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The Future of Manual Therapy

 

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  1. Great talk guys!

    Absolutely love the comments that there are some subgroups that will respond great to mechanical treatment.
    Neuroscience doesn’t say that we should not manipulate. Give that subgroup the manip if you have the skill, and then tell them with neuroscience what pain really is. For those without the skill to manipulate, what should they do?

    Making change in patient in first session – do whatever you can to decrease the threat value of the pain. We can do this with knowledge, and can also do it by changing the person’s pain. Either way, we are changing the output of the brain, and that is what shows the patient that change is possible.

    60% of people change with pain neuroscience education? really? isn’t that no better than doing nothing?
    Absolutely right John – get a better story (and get better at patient education) and you will get the buy-in.

    If you want to compare education and manips in this sub group, then you better get experts doing education and experts doing manips, and then control for their biases. It is a travesty that we would consider measuring the results of education when those providing it have no where the skill, practice and proven competence as the people who are doing the manips.

    What is the Reference for people getting worse and costing more if we don’t give them the ‘right’ treatment right off.

    Science says people want 4 things when they come to a health professionals. What is wrong? How long will it last? What can you do? What can I do?

    love to see more conversations like this

    Neil Pearson

    • Neil,
      Great to hear from ya! Before responding, I have to say that your latest “community discussion” on youtube was fantastic and would love you to do a guest post for this site on education. Shoot me an email (email: joseph.brence@physiocorp.com).

      So one of my points through this talk was to highlight the attempt (or lack-there-of) to control for clinical equipoise in research that compares 2 commonly used manual techniques. There are groups that exist, that perform research on manual approaches, that benefit financially from the demonstration that one technique is more beneficial than another. Because of this, clinical bias becomes a confounding variable, and individuals whom are biased, should be excluded from participating in the gathering of data. Don’t get me wrong, I have nothing against making a few bucks from teaching a course, residency or fellowship program. I simply believe that it gets in the way of true randomization and affects the patients perception of the technique that is given and skews data.

      As clinicians, we must strive for making a within- and between- session change on the initial eval and by the second visit respectively. We have discovered this is prognostic of outcomes (when an individual is receiving manual care). Changing the perception of pain must be goal #1. This leads to the setting of expectations by the patient, that we (patient + therapist) can work interactively in modulating their brains response to a threat.

      I agree whole-heartily that we must quit beating around the bush (as Moseley puts it) and assist our patients in re conceptualizing what pain is. Unfortunately, we cannot currently control for the nocebo effects that are elicited by physicians who primarily refer us patients (at least in the US). Until we are seen as the provider of choice and first point of contact for musculoskeletal pain, our patients will continue to be told about their “slipped discs” “mensical tears” “heel spurs” etc. and these words are often difficult to ignore. We just got to try our best to move them forward.

      If we are to perform a study on education vs. _________ , we need to identify what “education” is. Childs, George, et al. published the study last year which assessed education vs. core stab/exercising in the seeking of care for LBP in the military. This was a great start, but did the design control for external validity and are the results applicable to practice? I’m not sure that I would say yes. The education must be consistent but the number of metaphors, analogies, etc. may vary depending on the individualized neuromatrix and we must identify educational strategies that appear to hold face validity before conducting a RCT. I would likely start with a case series for some preliminary data, identify “words that hurt” vs. “words that do not hurt”, and identify the amount of time spent listening to the patient, educating the patient, etc. That affective interaction is much more difficult to study than a simple manipulation or mobilization.

      All of this stated, we got a long way to go…And I got my boots strapped in for the journey

  2. Loved this discussion…I’m a PTA who is practicing as a Personal Trainer and yoga instructor…I’m working on going back to school for DPT and I look forward to more neuro and pain science in the future. Wish me luck and keep up the great work!

    • Hey Ryan – just FYI – there is a group of PT-yoga therapists, started via a fellow named Matthew Taylor in Scottsdale. We are attempting to be a resource for each other. Connect with him if you want to get onto the Facebook group page we have.
      You might also be interested in a webinar series in January 2013 through a group called the CIRPD – yoga for people in pain. Lots of neuroscience will be discussed there.

  3. Best 58:45 minutes I’ve spent in a while. I especially liked John Ware’s comment that “the patient shouldn’t leave our office dumber than when they came in…” and Tim Flynn’s “window of opportunity” for reaching the patient, via manipulation in some cases, to prevent spinal surgery.

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