If you haven't read it yet, I would suggest checking out the recent post by Dr. Moseley as that is one of a number of things that got me thinking this week about Clinical Decision making. Here is a link to his post:
First, do no harm - by Lorimer Moseley
I do 100% agree with Dr. Moseley and his NOI / BIM group colleagues, as these brilliant clinicians and scientists are really leading the pack when it comes to the concepts we utilize in clinical practice related to pain science and the neuroplasticity of the brain. In no way am I challenging what is being said.
I do have a number of questions, however, and hopefully by posing them here to the world I can dialogue and gain some clarity.
My personal beliefs and biases are not set in one system versus another, but rather doing what works, is in the best interest of the patient/client, is in line with the patient/client's goals & beliefs, and makes the most lasting change in the shortest time possible while minimizing their risk of adverse events.
Tall order, I know....
My questions are not based in the dogma of 'doing because that's how it's been done', or in defense of a bias toward manual therapy & exercise interventions and the biomechanical mechanisms that have been beaten into my head over the years. Rather, they are an attempt to decipher where & how all these things fit together -- because my personal thought is that they can, and do, exist together every day.
(Sidenote - I have not yet watched MedBridgeEducation's Pain:Where Does Biomechanics Fit, it's on my short list, so don't hate on me too much about that!)
Sometimes I get sucked into blog posts, more the comments than the posts admittedly, when topics of pain, structure, function and the dreaded Evidence-Based Practice are thrown at each other. Clearly there are some with very strong beliefs one way or the other, which is cool. I mean really, we all have to believe in something. We wouldn't be doing what we do if we didn't.
'The Old School' was the Biomechanical/Postural/Structural Camp. The 'New School' seems to be the Pain Science & Movement Camps, and they are very separate and distinct camps. Sprinkled between & within these groups you have a good mix of the (Soft tissue & Instrument Assisted soft tissue) Mobilizers, the Manipulators, the (Dry) Needlers, the Screeners, the Tapers, and the Hands-offers. I guess there still are a few Shake & Bakers, but they don't often get into conversations like these.
Often with the changing of Schools, the pendulum swings from too far in one direction, to too far into the opposite direction. I'd like to maybe slow the swing and see if can land somewhere in the middle in an attempt to have the greatest reach and help the most people in the process. I venture to think that each School is correct, and each has their place. Yes, it's true and I am not ashamed -- in the Chiro world I would be a Mixer.
So if you bare with me, these are in no special order. Maybe some of you have had similar thoughts, maybe my thinking is on point, or maybe I am just out in left field somewhere...
1. All pain starts as acute. True. However, we base this definition solely on chronicity - pain that lasts beyond our definition of acute (first 2-3 days) & subacute (2-3 weeks) and is "beyond the time of normal tissue healing" is dubbed chronic (greater than 3-4 weeks). Where does "chronic-acute" fit into our definitions, and is that a concept clinicians are looking at.
I am not questioning the timelines or definitions. What I do question is the idea that chronicity and tissue healing are the only things at play here. The idea of chronic-acute as I was taught it, was that a person has an issue, say low back pain as an example. They have an episode, it lasts a few days, within a week it's gone and the patient is back to doing everything. Two months later, it happens again, and again, and again. The patient may get sick of the recurrence and see out medical advice. Or, the pain may stick around "longer than it normally does" which prompts them to see a medical professional.
Certainly the brain is perceiving a threat, which is why the patient has pain. But why repetitively. Why does someone make what seems like a full recovery only to repeat the cycle. Is it not plausible to look at things like biomechanics and movement patterns to identify a potential influence or cause of these chronic-acute episodes of pain?
2. Biomechanics Doesn't Matter -- is essentially what I am hearing and seeing from those who pounce on the idea that they do. I get this is probably a small population, but it has a big voice, so the question is made. It usually goes something like "the research says;" "pain is the brain, not the joint/muscle/tendon/fascia;" "manipulation is neurophysiological,it's all the brain." And on, and on.....
So, can we all just agree that the brain rules the roost, that nothing happens without it making it so, and that in every & all instances pain is as it is defined" the brain's perception of threat to the body."
It's an output, yes. Very well, I agree & understand -- But how does that discount or some how negate mechanics/structure and impact that clinical tools like movement assessments or manual therapies have in successfully treating patients every day? Just because a study's conclusion of " 'X' intevention versus 'Y' intervention yielded that neither was found to be superior to the other" doesn't mean we discount one or both. Perhaps we need to start asking better questions. Perhaps we need to tighten up our research design.
I know - big talk from a non-academic who isn't doing the research. But -- pehaps that's also part of the problem. Perhaps we as clinicians need to get a bigger voice and start posing the questions.
3. Terminology Sucks: Agreed. And I gather this is at the heart of what Dr. Moseley is getting at. Maybe it's not the looking at variables like structure that is the problem, perhaps it is the way in which we communicate the what we are looking for and why we feel it is relevant that is the issue. Is it relevant? Maybe, maybe not.
Someone can't rotate their neck due to pain and restriction, you apply manual intervention (really don't care what in this instance, MDT, soft tissue mobilization, joint manipulation, dry needling) and they then can move there neck and rotate with no pain, to me the structure mattered.
With regard to terminology: I kid you not, as timing would have it, I had a patient today who had a Nerve Conduction Study done yesterday by their Neurologist. Patient has been doing great. Long history, and without violating HIPPA what I will say is after being in pain for 12 months, having no relief with 'shake & bake' out patient physical therapy, we had them pain-free most of the time within 4 visits and when they had pain it was rated as 3/10 as opposed to the 8-10/10 they had been dealing with. (And when I say We, I refer to the patient & I - it's a team approach, we as clinicians don't 'fix people').
Today: 7/10 pain. Why? Because they were told they had a pinched nerve, and was shown diagnostic proof. The patient even recongnized and identified this as the trigger without any prompting or suggestion. They were then presented with the referral to pain management, which they refused, being the smart patient they are. "Why should I do that when PT has gotten me so far is such a short time? Wouldn't it make sense to do a few more visits and see if there is any pain left to even manage? (Right! It's great when they get it!)
Terminology, explanation, rationale. All of the communicating we do with our patients matter. This is where we fail. We also fail when we take things away from patients with our absolutes: 'Never bend over;' 'Never squat;' 'Never deadlift; 'Never run,' but that is another blog post all of it's own!
So now that we have gotten that out, here is the last question which kind of is the Grande Finale of sorts, as it comprises the first 3:
4. How are clinicians treating in clinic if mechanics, manual therapy, & exercise don't matter? And how we will we as a profession continue to exist if the majority of what we do is considered fodder based on the pain science explanation and EBP literature?
I will tell you, as I admitted earlier, that I am a mixer. In working with said patient above, I can tell you we did do the explanation of pain and where it comes from/what it is talk the first day along with the evaluation. And upon next visit -- they still had pain. Their sessions also included breath work, manual therapy, and exercise. Can I say definitely what 1 thing made the difference? No, I can not - at least not you your approval or that of the research which demands reproducability. Tricky thing that reproducability, as we have yet to reproduce two exactly the same human beings who act, feel, and experience exactly the same, even among twins. So why are we so bent on reproducible results when the next person is not the same as the last?
Yes, I still worked at correcting perceptions that I think are incorrect or not optimal related to pain, where it comes from, and should it be provoked (patients come up with the darnedest things!)
So how should it be done. Should each visit simply be a discussion of pain neurobiology? Is it the act of discussing it that makes the difference? Is it really that simple? If it were wouldn't Psychology be having far greater 'wins' in this realm if it were? I have seen many patients seeing the "Pain Psychologist" who still had chronic pain despite all of those sessions. Is perhaps the act of seeing the "Pain Psychologist" by title a reinforcement of the somatoemotional component of pain? (yeah, I went there!)
I know -- more questions than answers, welcome to the world of my brain.
Placebo. There is also the argument that manual therapy, exercise, etc. work, 'but not in the way we think they work.' No kidding. And we wonder why PT has an identity problem...again, topic of another post.
Back to Placebo. If we can show that placebo makes an impact as seen in brain imaging studies. And explaining the pain neurobiology also has an impact as seen in brain imaging studies. And manual therapy & dry needling also have impact as seen in brain imaging studies...is it super far fetched to ask whether the conversation ie counseling that you are giving patients about pain is also a placebo?
Is it possible that one patient's brain perceives threat differently than another patient's, which is why one patient responds to one intervention, and one responds to another, and both have a positive outcome?
Things that make you go Hmmm....
Oh, and despite all the questions and the elementary nature of some of them, I really have read a lot of the literature on the topic. Perhaps I'm just not looking at it through the right lens...
I'll cut it off there.
Love to hear feed back, criticism, or just your two cents.
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