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RE: Comments on this please
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RE: Comments on this please - December 16, 2007 6:01:06 PM
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Bournephysio
Posts: 576
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From: Calgary
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“well Doug,if you are suggesting myself and jason and everyone else who commented are biased, then I propose that you are biased in the opposite direction; towards random pokings.” No I am saying that if you or anyone else believes that they can conclude that acupuncture is a placebo from this is clearly biased. Jason clearly didn’t read this thread carefully and my comments are objective. In addition his tirade was clearly not called for. Lumping acupuncture in with homeopathy was clearly biased.
“Random pokings tends to take the onus of responsibility away from the patient” not if you educate your patient properly. If you were in pain how would you like it if someone held back a treatment that could help decrease your pain because it tends to take the onus of responsibility away from you? I don’t buy that argument at all.
“what is consistent with the literature on chronic pain?” How is choosing acupuncture inconsistent? The evidence is strong enough that a Cochrane review concluded: “Dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain.”
“Ther NEEDS to be more to it” Yes, but for chronic pain we haven’t been able to show that we can do anything more than help the patient learn to modulate their own pain. Its the common thread that runs through all of our treatment techniques.
“otherwise we may as well just accept that all kinds of alternative medicine seems to modulate pain. So what?” We can’t accept that until we have evidence that it is true.
ALL studies are full of holes. Lets take subgrouping patients into categories. At least according to Peter Huijbregts, only one of these classifications has been validated. It is just as full of holes as the study in question. The control group hasn’t been shown to be effective in this group. They had no placebo control. The population is different than what most therapist experience. There was no group receiving treatment that is typically used in practice. The study has not been replicated by another group. One of the assessment techniques used has questionable reliability. You can tear any study apart. The question is: Do you use the same criteria to evaluate different studies? If not, you are biased.
SJ: a well thought out post. I am only going to comment on one point “1) What would have happened if the small bit of evidence we do have for these types of patients was truly applied and put head to head with acupuncture?” Again I have no interest in seeing this. I would much rather see AP with other indicated treatments especially exercise. I would also like to see some attempt to determine what patients are best suited for acupuncture. It is impressive that AP has been able to achieve this level of evidence before subgrouping and the addition of exercise.
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RE: Comments on this please - December 16, 2007 8:09:45 PM
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proud
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Well doug, I'll comment on a few of your statements:
Here:
quote:
No I am saying that if you or anyone else believes that they can conclude that acupuncture is a placebo from this is clearly biased. Jason clearly didn’t read this thread carefully and my comments are objective. In addition his tirade was clearly not called for. Lumping acupuncture in with homeopathy was clearly biased.
Well placebo is not nessicarily a negative term. And sure the studies are not there for homeopathy but I am certain with appropriate funding, we would see that when the patient perception matches say... cranio-sacral therapy....pain is modulated. But you are correct we cannot assume....but it's a pretty good bet.
Here:
quote:
not if you educate your patient properly. If you were in pain how would you like it if someone held back a treatment that could help decrease your pain because it tends to take the onus of responsibility away from you? I don’t buy that argument at all.
I would love to know how you explain that to your patients without removing the "patient perception aspect". And....I think.....in that comment you have demonstrated a lack of understanding about persitent pain. The central changes that occur. The anterior cingulate cortex. The insular cortex etc. These patients have usualy endured and endless array of passive modalities. They require education of pain physiology( Moseley), an understanding of harmful pain verus non harmful pain. They require LESS passive treatments not more. YEP, AP can modulate the pain for a period, but long term, that patient in persistent pain will be right back to square one.
Here:
quote:
How is choosing acupuncture inconsistent? The evidence is strong enough that a Cochrane review concluded: “Dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain.”
NO. It shows that AP modulates pain. But as stated, for chronic pain, patients have usually been there...done that. I'd be willing to bet if you look into that 8 year Hx in most of those patients in the German study, they had a few "interesting" treatments that they found reduced their pain....for a period of time.
Here:
quote:
What would have happened if the small bit of evidence we do have for these types of patients was truly applied and put head to head with acupuncture?” Again I have no interest in seeing this.
Why? Why not?
Finally, you say you would rather see sub grouping for AP but sub grouping as in the CPR for manipulation has something different...the acute phase. Before the changes in chemistry occur in that group of persistent pain patients. Just as manipulation for chronic LBP can modulate pain for a period of time( some chiropractors have made a living off that party trick), in the end that patient is no further ahead. AP modulates pain but is yet another passive modality. As stated, these patients do not need more passive modalities...they need less.
< Message edited by proud -- December 16, 2007 8:32:58 PM >
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RE: Comments on this please - December 16, 2007 11:42:49 PM
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Bournephysio
Posts: 576
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From: Calgary
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I don’t think that you understand what neuromodulation is. It is not strictly cognitive but physiological. Patient expectation is not the only thing that can drive it as shown in animal studies, peripheral stimulation can drive it. There are different neural pathways that neural modulation can affect (such as serotonin or endorphin). Not all neuromodulation is created equal. TENS has never shown any long term effects. There is no reason to think that homeopathy would produce a similar effect to acupuncture.
“I would love to know how you explain that to your patients without removing the "patient perception aspect". And....I think.....in that comment you have demonstrated a lack of understanding about persitent pain.”
How? I don’t understand your problem here. Everything I have written is completely consistent with current pain science. If you disagree, specifically state why.
“They require education of pain physiology( Moseley),” you mean like this study that showed no clinically significant change in disability:
A randomized controlled trial of intensive neurophysiology education in chronic low back pain G Lorimer Moseley, Michael K Nicholas, Paul W Hodges
I see no reason why passive treatments can not be incorporated in a treatment program given the proper education and there is no evidence that I know of to the contrary. You just state they need less passive treatments and don’t offer any evidence. You present this as being well understood. Even with exercise and cognitive behavioural therapy, we are not doing particularly well with chronic pain.
“EP, AP can modulate the pain for a period, but long term, that patient in persistent pain will be right back to square one.” That’s why you never have a treatment plan that just includes manipulation or acupuncture even in acute cases. If you can immediately decrease their pain you get better buy in for the rest your treatment plan. Six months is a long time to promote a good exercise program which will hopefully translate into long term results.
“Finally, you say you would rather see sub grouping for AP but sub grouping as in the CPR for manipulation has something different...the acute phase. Before the changes in chemistry occur in that group of persistent pain patients.” That doesn’t preclude the possibility that a subgroup of patients would benefit from acupuncture. Chronic pain may act as homogenous subgroup itself but we don’t know that.
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RE: Comments on this please - December 17, 2007 8:06:28 AM
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Sebastian Asselbergs
Posts: 1105
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From: Barrie, Canada
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My 5 cents worth: "passive" as a qualification for certain therapies needs to be carefully examined. I think we can all agree that even when a person is lying fully still, a truckload of neurophysiology is going on: the processing of input/output is NOT exclusive to motion alone. For many of my patients (chronic pain patients), doing relaxation and centered breathing - a very "passive" looking activity - is a godsend and a major brain and consciousness and cognitive activity. In this context, one can argue for the benefits of TENS as a wedge in the door.
I agree with Doug that making an "interruption" in the pain experiences can open the door to more active self-regulation with motion, exercises or such.
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Mundi vult decipi
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RE: Comments on this please - December 17, 2007 9:34:34 AM
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proud
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Doug,
quote:
I don’t think that you understand what neuromodulation is. It is not strictly cognitive but physiological.
Right. The summery article I posted talks about that. Textbook of pain. 5th edition is a nice read as well.
quote:
I see no reason why passive treatments can not be incorporated in a treatment program given the proper education and there is no evidence that I know of to the contrary.
I never said there was. But AP is largely believed to recruit descending pain control systems. Much evidence in chronic pain suggets a large contributing factor is, as you stated cognitive. Yes, I would be extrapolating from the pain sciences, but AP is yet another party trick that modulates pain but does little to assist the patient in overcoming anxiety, anticipation, attention to pain etc. All aspects of chronic pain. By letting a patient believe that AP is "fixing" something, could it make the situation worse in the long run?
Doug, you never did explain to me how you went about explaining to your patients what your random pokings is doing. I would like to know how you explain things. Much evidence also shows that simple perception plays a role in pain and if you take away the "perception" of what AP is doing, I am not certain there would be a pain modulating effect. Because my thinking is that if the patient has the "perception" that AP is altering...."fixing"....pathways...then that patient will go on being focused on the anatomical explainations for their percieved pain( attending to pain appears to activate the insula....and we do not want to activate the central system any further right?). Perhaps this is why the plethora of past passive treatments for people in persistent pain have failed. My guess is that although those descending pathways are a nice way to be a wedge in the door for those in persistent pain( as Seb said), the attention to pain that passive treatments evoke could actually....long term.....worsen the outcome. And yes.....it's extrapolating from the science. But that is part of having discussions is it not?
Unless you have a clever way around that in your explaination regarding the effects of AP?
< Message edited by proud -- December 17, 2007 9:46:47 AM >
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RE: Comments on this please - December 18, 2007 12:00:02 AM
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Sebastian Asselbergs
Posts: 1105
Joined: September 29, 1999
From: Barrie, Canada
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"the attention to pain that passive treatments evoke could actually....long term.....worsen the outcome"
I have to put this forward: When I inform a patient of the therapy to be "utilized" in my clinic, I always preamble that with neurophysiology education (in the last two years or so) - and this includes the information that it is THEIR nervous system to be addressed. That it is their nervous system that is front and centre in ANY improvement they experience - no matter what techniques or therapies are used on them. They are often under lots of meds - THE most passive of therapies. So, if I decide to use a hotpack to enhance their relaxation, softening them, or use acupuncture, or TENS, or manual techniques, it is already clear that these are the lesser aspects of care - adjuncts. They are also informed of the potential value of their belief in their therapist. ( I obviously take a lot of time.....)
Acupuncture CAN play such an adjunct role. As manipulation can.
It seems up to the therapist to apply these, or to decide NOT to use any modalities at all, other than just verbal and manual techniques.
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RE: Comments on this please - December 18, 2007 9:19:25 AM
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proud
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Seb,
The distinction I think is the characteristics of persistent pain( ie chronic pain population) versus no persistent pain.
I would agree with you in suggesting that passive modalities can be useful( that includes manual therapy) in treating those without persistent pain because essentially...our main role is to prevent....as best we can.....the development of persistent pain. We can do this by identifying typical characteristics that might predict the progression towards this( fear avoidance, depression, poor work life satisfaction) You will note that the CPR for manipulation has that one variable: Duration of pain <16 days.....along with lower FABQ scores. Thus this passive modality is more admissible in my opinion because at least one predictive variable for the development of chronic pain is investigated.
Persistent pain is different. Central changes occur on a biological level. Also, evidence suggests that they often display characteristics of being "avoiders" so passive modalities should be kept to a minimun to help prevent further feeding into the potentially sef-destructive "avoider" coping strategy. Despite attempts to educate patients( I am still uncertain how Doug does this with regards to AP), the passive modality tends to have the effect of making patients MORE focused on pain thus potentially, further winding up the central changes( as studies on the insula suggest....attending to pain will activate things). There you have it...
< Message edited by proud -- December 18, 2007 10:08:50 AM >
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RE: Comments on this please - December 18, 2007 1:30:12 PM
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Sebastian Asselbergs
Posts: 1105
Joined: September 29, 1999
From: Barrie, Canada
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Proud, I guess it boils down to how we can convince the patient (and what type of caseload we have). The application of any modality is really a patient-to-patient variable in persistent pain situations. I have found that most of these patients are very happy to learn that they do NOT have a permanent condition, and that it is modifyable by themselves. The empowerment is suffient to preclude the development of dependency to anything -most express the disgust of having to depend on drugs to begin with. Mind you, these are MY patients - and I have found that my caseload tends to be self-selecting towards a certain persistent pain patient; those looking for profound help rather than a quick fix.
It is obvious that my clinical situation colours my view on these issues in PT.
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RE: Comments on this please - December 18, 2007 1:33:25 PM
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SJBird55
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Sometimes though, proud, it might be helpful from a patient perspective or even a patient/provider relationship to maybe initially include a passive intervention for the bare minimum reason of establishing trust and using the passive intervention as an initial step to move the person into an active direction. That passive intervention time can be spent educating and therefore potentially altering central cognitive pathways and even potentially altering motor pathways via performing the passive intervention but having the patient actively involved in mentally envisioning the performance of some activity. Mental imagery has shown to bring motor changes in patients with persistent pain. I personally believe that the rationale and critical thinking aspects of what we do are highly relevant. A treatment plan that is predominantly passive in nature for patients with persistent pain isn't going to cut it in the end... but does effectiveness change when the treatment plan has a multimodal focus of initially meeting patient perceptions by including a small passive portion (for those patients that initially believe that is what they need)... definitely including a cognitive portion (education)... focusing on changing perceptions/beliefs/expectations by definitely including a behavioral portion... ramping up into an exercise portion and then problem-solving what is working and empowering patients to also increase their independence and at the same time increase their self-efficacy and active coping mechanisms.
In treating patients with persistent pain, it is somewhat of a game... a game of altering perceptions and expectations while reducing fear so the patient's beliefs, expectations and perceptions are more in line with the bit of evidence out there. Sometimes in playing that game, as with life, we need to negotiate with ourselves if there really is a bit of harm in providing a passive intervention for a few sessions if the end result is a patient that has active coping strategies, less fear, less pain and increased function.
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RE: Comments on this please - December 18, 2007 2:29:05 PM
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proud
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As always SJ, an excellent posting. I agree with everything you said there.
I guess my experience with PT's and random pokings has been that very few use it in the matter you describe. Also, of all passive modalities, acupuncture has the largest patient perception component because there is an invasive nature to it( penetrating the skin). I think the chiropractic bag of tricks in convincing clients that a bone is "out of place" and requires adjustment.... approaches the same level of mind games as AP. Mind games in the acute stages may actually have a beneficial aspect because it helps the patient "get over the hump" faster and simply get moving before they start down that dark road of chronic pain "avoider" behaviors. That's how I see it.
I still wonder how one can remove the patient perception part of AP? Which likely is a large player in the pain modulation. I mean what do you say?
Knowing that preventing those acute pain patients from transitioning to persistent pain patients is a key part of what we do....I can see using passive pain modulating modalities as part of the strategy. But those in chronic pain already display passive "avoiding" type behaviors. They tend to "attend" already too much on pain. Introducing a passive modality....especially AP just further "winds up" the whole situation. As I stated, I maintain that they require less passive treatment...not more.
This German study that the Canadian Physiotherapy association chose to champion appears to miss the concept completely. Which again fits with my personal experience with PT's and AP.
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RE: Comments on this please - December 19, 2007 7:48:32 AM
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SJBird55
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From: Michigan
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I'm not sure how one would evaluate how large a patient perception component is... I know for me, I strongly dislike needles and I don't want any needle in me - not for injections, not for immunizations, not for tetanus shots, not for any deeper than removing a splinter. LOL I was even very against a spinal block during labor and delivery... but a combination of fatigue, continual waves of pain and no progress led me to have the thing. I don't NOT get immunized or tetanus shots, but whichever arm is free the opposite hand has a death grip on the arm of what I'm sitting in, I freeze, I refuse to watch, all color drains from me and anyone would swear I'm gonna drop.
A patient's experience and beliefs create perceptions, right? I would not tend to believe that the invasiveness of a procedure is a quality that would indicate how a patient would perceive the procedure.
There are times that you might be further ahead in meeting patient perceptions... I'm not one who generally does many passive interventions. There are times though that sometimes it is in the best interest of the patient so that they will have the ability to move in the direction I'd like to go with rehab - they just aren't there or ready to go in that direction because their perceptions might be off, their beliefs might be off and I need to do a bit of work to get them there, little by little. How about this for an example... I had a lady come in with chronic low back pain. I had MORE perceptions to change than you'd ever imagine... 1) she was from Iraq (northern area which she stressed) 2) she spoke hardly any English 3) she wanted massage Now, from my perspective... I do not know anything about her culture; I spoke through her daughters (thank goodness); I knew that since I couldn't communicate as effectively OR educate as effectively that by golly, I better meet her perceptions somewhat. You better bet she got massage! She got more massage than I'd ever do, but guess what.... slowly I was able to incorporate that stuff I wanted. Kind of a give and a take... AND I know things worked out fine because I've seen her for her knee replacement AND for an ankle problem each a year or so apart a couple of years after her back problem. Her back wasn't an issue any more. Now, was I more efficient with her? Nope... took me twice as long as normal. Could I have reached the same end point doing what I really thought I should be doing? That I can't answer, but I do know that I don't believe that exercise is a strong focus in their culture AND from my observations her daughters tended to coddle her and take over her role and limit her duties.... As she was able to do more in the clinic, I would suggest one or two activities that I wanted her to begin doing in the home to have her "mom" role established (i.e. cooking, dusting, whatever)
Patient centered treatments will get you a lot further than therapist centered treatments. Initially begin by meeting their perceptions and plug along to alter their beliefs and expectations to move toward a direction that may be in complete opposite of their beliefs. I just see it as a game. With every game there is a strategy... you know where you want to go, you know how you should do it, but you've got a patient splat in the middle that you're playing the game with. Each patient needs a different strategy. I had a guy yesterday who had severe pain and back spasms... he has a military background and he's supposed to go to Iraq. He didn't get coddled - he got my perspective of the situation straight up without any sugar coating and he got his "orders" of what he needs to do if he wants to go to Iraq. It's a whole different game and strategy with him.... I have to get the same message out, the way I do it will be different though.
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