Yeah.. I would generally agree with Joe, but I’m a little more concerned about the future in that I think if we do not embrace the current pain and neuroscience there will be some dire consequences for our profession. I think the divide that Joe mentioned is wider than his rather charitable comment indicated; I think there’s more (what I’ve heard referred to as) a chasm, in fact, between the traditional practice of orthopaedic manual physical therapy, and the way I think it should be moving. And I’m concerned. And I think this is reflected in some of the documents that guide our profession: our description of advanced specialty practice is very dated, it needs reform, the CAPTE standards desperately need reform, they need to start... we need to as a profession both as individual clinicians and the institutions within our professional body, we need to embrace the current neuroscience at our peril, and really, more importantly I think, at the peril of our patients. I’m a little older than Joe, so I’ve been around a little bit longer, and so I’ve just got a little more concerns.

      Tim: I would say that the big concern I have is ... I would echo what’s been said previously - that where we get into problems is our understanding and our explanations. Our explanations fail us, and we know it works... manual therapy works for a lot of conditions and it’s going to be a key driver in saving money, and frankly, saving lives in terms of some of the things that are happening in spine care.
      So, on the one hand we’ve never had more evidence supporting what we do, in my career as a physical therapist; so we have this good body of evidence that has been developed that suggests that in certain conditions manual therapy or manipulative care is very helpful; on the flip side we have this body of knowledge, or - I should say - an historical perspective that was focused around the description from the bones perspective. I mean, we come out of a bonesetter tradition, and that’s how manipulation began, and so we have the bonesetter mindset when in fact, that is not consistent at all with the mechanisms that are going on with the majority of manual therapy interventions.
      But people are hesitant which to give up the models, and accept the fact that it works and be embracing new models. And where I think I probably would agree in the last comment that my fear is this - and I think it’s best to put in an example of a therapist that is coming on in our practice [and we generally hire younger therapists that have been through an internship with us so they get our model and the language we talk to therapists] - had a very bright therapist that’s begun working and it was very clear that she started on an explanation to the patient about why she was doing things, based on the mechanics of the sacroiliac joint; and whether or not in your mind you are using that model - which is fine, in your mind - we should not use that with patient language. We should not be telling patients that what I’m doing is fixing something that’s out of position, out of place, and the reason that your pain is there is by some bony explanation.
      And that is my fear, that we are at risk for doing what I often rave about medicine causing fear in our patients in the explanations we give. And I’ve been a bit long-winded - I apologize.
      Diane
      www.dermoneuromodulation.com
      SensibleSolutionsPhysiotherapy
      HumanAntiGravitySuit blog
      Neurotonics PT Teamblog
      Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
      Canadian Physiotherapy Association Pain Science Division Facebook page
      @PainPhysiosCan
      WCPT PhysiotherapyPainNetwork on Facebook
      @WCPTPTPN
      Neuroscience and Pain Science for Manual PTs Facebook page

      @dfjpt
      SomaSimple on Facebook
      @somasimple

      "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

      “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

      “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

      "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

      "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

      Comment


      • #4
        QUESTION 2: "Should manual PTs utilize patient beliefs when using manual skills?"

        QUESTION 2: "Should manual PTs utilize patient beliefs when using manual skills?"

        Alex: No no, not at all. You actually bring up an interesting point: so another topic we were going to touch on was “Should manual PTs utilize patient beliefs when using manual skills?” So for instance if a patient believes that they need to be “cracked” should you “crack” them? So it sort of goes into - do you give them what you want? Do you explain it in layman’s terms..?

        Joe: To discuss maybe a little bit further where Tim was going.. um, I think that we need to set realistic expectation what’s going to happen once we perform a procedure with a patient. There is this.. this current belief by many individuals that are not medical profession as well as are medical professions that mechanics of the joint cause pain, that movement of the joint will result in decrease of pain. I think we need to move past that model as Tim was saying, because I do think it promotes fear. It promotes fear of one’s behaviour, it definitely shifts the way the brain perceives pain and allows patients to catastrophize upon their painful condition, and move differently because of that.
        Getting more to your question, I think that the patient expectation definitely has an impact on results. I wouldn’t say that I would expect manipulation to be more effective than manipulation... I recently participated in a randomized controlled trial with Chad Cook who investigated and compared mobilization versus lumbar manipulation when individuals had this comparable sign. And what we found was that one wasn’t more effective than the other. The patient expectation did matter; and clinician expectation also matters. So if I go into the patient’s room, and I think manipulation’s going to work for that individual, I may be biased - I may approach the patient differently if I go in to perform a low grade mobilization. So, not only does patient expectation drive result, but clinician expectation as well, or clinician bias.

        John: Yeah.. again, I generally agree with what Joe’s saying, and I would extend that to say, to say back out and look at the broader picture of just the epidemiology of say, chronic low back pain but really any persistent musculoskeletal pain problem: the common denominator, or at least “a” common denominator - I don’t want to over.. you know, jump too far out there on a limb - but a very consistent common denominator is this issue of patient self confidence, self efficacy, internal locus of control. And that’s huge. And how, as a manual therapist, I need to really be cognizant of the fact that a lot of these patients’ beliefs and ideas are really erroneous. They think things are going on that are just not accurate and like, their bones are out of alignment, out of place, things need to be put back, they’re not strong enough, they’re too weak, or they don’t sit up straight, all kinds of things that we’ve learned that just aren’t true.
        And, so, we shouldn’t be cracking backs just because the patient expects their back to be cracked. We, as a wise PT colleague of mine said, our patients shouldn’t leave our clinic dumber than when they came in. I think we can do a better job. We really have to if we want to start getting these people well, that Tim referenced in his opening comments that end up going to have fusion surgeries and all this nightmare that’s occurring on a daily basis with patients being maimed, literally, to the tune of about $60-80,000/pop, we’ve just got to change our mindset, and take a more, um, broader view of the patients who are utilizing the resources and we just - all three of us know that there’s just a much better way than these patients ending up under the knife.

        Tim: I think the challenge becomes, you know, that three-legged prong of patient values, current best evidence, and... (... help me out here)

        John: .. Clinician experience.

        Tim: Yeah, clinician experience. (Laughter)
        I think the challenge I find, it’s knowing, and I believe that experience - and that’s what drives me nuts about the experience talk - the true expert understands the window of opportunity you have to create change in a patient. In other words, I wouldn’t say carte blanche, that if a patient came in and wanted me to crack their back that I wouldn’t do it. If that gives me a window of opportunity to show change - this person has gone somewhere else all the time, and I can do that and get some immediate results, and then say, however, you know, if you want to help me buy a new car, you know, you could sign up for me to do this every two days or maybe three days, and I’m pretty game, but it’s not good for your health but it will be really good for what I’m driving, and depending on the humor, or where the patient’s at, I might go on a story about connecting with that patient.
        So I wouldn’t carte blanche not crack someone’s back that that’s what they believe needs - obviously it’s appropriate and safe from a safety perspective - but I think it’s.. that’s really where expertise has been undervalued. We thought expertise was actually what we did with our hands. Expertise is understanding who you can connect with, who you can kind of drag along to better health, and to make better decisions, based on science, you know, based on this is what’s going to be best for you, but they may not be there, and that’s where our job really is as an expert, is to kind of bring them in to make better informed decisions. At the end of the day we can choose to make bad decisions and I firmly believe that, but we shouldn’t be part of that bad decision - we should provide everything in our power to guide them to a more informed decision when it comes to their health.

        Alex: Very good - anyone have anything else to add to that? Ok, mo...

        John: So far we all agree pretty much..

        Alex: You all agree. Good..

        Joe: Just a little.. (unintelligible).. a little bit on his point, as moving into this doctoring profession, I mean “doctorus” means to teach [transcriber’s note: “docere” means “to teach”], and I think that’s very important, that we’re educating our consumer and we’re educating them in a manner that’s consistent with the most current literature. I think that as a practicing clinician, that’s the most important thing we can do at this point - admit that 5 years ago I thought your leg was longer than the other leg, but our perception of that test or our perception of things have changed a little bit - admitting that maybe we were wrong in the past but this is what we’re understanding from a pain science perspective - so that we don’t keep driving those false beliefs.

        John: And I would just also add, I as well would not make a carte blanche rule not to perform a manipulation on a patient but I just think it’s really important that we start helping to change the perception of what we’re doing when we decide to do a manipulation, and make it clear, you know, we’re not really sure what the mechanism of action is here, but we want to definitely eliminate the things that we know are not happening. And those are - we don’t want the patient, you know, coming out of the clinic holding those same erroneous beliefs that they may have when they came in.
        Diane
        www.dermoneuromodulation.com
        SensibleSolutionsPhysiotherapy
        HumanAntiGravitySuit blog
        Neurotonics PT Teamblog
        Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
        Canadian Physiotherapy Association Pain Science Division Facebook page
        @PainPhysiosCan
        WCPT PhysiotherapyPainNetwork on Facebook
        @WCPTPTPN
        Neuroscience and Pain Science for Manual PTs Facebook page

        @dfjpt
        SomaSimple on Facebook
        @somasimple

        "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

        “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

        “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

        "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

        "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

        Comment


        • #5
          QUESTION 3: "Do you think that clinician’s beliefs ever influence patients’ outcomes?"

          QUESTION 3: "Do you think that clinician’s beliefs ever influence patients’ outcomes if they are biased in their beliefs?"

          Alex: So we talked a little bit about patients’ beliefs, but do you think that clinician’s beliefs ever influence patients’ outcomes if they are biased in their beliefs?

          Tim: I’ll jump in there, can I take that question slightly different? I think beliefs.. well, I’ll let Joe answer that. I’ll let you answer that Joe, or John, then I have a switch on that.

          Joe: I definitely think the manner in which we approach the patient - it’s going to give off a vibe: if I think or if I’m confident that a manipulation’s going to impact that individual, versus not confident, my confidence going into that patient interaction is going affect the outcome. Patients pick up on things inherently, and I think that that also drives outcomes. I know with research right now, that study I just talked about, we looked at clinical equipoise, you know, how biased am I going into this study thinking that manipulation is going to be more effective than mobilization - because it has this potential variable which may affect the outcomes. So I definitely think that clinician beliefs, in that they’re buying into the system, is going to affect patient’s outcome.

          John: Yeah I would agree and I would also say that it can cut both ways in the sense if you’re very convinced, and you’re charismatic, and you have your salesman’s hat on, and you’re very convinced of the biomechanical model, um, that you most certainly can convince the patient that you - I have, you know, I’ve been guilty of saying to patients that I was able to, uh, restore their innominate position, uh, counter nutate their sacrum, and all those things. You know I’m guilty as charged. And I was a good salesman, and I think I was reasonably confident, and charismatic enough to do pretty.. you know get good outcomes, but not necessarily um, in the long run, from that broader perspective help to advance the science and our profession and really make a larger impact on this really big problem of persistent pain.

          Tim: Well, where I was going to go is, I think this bias of the clinician actually affects the decision making as well, before even the bias gets to the patient.
          And a great example is at the IFOMPT conference, um.. did a presentation where we had a case, and it... three different people from three different countries who were on the panel.. we decided what we would do with that patient. And I thought it was pretty, you know.. obvious that the patient was acute low back pain, no leg pain, and in most peoples’ mind - again, I’m biased probably to research I read - I thought well you know, at least early on manipulate them and provide thrust manipulation, because the value, the bigger bang for the buck, in the published research, for somebody that actually meets a subgroup that’s noted to respond, you know it’s kind of a no-brainer at least to do manipulation.
          That wasn’t the response.
          The response was three very different answers for a patient that had back pain less than 16 days, no leg pain, and was, no red flags etc.
          So I think the bias of the decision making is huge, and then you couple that with the bias of the patient - excuse me, the therapist - how they feel about the procedure and their comfort, then you throw in some more thoughts on the patient. And so I guess, part of me says, I’m still shocked in 2012, that again, our work and others that have replicated it, suggest at least for this small subgroup - which by the way not that many meet this subgroup - for those, it’s kind of a no-brainer, at least in the first couple visits, to consider some thrust manipulation on those folks. Unless, you know, it doesn’t fit the patient’s values, but other than that I still find that confusing, that you know, we don’t do that, and I’m interested to see what John and Joe feel about that. So let’s just throw out a case, where we have, you know, somebody that’s acute low back pain 16 days or less, no buttock... pain a little bit into the buttock but no red flags and you know, low fear avoidance beliefs, etc.

          John: Shoot Joe.

          Joe: OK, so, my perception which I know you worked on Tim so I want to give you credit for you know, getting published in the Annals of Internal Medicine and I mean big big article ; but I think that simply identifies responders to probably no matter what we do.
          Um, I think that a bigger predictor is if this individual is going to have maybe a between or within session change, so if I touch an individual and that feels good, then they’re probably going to be.. that’s probably going to be more predictive of a responder of manual therapy than if they just fit this rule; I think that less than 16 days, very acute case, you know.. no major disc issue, it’s only going maybe to their knee, not past their knee, uh, they haven’t, you know, developed fear avoidance yet - they don’t feel disabled because of this and they’re probably a mobile individual with greater than 35° of hip internal rotation so I think that that prediction rule, at least from my perspective, just tells me this person is probably going to get better no matter what I do with them. The biggest, you know the better predictor, for me, is if I put my hands on you and just touch you lightly, does that feel good. And that’s probably going to be more prognostic, at least in my clinical decision making model.

          Tim: Well, how do you reconcile that with Hancock’s work where they did have people where they looked at the subgroup of people and they met the rule, and when they got mobilization, they didn’t do as well. I mean they’re doing stuff to them, and Cleland’s follow up, where they compared mobilization with thrust manipulation, whether you put somebody on their side or on their back and the mobilization didn’t do as better.

          Joe: Yeah...

          Tim: … That argument falls, because if they meet the rule, and again, it’s a small subgroup, but I’m surprised that we can’t agree on even a small subgroup, because there’s two studies that suggest that your point is wrong.

          Joe: Well, and I would go back, and I would talk about clinical equipoise; was clinical equipoise used in that study?
          So if I’m going to be a participating clinician in a study, and my bias going in thinking manipulation’s going to be more effective, am I invested in manipulation? I keep seeing CEU courses on manipulation - there are different variables that may impact how I interact with my participants that study.

          Tim: But how does that explain Australia then? Because I would believe that the Australians, they believed in mobilization - I believe Aussies are into mobilization. Would you agree?

          Joe: Most definitely. (Laughter)

          Tim: So they were believing in this mobilization, but their belief in the mobilization didn’t show the effect sizes that have been shown elsewhere; in two other clinical trials there are marginal effect sizes and then when they looked at the responders, and they believed mobilization was going to work - their equipoise was there, you didn’t see it.

          John: Well, since Barrett Dorko’s not here I’m going to invoke him.

          Tim: Good. (Laughter)

          John: You know, Barrett would say, “The method is not the trick.” He published a letter in, I believe it was in JOSPT, wasn’t it, Joe? That letter with Jason? And um.. where they discussed this, you know, manual magic issue, and they discussed how, you know, what’s different about manipulation - it seems to be the ritual - you know.. the drama. And I think an analogous study that was done was a placebo study done, the famous Moseley study on arthroscopic surgery of the knee. And when the subsequent documentary that was done on that, one of the researchers that worked with Dr. Moseley remarked, well, the whole ritual around doing a surgery had a very strong placebo effect. So not all placebos are created equal, and then you add in some of the equipoise issues or factors that Joe mentioned, and then I’m just wondering if it’s not just the whole drama of the manipulative ritual that might not carry a lot of the effect.

          Tim: Boy.. I guess that’s a big stretch to say mobilization is not as dramatic as manipulation. I mean again just putting somebody on their back and rotate and pushing on them, that’s not that dramatically different than pushing on them like this and oscillate them. Oscillating on them with grade 3 type mobilization procedures.. I think in our mind it might be, but I’m not sure the patient is seeing that dramatic difference - again you’re talking effect sizes - dramatic effect sizes. Again, the Hancock group did not see much effect sizes with mobilization. You know, not 30° drops in the Oswestry. I mean if that’s the case why aren’t people replicating those types of drops? 30° drop in an Oswestry - going from 44’s to 12’s or 14’s.

          John: I think there isn’t some other neurophysiology going on, there’s the DNIC factor, so I’m not saying it’s all placebo, but I do think when you compare mobilization to manipulation, there’s a big difference: the big difference is the speed at which it’s done. And I think that adds quite a drama factor.

          Tim: Yeah.. Well... how can we resolve the issue? Because I do think this is at the heart of some of the debates on manual therapy - as if... first of all I don’t know how we ever got this term mobilization - it’s kind of interesting in and of itself; when you look at grades of mobilization, that clearly was one school, and frankly I don’t believe Geoff Maitland was that tied to grades of mobilization - it was one small little piece out of a large tome but boy we kind of jumped on it as being a big deal. And frankly, it got people away from doing manipulation. And if the drama is bigger with manipulation, awesome. If there’s a bigger placebo for it, great. And I’m all with you John - that argues for, let’s crank up our placebo effect and let’s not say I don’t want to give placebo to the patient because I’m not being “true” to my belief system.

          John: That to me is not the issue, and again, this comes back to the fact that we’re talking about a very small subgroup of people - we’re not talking about the people that end up costing the healthcare system the vast majority of resources. I agree though, getting back to what Joe said, I agree these are people that a lot of them are going to end up getting better anyway, and there’s a cost-benefit analysis that we have to weigh against what we know now about the neuroscience and the importance of internal locus and self-efficacy, and weighing all these other factors, we just have to kind of start shifting our paradigm a bit more towards looking at the big picture.

          Tim: I do not disagree John - but that would say again, the data shows, if you don’t get those people better quick, they cost the system more. We have shown that in groups that should respond, if they do not get their treatment, they end up taking more drugs down the line, their Oswestry scores are higher, those people are more likely to be using the system. You have a window - I agree, I think we all agree - we have a window of time to make a big impact on patients, and if we don’t use that window, and nowhere in there says that you do not talk about control and immediately get into the prevention of recurrence. All those studies immediately went into exercise, intervention, and prevention of recurrence. Manipulation was a small component of the overall treatment plan, right? You know, high quality examinations, manipulation, core stability and strengthening, and teaching the patient to stay active and doing things that the evidence says - and somehow we’ve anchored on this small little thing, about manipulation and mobilization. At least much of the debate, um, it’s still going on , at least last year it’s still a debate.

          John: Well Joe, your study cast - that you did with Chad Cook, well not your study but the study (unintelligible) casts.. there’s some.. (unintelligible) shed on this, and there’s also been a cervical study that also shed doubt on the fact that manipulation is more effective than mobilization, so, that jury’s still out anyway, and then when we take that, again, with all the current neuroscience suggesting internal locus, we need to move toward empowering patients, internal locus, self efficacy, I just think we might be jumping the shark here; we’re just ignoring the brain, we’re ignoring descending inhibitory control at our peril. And I think we need to take a more, shift towards a more interactive stance with our patient and less of an operative stance where we’re doing things to patients: I just really think we need to shift away and get out of the turf wars with the chiros and be what we really can be, which is real therapists, and educators.

          Tim: I have no disagreement whatsoever John, and I’m not sure how that changes when you talk about a subgroup, a small subgroup. If we look at.. and this is always where... I think.. my fear is this: that are we doing the same thing with the pain sciences. By the way, I don’t see any acute pain - I have chronic failed backs, and I always joke about the research I do - I get to see those patients occasionally when I’m out and about in the bar and somebody hurts their back - you know I mean I see chronic failed backs and I see it from a neuro perspective, and that’s the language we do.
          It’s a subgroup.
          To suggest that we now shift everything only to the neuroscience when that is very emerging evidence that I am 100% on board, but that doesn’t shift the fact that we need to change how we treat individual patients immediately - because if we did nothing, like just saw all back pain patients and got them in early and taught them to exercise, manipulated some that needed it, put others into other subgroups, we probably would dramatically decrease the numbers that go on to bad things. We’re not medicalizing it is my opinion. Other people are medicalizing back pain and I don’t think at least those on this show are medicalizing it but I don’t want to just throw the baby out with the bathwater now just say the neuroscience is going to solve it all - I don’t believe that.

          Joe: I think you made a great point there - um, in which we’re not seeing these patients early enough. I think that one reason why we’re seeing low back pain develop into something that’s a little bit more complicated is because we’re not seen as practitioner of choice yet for low back pain. We should be that first portal - the first thing that patients think of when they have low back pain they should be seeking our care. Uh.. so we’re seeing these patients that are 2, 3 months out, they have fear avoidance, they have catastrophizing, they probably have some type of kinesophobic behaviours... I think that we should be, you know, seen as that first access point, when you think low back pain, you need to seek our care. I think unfortunately the majority of us aren’t seeing that right now.

          Tim: I don’t think we will … are you going to go in if you have an ailment.. what do you normally go in for - what is your purpose when you have an ailment?

          Joe: Can you describe that a little bit further?

          Tim: If you are having a horrific cough, and you go in to see the provider, what are you hoping to get accomplished at the end of that?

          Joe: Get ..(unintelligible)

          Tim: So you’re just seeking a diagnosis?

          Joe: Yeah, making sure it’s nothing serious. I think that that’s..

          Tim: I don’t think that our patients … that’s a component... most of the patients I see are seeking relief. They’re coming in to feel better because they’re trying to get into a different state. Many of them are fearful of things that are serious, and by educating them we can depress their anxiety and things.. but most people don’t like to go to health care, at least in our neck of the woods. They only go if they need to feel better. So I believe that if we can’t make change within session, whatever mechanism we do … maybe talk therapy, which I do a lot of, maybe manipulation, it may be dry needling, it may be all these things, but if someone leaves our clinic in the first visit and we haven’t made a change, my likelihood of seeing them, and really getting buy-in goes way down. And I think we can all agree that data says that change within session is a cool thing. So I believe firmly that just talking with folks, breathing, you can make a change within session. It’s harder to teach that, to do well, to be confident enough that you can do that, and we’re not training our therapists in the other skill sets to do that well.. there are other things that give big bang for the buck that’s temporary, but it does make a change within session. So I always say, it’s just your therapeutic window. I don’t care what you do, but you better make that person feel better during that session because then they get buy-in that you can give them a pathway forward. And only then I believe will we be provider of first choice for musculoskeletal care. And just talking and just doing things, which I’ve heard this - where one school of thought says I want to totally make the patient do all the movements because I want to empower them so they are in charge - it’s a good theory, but if you don’t make them better during that session you’ve not improved their buy-in to that procedure. Having said that, there’s a subgroup of folks that just as they move, they will respond quite favourably, and they’ll get buy-in to locus of control and they can actually be in control. And that’s why I don’t feel there’s a huge... everybody has a piece of the answer I believe, in some of these manual therapy groups.. but they’re so tied to their belief system that they can’t see that it’s just a part of the process, and again, I’m on board on the neuroscience, but it is not the end-all be-all - it’s a part of the process that we need to integrate into the bigger whole.

          Joe: Great vision there.
          John, I’ll just make this real quick so you can add your points in: I think that to not make neuroscience you know the whole picture - why is the patient seeking our care - they’re seeking our care for low back pain. I mean pain one hundred per cent of the time is an output by the brain. We have to always understand that and look at that individual and understand, how can we communicate with their nervous system? Everybody’s brain and their neuromatrix, which is creating this perception of pain, is individualized. So to classify a subgroup of individuals and say, if they fit these prediction rules, then they have this neuromatrix. It just - from what we’re understanding from fMRI studies it just doesn’t work that way. I think that we have to take into account a ton of variables within these individuals that may not have been investigated - they should be investigated down the road and with revalidation of a rule, but I think there are other variables that are likely contributory and individualized.

          Tim: And I agree.. we have to function with the evidence that we have, not with the evidence we’d like to have. John.. I’m interested in your thoughts.

          John: I’m guilty of a neurocentric approach.. I don’t really separate out, when you say the neurosciences being the be-all end-all, you know.. I think it’s all neuroscience - What’s missing from some of the manipulation studies, the RCTs, is any kind of effort to incorporate some of Lorimer Moseley’s work with patient education. I mean, he found just doing with patients with nonspecific low back pain and this was back in 2003 I think it was Joe, where he did detailed pain neurophysiology education with the patient and found improvement in straight leg raise, and increase in their forward bending - they had small effect sizes there but significant reductions in their pain. That’s a within-session or between-session change. That’s not being really widely incorporated into physical therapists’ standard interventions for acute or chronic nonspecific low back pain. It’s kinda... it’s still... and it’s kinda like it’s emerging neuroscience - you know this neuroscience has been around.. you know, Melzack’s paper on the neuromatrix, published in 2001. Right Joe? The … (unintelligible).. yeah, it was published. So, you know, you could say emerging, but that’s before you published your CPR study wasn’t it, Tim?

          Tim: We’re talking about two totally different subgroups, and that’s where I’m struggling, because I’m agreeing entirely with you. I mean, our patient, I mean go to our website, I mean we have pain videos - they can’t see us until they’ve gone through some pain neuroscience education, because we see a lot of chronic failed backs. Having said that, you know, when the engineer comes in, and the engineer.. you would agree - when you try to talk about neuromatrix with an engineer - who’s a mechanical engineer, mechanically oriented, he is not there. And you know those are the ones that go onto multiple sub.. uh.. surgeries, because they don’t buy this thing. So I can talk about that all I want but you know, even Adrian and others say, you know, you’re a good hit rate if you can get 60% of people to buy into the neuroscience education. That’s been our experience - about 60%. But again, we’re talking about the subacute chronic population, and that’s why, again, I think we need to think about, if we didn’t.. if they didn’t get there, we have a different conversation. We know, I mean, I don’t know about you guys, but I’ve had acute low back pain, and neck pain, and you know what, quick do this, and boom, that’s better. It may well just have been the experience in the brain, and that’s cool - that’s the mechanism that happened, but I felt better and I’m not really thinking about it anymore.
          Patients don’t think about neuroscience, the mechanisms.. and I believe we’ve got to be careful... let’s not extrapolate it to the acute back pain - now, having said that, totally let’s not medicalize acute low back pain. Never use that’s why I started it saying things are out of place and this and that.. talk about you know the good news is this: you don’t have anything seriously wrong, you’ll a little bit stove up, you’re not moving well, let’s move you around a little bit, more more importantly, let’s teach you not to have this happen again. And not over-medicalize. And I think we’d all agree on that. And that’s neuroscience “education” if you will.. because we’re not catastrophizing or amping up that patient. We’re using the neuroscience to help in our education. But I don’t think we can just say, what we’ve seen in these small effect sizes in chronics - and by the way, small effect sizes in chronics are meaningful effect sizes - we should just say, well, we can get a 30% drop in your Oswestry, we can only get 10% if I educate you but can get you thirty points if I do something else.. that’s not very appropriate in my mind. And that’s really what I was trying to say. And again, small subgroup.

          John: And I don’t want to get too far afield, because I can’t remember the last time I saw somebody 16 days after onset of low back pain …

          Tim: Precisely!

          John: .. So, Joe’s point is well taken too - we need to be seeing more of those people but I just want to make this statement: I think pain is pain. I think this distinction between chronic and acute is pretty hazy. I think the people who come in who are going to end up having chronic pain - and the evidence pretty well shows this - is that it’s not the severity of their injury or even the severity of their pain, it’s other stuff up in their brain - it’s stuff - their beliefs, whatever all this stuff that’s going to lead them down that road to chronicity. And being very expensive to the system and end up having surgery, these worthless, fungus-infected epidural injections and all that kind of crap. And so I’m of the belief that pain is pain. And we’ve made a lot of, tried to make some artificial distinctions in that regard and I don’t think it’s doing us any good, and I just think we need to try to incorporate the neuroscience with the entire population - acute, chronic, subacute - all of it.
          And maybe the reason why we’re not so good at relating this information to people like engineers is we haven’t - we’re not good enough at it - we haven’t practiced it enough, um.. we need to come up with stories that are relevant to the mechanical people; I can make mechanical analogies with people, you know, I can talk cars with those guys, a little bit, so.. we just have to get better at it. That’s all. We just have to get better at it. We have to understand it better and we have to start teaching it to our colleagues.

          Tim: I’m 100% on board with that, and I just want to make sure that we’re not just thinking that will solve the problem. Because again, I was hurting like crazy after my two-hour trail run with my colleague and my shoes - just because it’s rocky in Colorado - and you know, I was hurting, and you know, but frankly, it went away after 3 days. But it was pain - it may have been a little puffy so maybe there was localized changes, etc - it was pain. Now, had it not gone away, would I.. it went away so it’s not even on my mind here, on Wednesday, and that was Saturday. So, you know, so I do think there’s a difference - persistent pain changes how we view because it affects my ability to go run again. And if I’m not getting effects in my life, it goes away, I’m moving on. So I do think there is rational reasons to separate things - we’ve seen the American Psychological Association change the idea of after death in the family or any death, a loss, you know, depression is normal. But at what point does it become abnormal..? OK, to suggest we shouldn’t feel sad, is a little bit not understanding the human experience right? To suggest that we should not feel pain, with doing something too much.. but there’s a point where well maybe it shouldn’t be persisting. So I think that maybe having some artificial timelines makes sense in musculoskeletal pain, OK? It does. And we can all agree there are different motivational factors - if I’m in a suck team in the MBA I might have more injuries at the end of the season, right? My incentives have changed. So, I don’t know, bottom line is, I think we’re agreeing pain is complex and we need to be good at educating, but I don’t think we should not put our hands on patients and use it as a window of opportunity to improve them.

          Joe: I agree - I think the hands-on patients definitely important Tim, so great point: I think that, you know I don’t want to speak for John but I think for myself that you know, taking that point when we have our hands on the patient and just reconceptualize what’s happening. Reconceptualize that this may not be doing a lot to your joints but we’re communicating with your brain, we’re communicating with this complex mechanism that’s creating this perception that sometimes pain’s not a bad thing - it’s a communicator - it’s your brain’s way of telling your tissue there may be something potentially wrong - doesn’t mean something major is wrong, but there may be potential for further damage if we don’t take care of this, so I definitely am advocate for hands on the patient but I think we should take that time to also educate and maybe reconceptualize for what’s happening.

          Tim: And I think we need to be better in papers describing the challenges describing all that we just said in words that we’re allowed to, because the thought is that none of that is happening in these studies, where there’s not communication going on with the patient, and describing again, what is that language of “this isn’t a serious problem” right? So the language is saying, “You know the good news is, you know you don’t have any signs of anything serious going on” which in studies we’ve been involved… all of it’s been going on. So that’s part of pain education, educating the patient that it’s not big, not catastrophizing the condition. So I think part of it might be that we look at literature - the more I’m listening tonight we read literature and we don’t really get into the … we’re not actually watching and observing what is happening and it kind of goes back to your study, Joe, really, of saying there’s a lot of stuff going on that we’re not talking about and we’re spending a lot of time arguing about whether we wiggle it fast or slow. (Laughter)

          Joe: Exactly! Alex?
          Diane
          www.dermoneuromodulation.com
          SensibleSolutionsPhysiotherapy
          HumanAntiGravitySuit blog
          Neurotonics PT Teamblog
          Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
          Canadian Physiotherapy Association Pain Science Division Facebook page
          @PainPhysiosCan
          WCPT PhysiotherapyPainNetwork on Facebook
          @WCPTPTPN
          Neuroscience and Pain Science for Manual PTs Facebook page

          @dfjpt
          SomaSimple on Facebook
          @somasimple

          "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

          “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

          “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

          "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

          "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

          Comment


          • #6
            QUESTION 4: "What do you think is going to happen?"

            QUESTION 4: "What do you think is going to happen?"

            Alex: Terrific. Well, we’re getting close to the end of our time here, and we’ve obviously touched on a lot of topics in the context of the future of manual physical therapy, so I’m going to leave up to everyone their last words about the future of manual physical therapy. What do you think is going to happen? What you want to see, let us know. Joe, you can start.

            Joe: I’m not going through fellowship right now for nothing. I think there’s importance in getting our hands on our patients. Whether about getting our hands to allow us to have some personal time to communicate with that patient, um, I definitely think that it’s a skill set that we should have as clinicians. I think you know that dark road comes when try to get a little too specific or think that things are happening that research may be telling us is not happening. From that point we need to develop or utilize Occam’s Razor and follow the theory that makes the least amount of assumptions. I think the neuroscience perspective of manual therapy is kind of that model. So I think the future of manual therapy is bright, and I know that Tim does some fantastic research to help support, and great advocacy work, so that’s appreciated, and I definitely think there’s a future to manual therapy. John?

            John: I agree, despite my.. some of the comments I’ve made tonight I put my hands on just about every patient that comes in the door - I just don’t do much manipulation anymore, I don’t manipulate necks at all anymore, I just think the cost benefit is just not worth it - too bad we weren’t able to talk about that a little bit, but... maybe another time. Again, I’m concerned about the future, I think we’ve gotten kind of mixed up into the turf wars too much with some of the other manual therapy disciplines unnecessarily, I think if we’re the ones who are really - go by our motto of the science of healing and the art of caring, we need to embrace the current science. And I just don’t think it’s really happening in a widespread way. And I know there’s a lot of issues in reimbursement - the way physical therapists are reimbursed, procedurally, and that drives a lot of it; there’s the issue of physician ownership - we don’t have widespread autonomy of practice, that’s a big issue that kind of affects us as manual therapists certainly, but I think we need to start with kind of a … getting our own house in order, I think we need to update a lot of our documents - the last DASP the academy came out with I think Tim met with was ‘04? And looking through that it still talks about arthrokinematics and there’s just a lot of old verbiage in there that really needs to be cleaned up. And you know the emerging neuroscience doesn’t make much of a presence in that particular document. The CAPTE standards are silly the OCS exam has a lot of silliness on it with a lot of alignment tests that just are not supported in the literature. We just need to do a better job about cleaning our house and decluttering, as Barrett would say: we’re hoarders, and we need to quit hoarding.

            Tim: (laughing) Well that’s a great statement, and I would say we agree on 99%, and that ultimately I believe the future’s bright, because at the end of the day, I look back to one of my mentors who was heavily invested in a biomechanical approach, Phil Greenman a DO, and that’s not how he talked to the patients - I mean all this stuff this is just stuff for us to chat about and keep us up at night, but that language wasn’t said to the patient. The language was, you know, let’s get the movement, you know? Connected, like be with the patient.. and be what positions and all health providers should be, working with your patient - and we spend way too much time on discussing some of this wiggling and thrusting and stuff. And people have not seen that that is just a component of what we do. So I’m agreeing entirely that, you know, clearly we have got to integrate neuroscience education in every patient. And how we do that depends, I believe, on that patient’s values and how much they're willing to listen to us. And I’m a firm believer in “buy-in is key” and that change within session gets you buy-in. And that is expertise, knowing that I can change through talk, through manip, through a needle, through whatever, and we can’t identify those subgroups. But we’re called, I believe, as educators, whether clinically, in the classroom, etc. - called, to not just say, oh, you’ll figure it out in the clinic - that’s just such a cop-out. And to give some structure to students and residents and fellows, to say, in general, try to dial up this type of approach with this patient, and dial it down with this patient. And I think that’s what we’re called to do, and my final statement will be, let’s keep the discussion going, but let’s not have this too high level of discussion with the patient - it’s simple, it should be based on science, that indeed this is an output, pain is an output, there are ways we can dial it up or down, totally agree with that - but let’s keep it very simple in our explanations, because to suggest that making things more complicated goes back to what we just heard - clutter is the issue and it doesn’t necessarily help who we’re here to help which is our patient.

            Alex: Great. Terrific. Well this is obviously a complex topic - we might have to do a Future of Manual Therapy Part 2 sometime; you guys have sparked a pretty powerful conversation on twitter, so, we’re definitely getting people thinking, and learning already - you can pop that with #PTTV6 if you want to keep talking about the future of manual PT or go online to therapedia.com to watch this episode again and share it with your friends whenever you’d like - and more PTTV is on its way at therapedia, and thank you so much for joining us, guys.
            DASP=Description of Advanced Specialty Practice
            Last edited by Diane; 16-12-2012, 02:24 AM. Reason: Add DASP
            Diane
            www.dermoneuromodulation.com
            SensibleSolutionsPhysiotherapy
            HumanAntiGravitySuit blog
            Neurotonics PT Teamblog
            Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
            Canadian Physiotherapy Association Pain Science Division Facebook page
            @PainPhysiosCan
            WCPT PhysiotherapyPainNetwork on Facebook
            @WCPTPTPN
            Neuroscience and Pain Science for Manual PTs Facebook page

            @dfjpt
            SomaSimple on Facebook
            @somasimple

            "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

            “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

            “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

            "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

            "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

            Comment


            • #7
              Here is the final pdf. It leaves out many of the ums, uhs, and youknows, and there were a few words I just couldn't catch. But the main gist of it is here.
              Attached Files
              Diane
              www.dermoneuromodulation.com
              SensibleSolutionsPhysiotherapy
              HumanAntiGravitySuit blog
              Neurotonics PT Teamblog
              Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
              Canadian Physiotherapy Association Pain Science Division Facebook page
              @PainPhysiosCan
              WCPT PhysiotherapyPainNetwork on Facebook
              @WCPTPTPN
              Neuroscience and Pain Science for Manual PTs Facebook page

              @dfjpt
              SomaSimple on Facebook
              @somasimple

              "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

              “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

              “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

              "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

              "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

              Comment

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