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Being open to Various Treatment Styles

7/6/2015

4 Comments

 
With the push for evidence-based practice, there is an increasing disregard for less common evaluation and treatment methods, such as craniosacral and visceral manipulation. Part of that may be due to the difficulty to formulate a quality and standardizd study using these theories. Personally, after PT school I thought the techniques were similar to the practice of witch doctors. My mind was set in a purely biomechanical perspective.

Recently, I spoke with someone who had intense pelvic and abdominal pain after surgery that had her pain eliminated with visceral manipulation. I've heard of similar presentations after gall bladder removal, appendectomy and more. While I am still uncertain of the true mechanism, I have definitely become more open to the atypical approaches. With the development of pain science, we understand how crucial a role the mind plays in our patient's pain levels and treatment. Simply put, if a patient thinks a treatment will work, it will work. There was a time when I thought the use of modalities was equated with out-dated physical therapy, but I have become open to its use in patients who report prior "success" with it (I, of course, educate the patient on the benefits of a more active treatment approach). Going back to a patient's beliefs, we as clinicians can play a significant role in the process. If we build trust with the patient, our explanations of why the patient is experiencing their symptoms can impact the patient's response to treatment. A patient who trusts a craniosacral therapist and their explanation may be more open to whatever changes occur with the treatment. Same rule applies for all treatments. While it is not so simple as to give an explanation to the patient then treat according to that theory, these factors may at least influence our patients. The most difficult aspect occurs when patients have had many various explanations for their pain in the past or were convinced in the past about the source of their issues. My most difficult patients to treat are the ones who memorize their MRI findings. Educating them on how insignificant those findings are can almost completely eliminate any trust that was there in the first place.
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In conclusion, as a profession, we shouldn't be so quick to eliminate anything that isn't supported by higher levels of evidence. Things like craniosacral therapy and visceral manipulation have been around as long as they have because there is some sort of success. Maybe part of the success is due to a particular subset of the population being more open to the concept and maybe not. Regardless, we should be open to any form of treatment that may benefit our patients, thus increasing the importance of developing an eclectic approach.

-Chris
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Complex Regional Pain Syndrome (CRPS)
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The Power of Placebo
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4 Comments
Glenn
7/10/2015 02:45:59 pm

I disagree.

According to your theory of treating patients by lying to them and then banking on the placebo effect, you could literally perform any treatment within your imagination. The flip side to these positive anecdotes, is the potential for unexpected side effects. For example, Chiros who claim to be doctors and perform cervical manipulations can induce strokes (even in children).

Follow the evidence wherever it leads, and reject the ideas that don't pass the test. The treatment that has been consistently been proven to be effective is exercise.

Reply
Chris link
7/10/2015 11:39:09 pm

Thanks for your opinion Glenn! Im not saying you solely perform the unsupported treatment without any others. Absolutely you educate the patient on what the research shows and incorporate that into your management. However it is foolish to ignore patient perception. One of the pillars of evidence based practice is patient beliefs!! If the usual treatment doesnt work with the patient, all im saying is we should consider other styles. If you solely treated based on treatments supported by systematic reviews, youd have a lot of patients not improving. We cant ignore the impact pain science/patient perception has on our treatment.

Reply
Glenn
7/11/2015 07:19:15 am

Hi Chris,

Thank you for the clarity. If the ultimate goal is to simply make the patient better, then it makes sense to provide the patient the treatment that they want, while educating them on the benefits, risks and research behind it. As long as one can ensure that they are providing no harm, then it may seem reasonable to use alternative methods as a last resort.

As PT is both an art and a science, perhaps an initial exercise-based approach, followed by supplemental treatments (acupuncture, IMS, ultrasound etc.) would be ideal for most patients.

Aaron
7/12/2015 01:34:14 am

I agree with your viewpoints. I feel like an important part of the patient interview is determining their perceptions/beliefs/preferences in terms of what the patient believes is the cause of their pain and what they believe will fix it. Some patients may not have many preconceived notions about their injury or preferences of treatment, but others may have very strong opinions and it is important to be aware in both circumstances. If we only selected interventions based on very high levels of evidence, we wouldn't have much to choose from and we likely wouldn't help many people. Luckily, we have the fortune of being able to spend significant time with our patients and individualizing a treatment approach based on many factors including patient preference.

On a side note, I had an interview that dealt with this issue. The company offered experience working with professional athletes, and the interviewer admitted that many athletes, particularly elite level athletes, have strong opinions about treatments and for lack of a better word come off as superstitious. He realizes many of the treatments he provides are not backed by evidence, but if he were not to provide some athletes what they desired, they would simply seek another therapist who would provide what they were looking for because they have that luxury. And he was interested in how I, as a new grad being taught the important of EBP, would react in such a situation. I think it's a tough line to walk because you do feel the need to educate the patient about the effectiveness of interventions without discrediting their knowledge/beliefs and/or reducing the likelihood of a particular intervention being effective (i.e. if you tell a patient you don't think a particular treatment is going to do much good, but then provide it anyway, can you expect the patient to have a positive outcome?). We want to be honest without being deceiving. At the end of the day, the goal is a positive outcome - and the interventions that get you there will be different for every patient. Some will be backed by high level evidence, but most will not be. And in choosing between interventions supported with minimal evidence, it is important to consider factors such as patient preference.

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  • Home
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  • Resources
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    • Special Tests >
      • Cervical Spine >
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        • Deep Neck Flexor Endurance Test
        • Posterior-Anterior Segmental Mobility
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        • Sharp-Purser Test
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      • Thoracic Spine >
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        • Extensor Endurance Test
        • FABER Test
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        • Gaenslen Test
        • Gillet Test
        • Gower's Sign
        • Lumbar Quadrant Test
        • POSH Test
        • Posteroanterior Mobility
        • Prone Knee Bend Test
        • Prone Instability Test
        • Resisted Abduction Test
        • Sacral Clearing Test
        • Seated Forward Flexion Test
        • SIJ Compression/Distraction Test
        • Slump Test
        • Sphinx Test
        • Spine Rotators & Multifidus Test
        • Squish Test
        • Standing Forward Flexion Test
        • Straight Leg Raise Test
        • Supine to Long Sit Test
      • Shoulder >
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        • Biceps Load Test II
        • Drop Arm Sign
        • External Rotation Lag Sign
        • Hawkins-Kennedy Impingement Sign
        • Horizontal Adduction Test
        • Internal Rotation Lag Sign
        • Jobe Test
        • Ludington's Test
        • Neer Test
        • Painful Arc Sign
        • Pronated Load Test
        • Resisted Supination External Rotation Test
        • Speed's Test
        • Posterior Apprehension
        • Sulcus Sign
        • Thoracic Outlet Tests >
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          • Costoclavicular Brace
          • Hyperabduction Test
          • Roos (EAST)
        • Yergason's Test
      • Elbow >
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        • Chair Sign
        • Cozen's Test
        • Elbow Extension Test
        • Medial Epicondylalgia Test
        • Mill's Test
        • Moving Valgus Stress Test
        • Push-up Sign
        • Ulnar Nerve Compression Test
        • Valgus Stress Test
        • Varus Stress Test
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        • Carpal Compression Test
        • Finkelstein Test
        • Phalen's Test
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        • Dial Test
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        • Fitzgerald's Test
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        • Labral Posterior Impingement Test
        • Long-Axis Femoral Distraction Test
        • Noble Compression Test
        • Percussion Test
        • Sign of the Buttock
        • Trendelenburg Test
      • Knee >
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        • Joint Line Tenderness
        • Lachman Test
        • McMurray Test
        • Noble Compression Test
        • Pivot-Shift Test
        • Posterior Drawer Test
        • Posterior Sag Sign
        • Quad Active Test
        • Thessaly Test
        • Valgus Stress Test
        • Varus Stress Test
      • Foot/Ankle >
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        • Calf Squeeze Test
        • External Rotation Test
        • Fracture Screening Tests
        • Impingement Sign
        • Navicular Drop Test
        • Squeeze Test
        • Talar Tilt
        • Tarsal Tunnel Syndrome Test
        • Test for Interdigital Neuroma
        • Windlass Test