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Evidence based PT a crisis in movement

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  • Evidence based PT a crisis in movement

    Worth a read:

    http://rogerkerry.wordpress.com/2014...s-in-movement/
    Kory Zimney, PT, DPT

    http://koryzimney.blogspot.com

    "Study principles not methods, a mind that can grasp principles will create its own methods." - Gill

    "All truths are easy to understand once they are discovered; the point is to discover them." - Galileo Galilei

  • #2
    Nice find Kory

    thank you

    andY
    "Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it." A.A. Milne

    Comment


    • #3
      I like what he is saying here
      Pain science is undoubtedly important in evidence-based pain management. Pain scientists have reminded us that we have brains. That’s good. Heed pain science data, but stop fawning over pain scientists. They are not Gods. We no longer need ‘institutes’ and ‘organisations’ of pain science. If the data is good enough, it will speak for itself. Don’t fall into the trap of moving from ‘clinical guru worship’ to ‘research guru worship’. There are no gurus. Don’t be drawn-in by general theories of the world, e.g. pain, which are underpinned by fragile evidence, but do understand the potential ways forward such evidence might point. If you are a disciple of such trends, stop posting random quotes from random ‘pain’ therapists as if this were some sort of confirmatory proof of theory. It’s not. The easiest thing is to stop being a disciple, and start to think for yourself. A bit like a professional would. Ignoring biological aspects of our patients’ complaints is evidence-based silliness. Calls to abandon a biomedical model is evidence-based moronicy. And downright dangerous. Psycho-social dimensions are of critical importance to our reasoning and management. So is differentiating non-specific back pain from aortic aneurysm.
      And let's not forget that regardless of how much we've learned from studying "pain science" or the "pain perspective", our pain related outcomes have not really changed significantly. This is humbling and does not allow us to have much confidence in that we've actually figured things (pain) out.
      -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


      • #4
        stop fawning over pain scientists. They are not Gods.
        Finally!!! someone has said it!! I'm still cross about that lecture I attended years ago where they behaved like rock stars. I totally heart Roger Kerry though and would wear a T shirt if/when there is one.
        Jo Bowyer
        Chartered Physiotherapist Registered Osteopath.
        "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi

        Comment


        • #5
          As a human-centred profession, let us learn from the humanities. The idea of causation on which all physiotherapy research is based is 266 years old and philosophically and sociologically un-sound. Why don’t we look at developing research methodologies based on enriched notions of causation? Throwing data onto a stressed-out workforce won’t make that workforce do evidence-based practice. It will just stress it further. Let’s look at ways in which change can occur in complex social structures.
          An interesting paragraph. I know he has links with one of the Norwegian Univerisies looking at causation and I wonder what an enriched model means, is it something they have developed?

          ANdy
          "Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it." A.A. Milne

          Comment


          • #6
            He makes some great points. I was interested in this statement:

            Calls to abandon a biomedical model is evidence-based moronicy. And downright dangerous. Psycho-social dimensions are of critical importance to our reasoning and management. So is differentiating non-specific back pain from aortic aneurysm.
            This is a division I hear often when discussing pain science and the BPS approach. Why does it have to be one or the other (Biomedical vs. BPS)? If someone is incorporating the use of TNE into their practice why assume that they abandon manual therapy, differential diagnosis, exercise etc. I wish people would stop making this assumption.
            Last edited by advantage1; 30-09-2014, 06:43 PM.
            Rob Willcott Physiotherapist

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            • #7
              Unfortunately people have been abandoning the biomedical model. Red flags should be cleared at each attendance, not just at the initial assessment. It doesn't take long to do and can save a great deal of trouble.
              Jo Bowyer
              Chartered Physiotherapist Registered Osteopath.
              "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi

              Comment


              • #8
                Jo, how has that lack of red flag testing become evident to you? Was it a study or personal experience?
                We don't see things as they are, we see things as WE are - Anais Nin

                I suppose it's easier to believe something than it is to understand it.
                Cmdr. Chris Hadfield on rise of poor / pseudo science

                Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                We don't need a body to feel a body. Ronald Melzack

                Comment


                • #9
                  Joe,

                  What red flags would you check daily in say a chronic low back patient? I too am interested in why you think health providers aren't checking red flags at least on initial exam?
                  Rob Willcott Physiotherapist

                  Comment


                  • #10
                    Originally posted by Bas Asselbergs View Post
                    Jo, how has that lack of red flag testing become evident to you? Was it a study or personal experience?
                    Anecdote and grapevine over the last six years or so. Pain science has caught on in the UK, lectures are well attended and there is a danger in my opinion that practitioners lacking mileage could dismiss patients' claims that there must be something wrong with them, because pathology is rare.

                    We don't routinely work up MSK cases to the extent that you do in the USA and the younger generations of UK physios have less exposure to ward and clinic based experience than previous generations.

                    There has been a documented problem with UK physios missing cases of cauda equina syndrome. The lack of red flag testing and failure to manage has led to litigation. The taking and documentation of adequate case history and asking relevant questions on subsequent visits gives a better chance of timely intervention.

                    The same goes for dizzy patients, I may have a working diagnosis of visual vertigo and/or BPPV but I'm still going to keep an eye out for CNS and CVS red flags.

                    There is a reluctance to talk to patients about pathology in case it is nociceptive, it needn't be and forewarned is forearmed.
                    Jo Bowyer
                    Chartered Physiotherapist Registered Osteopath.
                    "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi

                    Comment


                    • #11
                      Wow. I can appreciate your concern.
                      I never thought I'd say this, but the lawsuit crazy cultures here may have had a good side-effect: focus on red flags - always.
                      We don't see things as they are, we see things as WE are - Anais Nin

                      I suppose it's easier to believe something than it is to understand it.
                      Cmdr. Chris Hadfield on rise of poor / pseudo science

                      Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                      We don't need a body to feel a body. Ronald Melzack

                      Comment


                      • #12
                        Originally posted by advantage1 View Post
                        This is a division I hear often when discussing pain science and the BPS approach. Why does it have to be one or the other (Biomedical vs. BPS)?
                        It doesn't! The BPS model incorporates the biomedical....that's the 'bio' is it not?! The pendulum swings in emphasis, dependent on clinical examination, surely. My PT training was imbedded in the BPS model and we covered red-flags thoroughly. Screening for them is not complicated but of course very necessary.

                        Comment


                        • #13
                          I find these discussions interesting - mainly because it seems like we are blaming a particular framework (pain science or a BPS approach) for a particular outcome (missed red flags).

                          I find it interesting because pain science has NOT caught on in America (not yet anyway), and yet people still miss red flags all the time. Just this week I had a gentlemen who had been to 2 different doctors with symptoms that looked just like compartment syndrome - but nobody actually did a test to rule it out. Someone did an MRI on his knee which showed a torn meniscus and MCL strain and apparently thought that was enough to explain how his entire foot goes numb when he moves it, excruciating pain in the anterior compartment, and a general picture that suggested to me that he didn't belong in my clinic. I'm still waiting on further results. This hasn't been the first time where I have seen something missed because somebody wanted to fit a patient's presentation into their favorite paradigm.

                          Point being, the problem doesn't seem to be enhanced knowledge of pain, but rather poor vigilance on the part of the health care practitioner that leads to these problems. That and I find that many therapists don't have very good differential diagnosis skills - partly because this is a very difficult area, but partly because I don't think many therapists develop this much after a few years of practice. That's only my hunch however, I could be completely wrong.

                          Overall though, this was an excellent post by Kerry - and a good reminder that clinical progress should be driven by data, not individuals.
                          Ryan Appell DPT
                          @Rappell_PT

                          Comment


                          • #14
                            That and I find that many therapists don't have very good differential diagnosis skills - partly because this is a very difficult area, but partly because I don't think many therapists develop this much after a few years of practice.
                            I agree. And also there's all the time spent piddling around with patients' spines and pelvises searching in vain for mal-alignments and aberrant motions. Or looking for muscle imbalances. Or following some inscrutable classification system that requires performing dozens of special tests to move to the next block in the algorithm.

                            In the US, PTs still get a solid education on ruling out serious pathology, but once they get in the clinic I think these skills can begin to deteriorate as they focus more on finding the angle of the dangle. The documentation requirements are becoming increasingly onerous as well. In Medicare, with functional limitation reporting and the so-called "G-codes, it's become downright ridiculous. I've yet to see a single patient in one of the contracts I'm doing, yet I've already done about 12 hours of training- most of it in learning how to document for Medicare.
                            John Ware, PT
                            Fellow of the American Academy of Orthopedic Manual Physical Therapists
                            "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
                            “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
                            be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

                            Comment


                            • #15
                              Funny, I missed this thread completely and just commented on it over at this thread.

                              I guess I was not particularily impressed with the piece. Something about it just suggested to me that he still thinks there is a fragment between the biomedical model, psycho-social and pain science. It's as if he is suggesting a fellow like Moseley (a guru I guess) would somehow miss an aortic aneurism due to his monocular focus on pain science.

                              I just found the whole piece fluffy and made an awful lot of points that really should not astound an engaged clinician.

                              meh...I'm hard to impress I guess.

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