Critical Thinking

Input.

As Physical Therapists, we interact with our patients in many different ways.  We talk to our patients.  We touch our patients.  We teach our patients.  In doing this, we provide a significant amount of “input” to their individualized nervous systems.

But despite many of us grasping this idea, I feel we are plagued by the “search for the holy grail“.  What I mean is we all want to have an edge.  We all want to find that modality that is superior to the other.  We all want to boast about our superior outcomes utilizing that modality and we all want to downplay any argument that suggests the possibility that that modality is simply just another modality.

TRILOGIE INDIANA JONES

I am going to be quite blunt here:  I do not think there is a superior modality in the treatment of pain.

That stated, I do think we can be quite successful in the treatment of pain…by simply understanding that there are two forms of input we provide (these are the variables that need manipulated in the complex equation of treating pain).  And sometimes those modalities assist us in providing the necessary equation of input.  But the equation is dependent on the person in front of us.

1. Clinician Directed Input: This is the input that is provided by the clinician.   This type of input includes the clinicians hands; their confidence; their words; their appearance; etc.

None of us interact with our patients in a one-dimensional manner.  We all interact in a multitude of ways, to attempt to convince our patient’s nervous system, that the actual (or potential) threat to their tissues is diminishing (in simplistic terms, this is what we do).   In this, I suspect a bit of theatrics come into play, which varies based upon the patient in front of us (which is ok.  Its humanistic.).   This complex series of inputs eventually leads to some form of outcome  (which confuses me why we spend so much time tightly controlling for internal validity in RCTs—or perform so many RCTs looking at all of these different forms of input in isolation without accounting for things such as examiner’s equipoise).

Every bit of interaction matters.

2. Non-Clinician Directed Input:  This is the input that is provided to the patients nervous system that is not directly related to the clinicians interaction.  It involves the sounds in the clinic; the lighting;  the grimacing of another patient on a plinth.

We have all been in situations which have made us feel comfortable and uncomfortable.   When a patient comes in your door, in pain, they need to enter a clinical environment that is not threatening.   We need to understand which patients perceive the gym as beneficial; and which patients view it as scary.  We do not want to create a “haunted house effect”, making the patient even more fearful of moving (because they don’t know what that piece of equipment is).   We need to understand that the environment in which we treat, may be just as valuable as the tools which we use.

These concepts are part of the MIP (Motivation, Input, Plan) algorithm which myself and Dr. Francois developed a couple of years ago.   We have lectured on this idea at national conferences, it is taught within our residency and fellowship programs and I will be presenting on this concept in San Diego in February.   I want you, the readers of FTPT, to help me in further developing the concept of input—in the comment section: lets discuss this idea further, provide me with some clinical examples or even provide some references for research supporting OR refuting our idea.  Let’s begin a discussion and determine if this search for the holy grail is really necessary…

-Joe B

 

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9 replies »

  1. Hi Joe,

    Thanks for sharing your post. I’ve enjoyed following the work you and Francois have shared on the MIP over the last few years here, over at SS and during Karen Litzy’s HWS video conference. I have a few questions/comments, mostly regarding the following passage:

    “I do not think there is a superior modality in the treatment of pain … In this, I suspect a bit of theatrics come into play, which varies based upon the patient in front of us (which is ok.  Its humanistic.).   This complex series of inputs eventually leads to some form of outcome  (which confuses me why we spend so much time tightly controlling for internal validity in RCTs—or perform so many RCTs looking at all of these different forms of input in isolation without accounting for things such as examiner’s equipoise).”

    From this I gather, and I may be wrong, the MIP algorithm states that what matters not is the clinician directed intervention (or input) itself, but how it is received by the patient (or their nervous system). The reception of the clinician directed input by the patient would be modulated by the clinician’s equipoise, confidence, and the language used (among other things) as well as the innumerable factors on the patient’s end (not limited to expectations, beliefs, past experiences). With this in mind, how do you suggest a clinician determines what interventions/inputs are acceptable? Does one limit inputs to those that are non-threatening? Those that have a strong science based premise? Those that the patient expects will produce relief?

    Further, is there potential for harm in utilizing a more passive intervention or input (ultrasound is an easy example here) that the patient firmly believes will help and has produced some moderate relief with in the past, the practitioner is confident in administering and also believes will help modulate their pain, but has failed to demonstrate efficacy or substantial biophysical effects?

    Under the MIP algorithm, are interventions that may not be science based or constructed with a sound premise acceptable in the treatment of pain if the patient perceives it as a beneficial input in the overall process of care?

    The concept of MIP seems to be an excellent algorithm in building awareness in the PT community that “every interaction matters” when dealing with the complexity of pain. Cory Blickenstaff’s notion of being a “contextual architect” is relevant here. The challenge (as I see it) is integrating it with what current science informs us (while being aware of it’s limitations) and avoiding using it as a justification for a “whatever works” mentality when applying inputs/interventions. I look forward to hearing your response! I wish I could make it out to San Diego this year, looks like it’ll be an extraordinary conference.

  2. “From this I gather, and I may be wrong, the MIP algorithm states that what matters not is the clinician directed intervention (or input) itself, but how it is received by the patient (or their nervous system).”

    Exactly Kenny. I love how you phrased this. It’s a process that is built around the individual patient; not a set of concrete rules.

    You bring up some fantastic questions. If the patient believes they should walk on hot coals, I would probably intervene and educate on why this isn’t an intervention which I would recommend. We should follow scientific principles when intervening, but we should not allow research to limit our intervention (due to generalizable limitations of many RCTs to practice).

    Do you suspect there is potential harm in reinforcing patients beliefs, if they are not routed in science?

    • It’s a complex topic, but I do believe there is potential harm in reinforcing maladaptive beliefs regarding pain, disability and treatment. It is also important to acknowledge that there is the possibility of harm in trying to re-conceptualize a patient’s maladaptive beliefs as well.

      If a patient were to present with complaints of reoccurring low back pain which they attribute to a subluxed vertebra and believes an adjustment/manipulation is necessary to reduce/abolish their pain — Do we address this maladaptive and potentially harmful belief? It is a tricky question in the context of the MIP algorithm (and in general). In trying to address this maladaptive belief, we are providing another input which may or may not be well received depending on many factors (such as how firmly said belief is held, the clinician’s skill as an educator). If we choose not to address the belief and provide the manipulation, are we reinforcing beliefs that may be contributing to continued pain and disability? (see Zusman here — http://www.ncbi.nlm.nih.gov/pubmed/?term=belief+reinforcement+zusman)

      Tory Madden had a fascinating post (and publication) over at BiM titled “A clash of beliefs: why our Western approach to pain didn’t work in a rural Zulu community” (http://www.bodyinmind.org/physiotherapy-in-rural-south-africa/) that is relevant to this discussion, I think. At what point do differing beliefs override any potential therapeutic effect?

  3. Joe,
    I disagree with the implication from your assertion: there is no “superior modality in the treatment of pain”- the implication being that there is no intervention that has been shown to be superior to others. Not only do I think a superior modality exists, but it must precede anything else that we do-or at least concurrent with manual therapy and/or instructing the patient in choreographed movements. That modality is education; specifically, therapeutic neuroscience education. Some form of this educational content should lay the groundwork, the foundation, for any intervention that we provide to patients with a persistent pain problem. We must address their beliefs, appraisals and attitudes that they have acquired from living a life in this culture as well as from interacting with other, however well-intentioned though grievously uninformed, healthcare providers.

    The form that this education takes should be an area of vigorous investigation and fine tuning both by clinicians and researchers. It would be prudent, in fact, to re-direct research funding away from all the “tooth fairy” projects on the effects of needles, scraping tools, and even particular manual therapy methods, and investigate how we can best educate our patients about why they hurt and why it is so critical that they come to understand the power of their own brain in extricating themselves from the prison that is persistent pain.

    • John. You make a very good argument for the superiority of one form of “input” (education) over others. While I am convinced that having an understanding of content is important, I suspect the method/delivery of the education is just as important. Take Lorimer for example. He is a very, very good story-teller. I suspect his theatrics may be just as important. Lorimer, and his team, has done wonders for the study of pain and they have produced some fantastic research. But I wonder what would happen if his crew began to produce more multi-examiner, multi-site RCTs with clinicians who have different beliefs and educational delivery models?

      What would happen if a clinician delivered fantastic neuroscience education, but did so without a hair of confidence?

      Is it about the education? Or is it about the excitement we exhibit when delivering it?

      • Well, TNE has been delivered in RCTs by several groups other than Moseley (see the systematic review by Louw et al, 2011, Arch Phys Med Rehab), and the results show that it is effective in reducing pain, disability, and improving other psychosocial factors commonly associated with persistent pain. The theoretical basis in support of addressing patient’s beliefs and appraisals of pain is very well established in the psychology literature (see Turk and Rudy, Flor- just to name a couple). Furthermore, the important role of psychosocial variables in the transition from acute to chronic pain has wide support as well (see Linton, 2000; Williamson et al, (MINT trial) 2011).

        So, I think attributing the results of TNE to the “theatrics” of a particular individual fails to acknowledge the breadth and depth of research that has been done in this area. That’s not to diminish the importance of establishing an effective therapeutic alliance with the patient so that they are more willing to buy in to what the therapist has to offer, but the content does matter to the extent that it reduces threat and moves the patient away from the conditioned response to avoid movement.

  4. Hello, are you suggesting a non-evidence based approach because you regard all therapy interventions as placebos? For me, there has to be some interventions that work better than others and the only way to assess these would be through fair tests. I am not denying the effect of ‘input’ but I think we should look for input plus an intervention effect.

    • Hey,
      I am not suggesting we take a non-evidence based approach—I suspect we should be very “evidence-informed”. I suspect we need to put the patients response to treatment at the forefront and modulate our approach based upon their response.

      I do not view all therapy interventions as “sham” (which needs to be distinguished from placebo— which can be viewed as an “active hypoalgesic agent” (described by Bialosky et al)). We need to instead first determine plausibility of intervention, and couple that with things such as patient beliefs and expectations.

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