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Re: Fierce Conversations
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Re: Fierce Conversations - June 25, 2005 2:59:00 AM
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Barrett
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From: Cuyahoga Falls, Ohio
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Alex,
Well, most of what happens in the body isn't like this. That's why almost anybody can competently treat an ankle sprain.
I think the frustration that many have with problems containing a less obviously involved tissue or a linear response to care is often transfered to the caregivers with the courage necessary to take a shot at treating them. PTs willing to take on something less "concrete" than ankle sprains are dubbed the "crazy" one in their department and are sent the "crazy" patients. This usually means a patient with nothing more than spreading symptoms (a hallmark of an abnormal neurodynamic).
Instead of reasonably discussing the complex issues involved, the treating therapist is characterized as crazy or, as Childs called me "reckless" and "disingenuous" (read "liar"). Obviously I've not forgotten this. We are castigated for simply pointing out that many issues confound our ability to truly "know" what is happening or what to do. These aren't fierce conversations because one side refuses to interrogate reality-and it isn't my side.
Check out Jon's thread "Behavioral Switching" at the top of the Bullypit. I'm guessing it will point out some things about outcome studies subsequent to movement therapies that will make you wonder why we ever even try, and it might solidify the "concrete" you'd prefer to consider.
Of course, many things about painful dysfunction will forever remain less than obvious or easily studied. They will remain present in our patients nonetheless and I for one am grateful for the therapists willing to consider them. Quite simply, I don't hate what such a situation dictates-it's what keeps me awake at work.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Fierce Conversations - June 25, 2005 1:58:00 PM
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nari
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I would dare to say that if all I treated were joints and 'concrete' bread and butter PT work (which many others can do, as Barrett says) then I would have abandoned the profession years ago, for my own sanity and for the sake of the bread and butter patients....
Nari
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Re: Fierce Conversations - June 25, 2005 2:24:00 PM
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SJBird55
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Wouldn't we do better if we could identify those patients that have the potential to be less than "concrete" and maybe assist and guide them so they don't head down that pathway of chronic pain?
When it comes to patients with chronic pain, there are SO many various theories out there and differing views from various researchers. The scientist that I met and listened to from Michigan State University, was very much into the peripheral nerve changes - chemically and structurally and how they became excitated via normally non-exicitatory chemicals. But then, when one starts reading fMRI, wow... those changes in the brain seem to indicate some neural plasticity and some "practiced pathways" that become the dominant pathway - combined with the biochemical changes. In my opinion, we don't want patients ever reaching that point... neuroplasticity is GREAT after a stroke, but geesh, what a mess after a "simple" injury. I think our role should be more at the front end to potentially put a stop to that whole type of response before it even happens. So, Barrett, I've tried to understand what you do, but technically that theory still seems to have a flaw - how did the engrained pathway get eliminated via peripheral inputs? And, without actually testing your theory by assessing your outcomes, well, how do you know that your treatment preference style does give you good outcomes or to what degree do outcomes occur? I have always seen Childs view... but at the same time, I'm not going to say you don't know what you are doing... instead, I'd rather ask that you prove to me that you are getting decent outcomes. If not you, then someone who at least practices as you do. But instead of trying to answer what some of us "concrete" thinkers are screaming for, there is a tendency to toss out the simple fact that no one knows how manipulation works. Well... no, but geesh, there are outcomes as to when to use it for low back pain and the results you will get. Reality is that you have a theory... hmmm, just as Kendall has a theory... just as Sahrmann has a theory... well, the guru days are over - proof. That's all that's needed. When you have that, wow, you have one amazing package to offer.
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Re: Fierce Conversations - June 25, 2005 2:52:00 PM
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Barrett
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From: Cuyahoga Falls, Ohio
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Gurus aren't gurus just because they espouse a theory but because they display some combination of greed, sociopathy and a continual refusal to entertain opposition. Any implication that I behave as a guru would behave is an insult, plain and simple.
In addition to that, not all theories are worth the same. Some, like Kendall's, have been thoroughly undermined and should have been abandoned long ago. The presence of a few well-placed fierce conversations in our profession would have accomplished that but I've yet to see this. No outcome study has held it in place-it's just doctrine, tradition, ease of practice and billing combined with the polite discourse common to the culture of national conferences.
This, in my experience, is far too large to overcome without something I can't yet imagine happening.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Fierce Conversations - June 25, 2005 3:20:00 PM
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SJBird55
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I don't view a guru as you do... I just view a guru as a teacher or a leader. I do think that most a guru will generally "refuse to entertain opposition" though, especially if the opposition is questioning the guru.
I didn't post my previous post to insult you... this is all under "fierce discussion" and hey, I've got questions.
I'm just really confused... you'd love to see "tea party" atmosphere in the physical therapy world be abolished... you'd like to see theories proven wrong abandoned and overall more fierce discussions would be a good thing but, when I try to have a fierce discussion, the actual meat of the discussion is ignored and instead twisted to insinuate that I insulted you. So, my perception ends up being that you don't want to talk meat and potatoes, you'll just keep with the fluff.
And honestly, from my perspective, my goal isn't to be fiesty or to put you on the spot or to be disrespectful - I just don't have anyone to ask the questions I have asked or anyone to communicate my view with because you're the guy. Why do it behind your back? Just bring it to you... Since you brought up the whole "fierce conversation" topic, I figured you were ready for what twists in turns this particular thread took...
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Re: Fierce Conversations - June 25, 2005 5:46:00 PM
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Jon Newman
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I'd like to add some thoughts at this time. According to Leslie Portney and Mary Watkins in their book "Foundations of Clinical Research: Applications to Practice", they say this about theory testing (p. 23)
[QUOTE] When we speak of testing a theory, we should realize that a theory itself is not testable. The validity of a theory is derived through the empirical testing of hypotheses that are deduced from it and from observation for the phenomenon the theory describes. The hypotheses predict the relationships of variables included in the theory. The results of research will demonstrate certain facts, which will either support or not support the hypothesis. If the hypothesis is supported, the theory from which it was deduced is also supported.
When we compare the outcomes of individual research studies with predicted outcomes, we are always aware of the potential for disconfirmation of the underlying theory. In essence, the more that research does not disconfirm a theory, the more the theory is supported. This may sound backward, but in actuality we can never "prove" or "confirm" a theory. We can only demonstrate that a theoretical premise does not hold true in a specific situation.
[/QUOTE]I've some more thoughts that apply the above concepts but invite others to make this a conversation.
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Fierce Conversations - June 26, 2005 1:54:00 AM
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hinchinbrookphysio
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Unrelated to physio I recently had a "fierce conservation" with the local council and have never been more satisfied with myself. They told me I could not do something because of a State Policy and that they had been fighting for five years against the state to do the same thing. In short I reviewed the State Policy (150 pages long) found a flaw/loophole; had a fierce conservation with the State Ministers Office; and subsequently the local council; and now will make history as the first test case to be passed. As I said I have never been more satisified and all thanks to fierce conservation.
I will say though that my fierce conservation skills were developed by my physio mentor who always pushed the boundaries and questioned me but did not mind what treatment I chose as long as I could explain the rationale.
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Re: Fierce Conversations - June 26, 2005 6:43:00 PM
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dragonfire
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From: usa
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jon,
based on what you just posted, i'm thinking that we can consider a tx approach that has been observed to lead to a desired result/outcome numerous times and in numerous situations, eventhough we still may not have the full picture as to why such an approach works. is this considered evidence based practice? anyone can answer this. i have asked this question before and have not yet found a satisfying answer to this.
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Re: Fierce Conversations - June 26, 2005 7:02:00 PM
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Jon Newman
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Yet another link that I think is useful to a discussion about theory.
[URL=http://www.corante.com/loom/archives/2005/06/23/evidence_and_exasperation.php#comments]Evidence and Exasperation[/URL]
DF,
I'm not sure that helps answer your question. You could also visit a previous thread on [URL=http://www.rehabedge.com/cgi-bin/ultimatebb.cgi?/ubb/get_topic/f/25/t/001468.html]evidenced based medicine[/URL]
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Fierce Conversations - June 27, 2005 9:28:00 AM
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dragonfire
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From: usa
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tahnk you for the redirect. will read the 2 threads. i also chanced upon a thread on LBP manipulation prediction rule started by jma which was loaded with views on evidence based practice. tons of reading to do!
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Re: Fierce Conversations - June 27, 2005 11:11:00 AM
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Jon Newman
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Consider [URL=http://www.rehabedge.com/ubb/ultimatebb.php?/ubb/get_topic/f/15/t/000149.html]this thread[/URL] also when you are done with those.
Enjoy
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Fierce Conversations - June 28, 2005 5:45:00 AM
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JLS_PT_OCS
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Jon-
I can't believe you would risk re-animating the now-infamous "Thoughtfulness Dies" thread!
When I think of Fierce Conversations, that's what I think of. I learned a lot in that thread, and I am still digesting the thoughts and new directions given me by Jon, Barrett, Nari, Diane, and others.
It has lead me to very interesting places lately, and I must say the world looks a lot different to me now than it did when we had that conversation. If it had not been as Fierce as it was, I doubt I would have evolved to the place I am currently located. That indeed would have been a shame.
"You do not truly know someone until you fight them." -Seraph, from The Matrix
It is as true on the jui-jitsu mat as it is on a forum board.
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Fierce Conversations - July 12, 2005 1:41:00 AM
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nari
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From: Australia
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What happened to the Fierce Conversations thread?
Nari
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Re: Fierce Conversations - July 12, 2005 2:29:00 AM
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Barrett
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From: Cuyahoga Falls, Ohio
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Nari,
Maybe it has run out its string.
In any case, a portion of my opening lecture now includes a few comments about what motivated the therapists present to attend. At this point it's been clearly established that they haven't investigated any of the literature as suggested in the brochure, they hadn't ever heard of me before the brochure arrived and most haven't read the description of my career provided. It's clear that most are there only because the word "pain" is in the course title. I must conclude that they are desperate enough regarding this issue in their clinic that they will go anywhere and listen to anybody who seems (or claims) to have a solution for them. There is no due diligence. I say, "Can't you imagine that many con men see your desperation and prey upon it?"
These aren't the kind of observations designed to make others comfortable, but they "interrogate reality" as Scott suggests-and then we go on from there.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Fierce Conversations - July 12, 2005 2:30:00 AM
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JLS_PT_OCS
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From: USA
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I hope I didn't kill it with the cheesy Matrix quote...
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Fierce Conversations - July 12, 2005 2:34:00 AM
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Barrett
Posts: 967
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From: Cuyahoga Falls, Ohio
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Jason,
Certainly not. Of course, I'm the guy who thinks that just about everything we need to know is in movie form somewhere.
Ever read "The Matrix and Me" on my site?
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Fierce Conversations - July 12, 2005 5:24:00 AM
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JLS_PT_OCS
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From: USA
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Yeah, I enjoyed that essay quite a bit.
There is a lot of interesting reading on your site, and I'm sorry I had to miss you in Fairfax last month.
I will definitely be at one of your courses in the future, perhaps only now that I have done the "due diligence" you referred to above.
Maybe I can be a counterweight to some other participants who come in as prepared as you suggest they are. Or unprepared, as the case may be. :)
I agree that not many Fierce Conversations happen in our profession, but I state with confidence that this phenomenon of the "tea party" atmosphere is not unique to PT, nor even to health care professions. That doesn't make it OK, just makes it more of a widespread problem (which clearly is not good news...).
I think one reason that happens is that one must be informed well about a topic (or in my case, just have a strong opinion) in order to truly have a Fierce Conversation. If the information level is not balanced, then one party is "out-gunned" and usually responds by shrinking away from the debate. I think this explains a lot of what happens at your courses and I'm sure you have realized this already.
There are not many people who have the requisite knowledge to play in your backyard on the issues you discuss.
Other perhaps more "concrete" subjects that more PTs are familiar with have a much larger pool of potential players.
So I think having a Fierce Conversation starts with helping people see that a given issue is important enough to get informed on, in order to set the stage for such a conversation to occur in the first place...
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Fierce Conversations - July 12, 2005 8:35:00 AM
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SJBird55
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From: Michigan
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In my opinion, a fierce conversation can't even occur if two parties or more aren't interested in partaking. I'm still waiting for answers... A non-response to any questioning never leads to any fierce anything - both parties are either at limbo, or a stalemate, or moving on into a different direction. Questioning, debating and disbelief should never be associated with negativity... poking, prodding and questioning can have the positive effect leading to change.
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Re: Fierce Conversations - July 12, 2005 2:25:00 PM
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nari
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From: Australia
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Jason
I think that having well-informed topics is important, but so is a strong opinion. After all, what comes across to patients if a PT has strong opinions? Having solid opinions on a well-versed topic or two is ideal; and then,often, the label of guru is attached. I think those of us who are not gurus can handle that; (I am one of them, and I do have strong opinions on certain things).
SJ - I agree, it takes more than one or two to partake in a tea party OR a fierce conversation.
In some situations, a sort of protocol is (or should be)implicit, I guess, to prevent too much carpet-pulling.
Then again, as Barrett says, maybe the yoyo has reached the end of its momentum. Perhaps a topic closely held in people's cognisance could be raised as an issue which is relevant to all of us.
Anyone want to start the ball rolling on a juicy topic within clinical practice? :cool:
Nari
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Re: Fierce Conversations - July 12, 2005 3:30:00 PM
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SJBird55
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From: Michigan
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So... Barrett... I'm ready to continue the fierce conversation. I'll be much more blatant and concise in my questions.
With the manual technique that you use, generally speaking
1) How much time do you spend during an individual session with the patient?
2) Let's talk money - I'm supposing you use the 97140 code. So, how many units do you bill out per session? Well, and what other codes, if any? And, how well are your charges reimbursed?
3) How do you document your treatments provided to correlate with your charges and to what amount of detail?
4) On average how many sessions of physical therapy are utilized for one episode of care?
5) What is the average amount of disability prior to initiation of services? What is the avarage amount of disability at discharge?
6) Same two questions but put "pain" in for "disability."
7) What stage of healing are most of your patients in that you utilize your manual techniques? (acute 0 to < 6 weeks; subacute 6 weeks to 6 months; chronic > 6 months)
8) Demographics: age, gender?
9) Characteristics of the complaint of pain in which you use your techniques? In other words, how does the patient describe his/her pain experience?
For me, I think the answers to the above would be a great place to start so that the discussion can continue. The ball's in your field, Barrett... the discussion either dies in my mind, or it can continue.
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