Joined: November 15, 2003
You write: "the current system of MSK management is failing"... Although we are coming from somewhat different directions, that is an honest statement, and rather sadly, is true. The incidence of chronic pain appears to be rising, according to what I have read over the last year or so, and it may be due to factors totally unrelated to whatever PTs and chiros are trying to do to resolve the acute/chronic pain circuitry; but I don't think our interventions have much impact on the whole. I reckon we keep athletes going well, so they can go off ane re-injure themselves again ;) but for the vast numbers of ordinary folk who would just like to be free of shoulder/knee/back/neck pain... anything more than a temporary result seems almost out of reach for most.
The information patients receive on their condition/s is indeed all over the place - consistency is an alien word. That is equally applicable to the medical field, I think; but the establishment of "experts" is tricky - who deems a person to be an expert in a particular field? If a patient takes his painful knee to three orthopaedic experts, he is likely to get three different diagnoses; unless the XR clearly shows the joint is falling apart. The same might occur if that person goes to a PT with XRs that look OK...but who deems a certain PT to be expert in MSK? Positive outcomes aren't sufficient - then we are relying on placebo, personality, communication skills, and other rather nebulous factors which make that certain PT "good".
We need a deeper model of practice - one which addresses patients' needs and ours. That is a looong way off yet.
Joined: March 23, 2006
Nice response. And I think you are correct that we are a long way off, however the wheels in North America anyway are spinning in the direction I define. Out of neccesity.
And the one thing I might point out about the knee Dx example you gave is this: notice it was always an orthopeadic surgeon giving the DX? Getting a second opinion from another expert is always an option.
It is hard to define expert, however once one is established, that profession can build from there and accountability will follow. Otherwise we have the "free for all" system that we have now.
Your theory that patients should have the right to choose? Is not that pretty close to the system we have now? The one that is failing miserably? But why wouldn't a chiropractor favour that system? It is the one that generated wealth for many. Unfortunately, it is also the system that has done nothing to advance our knowledge and understanding of pain and functional impairments.
Until recently, patients with back pain might obtain the services of a Chiropractor. Unfortunately Jbird007, you know as well as I do that the chiropractic profession has done a horrific job at self regulation. You may be an ethical and EBP practitioner, however the two beside you are likely not. The end result? Patients sold on the notion that they have "hot spots" and twisted spines...talk about feeding into fear avoidance and illness behavior.
And before you claim that I am chiro bashing, I think it has been pretty clear that I am all for improved regulation within my own profession before it reaches the current state of chiropractic.
Joined: October 8, 2004
Proud, Onstudent and everyone else who has posted,
I entered this thread, to tell my experience.
I studied at an EBP school, and am happy that I did. I can take what I learned and apply it to my practice.
I also found out quickly, that there are many techs. that help pts., and that do not have great studies behind them.
I use Mulligan, McKenzie, ART, ASTSM, post grad manual courses, bought Shaclock's book (and will use it),etc, and most importantly exercise. These are all tools. I am aware of the studies behind them all. I use what I feel is best for each pts. I treat.
I work with a chiro, and his pts. leave feeling great, so do mine. We may use differnt techs.,but our outcomes are similar.
I agree that in Canada, the Chiro's are not regulated stickly, but I know a few Chiro's, who teach at the College and practice EBP.(they do not work with me or work in the same clinic, we are friends)
In Canada there are fellowships at Chiro College in "Rehab" that teach Mulligan and McKenize etc.In short, they study what PT's do.
My goal is to get my Part B in Canada, which involves manipulation of the spine and to learn and practice neurodynamics. Not too different than my friends.
Why keep having this conversation? If we are good at what we do.... and pts. get better....why not embrace and learn differnt skills?
If you are able to perfrom the studies behind the skills you are using, do it! (I do not have the resources at this time, but in the future I would like too)
I feel in Canada, my College and my association restricts our fee's. I have written to both and will continue to speak up.
Bottom line.... if your patients get better...no matter what techs. you are using, you are providing a great service and are doing a good job.
What I love about this site is all the helpfull information. Let's stop the profession bashing, and share our experience.
I think that what the others are arguing is that we, as a society, aren't doing a good job of managing pain and dysfunction. I keep hearing aout "good results" but I go to patient support boards and the message is entirely different. I believe there is general agreement that we need to know what is effective and begin treatment there, this means some type of accountablitly by outcome. Secondly, we need to have an understanding about why treatments work or we are just throwing things on the wall and seeing what sticks. If we want to improve what is done, we need to have the theory drive new techniques and not simply come up with post-hoc explanations. Sharing experiences is a good thing, but it isn't going to improve what we do to help people.
Joined: November 15, 2003
Randy, what you wrote is true. I work in a pain clinic with complex pain patients, and they are there in their hundreds because PT, chiro, massage therapists, et al, have not been helpful. Sometimes attendances have resulted in more pain that did not resolve anything. The reasons why they failed to improve are multiple, of course; but very few have actually had pain explained to them. Their attitude towards their perceptions of pain can change significantly with appropriate pain physiology explanations. More than anything, it confirms the reality of their pain, and sometimes, they understand it is not necessary to have this pain as a warning of pathology gone wrong.
Admittedly, those who did improve with phsyiotherapy don't end up in pain clinics. But there are a large proportion of patients whom we are not assisting. This is the real challenge - the challenge of managing pain, not function.
Joined: March 21, 2006
In terms of pain management, there has been recent research on fear-avoidance beliefs. Many patients with chronic pain develop fear of performing activity. There have been studies that show the importance of identifying these patients early and having them perform specifc exercises. The research I have read pertains to back pain and they used the FABQ( fear avoidance beliefs questionnaire) to identify these patients. They recommended that these patients be placed on a set graded exercise program with a gradual increase in sets and reps.
Is this an approach you use in your clinic? I've only recently come across the research and think it makes sense. Any thoughts?
Joined: April 25, 2004
From: Amherst, WI
I use graded approaches even in the absence of "fear avoidance" because it seems biologically sound to do so and often averts unnecessary suffering. I also wonder about the "fear avoidance" label. It seems more like the construct captures a simple knowledge gap more than some sort of psychological construct. Perhaps if it persisted in the face of improved understanding it would be more problematic.
Also, while we typically focus on the beliefs of our patients, don't forget our own.
Thanks Chris Barnett for the reference. It was an interesting read.
Pincus, T, Vogel S, etal(2006) The Attitudes to Back Pain Scale in Musculoskeletal Prcatitioners (ABs-mp): The Development and Testing of a New Questionnaire. Clinical Journal Of Pain. Vol 22(4) 378-386
Joined: April 25, 2004
From: Amherst, WI
Thanks. I have read those. I agree that people with fear avoidance represent a group of people that would benefit from addressing those concerns. Understanding that both may be quite important, I'm curious whether it was the graded exercise or the education that had the most impact. It would be interesting to see a SSRD (or a series of them) starting with a graded approach and adding specific education at a specific time points to observe the influence.
I'd also be interested in what would happen if the baseline "exercise quota" was determined by the patient.
I'm currently of the opinion that people are often not "avoiders" as much as they are simply presenting with an understandable knowledge deficit. Perhaps I'm wrong though.
Joined: March 21, 2006
I agree that education of the patient is always important. And I think especially important when dealing with the chronic pain population. Do you think there is a specific approach to take when educationg these patients? I'm thinking in terms of implementing cognitive behavioral therapy techniques. Or do we have to be that specific?
I think a good study would be to have four groups. A control; graded exercise; specific education on pain; and finally a combination of graded exercise and pain education.