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Re: Painless physical therapy vs. pain during treatment
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Re: Painless physical therapy vs. pain during treatment - September 4, 2006 11:16:00 AM
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nari
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This is worth a read, Rob, but did not contain anything new; I guess its references are rather old.
It does not alter anything much in this debate, however. Pain is pain, regardless of its much debated causes/sources in the body; it is a recognition of a threat. Whether we choose to stabilise, stretch, strengthen,or talk about 'good pain', 'bad pain', or 'pain and gain', it behoves all to understand pain physiology in its own context - ie the nervous system - and not in a mesodermal context which can mislead on its true origin.
Nari
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Re: Painless physical therapy vs. pain during treatment - September 4, 2006 6:40:00 PM
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rv36116
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nevermind.
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Re: Painless physical therapy vs. pain during treatment - September 4, 2006 8:38:00 PM
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avalon
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[QUOTE]What on earth is a patient with back pain supposed to believe nowadays?[/QUOTE]What do you really bring to these patients since 50 years? The insurance that their backs will hurt more in some delay? It is an evidence that LBP are still constant in our countries but we are saying that, now, PT is evidence based and effective
I miss something there!
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Re: Painless physical therapy vs. pain during treatment - September 5, 2006 4:27:00 AM
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Jon Newman
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Hi Junction,
Can you elaborate on what it means that you don't treat for pain, only function?
I think I get what you mean but what you stated could be interpreted that you ignore the patient's pain and push to meet certain functions in certain time frames--buck up soilder, no pain, no gain--that sort of thing.
Thanks for any clarification you may offer.
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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: Painless physical therapy vs. pain during treatment - September 5, 2006 5:26:00 AM
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johngoodrich
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Doug, your post was as articulate on this topic as any I've seen here in a while, both in clinical and scientific terms, and is all the more credible given your background. But you're wasting your time. The people you are debating have no interest in your background or your research. If there is any evidence to be considered, they will let you know what it is. RCTs? Who needs them? We have letters and essays from Barrett Dorko. They have taken a theory that is worthy of serious dialogue in our profession, one that is in fact taking place on more objective and balanced terms in other circles, particularly those committed to evidence based practice (in spite of what they would have you believe), and they have co-opted it into a philosophy of practice that only they understand and is limited only to those willing to join their clan. Part of my frustration comes from having a colleague who is a Dorko groupie. Sure he helps some people. But a significant number stop coming or complain about his ineffectiveness; those that don't get better continue to be scheduled to receive the same "treatment", as he doesn't have anything else to offer. I recently received 3 complaints from patients who didn't want to see him again because they were led to believe that their pain was "in their head" or that they were crazy. So apparently even patients don't warrant their respect. That may or may not reflect the approach of some of the regulars here, but then who would know? I took the bait and read Matheson's essay. I didn't find it the least bit amusing. This is guruism of the worst kind. Doug, you're on track as far as I'm concerned. I'm just venting. You can offer a counter argument much better than I. I just don't know if it's worth the trouble.
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Re: Painless physical therapy vs. pain during treatment - September 5, 2006 6:14:00 AM
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avalon
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Hi,
I'm fortunately very tolerant and all the "detractors" of Doug are aware of the IASP pain definition.
http://www.iasp-pain.org/terms-p.html
[QUOTE]Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons.[/QUOTE]Many of you, just, ignore the scientific basis of our intervention.
The Clan has a site (I'm the admin) that is accredited by "Health on the Net"
http://www.hon.ch/HONcode/Conduct.html?HONConduct261683
Of course, you can contest it but we provide Pubmed citations when needed. I never found only one paper saying that pain is ever related to a physical injury. Just never.
Perhaps you could provide one: That's is not guruism, that is scientific evidence.
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Re: Painless physical therapy vs. pain during treatment - September 5, 2006 6:41:00 AM
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proud
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Can someone give me a little understanding of what this Barrett Dorko teaches? I attempted to look him up however my computer seems to have problems with any of his sites.
Thank you,
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Re: Painless physical therapy vs. pain during treatment - September 5, 2006 6:49:00 AM
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avalon
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Perhaps it doesn't work on this kind of "rigorous" computer.
http://barrettdorko.com/
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Re: Painless physical therapy vs. pain during treatment - September 5, 2006 7:13:00 AM
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Jon Newman
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jwg states
[QUOTE]The people you are debating have no interest in your background or your research.[/QUOTE]I don't know you (and apparently you don't want anyone to know who you are) so don't presume to speak for me.
[QUOTE]They have taken a theory that is worthy of serious dialogue in our profession, one that is in fact taking place on more objective and balanced terms in other circles, particularly those committed to evidence based practice (in spite of what they would have you believe), and they have co-opted it into a philosophy of practice that only they understand and is limited only to those willing to join their clan. [/QUOTE]Who is "they" and what theory are you talking about?
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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: Painless physical therapy vs. pain during treatment - September 5, 2006 8:07:00 AM
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steve
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Junction,
Nice comments. Jon, I actually use the approach that you state - scheduled gradual increments in function and ignoring pain. I dont say march on soldier but rather explain to them about pain and its multifaceted issues and how research has shown that those people with high fear avoidance beliefs benefit from this treatment over standard physical therapy. Really its a form of CBT, challenging their disability beliefs.
Steve
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Re: Painless physical therapy vs. pain during treatment - September 5, 2006 9:26:00 AM
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Jon Newman
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Hi Junction,
It does seem that you address the person's pain through "this and that" and hot packs, and Steve through pain education and graded activity. Also, if you rate their pain and cite a change in pain as success, you aren't ignoring it. I'm glad for that.
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Re: Painless physical therapy vs. pain during treatment - September 5, 2006 9:43:00 AM
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steve
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Jon,
Your right, again I think this is a semantic issue brought on by communication through computers. I should also note that I use this approach only with patients with high fear avoidance beliefs or clinically inconsistant examination results.
Steve
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Re: Painless physical therapy vs. pain during treatment - September 5, 2006 12:09:00 PM
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Bournephysio
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This will probably be one of my lasts posts for a while as I really need to get a lot of work done. There have been several really good posts that should be explored further but I’ll limit this to a few comments.
So no one picked up on my Kill Bill reference?
Henry, your “detractors” of Doug comment suggests that someone has made comments that detracted from comments made by me. That has not been done yet. The pain definition that you mention has one serious drawback which has already been brought up. There is now way to prove the absence of tissue damage or a pathophysiological cause. Besides this no one has said that pain has to occur in the presence of tissue injury. The question is what do you think happens most in the patients we see? It really does not make sense that in chronic pain the nerves most often get irritated without any tissue damage. It doesn’t make sense that the system would be designed that way. If it did anyone consistently moving near end of range would likely be in constant pain. “Many of you, just, ignore the scientific basis of our intervention.” I don’t see any support at all for this comment.
There are two big points that I want to get across.
First, There is still a continuing misunderstanding of what evidence based medicine is and how scientific studies including basic science and rcts fit in. Basic science studies can suggest possible treatments or explain why certain treatments may work. By themselves they are not strong evidence for the efficacy of a treatment technique. There is no way of knowing how the many variables will interact in real life. I don’t care if you are Einstein. There is no way to predict this in the vast majority of cases. While a simplification, basic science can be considered a hypothesis generator for clinical studies. Randomized clinical trials, depending on the design, can take these variables into account or at least ensure that they are randomized across subjects. They are not perfect but they are much stronger evidence to suggest a treatment works. That is why no matter how well thought out a theoretical framework is, rcts are needed to test if the treatments work. It is not a matter of what is more important. It is a matter of what questions different research designs are best able to answer. Clinical experience is also not strong evidence for the efficacy of a treatment. There are way too many factors that are not controlled at all. In clinical practice you can see many patients in a relatively short period of time. You may recognize patterns such as certain patients seem to do better with treatment A. Thus clinical practice makes for a great hypothesis generator for basic science or clinical studies but is poor evidence in of itself.
The second point I want to make is the need to carefully think through all of the assumptions you are making in your theoretical framework. There is no way around this. You have to make assumptions. Some will have significant evidence others won’t. You need to understand what the assumptions are and what the evidence is for them. The more concrete the theory the better able you will be to support or refute your assumptions. Precise definitions are essential. Vague definitions are open to interpretation and can be changed midway through an argument. This is why neurodynamics makes a horrible term to use during a discussion. It has too many meanings and you have to be careful not to change it in the middle of an argument. Finally, never take ownership of a theory. If you do it will be very hard to change if the evidence goes against it. The theory needs to fit the evidence. You don’t force fit the evidence into your theory.
Doug
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Re: Painless physical therapy vs. pain during treatment - September 5, 2006 12:13:00 PM
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Sebastian Asselbergs
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Obviously, the words we use CAN polarize any exchange:
"The clinicians serving this population are evidently obsessed"
Nah, I am a clinician who gives a lot of attention to the issue of pain - since that is the most common reason for my patients to come to the clinic. And then I try to explore ways WITH the patient to improve their condition, whether it is with manual techniques, just education, or ergonomic suggestions or whatever.
Not "obsessed".
It just seems that way when one discusses the issue of this thread : "....PAIN during treatment ...."
Hard to get around focusing on it, isn't it?
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Re: Painless physical therapy vs. pain during treatment - September 5, 2006 12:19:00 PM
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srcase
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From: Michigan
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Doug,
Your post really hones in on the major flaws in the debate, and the logical fallacies that can accompany polarized arguments. I hope you will find time to contribute more in the future, because you have quite a bit to teach us about how to think and present our ideas. I will try to be more precise in my posts, as my thinking becomes more precise. Thank you.
Sarah
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Re: Painless physical therapy vs. pain during treatment - September 5, 2006 12:20:00 PM
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Bournephysio
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Sebastian, for some reason we need to be on teams. To have teams we need to polarize peoples opinions. Maybe we should just choose teams since I'm not sure who belongs on what team. Who wants to be a captain? Sorry, this us versus them thing gets tiring.
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Re: Painless physical therapy vs. pain during treatment - September 5, 2006 12:23:00 PM
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srcase
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From: Michigan
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We really are our own worst enemy as a profession aren't we?
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Re: Painless physical therapy vs. pain during treatment - September 5, 2006 12:35:00 PM
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Sebastian Asselbergs
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Doug, I obviously cross-posted with your 5.09 post. I appreciate your thoughtful postings anytime.
I am the captain of my team (of one = me), but also the waterboy....
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Re: Painless physical therapy vs. pain during treatment - September 5, 2006 2:05:00 PM
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Jon Newman
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Sarah,
I don't think we are our own worst enemy actually. This type of thing, while tiring, is helpful. Viewing people who disagree as an enemy is a problem.
Doug,
I think there are people looking at the pain problem at different levels. I'm glad there are people exploring from the genes, to the brain out into culture.
[QUOTE] The question is what do you think happens most in the patients we see? It really does not make sense that the nerves most often get irritated without any tissue damage. It doesn’t make sense that the system would be designed that way.[/QUOTE]I disagree a bit with this. Pain was built to prevent tissue damage thus our nerves can become irritated without tissue damage. Not only, but also. That is a critical point. Basic nociceptive pain is uncomplicated and follows a predictable course and often can be tracked to some tissue damage cause. It is those patients with no detectable pathology--and I mean pathology, not, 'They move funny compared to the books or someone not in pain'--that pose a problem. Fibromyalgia is unlikely due to frequent disperse areas of tissue damage and healing.
In your research, if you are able to describe how eccentric training is associated with a change in genetics and the type of collagen produced that would be cool. If it also results in a decrease in pain wouldn't you have more explaining to do?
Junction,
I would argue that we are not interested enough in pain and I'm quite sure our patients, inpatient or otherwise would agree.
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