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Effects of practitioner's belief

 
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Effects of practitioner's belief - February 13, 2011 2:46:57 PM   
Sebastian Asselbergs

 

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From the chapter on pain by Lester Jones and Lorimer Mosely in Tidy Physio (with thanks to Diane for finding that so quickly!):

quote:

There is some evidence that the clinician's thoughts and beliefs about pain modulate the effect of the treatment. For example researchers undertook a placebo-controlled double blind study of fentanyl (a powerful analgesic) during wisdom teeth removal (Gracely et al.1985). Although all patients had the same likelihood of receiving fentanyl, the researchers told some of the dentists that the patient wouldn't receive fentanyl. This was a lie. When the clinician thought that the patient might get fentanyl (which was true), pain dropped by 2 points after the placebo injection. When the clinician thought that the patient could not get fentanyl (which was a lie), pain increased by 5 points after the placebo injection. This difference (~7 points!) was due to the belief of the dentist!


Worthy of further exploration, isn't it?
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RE: Effects of practitioner's belief - February 14, 2011 6:17:12 AM   
JSPT

 

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I want this to be true. 

I actively do my own "positive thinking" for patients while doing manual for them.

But man, there needs to be a mountain of evidence for me to believe this one.  Where is the original research from?  This sounds like a CAM trial that people are going to be taking huge liberties with. 

Does it prove quantum touch (disproved by an 11 year-old)?

Yes, Bas, it certainly warrants further investigation and is interesting.  I hope further trials confirm it.  But yeah, gonna need to see a dumptruck-sized load of evidence on this one. 

(in reply to Sebastian Asselbergs)
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RE: Effects of practitioner's belief - February 14, 2011 8:16:01 AM   
Sebastian Asselbergs

 

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It certainly does NOT prove any particular technique at all.

In its small set-up to test a drug, they found this interesting statically significant aspect.

All it points at, is that the attitude of the practitioner (and the related beliefs) may have more impact than already assumed. It is likely related to subtle non-verbal cues picked up by the recipient of the intervention - in other words, two neuromatrices interacting on deeper levels than just verbal. That is not exactly revolutionary.
THAT would be a good reason why some "techniques" have good outcomes, despite their poor theoretical or outright fantastical basis.

It just gives more credence to the massive processing that the brain is constantly involved in with its filtering of inputs, cognition, and outputs.

The crappy part is, that many of the woo-woo practitioners already know this. They let it trump the absolute lack of evidence for their "energy" claim.
quote:

The practitioner’s attitude toward how Reiki itself works will also greatly affect the client and the outcome of the treatment.

(in reply to JSPT)
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RE: Effects of practitioner's belief - February 14, 2011 8:31:34 AM   
Shill

 

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What journal was that study in back in 1985? I cant find it with an Author search.

Thanks,

_____________________________

Steve Hill PT

(in reply to Sebastian Asselbergs)
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RE: Effects of practitioner's belief - February 14, 2011 9:21:19 AM   
Sebastian Asselbergs

 

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Steve, I'll check the original reference.

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RE: Effects of practitioner's belief - February 14, 2011 9:28:11 AM   
Sebastian Asselbergs

 

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Gracely, RH, Dubner R, Deeter WR, PJ 1985
"Clinicians' expectations influence placebo analgesia"
Lancet 1:43

(in reply to Sebastian Asselbergs)
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RE: Effects of practitioner's belief - February 14, 2011 11:03:53 AM   
Myostrain

 

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This might be a dumb question but, if the research tells the phys that fentanyl will not be available for a patient; won't the phys disclose some form of that to the patient?
"I'm sorry, we weren't able to get the authorization to use our normal strong pain med, we'll have to use xxx".
Would it be normal practice in that type of care for the provider to not disclose what type of pain medication will be used or even that they will be using a pain medication? If no, then I think that would be doable enough to power up the findings.


It would definitely heighten one's sensory perceptions, pain would be an expectation but also there would be a likely amplification.

If you were a clinician and you knew you were not prescribing a desired strong analgesic but a less powerful one, you may likely a.  have greater focus on what you are doing-trying to minimize the pain likeliehood b. tell the patient  c.  a+b

Would this relate in a similar way to a patient having faith that if PT doesn't work,like the dr said, a cortisone shot in the jt will help the problem. Ie. strong confidence with the doctor and the perception that a cortisone shot will hip along with with the "if" of PT.

Interesting tidbit of the article, but interpreting one little part of an article in stand-alone, is the definition of "Fuzzy Math".

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RE: Effects of practitioner's belief - February 14, 2011 11:53:27 AM   
proud

 

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Further highlights my belief that the smarter one actually gets( as in actually understanding the available neuroscience that is available)....the worse ones outcomes could potentially become.

I've noted this. I work with PT's who honestly think that they can feel that L5/S1 is not moving in a superior-anterior-lateral manner( literally picking out whether it's the lateral aspect versus the superior aspect that's not moving quite right). It's all crap of course...

But so blinded by their own ignorance....they believe so strongly that they can "mobilize" that bone to move "correctly"....that this absolute belief is transmitted to the patient....and voila....patient responds due to the ritualistic/expectation of improvement factor.

It also explains why two polar opposite treatments can result in the same positive outcome.

Party tricks are fun are they not?

It's why I believe the only valid thing we have left is truth in practice. Which likley means far less ### of patients that we actually need to see. Patient would be prety well served with:

1) Motivation

1) Education

2) Identify no red flags and then Re-assurance to move

3) Advice to adopt a healthier lifestyle...and guidance on how to do that.

MERG...

< Message edited by proud -- February 14, 2011 11:55:59 AM >

(in reply to Myostrain)
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RE: Effects of practitioner's belief - February 14, 2011 9:05:18 PM   
Sebastian Asselbergs

 

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quote:

This might be a dumb question but, if the research tells the phys that fentanyl will not be available for a patient; won't the phys disclose some form of that to the patient?
"I'm sorry, we weren't able to get the authorization to use our normal strong pain med, we'll have to use xxx".


Myo, it was a double blind controlled study. In this type of study there is NO disclosure from practitioners to patients whatsoever about the applied substance/technique/method.

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RE: Effects of practitioner's belief - February 15, 2011 1:49:15 AM   
ginger

 

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Proud, maybe there is a new future for you( now that you appear to be withdrawing from providing manual treatments) as a GP. Only five more years at University. Though for a clever fellow like you the road will no doubt open up as you step forward. What would you call your practice?

< Message edited by ginger -- February 15, 2011 6:21:30 AM >

(in reply to Sebastian Asselbergs)
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RE: Effects of practitioner's belief - February 15, 2011 7:35:07 AM   
Sebastian Asselbergs

 

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Ginger, I don't get the "withdrawing from manual treatments" from that post.

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RE: Effects of practitioner's belief - February 15, 2011 7:48:22 AM   
proud

 

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quote:

ORIGINAL: ginger

Proud, maybe there is a new future for you( now that you appear to be withdrawing from providing manual treatments) as a GP. Only five more years at University. Though for a clever fellow like you the road will no doubt open up as you step forward. What would you call your practice?


Interesting Ginger. But I think some clarification here is required. I still utilize manual treatments for a variety of conditions( decreased ankle dorsiflexion post inversion sprains and the like). I still look for centralization with my acute LBP patients who present with radiculopathy. I still apply tape when it results in a reduction of symptoms( thus allowing improved range of motion or something like that...maybe/likley just giving some confidene TO move).

I still use proprioception tools such as the star excursion and subsequently implement programs as per the available evidence with proprioception defiects. I still educate/motivate like any good PT should.

Among other certainly "PT" items.

I don't perpetuate myths. I don't mis-inform patients or come up with absurd patho-anatomical rationales to explain why they might have pain. The gig is up for this sort of practice and the profession is literally at a fork in the road here...either get informed or become an even more marginalized "trade".

I set out to understand how/why patients respond to various treatments. I am committed to evidence-based( in conjunction with science-based) Physiotherapy care. I read alot about PT and the things that impact the care I provide.( I have two young kids so tend to hang around the house more than the average cat perhaps...).

I don't succumb to guruism like most PT's I have come to know.

I don't want to be a GP....to general for me. I'm a specialist()....I'm not kidding by the way.

< Message edited by proud -- February 15, 2011 7:56:03 AM >

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RE: Effects of practitioner's belief - February 15, 2011 9:00:24 AM   
Shill

 

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Proud,
Your discussion on Ginger's post is a very helpful description of what more practitioners should do, take a deep, long look at what they are doing.  Some are too blinded by time and $$ invested to discard what has been drilled in at various points in their didactic work and/or careers, often despite fairly convincing evidence.   I appreciate that you note that you still use A, B, and C, but with different education as to why this might hurt, and avoidance of perpetuating the fanciful theories that some use.  Very nice. 

Sebastian.  Thanks for the info on the study.  I dont have full text to this article unfortunately.  I would however question whether it is truly double blinded when the physicians were told something.  Whether what they are told is true or false, in a true double blind, they have no idea what they are providing, and thus can form no solid beliefs of what is going on.  I have no idea how often this is done with research, but I would venture to guess that it is not too frequent, unless for behavioral studies on honesty.  Seems to me there may be ethical issues with this model.  I wonder if any of the physicians said, with a wink and a nod here is your "Fentanyl (wink) or placebo (nod)", and then made the quote signs in the air.   I am of course kidding on that.  However, body language does speak volumes, and this may be a study more on how body language and movement patterns can project confidence and security, or lackthereof.   There is no doubt in my mind that charismatic practitioners can often get better results than drones, but I think they can probably get those results whether they believe in their method, or are just good actors.  This is probably why revered actors and actresses are often used as spokespeople.  Interesting.

(in reply to proud)
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RE: Effects of practitioner's belief - February 15, 2011 12:13:45 PM   
Sebastian Asselbergs

 

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quote:

However, body language does speak volumes, and this may be a study more on how body language and movement patterns can project confidence and security, or lackthereof.   There is no doubt in my mind that charismatic practitioners can often get better results than drones, but I think they can probably get those results whether they believe in their method, or are just good actors.  This is probably why revered actors and actresses are often used as spokespeople.  Interesting.
(my italics)
Steve - exactly. And that is the conclusion Mosely and Jones come to. After all, body language is just another aspect of communication - another way in which one neuromatrix interacts with another. 
Undoubtedly, there are some good actors amongst practitioners, but I choose to believe that most are really believing in what they do.

Is it ethical? Why not? The participating patients are knowingly in a study in which rules of disclosure require their acknowledgement of being in the placebo or the fentanyl group. The chances of getting either one haven't changed. No-one is getting put in any additional health risk.

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Post #: 14
RE: Effects of practitioner's belief - February 15, 2011 5:07:00 PM   
ginger

 

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Proud, I'm sure you'd make a good GP just the same. As for the notions about path-anatomical rationales, guruism and the like, I'm in complete agreement. By the way, what is the "star excursion" ?, apart from the bus that visits celebrity's homes of course.

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RE: Effects of practitioner's belief - February 15, 2011 5:39:39 PM   
Tom Reeves DPT ATC

 

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Proud,
Correct me if I'm wrong, but I think you don't dispute what PTs are doing, but the reasoning behind what they do. Is that a accurate understanding?

For example, you will do mobilization, but not to "free up a stuck inominate" You will do centralization/extension ROM/exercises but not to "suck back in an extruded disk".

True or untrue?

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RE: Effects of practitioner's belief - February 15, 2011 6:10:02 PM   
proud

 

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quote:

ORIGINAL: Tom Reeves DPT ATC

Proud,
Correct me if I'm wrong, but I think you don't dispute what PTs are doing, but the reasoning behind what they do. Is that a accurate understanding?

For example, you will do mobilization, but not to "free up a stuck inominate" You will do centralization/extension ROM/exercises but not to "suck back in an extruded disk".

True or untrue?


Hmmm. Mostly true I guess. Your example would be a correct one.

But on the other hand...I greatly disagree with a fair amount of needless manual care that exists out there so I think it would be a full stretch to say that " I don't dispute what PT's are doing...."

I suspect Tom...in reading along with you for a while now that your practice patterns are along similar lines as mine for the most part. But you seem like a more rare breed in that you don't seem swayed by blatent gurusim so much.

It's not just the guruism that seems to infiltrate our profession thats a problem either I suppose as simply putting the Kraft dinner on the table often interfers with clinicians ability to actually admit that much of what they have been taught/paid big $$$ for is pure bunk. When telling someone that their innonimate is anteriorly rotated and you have the skill to de-rotate it for them is both A) making the patient feel better and B) getting you paid.....what's the incentive to actually inquire deeper about what is really going on unless you really want to know....

Especially when spending the time deconstructing your own practice patterns and making them more consistent with the known science might really make one very very uncomfortable at first.

That's tough.

You are what I would classify as a dynamic practioner. Someone who actually thinks about what they are doing. They make the best clinicians I think. Maybe not the most succesfull with outcomes( generally short term) and patient satisfaction...but certainly the best( if you can wrap your head around that concept.....).

< Message edited by proud -- February 15, 2011 6:22:23 PM >

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RE: Effects of practitioner's belief - February 15, 2011 6:16:56 PM   
proud

 

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Oh and Ginger:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC164384/

And thanks for thinking I'd make a good GP. I think you'd make a good stenographer...

< Message edited by proud -- February 15, 2011 6:39:45 PM >

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RE: Effects of practitioner's belief - February 15, 2011 6:40:04 PM   
ginger

 

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thanks proud, I do an eyes closed version of this without the reaching, recording time able to maintain balance with them closed, compared to the unaffected side.

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RE: Effects of practitioner's belief - February 16, 2011 2:28:30 PM   
honker23

 

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The more you critically review studies and current literature, the more you should be skeptical of evidence.  That being said I don't think we should completetly throw out principles and theories that haven't been "proven" with sound research.  I think the focus should be on setting up sound research for future studies to help guide our practices.  I think clinicians should cross over and join researchers to help with setting up studies, as well, I feel researchers should take their "evidence" into the clinic and assess the real life applications. 

One thing I find frustrating is most studies on LBP have an inclusion criteria of age range of 18-65, no pain below the knee.  I'm pretty sure I treat an 18 yr old and a 65 yr old completely different because of pathoanatomy.  From a pure neuroscience perspective, shouldn't perception of pain similar.  It's no wonder studies don't "prove" something.  I'd like to see a study with a more homogenous group and one with very specific treatments not "standard therapy" vs the new techniques. 

What do you guys and gals do when a patient comes in with a diagnosis from a doc, who they really trust, that is way off base.  But the treatment as far as PT goes will be the same.  Do you fit your treatment into their preconcieved beliefs or explain the real nature of the condition and discredit their favorite doc's explanantion, which has them doubt you and your treatment.

Sorry for getting off track, i feel the patients beliefs are more important than the practitioners beliefs.  But the agreement of the two is key.  If both are the same=success, if they contrast=poor success




(in reply to ginger)
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