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RE: ACL rehab
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RE: ACL rehab - March 11, 2008 7:11:30 PM
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pappawheelie
Posts: 40
Joined: September 19, 2007
From: Vermont
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quote:
I think the reason is that people want immediate or complete resolution of their problem, often without having to commit any effort whatsoever. "Crack my back and it will feel better" vs "stretch your hamstrings and pick up that cement block a different way"
I think we should give them both (cracking only when appropriate of course).
quote:
Unscrupulous providers, who get into the business for the money are able to use fancy words and models and posters to convince people, to play on their hopes and fears. I have had "alternative" practitioners tell their patients (who later became my patients) that if they didn't sign on for 20 treatments and pre pay for them, they might not be walking in 3 months.
They don't "know" , they just know how to extract $$ from people in need.
I have to agree. But if people are in pain and they find relief from their pain--no matter what the method is, won't they believe in that method? And if a method is totally bunk, or a practitioner worthless, why would anybody return? How come there is such a thriving market in alternative therapies? I think some can be attributed to mis-information, but some can also be attributed to personal testimonials.
_____________________________
Ted Lamb, MSPT
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RE: ACL rehab - March 11, 2008 7:19:36 PM
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PTupdate.com
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Joined: October 8, 2001
From: Pittsburgh, PA USA
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Ted: I do see your point, and agree with much of it. But, if someone comes to you in pain, and you relieve that pain, how is that treatment considered bunk? Instead, it was a successful and beneficial treatment. Now, if you relieved that pain with a method that will have short lasting results, and don't do anything attempting to resolve an underlying issue, then you will be more open to criticism. But, if you relieve pain, giving someone at least a good nights sleep, or perhaps relieve it enough that they can perform exercises or other techniques that are beneficial, then you are going to have some happy customers.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: ACL rehab - March 11, 2008 8:41:20 PM
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proud
Posts: 875
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TRUTH. That....is the distinction we as professionals should be striving for. WE ARE ETHICAL PROFESIONALS.
There it is. Simple.
"Relieving" pain is okay if the method involves some truthiness....
We can all choose to "relieve" pain through deception. Deception in medicine has been around as long as money and it can be powerful....but in the end( read: longterm), it is harmful.
And we are not in the business of being harmful.
Ask yourself that simple question. "Am I deceiving this client". I'll start:
1. If you claim to release energy through the fascia....that's deception.
2. If you claim a spine is "out of alignment"....that's deception.
3. If you claim that a patients muscles are "full of knots that my massage therapist can work out for you...".....that's deception.
4. If you perform cranio-sacral therapy....that's deception.
5. If you spend more than 10 mins with an eloborate patho-anatomical explanation for your persistent pain patients....that's deception( this one requires some in depth understanding of the distinction between acute pain and persistent pain)....
And this one may sound politically incorrect but in a great number of instances, patients are just plain D.U.M.B...
I overheard a lady at the gym the other day talking to a friend about how great her cranio-sacral sessions were( paid for compliments of her insurance). Kept listening and what do you know....she has been attending for about 2 years; stopped working one year ago; stopped playing sports one year ago; stopped going to swimming lessons with her kids 6 months ago; her pain is increasingly interfering with her ability to enjoy life. Yet....thank goodness for that CST as it has "worked wonders". True story.
That is why testimonials are worthless. In this persons mind....because after a CST session she felt great, then that is a great and valuable treatment. What is the TRUTH in this case? I'm willing to bet it is not going to be found with CST( fully funded by insurance to boot)....
< Message edited by proud -- March 11, 2008 9:04:54 PM >
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RE: ACL rehab - March 11, 2008 10:55:14 PM
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jlharris
Posts: 468
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From: Nebraska
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Ted,
I'm not against "massage". However, if a person walks into your clinic with onset of LBP 1 week ago, no pain below their knee, hip IR > 35°, what you think is lumbar hypomobility at any level you better be manipulating that pt, then giving them a massage (assuming they are not afraid of a manipulation or have some other pathology that precludes them from being maniped).
We need to be able to be creative with our treatments. The Manip CPR has a NNT of, what, 2? So one person isn't going to get a 50% reduction in their ODI in 2 visits, so now what? That where clinical experience and intuition seperate you from satisfactory PT's.
EBM is about prioritizing out treatment decisions, not blindly following a "cookbook" or throwing out one's hard earned clinical experience.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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RE: ACL rehab - March 12, 2008 7:49:48 AM
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Tom Reeves DPT ATC
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my issue with alternative therapy is that ALL they do is give the patient relief.
The stuff we do often will give them relatively immediate relative relief, but offers a long term solution that makes us obsolete (a good thing, that means they are empowered to manage their own affairs) I love the CST example above. I get that from former chiro patients that "saw the light" that 2 years later, they are not better and their insurance quit on them. If we had to pay out of pocket, that leash would a lot shorter.
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RE: ACL rehab - March 12, 2008 9:14:31 AM
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PTupdate.com
Posts: 1436
Joined: October 8, 2001
From: Pittsburgh, PA USA
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" "Relieving" pain is okay if the method involves some truthiness"......well, if the pain was relieved, obviously the method involved something "truthy"....perhaps you mean more the explaination, as opposed to the act itself.
With regard to proud's notations above:
1. Quite true. That one cannot be argued
2. Not quite. I am treating my brother currently for what appears to be (another) HNP in the back. I've known him 43 years, and when I stood behind him a few weeks ago and said "Dude, your really friggin crooked" I certainly was not practicing the art of deception...he indeed was out of his normal "alignment" Radiographs often reveal a flattening or reversal of the cervical curve after a soft tissue cervical injury, another instance where one could use various terminology, including the word "alignment". You may be alluding to chiropractic terminology of subtle subluxations
3. I'd bet 95% of the therapists on this forum have used the term "knot" on a patient, and they certainly are not being deceptive. It's a general term meant for a local muscular palpable formation, be it a localized twitch response, connective tissue injury and re-heal, referred myospasm, or even local myospasm. Either way, these formations more often reduce in size and discomfort with manual work. Sometimes the use of generic terms with patients is used to ease the process of the communication, not to be deceptive. The cortisone shot may not have actually been Cortisone (a brand), but rather Decadrop of Depo-Medrol. When I said "here is a Kleenex" when I actually had a box of Puffs, I was not being deceptive.
4. Remember, there are many therapists practicing, feeling that what they are doing is correct, beneficial, and factual. Most PT schools are still teaching kids stuff that has not yet been proven, some are teaching energy medicine (see EIM blog), and some are still teaching incorrect mechanics for GH humeral glides. In fact, until last night, I was telling patients with a subluxating biceps tendon that one of the possible reasons was due to a rupture of their transverse humeral ligament. But guess what! There ain't such a thing as a transverse humeral ligament! I was not being deceptive, I was telling people something I was taught and thought to be true.
How are PT's really supposed to find out all the truths? Join the APTA? Not when their magazines are loaded with ads and courses that continually promote non-scientific equipment and/or treatments. Go back to PT school? Not when faculty continues to teach off the wall stuff. Read more? I don't personally know one PT that reads as much as I do, and I barely can scratch the surface of what is out there.
5. My same poor brother has had almost one year of foot pain. His duck-wide Duffy forefoot was being jammed into the toebox of of a non-supported penny loafer. I probably spent 10 minutes explaining the biomechanics and soft tissue response(s), including the neuroma, callouses, and plantar fascia pain of his persistent pain problem.....I was not being deceptive.
Jason hit the nail on the head with "EBM is about prioritizing out treatment decisions, not blindly following a "cookbook" or throwing out one's hard earned clinical experience" The majority of the medical literature has flaws and omissions, and too many times it's taken as gospel.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: ACL rehab - March 12, 2008 9:19:57 AM
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proud
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quote:
The stuff we do often will give them relatively immediate relative relief, but offers a long term solution that makes us obsolete (a good thing, that means they are empowered to manage their own affairs)
Exactly. This is what should define our practice. We should be ALWAYS, ALWAYS the primary access point of all things MSK( assuming we can rid ourselves of PT's who utilize CST, MFR as a central treatment). The key in my eyes is to have exceptional differential diagnosis skills to stream inappropriate patients to the appropriate providers( Moore at al 2005 JOSPT had a nice study outlining PT's exceptional ability to differentially diagnose).
Once a patient is provided with the CORRECT medical advice rather than a business building model including wacked out patho-anatomical explanations designed to increase fear and subsequent dependance on the provider, we should see less persistent pain development out of simple NMSK issues. This format will decrease the need for useless diagnostic tests and pharmacological prescriptions( there is a study that demonstrated the number one predictor of chronicity development was the prescription of NSAIDS and referral to a specialist). Physicians are ill equiped to understand NMSK issues at the level a PT is capable of. We are by all accounts the provider of choice for NMSK.
BUT...BUT....if we have PT's who fail to understand "PAIN". What it is. What happens on a cellular level, central factors, catastrophizing, fear avoidance, perception etc. Then we will have PT's who simply contribute to the development of chronicity and all the potential problems for treatment it presents( Wind up for example pretty much spells the end for most persistent pain patients). Telling patients they have spines out of aligmenent sends people down a dangerous path. Telling patients that they require their sutures mobilized sends the wrong message. And the cost to healthcare is very large. Our current system of dealing with NMSK issues is simply terrible and by allowing so many pseudo providers access to these patients, it actually contributes to the escalating costs.
< Message edited by proud -- March 12, 2008 9:37:33 AM >
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RE: ACL rehab - March 12, 2008 10:09:44 AM
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proud
Posts: 875
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John,
quote:
I am treating my brother currently for what appears to be (another) HNP in the back. I've known him 43 years, and when I stood behind him a few weeks ago and said "Dude, your really friggin crooked" I certainly was not practicing the art of deception...he indeed was out of his normal "alignment"
No doubt. I once had a instuctor tell me that if you look at a patient for more than 3 seconds looking for 'aligment' issues and it does not jump out at you....don't tell patients their spine is out of aligment....it likely is not.
quote:
I'd bet 95% of the therapists on this forum have used the term "knot" on a patient, and they certainly are not being deceptive. It's a general term meant for a local muscular palpable formation, be it a localized twitch response, connective tissue injury and re-heal, referred myospasm, or even local myospasm.
The deception part was suggesting the massage therapist you employ will "work it out"( meanwhile you take a portion of the profits). In my opinion, PT's can use masseurs when they have a client who has associated stress which may be impeding their progress. Massage is not therapeutic in a tissue healing sense( I'll wait for the argument on that....but I'm right...).
quote:
In fact, until last night, I was telling patients with a subluxating biceps tendon that one of the possible reasons was due to a rupture of their transverse humeral ligament. But guess what! There ain't such a thing as a transverse humeral ligament! I was not being deceptive, I was telling people something I was taught and thought to be true.
First off....really? No transverse humeral ligament? Do you have a reference?
And secondly, then you passed my "question" test..."am I decieving this patient...".
And thirdly....if a therapist is performing MFR, CST etc and they truly think there is a sound scientific basis for the treatment, then no they are not decieving the patient...they are just not worthy of the PT credential. D.U.M.B....
quote:
How are PT's really supposed to find out all the truths? Join the APTA? Not when their magazines are loaded with ads and courses that continually promote non-scientific equipment and/or treatments. Go back to PT school? Not when faculty continues to teach off the wall stuff. Read more? I don't personally know one PT that reads as much as I do, and I barely can scratch the surface of what is out there.
Yes. This is the career path chosen and it requires a comittment. You will not find the truth. But at least you can scan your information bank and determine quite well if you are indeed providing "best practice" in this case. If you don't read and remain current...you fall back on experience rather than emerging evidence.
quote:
The majority of the medical literature has flaws and omissions, and too many times it's taken as gospel.
I agree. Very few of the available studies are definitive really. But it's far worse to perform treatments that have no sound theoretical basis( CST, MFR), then to attempt to aplly the best available literature. If the available literature fails....fall back on clinical experience.....not a problem.
< Message edited by proud -- March 12, 2008 10:12:10 AM >
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RE: ACL rehab - March 12, 2008 10:24:17 AM
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PTupdate.com
Posts: 1436
Joined: October 8, 2001
From: Pittsburgh, PA USA
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"Massage is not therapeutic in a tissue healing sense( I'll wait for the argument on that....but I'm right...)."....you GOTTA open a new thread on this one....should be a good discussion for all
" First off....really? No transverse humeral ligament? Do you have a reference?"....Yup, sitting right here. Is going to be today's/tonights update on PTupdate.com
As far as the massage therapy part....in PA that cannot be done, so it's not really an issue. However, chiro's in the area are able to employ them, and bill for their services. I have had quite a few people admit to me that the chiropractic portion does not help them, but they go because they like the massages and they're covered by the insurance. As Reeves notes, put part of the tab in their wallet and they may not be so aggreeable to continuation
An interesting thought comes to mind: Since you said we are not in the business of being harmful, are we harming someone who has failed all other forms of conventional medicine by denying someone who thinks/says that something works for them? Take a chronic pain patient, legit (no comp or lawsuits) who has tried 4 different PT's, been to numerous physicians, underwent injections, underwent psychotherapy, and the only thing that gets her relief is accupuncture every 6 months, or someone saying they are providing CST (perhaps their hands on technique is working on a problem, just not for the reasons they think). Can we really deny this person the treatment? Some may say "No, we're not denying, it's just that the insurance should not cover it". But, didn't the insurance cover all those other failed treatments? It's kind of goofy to pay them, and then NOT pay what appears to work, at least for that patient.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: ACL rehab - March 12, 2008 5:25:34 PM
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pappawheelie
Posts: 40
Joined: September 19, 2007
From: Vermont
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Yikes-I just wanted to know what to do with my young lady with the new ACL. (she's at -10/75 and I called her surgeon).
Crevidence posted a nice logorhythm for practicing therapy, which seems a little bit rigid, especially in light of the fact that our knowledge base as PTs continues to evolve--sometimes to the point that what we once accepted as truth, turns out to be failable theory (coupling theory of the spine comes to mind).
I think if I based all of my actions on what I absolutely knew to be real and factual, especially in the realm of physical therapy, I would be somewhat stymied, mainly because I'm not really sure what we do absolutely know (except for, of course, the beneficial effects of aerobic exercise, and the fact that something like 95% of people who meet 4 out of 5 criteria for acute LBP will benefit from a good manip).
Personally, I like Jason's take:
quote:
EBM is about prioritizing out treatment decisions, not blindly following a "cookbook" or throwing out one's hard earned clinical experience.
Clinical experience to me is the art of physical therapy--the part we have such a hard time quantifying and proving through clinical trials.
But, in reading all of this I'm wondering what are exactly "Alternative" practices? And if our calling is to use our best available evidence before falling back on theoritical principles--who can really say whose theory is best? I mean, what if your belief system is firmly grounded in Eastern philosophy? Accupuncture wouldn't be alternative. I dunno, just a thought.
I just get a little dismayed at our profession when we tend to belittle other healthcare practioners and place ourselves on a scientific pedestal. To call practioners of therapies different from ours schysters and snake oil vendors smacks of elitism and shows blantant disregard for the practioners who do not fit the sterotype. I think Tom said it best quote:
my issue with alternative therapy is that ALL they do is give the patient relief. Relief from pain, isn't that what we strive for? (Although I think he meant short-term relief--thought it was kinda funny though)
Proud's example of CST and chronic pain is a valid point, but I can find many examples of people with chronic pain cycling through the hospital outpatient clinic doors for walks on the treadmill, ultrasound and hotpacks. I just dont think we can say that PT always provides longterm relief--it should be our focus, no doubt.
I just have to say that when my father was having excruciating leg pain I encouraged him to go to a PT clinic. He went. He says it cost about $1500 and the therapists chatted while watching him exercise (she didn't even coment on his grotesquely protuding abdomen). After that he went to a massage therapist--felt good, $50/week, but his leg still hurt after six visits. When to a chiro, got maniped, felt better, went back about six more times, now goes when he feels he needs it (I've talked to him about the "adjustments"). My dad believes in chiropractors, because they helped him. Show him any evidence you want, he will still go where he feels he is getting the best treatment for him.
I'm not going to throw out the baby with the bath water and say "all alternative therapies suck", because I do not believe we as physical therapists know everything there is to know about healing NMSK conditions. And, I'm going to say that those "alternatives" exist mainly because 1) people believe in them, and 2) they must work on some level--why would so many people seek them out?
P.S. How do you guys find the time to write all this stuff? I gotta get back to work.
_____________________________
Ted Lamb, MSPT
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RE: ACL rehab - March 12, 2008 7:09:20 PM
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proud
Posts: 875
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Crevidence,
I'll return the favour. THAT was brilliant.
It's so strange isn't it? We have our fair share of whacked PT's around. Added to that we seemingly have PT's that are alternative therapy apologists.
This really has nothing to do with being "too ridgid". Crevidence did a bang up job of differntiating an ethical medical profession from a "theory" based trade that is not dynamic with emerging information and evidence.
I mean....is the concept really so difficult?
Oh and pappa...coupling motion of the spine? This is a superb example of what happens when universities churn out poor PT's. Accepting this garbage as "truth" without adequate evidence is what get's us in so much trouble. A little thought and low and behold any acedemic would have thrown that information in the trash where it belongs....
Also, although I think I follow your thought process with regards to alternative therapies, It is clear to me that I was unsuccessful in my attempts to clarify the distinctions. Your dad is a prime example of how our current NMSK system is faulty. That PT your dad saw...I'm guessing "evidence" is not on her list of things to do.....shame.
< Message edited by proud -- March 12, 2008 7:24:02 PM >
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RE: ACL rehab - March 12, 2008 8:51:56 PM
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Kaden
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If some PT's want to gravitate toward "alternative" therapies, and they will continue to do so, I wish it could somehow be without using the PT initials.
I doubt any PTs soley doing MFR,from the Barnes perspective, would be willing to set aside their PT initials, although they should b/c they are not actually practicing PT with this junk. The fact that one continues to carry the PT initials to provide some credibility to their shaky practices, in this case MFR, speaks loudly to how much credibility these services truly lack.
I challenge those practicing "alternative" therapies in such a manner, for the sake of those trying to bring credability to the PT profession, to stop hiding behind the PT initials and let your services stand for what they truly are, which IMO is crap. But if you don't think their crap then market them side by side with traditional therapy and stop using PT credentials as a cover.
< Message edited by Kaden -- March 12, 2008 8:55:22 PM >
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RE: ACL rehab - March 12, 2008 9:39:48 PM
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SJBird55
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From: Michigan
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I believe EBP/EBM captures the relevance of mathematics in clinical decision-making - meaning, statistics being used to assist with the decisions. Most of the therapists that I know hate mathematics and in all honesty don't understand applied mathematics. Applying mathematics to clinical situations in the clinical world is what is going to drive our effectiveness (by improving our ability to more accurately diagnose and also with recent research implement appropriate treatment strategies) AND potentially improve our ability to determine a prognosis. I'm not saying everyone is going to fit into a nice box, but I do think that mathematics can capture certain patterns better than our observations alone and mathematics can define those patterns for us.
As a whole, medical professionals do not make accurate blink decisions - sometimes we get lost in the quagmire of symptoms and the unnecessary information clouds our clinical decision-making. So, when professionals don't understand mathematics and don't connect with the numbers or statistics or find relevance in numbers, those professionals will turn to the stories/testimonials that connect with them. Often times it seems to be the "alternative" therapies that are more palatable. It is cognitively quite a bit easier to understand a testimonial and "it works" than it is to delve into numbers.
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RE: ACL rehab - March 12, 2008 10:10:42 PM
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PTupdate.com
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Well, most of us became PT's because we sucked at math. I'd be curious as to examples (besides the obvious---MFR, CST, Reiki) what members here would consider "alternative" medicine.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: ACL rehab - March 12, 2008 11:00:15 PM
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jlharris
Posts: 468
Joined: April 12, 2006
From: Nebraska
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I'd like to just comment on the term "alternative medicine". In my mind, either a treatment in shown to be beneficial - thus "medicine" - or it's not. So, if, say, accupunture is shown to be beneficial for X, then it is medicine. If Reiki is shown to be benificial only for the practitioner's pocketbook, then it is not medicine. No matter what adjective you want to put in front of it.
Until then, dump the the "alternative medicine" PR tag and just call it what it is - snake oil.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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RE: ACL rehab - March 13, 2008 7:07:07 AM
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rwillcott
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I was speaking with a patient who has been having chronic neck and shoulder pain. He has been going to a massage therapist that has been performing CST. I asked him to describe the techniques she is using. He told me that she is placing one finger on his neck and the other on his opposite intercostal. She then repeats on the other side. He described some other 'interesting' techniques to me as well. What amazes me is that he continues to see her and has no sense that what she is doing isn't helping him. He even told me he has shown no improvements. The problem is that this MT is very convincing and passionate about these techniques. I think he is feeding off of this and wants to believe it will help.
Insane,
Rob
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RE: ACL rehab - March 13, 2008 8:18:54 AM
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proud
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quote:
ORIGINAL: rwillcott
I was speaking with a patient who has been having chronic neck and shoulder pain. He has been going to a massage therapist that has been performing CST. I asked him to describe the techniques she is using. He told me that she is placing one finger on his neck and the other on his opposite intercostal. She then repeats on the other side. He described some other 'interesting' techniques to me as well. What amazes me is that he continues to see her and has no sense that what she is doing isn't helping him. He even told me he has shown no improvements. The problem is that this MT is very convincing and passionate about these techniques. I think he is feeding off of this and wants to believe it will help.
Insane,
Rob
Yes...and the even more astounding fact is that in Canada, getting a rub down from a masseur is paid for by insurance!
Someone please explain that to me? We have people having difficulties paying the premiums for insurance yet companies like Blue Cross for example cover rub downs?
Heck, why not pay for a day at the spa, a margarrita, and cucumbers over the eyeballs? About as much evidence in that really....and guess what, if it was covered....people would do it.
Geeesh.
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RE: ACL rehab - March 13, 2008 9:11:07 AM
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pappawheelie
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From: Vermont
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Just to be clear, I am not advocating that PTs practice alternative therapies, and, personally, I do not myself. I definitely believe in truth through advertising and do not build my practice on informing people that their pelvis is out of alignment or that one leg is longer than the other. In addition, the thought of moving a cranial bone with 5 grams of force seems a little far fetched. Furthermore, in an effort to improve my skills as a therapist, I am finding that some of what I have learned both in college and through continuing education courses is not as factual as it once seemed. It is a continual process that requires some commitment to research and reading. So thanks Crevidence for the reference, I will check it out.
_____________________________
Ted Lamb, MSPT
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RE: ACL rehab - March 13, 2008 2:47:51 PM
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rwillcott
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I wonder if the former NY governor went to massage?
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would be a start. From there....our professional regulators weed out the foolishness that is finding it's way into our profession.