Activity and exercise, small to moderate effect size for pain and functional improvement.

[Azimuthal]

Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews (2017).

Small to moderate effect sizes for pain and functional improvement. Inconsistent results.

The APTA has been pushing hard for PT as an alternative to opioids, but are therapists up to the task? I my view, the APTA needs to assess where the average therapist is in terms of the knowledge-base on modern pain science. Movement alone without patient education and counseling are not promising.

Thoughts?

Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews

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[jadedphysiotherapist]

Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews (2017).

Small to moderate effect sizes for pain and functional improvement. Inconsistent results.

The APTA has been pushing hard for PT as an alternative to opioids, but are therapists up to the task? I my view, the APTA needs to assess where the average therapist is in terms of the knowledge-base on modern pain science. Movement alone without patient education and counseling are not promising.

Thoughts?

Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews

No they don't. Therapists have a better understanding of pain than other providers besides physiatry (well...maybe), anesthesia, and interventional pain as its in the entry level curriculum and our scoring is based off of pain scales with researchers constantly adding literature to the field.

CBT, endorphins, education, and graded exercise aren't lethal. If one in isolation isn't working, then combine and compare to baseline.

We have a national epidemic from pain medicine and overprescription. Even orthopods who have been the most vocal in limiting therapist scope and access due to competition are publicly voicing their approval of PT. Therapy is also cheaper than interventional pain injections and hvla is perfectly fine when applied following contraindication screening.

In my view people should not worry so much about effect sizes when death is a serious issue with current treatments. Even a straight placebo pill would be better than what is currently happening

Also, compare this stuff to spine surgery.

 

[Azimuthal]

No they don't. Therapists have a better understanding of pain than other providers besides physiatry (well...maybe), anesthesia, and interventional pain as its in the entry level curriculum and our scoring is based off of pain scales with researchers constantly adding literature to the field.

CBT, endorphins, education, and graded exercise aren't lethal. If one in isolation isn't working, then combine and compare to baseline.

We have a national epidemic from pain medicine and overprescription. Even orthopods who have been the most vocal in limiting therapist scope and access due to competition are publicly voicing their approval of PT. Therapy is also cheaper than interventional pain injections and hvla is perfectly fine when applied following contraindication screening.

In my view people should not worry so much about effect sizes when death is a serious issue with current treatments. Even a straight placebo pill would be better than what is currently happening

Also, compare this stuff to spine surgery. If your moral compass doesn't shatter and you get sick from reading then idk what else to tell you.

So, did you read the article?

The point that I was making has nothing to do with garnered support, but your dismissal of the effect size is concerning. Does inconsistency of outcomes not worry you? “If one in isolation isn't working, then combine and compare to baseline”. That comment is akin to a bad mechanic switching out parts until something works. It may pass in a typical setting, but if you’ve worked with chronic pain patients, most of the time you will get ONE chance to make a difference. If you’re lucky, two. This poplulation is far less forgiving than others, but what is there to lose? Perhaps our professional reputation? But it’s monetarily cheap, correct?

Also, I see that your professors have made quite an impression on you. Pain scale? Oh, my... Sorry, but you’re going to begin practice and be struck with a severe reality check. Most PT’s are not competent in pain management, let alone be leaders in the field. @jesspt is an exception and by far not the norm. It is one of our developing areas. I’d say that we’re somewhere in the mid-upper half. No faculty fluff included.

I’d like to have you visit one of our pain clinics. It may also humble you working with OT’s, educators, and members of the mental health team. And let’s not forget the DDS/DMD’s who are established pain professionals in maxilla and TMJ.

Now, if your argument is that we should be partners and active leaders in the pain management realm, I absolutely agree. However, PT’s need to step up their game and ‘get gud’. Activity and exercise is not the be all end all. Pain management works best in combination with patient education and counseling. And in many cases, while working side by side with a pain doc.

 

[jadedphysiotherapist]

So, did you read the article?

The point that I was making has nothing to do with garnered support, but your dismissal of the effect size is concerning. “If one in isolation isn't working, then combine and compare to baseline”. That comment is akin to a bad mechanic switching out parts until something works. It may pass in a typical setting, but if you’ve worked with chronic pain patients, most of the time you will get ONE chance to make a difference and if you’re lucky, two. This poplulation is far less forgiving than others, but what is there to lose? Perhaps our professional reputation? But it’s monetarily cheap, correct? (In the short-term anyways)

Also, I see that your professors have made quite an impression on you. Pain scale? Oh, my... Sorry, but you’re going to begin practice and be struck with a severe reality check. Most PT’s are not competent in pain management, let alone be leaders in the field. @jesspt is an exception and by far not the norm. It is one of our developing areas. I’d say that we’re somewhere in the mid-upper half. No faculty fluff included.

I’d like to have you visit one of our pain clinics. It may also humble you working with OT’s, educators, and members of the mental health team. And let’s not forget the TMJ DDS/DMD’s who are established pain professionals. Sorry, not limited to physicians.

Now, if your argument is that we should be partners and active leaders in the pain management realm, I absolutely agree. However, PT’s need to step up their game and ‘get gud’. Activity and exercise is not the be all end all. Pain management works best in combination of patient education and counseling. And in many cases, while working side by side with a pain doc.

I'm a little too cynical on believing in teamwork across the board given the reimbursement system, tho OT and mental health work together fine. Conservative competitor competition mixed in works for me for physicians and many dentists....most exceptions being within the hospital away from private pactice.

You do know that all healthcare providers try interventions out until things work right? The frequency of getting it right may increase with a field but that's how things work. Do we cause harm compared to others that treat pain? Sure, but NNH is likely very high for therapists vs. other providers.

Effect size is important....but when the answer is so blatantly obvious as to stop having ppl continue on a care system that has led to a national epidemic I'm not as concerned on crossing my is and dotting my ts to make a statement that PT shouldn't be one of the first management lines.

His viewpoints are getting more mainstream with education btw

 

[Azimuthal]

You do know that all healthcare providers try interventions out until things work right? The frequency of getting it right may increase with a field but that's how things work.

Yes, but I’m speaking to PT and pain management.

What impact will you make when your patients stop showing up after their first treatment sessions? What if patients begin reporting, “how much PT has made it worst” to colleagues, friends, family, social media? How will this benefit society? It’s happened, and is continuing to happen. As I said, this population is less forgiving.

Here’s a truth bomb. The local schools here predominantly model their pain education around gate control theory.

 

[NewTestament]

Movement alone without patient education and counseling are not promising.

In order to educate, you have to understand pain and deal with patients who have chronic pain. Chronic pain patients can be complicated and demanding. It's much more fun to rehab an ACL than chronic pain.

I like the idea of therapeutic neuroscience education promoted by Adrian Louw. I've seen a couple of his webinars and have been impressed. Education might be the cheapest and most effective intervention. Why not start there before telling Ms. Jones to start walking 45 minutes day?

It's too simple to say, "just go exercise." If it were only that easy. When I was in school I was told that PT would "save health care" and "lower health care costs." Maybe. Enthusiasm needs to be combined with data.

I don't think most PT's, including me, are qualified to manage chronic pain. It deserves its own section in the APTA. But it's a huge opportunity for this profession.

Note: I did NOT read the entire article due its length.

 

[jesspt]

No they don't. Therapists have a better understanding of pain than other providers besides physiatry (well...maybe), anesthesia, and interventional pain as its in the entry level curriculum and our scoring is based off of pain scales with researchers constantly adding literature to the field.

I see you haven't been on the Doctor of Physical Therapy Students Facebook page recently. Or ever.

In my view people should not worry so much about effect sizes when death is a serious issue with current treatments. Even a straight placebo pill would be better than what is currently happening

I would agree that I'm less concerned about effect sizes than I am about looking at risk vs. reward. And PT, in most instances, has little to no risk to the patient.

However, PT’s need to step up their game and ‘get gud’. Activity and exercise is not the be all end all.

Yup. We've been over-promising for quite a while now, and the data regarding the small to moderate effect sizes for treating patients who are in pain has been around for more than a few years. PTs should be a part of the course of treatment for a patient in chronic pain, with all of the involved stakeholders (including the patient) on the same page regarding pain science, establishing a therapeutic alliance, avoiding the nocebo effect, etc.

Here’s a truth bomb. The local schools here predominantly model their pain education around gate control theory.

Ugh.

 

[TheIron]

I'm about to graduate from PT school in December and I learned little about conventional pain science besides the occasional "here's the biopsychosocial model of pain." I was incredibly lucky to have a CI who was passionate about pain neuroscience education. I also had the privilege to see Dr. Louw speak at the annual CPTA conference last September. From what I've seen, the average therapist knows little about how to approach pain management. Patients see you because they are in pain. We should be emphasizing up to date pain neuroscience in DPT curriculums.

Patient education is the intervention you give every patient you see. If we suck at explaining why people hurt I think we're doing patients a huge disservice. PNE isn't just theory anymore, it has a significant correlation with pain reduction/functional improvement.

To those who want more info, here are a couple articles to start with:

Combined physiotherapy and education is efficacious for chronic low back pain; Moseley
The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature; Louw

 

[Azimuthal]

Another example to strengthen our understanding of pain.

Interactions between brain and spinal cord mediate value effects in nocebo hyperalgesia.

https://sci-hub.io/saveme/ad06/[email protected]