Physical Therapy Effectiveness: Questions from a New Student

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I am a student who has recently been accepted to physical therapy school. I have spent a lot of time observing and researching physical therapy. Through this research and observation, I have come to have some reservations about the profession. I was hoping you could give me some insight into a few questions I have about physical therapy.

My main questions are:

1. Is there enough evidence today that you would confidently say the majority of the practices used in physical therapy are more effective than a placebo treatment?

2. Do you believe future research in rehabilitation will provide evidence for or against the use of physical therapy?

3. If I attend PT school, will I be taught things that are not supported by peer-reviewed research? Will I be taught anything pseudo-scientific?

4. Is there any area in PT which is notably more evidence based or "proven" (neuro, inpatient acute, outpatient sport therapy, etc.)?



I ask because I cannot see myself getting a doctorate in a health field that is not convincingly evidenced to be effective beyond placebo. I am having trouble finding a substantial amount of convincing evidence supporting the practices used in physical therapy. I have even seen practices used which have substantial evidence against them. I have asked physical therapists and most have politely danced around the kernel of my questions.

I do not mean to be confrontational with these questions. It is just an important decision for me and I hoping the therapists on these forums could give me some real talk about the state of the profession since it is such a big life decision for me.

If there is anything else you would like to know about me or questions you have for me, please feel free to ask.

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I am a student who has recently been accepted to physical therapy school. I have spent a lot of time observing and researching physical therapy. Through this research and observation, I have come to have some reservations about the profession. I was hoping you could give me some insight into a few questions I have about physical therapy.

My main questions are:

1. Is there enough evidence today that you would confidently say the majority of the practices used in physical therapy are more effective than a placebo treatment?

2. Do you believe future research in rehabilitation will provide evidence for or against the use of physical therapy?

3. If I attend PT school, will I be taught things that are not supported by peer-reviewed research? Will I be taught anything pseudo-scientific?

4. Is there any area in PT which is notably more evidence based or "proven" (neuro, inpatient acute, outpatient sport therapy, etc.)?



I ask because I cannot see myself getting a doctorate in a health field that is not convincingly evidenced to be effective beyond placebo. I am having trouble finding a substantial amount of convincing evidence supporting the practices used in physical therapy. I have even seen practices used which have substantial evidence against them. I have asked physical therapists and most have politely danced around the kernel of my questions.

I do not mean to be confrontational with these questions. It is just an important decision for me and I hoping the therapists on these forums could give me some real talk about the state of the profession since it is such a big life decision for me.

If there is anything else you would like to know about me or questions you have for me, please feel free to ask.

The research is solid and better than some fields in medicine specifically pain medicine, some physiatry, a good bit of ortho and spine. Obviously it pales in comparison to evidence for internal medicine, however insurance dictates everything.

Many modalities have fallen out of favor but dosed exercise as well as physical stress to tissue or repetition for habituation have solid science. However, insurance only reimburses for the cpt codes that are given to us and therapists are undercompensated due to that, particularly in general musculoskeletal care.

You can't see it when not further into school, but a lot of healthcare doesn't even follow current best practice and science can take a decade to actually get reimbursable and implemented.

If you've gotten into a state school with a manageable debt to income ratio and is research oriented and not a newer school then I say go for it.
 
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I am a student who has recently been accepted to physical therapy school. I have spent a lot of time observing and researching physical therapy. Through this research and observation, I have come to have some reservations about the profession. I was hoping you could give me some insight into a few questions I have about physical therapy.

My main questions are:

1. Is there enough evidence today that you would confidently say the majority of the practices used in physical therapy are more effective than a placebo treatment?

2. Do you believe future research in rehabilitation will provide evidence for or against the use of physical therapy?

3. If I attend PT school, will I be taught things that are not supported by peer-reviewed research? Will I be taught anything pseudo-scientific?

4. Is there any area in PT which is notably more evidence based or "proven" (neuro, inpatient acute, outpatient sport therapy, etc.)?



I ask because I cannot see myself getting a doctorate in a health field that is not convincingly evidenced to be effective beyond placebo. I am having trouble finding a substantial amount of convincing evidence supporting the practices used in physical therapy. I have even seen practices used which have substantial evidence against them. I have asked physical therapists and most have politely danced around the kernel of my questions.

I do not mean to be confrontational with these questions. It is just an important decision for me and I hoping the therapists on these forums could give me some real talk about the state of the profession since it is such a big life decision for me.

If there is anything else you would like to know about me or questions you have for me, please feel free to ask.

Also a shorter answer....

What is being taught in school beats placebo most of the time. Some of the passive modalities do not....but current practice uses them to reduce inhibition of movement and progress to active exercise/stress.

Further research is very promising in neuro and pediatric developmental delay. Science for ortho and sport is good but patients continue to heal after pain subsides sometimes which means they stop coming back and without proper education may reinjury themselves. PRP and TESIs currently do not eliminate the need for therapy as a service.

In acute care, therapy decreases risk of dvt and pulmonary embolism as well as deconditioning. In oncology, it helps maintain strength when patients have cachexia and maintains bone integrity through increased osteoblastic activity.

Practices that have fallen primarily out of favor that aren't traditional allopathic medicine are chiropractic spinal manipulation as well as acupuncture.

Best practice and evidence usually complements physician services to maintain or increase functional strength
 
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Most of medicine is not as "evidence-based" as you think it is. Healthcare professionals in all disciplines by and large are going with the best that we've got.

Excellent reading below:
2005 - Why Most Published Research Findings Are False
Maintenance Page | PLOS

2016 - Why Most Clinical Research Is Not Useful
Maintenance Page | PLOS

Conclusion: "Overall, not only are most research findings false, but, furthermore, most of the true findings are not useful."
Both by John Ioannidis, one of the most cited medical scientists of the 21st century.

 
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Nor do we need studies that pass the benchmarks of the EBM Nazis for many interventions. A PT evaluating someone's needs for a manual or power wheelchair and working with an equipment specialist to get the person fitted and equipped correctly is not something you learn from rigorous controlled trials, it is a skill that is taught through experience that fills a need. Similarly, surgical removal of a knife from someone's back or bolting a snapped tibia back together in the trauma OR are not things that are learned from an armchair perusing PubMed, it is an advanced trade that is learned through physical labor. We rely on the skills, not just the theoretical knowledge of highly trained healthcare professionals to take care of us when we are sick, injured and disabled. Theory is crucial, but reading review after review stating that "we found weak to moderate evidence for x but more research is needed to determine x, y & z" doesn't actually help you help your patients that much.

PT is a young profession relative to other disciplines and the body of research has only really started to explode in recent decades. Also realize that high-level randomized, controlled, double-blinded trials are very difficult and sometimes impossible to conduct for physical therapy interventions for numerous reasons, and that what journal you read in makes a big difference. Remember too that "physical therapy" is not an intervention, it is a profession, so if you are searching for papers that show that "physical therapy" is more effective than placebo, you will struggle. Prescriptive/therapeutic exercise, manual therapy, functional training and task-specific practice are effective interventions for hundreds of diagnoses, and that is what PT's provide. Medical journals like to publish papers that compare "physical therapy" to something else, and the results are almost invariably underwhelming. Again, that would be like comparing "optometry" to "usual care" and seeing if there is a difference. Doesn't make any sense. Read journals that publish actual rehabilitation research and you will find what you are looking for. Again though, most studies in PT don't have the sample size you would in a medical research setting, so don't expect a miracle in every paper. Also keep in mind that since you haven't actually had any training in PT yet, you don't have much of a basis to gauge the effectiveness of what PT's do based on what you read.

Finally, physical therapy is almost as diverse with almost as many specialties and sub-specialties as medicine. If you had been accepted to medical school, would you post a thread asking "Is there enough evidence today that you would confidently say the majority of the practices used in medicine are more effective than a placebo treatment?" That would be an impossible question to adequately answer, just as the one you are posing here is. Many things physicians do are indeed more effective than placebo, many are not, and the same is true for PT and every other healthcare discipline. Arthroscopic surgery for knee OA, radiofrequency ablation for back pain and vertebroplasty for compression fracture have all been shown to be no more effective than sham surgery. Surgery is indeed the most powerful placebo in medicine. The majority of people who undergo rotator cuff repair for large degenerative/atraumatic tears re-tear within a year and never know it, but they still get better. Most drugs are not actually
that much more effective than placebo. But can you say exercise or re-learning a functional skill is more or less effective than placebo? Doesn't make any sense. It is true that many of the interventions we provide that are targeted only at improving pain might not hold up in a RCT. But much of what we do in PT can't be compared to placebo, nor should it be, and it shouldn't take much at this point to convince you that exercise and practice to improve function is helpful for most pt's regardless of diagnosis.
 
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I actually thought exactly what you are thinking before I started PT school and had the same questions. Attending PT school resolved my concern. Like I alluded to above, you are not much more or less likely to receive sub-optimal and/or non-evidence-based care visiting a PT than you are visiting your doctor.

There are many, many non-evidence-based treatments (and occasionally full-blow quackery) being provided by PTs in the field, no doubt. But PT school teaches you what the current best evidence actually says (for the most part), and shows you all the conditions PT is effective for, and it is then up to you to find a way to implement that knowledge while navigating the cesspool that is our healthcare system.
 
Most of medicine is not as "evidence-based" as you think it is. Healthcare professionals in all disciplines by and large are going with the best that we've got.

Excellent reading below:
2005 - Why Most Published Research Findings Are False
Maintenance Page | PLOS

2016 - Why Most Clinical Research Is Not Useful
Maintenance Page | PLOS

Conclusion: "Overall, not only are most research findings false, but, furthermore, most of the true findings are not useful."
Both by John Ioannidis, one of the most cited medical scientists of the 21st century.

Nor do we need studies that pass the benchmarks of the EMB Nazis for many interventions. A PT evaluating someone's needs for a manual or power wheelchair and working with an equipment specialist to get the person fitted and equipped correctly is not something you learn from rigorous controlled trials, it is a skill that is taught through experience that fills a need. Similarly, surgical removal of a knife from someone's back or bolting a snapped tibia back together in the trauma OR are not things that are learned from an armchair perusing PubMed, it is an advanced trade that is learned through physical labor. We rely on the skills, not just the theoretical knowledge of highly trained healthcare professionals to take care of us when we are sick, injured and disabled. Theory is crucial, but reading review after review stating that "we found weak to moderate evidence for x but more research is needed to determine x, y & z" doesn't actually help you help your patients that much.

PT is a young profession relative to other disciplines and the body of research has only really started to explode in recent decades. Also realize that high-level randomized, controlled, double-blinded trials are very difficult and sometimes impossible to conduct for physical therapy interventions for numerous reasons, and that what journal you read in makes a big difference. Remember too that "physical therapy" is not an intervention, it is a profession, so if you are searching for papers that show that "physical therapy" is more effective than placebo, you will struggle. Prescriptive/therapeutic exercise, manual therapy, functional training and task-specific practice are effective interventions for hundreds of diagnoses, and that is what PT's provide. Medical journals like to publish papers that compare "physical therapy" to something else, and the results are almost invariably underwhelming. Again, that would be like comparing "optometry" to "usual care" and seeing if there is a difference. Doesn't make any sense. Read journals that publish actual rehabilitation research and you will find what you are looking for. Again though, most studies in PT don't have the sample size you would in a medical research setting, so don't expect a miracle in every paper. Also keep in mind that since you haven't actually had any training in PT yet, you don't have much of a basis to gauge the effectiveness of what PT's do based on what you read.

Finally, physical therapy is almost as diverse with almost as many specialties and sub-specialties as medicine. If you had been accepted to medical school, would you post a thread asking "Is there enough evidence today that you would confidently say the majority of the practices used in medicine are more effective than a placebo treatment?" That would be an impossible question to adequately answer, just as the one you are posing here is. Many things physicians do are indeed more effective than placebo, many are not, and the same is true for PT and every other healthcare discipline. Arthroscopic surgery for knee OA, radiofrequency ablation for back pain and vertebroplasty for compression fracture have all been shown to be no more effective than sham surgery. Surgery is indeed the most powerful placebo in medicine. The majority of people who undergo rotator cuff repair for large degenerative/atraumatic tears re-tear within a year and never know it, but they still get better. Most drugs are not actually
that much more effective than placebo. But can you say exercise or re-learning a functional skill is more or less effective than placebo? Doesn't make any sense. It is true that many of the interventions we provide that are targeted only at improving pain might not hold up in a RCT. But much of what we do in PT can't be compared to placebo, nor should it be, and it shouldn't take much at this point to convince you that exercise and practice to improve function is helpful for most pt's regardless of diagnosis.

These perspectives are phenomenal.

I will maintain that physical therapy is not as broad as medicine however, but other than that, this guy has provided good advice.

Make sure to focus on his pain comment. Many times it's "did physical therapy make the pain go away" and the practice actually encompasses strength, endurance, motor relearning for tasks, speed, aerobic capacity, regeneration of tissues with activity change, education, and physical stress, increase in balance, coordination, and response to stimuli from altering the environment to help a patient return to a baseline level prior to injury
 
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I will maintain that physical therapy is not as broad as medicine

Of course, there are many millions of people every year who need to see a doctor but don't need to see a PT. I guess my point was that PT's work with a ton of pt populations that the average pre-PT student isn't even aware of.

Obviously, we are pretty specialized out of the gate compared to a third year medical student. But their are literally dozens of specialties and subspecialities within PT. I guess we are generalized specialists. :)

Comparing PT to medicine on any topic is generally an effort in futility, they are mostly unrelated professions.
 
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PT's have done more research in the last 20 years than before then. There's never been a better time to be a PT.

As in any profession, some PT's are going to continue to perform interventions that have little evidence in the literature: most physical agents, dry needling, lumbar traction, posture re-ed, etc. Others will continue to educate themselves.

Think of yourself as a consultant and less a mechanic and you'll be a great PT. Quit thinking you can "fix" people. If you want to "fix" people be a chiropractor. How can you teach the patient to help himself? If you do that, your patient will get better results and you will reduce health-care costs.

I've written several articles for New Grad Physical Therapy on research and staying up-to-date. I have a lot more to say there.
 
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I am a student who has recently been accepted to physical therapy school. I have spent a lot of time observing and researching physical therapy. Through this research and observation, I have come to have some reservations about the profession. I was hoping you could give me some insight into a few questions I have about physical therapy.

My main questions are:

1. Is there enough evidence today that you would confidently say the majority of the practices used in physical therapy are more effective than a placebo treatment?

2. Do you believe future research in rehabilitation will provide evidence for or against the use of physical therapy?

3. If I attend PT school, will I be taught things that are not supported by peer-reviewed research? Will I be taught anything pseudo-scientific?

4. Is there any area in PT which is notably more evidence based or "proven" (neuro, inpatient acute, outpatient sport therapy, etc.)?



I ask because I cannot see myself getting a doctorate in a health field that is not convincingly evidenced to be effective beyond placebo. I am having trouble finding a substantial amount of convincing evidence supporting the practices used in physical therapy. I have even seen practices used which have substantial evidence against them. I have asked physical therapists and most have politely danced around the kernel of my questions.

I do not mean to be confrontational with these questions. It is just an important decision for me and I hoping the therapists on these forums could give me some real talk about the state of the profession since it is such a big life decision for me.

If there is anything else you would like to know about me or questions you have for me, please feel free to ask.

You said you came to this conclusion after examining research in the field. Can you provide some of the research that led you to this conclusion? As everyone before me pointed out the profession as a whole is pretty new and the movement towards evidenced based practice is basically in its infancy (although this is the case in many fields, not just PT). As a whole I think the field is headed in the right direction.
 
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You said you came to this conclusion after examining research in the field. Can you provide some of the research that led you to this conclusion? As everyone before me pointed out the profession as a whole is pretty new and the movement towards evidenced based practice is basically in its infancy (although this is the case in many fields, not just PT). As a whole I think the field is headed in the

I was actually astounded to learn this but the pure science research and hoops for things to get FDA approval like blood flow restriction therapy etc. can take a decade to become a practice pattern and receive reimbursement.

There's so much new therapists and the old leadership need to do to maintain smooth transitions within this profession.
 
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the OP may be talking about cupping, dry needling, acupuncture, MFR, kiinesiotaping, manual therapy etc . . . recent paper suggests (and I have thought this for a long time) that the results people see with most forms (maybe all forms?) of manual therapy is more of a central nervous system model and therefore based more upon the beliefs of the patient (placebo) than the actual technique. That would be consistent with some of the best science coming out now which is in the area of pain research. If you are treating pain (and that is what manual therapists do) you need to influence the brain. If the patient believes that it will help, it will.
 
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when talking about biomechanical things, there are so many variables that researching "the best" way to rehab an ACL for example is not really a reasonable expectation. every patient has unique needs (what do they want to return to, and at what level)and challenges (gender, foot structure, fast twitch vs slow twitch, coordinated or not, co-morbidities like chronic ankle sprains or peripheral neuropathy, motivation) So the models are useful but research that seeks to create a "protocol" or cookbook for rehabbing any particular MSK injury will fail as much as it will be successful because it does not take into consideration the uniqueness of every individual.
 
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the OP may be talking about cupping, dry needling, acupuncture, MFR, kiinesiotaping, manual therapy etc . . . recent paper suggests (and I have thought this for a long time) that the results people see with most forms (maybe all forms?) of manual therapy is more of a central nervous system model and therefore based more upon the beliefs of the patient (placebo) than the actual technique. That would be consistent with some of the best science coming out now which is in the area of pain research. If you are treating pain (and that is what manual therapists do) you need to influence the brain. If the patient believes that it will help, it will.

Please see Bialosky's essay in this month's issue of JOSPT. The technique matters less than the expectation, the presence of a professional, and the experience of receiving manual therapy.
 
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Please see Bialosky's essay in this month's issue of JOSPT. The technique matters less than the expectation, the presence of a professional, and the experience of receiving manual therapy.
that's the one I was referring to. couldn't remember the name of the author, thanks for the reference.
 
If anyone wants the full article, I can send it to you.
 
Totally agree with the Bialosky article. We need to stop placing a negative connotation on the word "placebo" all the time. Most of healthcare has somewhat of a placebo effect, especially when it comes to treating pain. Placebo analgesia is an active neurobiological process taking place in the brain and if our interventions are causing that to happen in the brain without truly altering peripheral tissues, who cares? The pt still gets better and the intervention is helpful. Whose to say we can't reframe what we do to say that the so-called "placebo" effect, rather than physically altering peripheral tissue, is the actual target mechanism of the intervention in the first place, making it not a placebo at all? Now obviously this perspective opens the door to all manner of far-flung pseudoscience and quackery becoming acceptable, so we do need to maintain more than a modicum of moderation in all things. Our historical roots in muscle, bones, joints and capsules as PTs need to remain in place, but with a modern understanding of neurophysiology overlying them.

PT is undergoing a rapid evolution right now with ever-increasing understanding that the entire body is truly subservient to the nervous system, and that the entire lived experience of a pt is dictated by what is going on in the brain. Regardless of what is truly happening in the peripheral anatomy (which we often can't reliably diagnose anyway), the way the brain perceives what is happening is what matters and what determines symptoms and prognosis. PTs are shifting from from a bottom-up to a top-down approach more and more, both in the neurologic world (think modern motor learning principles vs older neurofacilitative/relfex-based approaches) and in the orthopedic world (think "explain pain" vs older patho-anatomy focused models).

There is a time and a place for both the old and the new, but I think the growing appreciation that most of our interventions affect the nervous system a lot more than the MSK system is making a lot more PTs wary of throwing out interventions that don't perform better than "placebo" or "sham" (which is often impossible to truly create in a controlled trail anyway - see Bialosky article), even in the face of the ever-growing emphasis that everything has to be "evidence-based". You're seeing the term "evidence-informed" starting to gain popularity right now as well, and I think it's for a lot of the same reasons.
 
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the OP may be talking about cupping, dry needling, acupuncture, MFR, kiinesiotaping, manual therapy etc . . . recent paper suggests (and I have thought this for a long time) that the results people see with most forms (maybe all forms?) of manual therapy is more of a central nervous system model and therefore based more upon the beliefs of the patient (placebo) than the actual technique. That would be consistent with some of the best science coming out now which is in the area of pain research. If you are treating pain (and that is what manual therapists do) you need to influence the brain. If the patient believes that it will help, it will.

Manual therapy physically stresses ligaments and influences range of motion. As for oswestry changes, that is acute change. It works and has been undergoing stratification I.e. Mob grading etc. The placebo work is in regards to pain modulation in which grades 1 and 2 are used since they modulate the pain and produce a calming effect prior to other interventions. That combined with environmental exposure changes perception of pain from my understanding so yes it is related to the nervous system.
 
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Manual therapy physically stresses ligaments and influences range of motion. It falls under physical stress theory and pre and post scores change.

How much physical stress do we need to impart in order to see long-lasting change in ROM?

*HINT*


The placebo work is in regards to pain modulation in which grades 1 and 2 are used since they modulate the pain and produce a calming effect prior to other interventions.
The placebo effect (or placebo response) is a positive impact on a patient's symptoms due to non-specific treatment effects, or those that cannot be attributed to the intervention being applied. It has nothing to do with the type of joint mobilization you are using, but rather is contributed to by patient expectation and bias and how the clinician impacts those expectations and biases.
 
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How much physical stress do we need to impart in order to see long-lasting change in ROM?

*HINT*



The placebo effect (or placebo response) is a positive impact on a patient's symptoms due to non-specific treatment effects, or those that cannot be attributed to the intervention being applied. It has nothing to do with the type of joint mobilization you are using, but rather is contributed to by patient expectation and bias and how the clinician impacts those expectations and biases.

My misunderstanding. I thought it was patient perception and expectation with regards to the intervention

Thank you for clarification.

As for longlasting? I thought this was acute change until active motion. Your post doesn't appear. Parameters need development unless youre working at a place with really expensive equipment.
 
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Totally agree with the Bialosky article...

I think the neurological model explains a lot and is consistent with what we know about neuroscience and psychology. The 500-year-old model of pain is outdated (tissue damage-> pain), but unfortunately, I think a lot of PT's are operating under that paradigm. Manual therapy also assumes that there is a mechanical fault, and that manual therapy can correct the fault and alleviate the pain. PT would be much more effective, however, if it rewired the brain.

If an intervention is placebo only, then it should be discarded. There are cheaper ways to create a placebo effect and you don't need to learn sophisticated techniques (ie- thrust) to get a placebo effect. There's a lot of ways to get it.
 
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I think the neurological model explains a lot and is consistent with what we know about neuroscience and psychology. The 500-year-old model of pain is outdated (tissue damage-> pain), but unfortunately, I think a lot of PT's are operating under that paradigm. Manual therapy also assumes that there is a mechanical fault, and that manual therapy can correct the fault and alleviate the pain. PT would be much more effective, however, if it rewired the brain.

If an intervention is placebo only, then it should be discarded. There are cheaper ways to create a placebo effect and you don't need to learn sophisticated techniques (ie- thrust) to get a placebo effect. There's a lot of ways to get it.

Get back to me when private practice physicians stop doing that charging outrageous prices....

There's literally a PRP thread right now with some guys discussing how to market and sell it to patients
 
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the thing about PRP is that there is some plausible hope that it will end up being helpful (i.e. better than placebo). I listened to quite a few orthos at one of my courses talk about how there are different kinds of PRP and some are specific to different tissues. Most of it was over my head though so it could have just been a sell job.
 
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This is a very interesting topic, and as a experienced therapist something I deal with routinely. And, what I tell others is that there is enough evidence out there that PT is more than a mind trick. Yes, the effort and readiness plays a part in effectiveness of the treatment, but the skill of the PT plays a bigger part. I deal with neuro patients everyday who have gone through traumatic brain injury, and are often starting from scratch when they get out of the hospital. This is where I see these patients go through the road of recovery successfully with effective Physical Therapy. I actually wrote a case study recently about the topic on my blog, which you can read here: Tale of a TBI survivor: From ventilation to Ambulation with Physical Therapy - Life in a day of a Physical Therapist
 
This is a very interesting topic, and as a experienced therapist something I deal with routinely. And, what I tell others is that there is enough evidence out there that PT is more than a mind trick. Yes, the effort and readiness plays a part in effectiveness of the treatment, but the skill of the PT plays a bigger part. I deal with neuro patients everyday who have gone through traumatic brain injury, and are often starting from scratch when they get out of the hospital. This is where I see these patients go through the road of recovery successfully with effective Physical Therapy. I actually wrote a case study recently about the topic on my blog, which you can read here: Tale of a TBI survivor: From ventilation to Ambulation with Physical Therapy - Life in a day of a Physical Therapist

Neurorehab isn't where there's a problem....its when dealing with musculoskeletal pain that there are sometimes issues.
 
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Well, it depends on your ability to perform evaluations, deferentially diagnosing the correct issues and than treat it. If you can do that than yes, physical therapy is a very effective tool. PTs can cure injuries - sprains and strains but can not cure the disease - can just reduce the symptoms like pain and inflammation in that case.
 
Well, it depends on your ability to perform evaluations, deferentially diagnosing the correct issues and than treat it. If you can do that than yes, physical therapy is a very effective tool. PTs can cure injuries - sprains and strains but can not cure the disease - can just reduce the symptoms like pain and inflammation in that case.

That wasn't the point. Pain symptoms can decrease from straight placebo and using passive modalities that only cause an acute effect


Neurorehab works to give sensory, motor, and cognitive function back through habituation
 
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Hi everyone,

This discussion strikes a chord with me although I am a first year physical therapy student from a country very different from and sometimes far behind the US in terms of the physical therapy training, scope of practice, regulations, the relationship with medical field, general healthcare settings, cultural background (thus the patients' expectations are very different as well).

I wonder maybe someone could share their thoughts on what areas of physical therapy in your experience are the most spared of the placebo effect? Apart from neurorehabilitation which was mentioned above (I do not feel inclined to it at the moment being). Maybe pediatrics? (but they have their parents and the parents do have expectations...)

The thing is that I would like to feel that an intervention I will provide or participate in is meaningful and (don't know how to say it in a more mature way but) makes a difference. However, since it is considered to be evidence-based that the placebo effect exists, works (and apparently is getting reassessed as a legitimate tool?) now I feel uncertain of almost everything.

First, since the placebo effect works and the patients do have their expectations, how responsible it would be to try to rationalize to every patient the whole situation, to educate them? It seems the only right and ethical thing from the point of view of a health care provider's mental wellbeing, but if a patient is stripped off their belief in some form of voodoo therapy and no placebo thing is given instead, how they will achieve their peace of mind then? What if they turn instead for some type of behavior which is more harmful for their health than the placebo therapy was, e.g. addictive behavior? Is it theoretically possible to select your clients by finding out what are their expectations first of all - do they look to learn new ways to independently manage themselves or do they look for a someone to "fix" their body and mind from time to time? And refer the latter to those who provide passive therapy?

Second, if the placebo effect works in every healthcare field including surgery, then many healthcare interventions are inevitably have no choice than to address it and sell the placebo (or deny the placebo - and potentially add to their anxiety?) Personally I would feel not satisfied with my life if I know that I sell the placebo for a living, moreover, looking around in our settings I see that people who haven't invested their time and money into getting any healthcare degreee, tend to be more effective and convincing in selling their placebo (they tend not to question their methods and it eventually creates a stronger placebo effect for a patient, which is better for a patient, isn't it?). So it seems that evidence-informed doubts will make a placebo treatment less effective.

Third, simply knowing about the placebo effect, that it is an inevitable part of human nature, and that it works, makes me feel that I will be engaged in either an unethical practice if I sell it, or in a potentially disturbing a patient's mental wellbeing practice if I constantly educate them that "this is all in your mind"; and eventually what is all this education for?..
 
Hi everyone,

This discussion strikes a chord with me although I am a first year physical therapy student from a country very different from and sometimes far behind the US in terms of the physical therapy training, scope of practice, regulations, the relationship with medical field, general healthcare settings, cultural background (thus the patients' expectations are very different as well).

I wonder maybe someone could share their thoughts on what areas of physical therapy in your experience are the most spared of the placebo effect? Apart from neurorehabilitation which was mentioned above (I do not feel inclined to it at the moment being). Maybe pediatrics? (but they have their parents and the parents do have expectations...)

The thing is that I would like to feel that an intervention I will provide or participate in is meaningful and (don't know how to say it in a more mature way but) makes a difference. However, since it is considered to be evidence-based that the placebo effect exists, works (and apparently is getting reassessed as a legitimate tool?) now I feel uncertain of almost everything.

First, since the placebo effect works and the patients do have their expectations, how responsible it would be to try to rationalize to every patient the whole situation, to educate them? It seems the only right and ethical thing from the point of view of a health care provider's mental wellbeing, but if a patient is stripped off their belief in some form of voodoo therapy and no placebo thing is given instead, how they will achieve their peace of mind then? What if they turn instead for some type of behavior which is more harmful for their health than the placebo therapy was, e.g. addictive behavior? Is it theoretically possible to select your clients by finding out what are their expectations first of all - do they look to learn new ways to independently manage themselves or do they look for a someone to "fix" their body and mind from time to time? And refer the latter to those who provide passive therapy?

Second, if the placebo effect works in every healthcare field including surgery, then many healthcare interventions are inevitably have no choice than to address it and sell the placebo (or deny the placebo - and potentially add to their anxiety?) Personally I would feel not satisfied with my life if I know that I sell the placebo for a living, moreover, looking around in our settings I see that people who haven't invested their time and money into getting any healthcare degreee, tend to be more effective and convincing in selling their placebo (they tend not to question their methods and it eventually creates a stronger placebo effect for a patient, which is better for a patient, isn't it?). So it seems that evidence-informed doubts will make a placebo treatment less effective.

Third, simply knowing about the placebo effect, that it is an inevitable part of human nature, and that it works, makes me feel that I will be engaged in either an unethical practice if I sell it, or in a potentially disturbing a patient's mental wellbeing practice if I constantly educate them that "this is all in your mind"; and eventually what is all this education for?..

Placebo is inevitable.

You operate on the best of what you've got in healthcare while creating and conforming with business models.

People come to you seeking a service.

Don't market nonspecific effects.

Education is 'therapy' many times.

All of physical therapy has evidence. The degrees of specificity are varying.

Medicine, dentistry, etc. are the same way.
 
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Placebo is inevitable.

Well, I understand that evidence says placebo is inevitable in healthcare, including even in pharma. I do not mean it anyhow specific to physiotherapy.

I shadowed an orthopedist who provides conservative care and have noticed that he prescribed the same staples of orthotics + foot exercises + footwear recommendations for almost every foot pain presentation. Most patients seemed satisfied because, as he sincerely explained to me later, the main things are his white coat persona and his patient communication skills matching his patients' expectations. To me, such a patient education role ought to be depressing because his degree and knowledge are underutilized and it will be the same for a PT role since foot pain and low back pain are the most widespread outpatient presentations in our settings. I anticipate no professional satisfaction when low-back pain may be treated with such a wide range of interventions (e.g. pilates, spinal manual "adjustment", accupuncture, whatever they believe in. Or it will go away on its own but will be attributed by a patient to something he was doing prior to the improvement). In my view, the placebo effect + natural history of a condition to improve on its own makes such an area of conservative care not very special in comparison to what other professions or even charlatans have to offer.

All of physical therapy has evidence. The degrees of specificity are varying.

Medicine, dentistry, etc. are the same way.

I see, I digressed from the OP's question about how much physical therapy is evidence-based (which is not a question for me, even if as far as I understand physical therapists have been conducting research of their own for a relatively short period of time, surely some of the areas of physio practice have been covered by research in exercise physiology, sports medicine, etc). And I guess the chances are next to nothing that any future research will find out that physical activity is detrimental to physical and mental well-being.

The neuro theory you were talking about and psychosocial approach which seem to be so widespread in English-speaking PT communities are likely to come to my country when I graduate and it doesn't feel amazing at the moment, because, in my understanding, it makes a psychologist out of a physio, it's a psychologist's job to talk people into feeling good. I wonder about those physiotherapy areas of practice which have to be more based on actual physiological effects of physical therapy apart from non-specific influence on a patient's mental well-being. For instance, in an LBP example, exercises can increase insulin sensitivity which is important in the long term for someone with LBP and type 2 diabetes (and at the same time, other treatments, say, accupuncture or spinal manipulation have no such important contribution to their long-term health).
 
Well, I understand that evidence says placebo is inevitable in healthcare, including even in pharma. I do not mean it anyhow specific to physiotherapy.

I shadowed an orthopedist who provides conservative care and have noticed that he prescribed the same staples of orthotics + foot exercises + footwear recommendations for almost every foot pain presentation. Most patients seemed satisfied because, as he sincerely explained to me later, the main things are his white coat persona and his patient communication skills matching his patients' expectations. To me, such a patient education role ought to be depressing because his degree and knowledge are underutilized and it will be the same for a PT role since foot pain and low back pain are the most widespread outpatient presentations in our settings. I anticipate no professional satisfaction when low-back pain may be treated with such a wide range of interventions (e.g. pilates, spinal manual "adjustment", accupuncture, whatever they believe in. Or it will go away on its own but will be attributed by a patient to something he was doing prior to the improvement). In my view, the placebo effect + natural history of a condition to improve on its own makes such an area of conservative care not very special in comparison to what other professions or even charlatans have to offer.



I see, I digressed from the OP's question about how much physical therapy is evidence-based (which is not a question for me, even if as far as I understand physical therapists have been conducting research of their own for a relatively short period of time, surely some of the areas of physio practice have been covered by research in exercise physiology, sports medicine, etc). And I guess the chances are next to nothing that any future research will find out that physical activity is detrimental to physical and mental well-being.

The neuro theory you were talking about and psychosocial approach which seem to be so widespread in English-speaking PT communities are likely to come to my country when I graduate and it doesn't feel amazing at the moment, because, in my understanding, it makes a psychologist out of a physio, it's a psychologist's job to talk people into feeling good. I wonder about those physiotherapy areas of practice which have to be more based on actual physiological effects of physical therapy apart from non-specific influence on a patient's mental well-being. For instance, in an LBP example, exercises can increase insulin sensitivity which is important in the long term for someone with LBP and type 2 diabetes (and at the same time, other treatments, say, accupuncture or spinal manipulation have no such important contribution to their long-term health).

Psychologists prevent suicide, broken marriages, enhance self efficacy, and mediate stress while influencing behavior rather than just "feeling good"

Pain has a neurophysiological and psychological component heightened by affect and environmental stresses, influenced physiologically from the initial stimulus and experienced after the brains interpretation.

Therapists need to integrate psychology into practice.

That's also just pain. Therapists need an understanding of developmental psychology to make interventions creative and have meaning throughout the lifespan so people can maintain independence.
 
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Education is 'therapy' many times.

And I would argue vastly underrated. There's too much emphasis in this profession on "high-level" skills like manual therapy. But education is a powerful tool. We have a lot of knowledge and good PT's know how to explain it in simple terms.
 
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Agree to disagree since we live in different healthcare systems with different roles of physical therapy in it, plus other individual factors in play. In my book, if I wanted to be an educationalist in healthcare, there is a degree in public health (or the Internet which often leaves educationalists look obsolete), if I wanted to do counselling, there is a degree in psychology. If active movement and exercise are the most specific to physiotherapy tools, I would rather concentrate on their application and physiology.
 
Agree to disagree since we live in different healthcare systems with different roles of physical therapy in it, plus other individual factors in play. In my book, if I wanted to be an educationalist in healthcare, there is a degree in public health (or the Internet which often leaves educationalists look obsolete), if I wanted to do counselling, there is a degree in psychology. If active movement and exercise are the most specific to physiotherapy tools, I would rather concentrate on their application and physiology.

Ask a psychologist or a public health person to educate a patient on the healing timeframe of tissues and what activities to avoid to prevent reinjury. Sometimes that's all they need and other disciplines don't have that.
 
Hi everyone,

This discussion strikes a chord with me although I am a first year physical therapy student from a country very different from and sometimes far behind the US in terms of the physical therapy training, scope of practice, regulations, the relationship with medical field, general healthcare settings, cultural background (thus the patients' expectations are very different as well).

I wonder maybe someone could share their thoughts on what areas of physical therapy in your experience are the most spared of the placebo effect? Apart from neurorehabilitation which was mentioned above (I do not feel inclined to it at the moment being). Maybe pediatrics? (but they have their parents and the parents do have expectations...)

The thing is that I would like to feel that an intervention I will provide or participate in is meaningful and (don't know how to say it in a more mature way but) makes a difference. However, since it is considered to be evidence-based that the placebo effect exists, works (and apparently is getting reassessed as a legitimate tool?) now I feel uncertain of almost everything.

First, since the placebo effect works and the patients do have their expectations, how responsible it would be to try to rationalize to every patient the whole situation, to educate them? It seems the only right and ethical thing from the point of view of a health care provider's mental wellbeing, but if a patient is stripped off their belief in some form of voodoo therapy and no placebo thing is given instead, how they will achieve their peace of mind then? What if they turn instead for some type of behavior which is more harmful for their health than the placebo therapy was, e.g. addictive behavior? Is it theoretically possible to select your clients by finding out what are their expectations first of all - do they look to learn new ways to independently manage themselves or do they look for a someone to "fix" their body and mind from time to time? And refer the latter to those who provide passive therapy?

Second, if the placebo effect works in every healthcare field including surgery, then many healthcare interventions are inevitably have no choice than to address it and sell the placebo (or deny the placebo - and potentially add to their anxiety?) Personally I would feel not satisfied with my life if I know that I sell the placebo for a living, moreover, looking around in our settings I see that people who haven't invested their time and money into getting any healthcare degreee, tend to be more effective and convincing in selling their placebo (they tend not to question their methods and it eventually creates a stronger placebo effect for a patient, which is better for a patient, isn't it?). So it seems that evidence-informed doubts will make a placebo treatment less effective.

Third, simply knowing about the placebo effect, that it is an inevitable part of human nature, and that it works, makes me feel that I will be engaged in either an unethical practice if I sell it, or in a potentially disturbing a patient's mental wellbeing practice if I constantly educate them that "this is all in your mind"; and eventually what is all this education for?..

canalith repositioning is maybe the only intervention that I do that has almost no placebo, and I might be stretching it a little there. You are not selling something that doesn't work, just don't sell a punch card and tell people that they need you weekly for life. teach them to manage themselves and you will sleep at night.
 
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Well, I understand that evidence says placebo is inevitable in healthcare, including even in pharma. I do not mean it anyhow specific to physiotherapy.

I shadowed an orthopedist who provides conservative care and have noticed that he prescribed the same staples of orthotics + foot exercises + footwear recommendations for almost every foot pain presentation. Most patients seemed satisfied because, as he sincerely explained to me later, the main things are his white coat persona and his patient communication skills matching his patients' expectations. To me, such a patient education role ought to be depressing because his degree and knowledge are underutilized and it will be the same for a PT role since foot pain and low back pain are the most widespread outpatient presentations in our settings. I anticipate no professional satisfaction when low-back pain may be treated with such a wide range of interventions (e.g. pilates, spinal manual "adjustment", accupuncture, whatever they believe in. Or it will go away on its own but will be attributed by a patient to something he was doing prior to the improvement). In my view, the placebo effect + natural history of a condition to improve on its own makes such an area of conservative care not very special in comparison to what other professions or even charlatans have to offer.



I see, I digressed from the OP's question about how much physical therapy is evidence-based (which is not a question for me, even if as far as I understand physical therapists have been conducting research of their own for a relatively short period of time, surely some of the areas of physio practice have been covered by research in exercise physiology, sports medicine, etc). And I guess the chances are next to nothing that any future research will find out that physical activity is detrimental to physical and mental well-being.

The neuro theory you were talking about and psychosocial approach which seem to be so widespread in English-speaking PT communities are likely to come to my country when I graduate and it doesn't feel amazing at the moment, because, in my understanding, it makes a psychologist out of a physio, it's a psychologist's job to talk people into feeling good. I wonder about those physiotherapy areas of practice which have to be more based on actual physiological effects of physical therapy apart from non-specific influence on a patient's mental well-being. For instance, in an LBP example, exercises can increase insulin sensitivity which is important in the long term for someone with LBP and type 2 diabetes (and at the same time, other treatments, say, accupuncture or spinal manipulation have no such important contribution to their long-term health).
read Explain Pain Supercharged or the first one Explain Pain by Moseley and Butler. We don't talk people out of being in pain, we help them understand what the pain means and what it DOES NOT necessarily mean. there is a massive difference there.
 
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Agree to disagree since we live in different healthcare systems with different roles of physical therapy in it, plus other individual factors in play. In my book, if I wanted to be an educationalist in healthcare, there is a degree in public health (or the Internet which often leaves educationalists look obsolete), if I wanted to do counselling, there is a degree in psychology. If active movement and exercise are the most specific to physiotherapy tools, I would rather concentrate on their application and physiology.
with all due respect, you can agree to disagree, but you would be wrong. If you think that being a PT is knowing a set of techniques then you are not a complete PT. physical therapy is more of a way of thinking than a set of skills or techniques. You can't move without the central nervous system, AND bones, AND muscles, AND ligaments, AND , probably most importantly, the integration of all of it.
 
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Ask a psychologist or a public health person to educate a patient on the healing timeframe of tissues and what activities to avoid to prevent reinjury. Sometimes that's all they need and other disciplines don't have that.

This information is within core competency of physiotherapy I believe. But unless they ask for an assessment of their individual case, to me it feels like this information could be pretty general overall, some people may be OK to learn it from a free educational leaflet on the subject.
 
read Explain Pain Supercharged or the first one Explain Pain by Moseley and Butler. We don't talk people out of being in pain, we help them understand what the pain means and what it DOES NOT necessarily mean. there is a massive difference there.

Out of respect for the nervous system, I do not think I would ever be able to have my own reasonable judgement on the subject, not being a neurologist or a neurophysiologist. I can only hope - perhaps - someday - to learn the current neurophysiological opinions on this matter in due time, by reading bits of their literature, but not sure I will ever comprehend it. I only speak for myself, I will not feel OK to explain people something I do not understand but have read a popular book on it.
 
Out of respect for the nervous system, I do not think I would ever be able to have my own reasonable judgement on the subject, not being a neurologist or a neurophysiologist. I can only hope - perhaps - someday - to learn the current neurophysiological opinions on this matter in due time, by reading bits of their literature, but not sure I will ever comprehend it. I only speak for myself, I will not feel OK to explain people something I do not understand but have read a popular book on it.
Its not just a "popular book" as you put it. It is written by neuroscientists/researchers and it is a thorough treatise on what pain is. they both are prolific researchers, writers, and teachers. So don't dismiss what you can learn from it. Both are very well referenced and honestly plenty of it is over my head.
 
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with all due respect, you can agree to disagree, but you would be wrong. If you think that being a PT is knowing a set of techniques then you are not a complete PT. physical therapy is more of a way of thinking than a set of skills or techniques. You can't move without the central nervous system, AND bones, AND muscles, AND ligaments, AND , probably most importantly, the integration of all of it.

Not going to argue with you since you are a PT, I am not one. As a student I am interested in learning marketable and useful skills because nobody is going to buy my way of thinking.
 
Its not just a "popular book" as you put it. It is written by neuroscientists/researchers and it is a thorough treatise on what pain is. they both are prolific researchers, writers, and teachers. So don't dismiss what you can learn from it. Both are very well referenced and honestly plenty of it is over my head.

I do not doubt them specifically, I doubt my level of understanding of the basics of the subject, which is not a good foundation to read more advanced theories with the aim to explain them to others. I am basically interested to learn about other PT areas of specialization than chronic pain or neurorehabilitation.
 
Not going to argue with you since you are a PT, I am not one. As a student I am interested in learning marketable and useful skills because nobody is going to buy my way of thinking.

if you are going to simply think that you learn a toolbox full of techniques and sell them to people, I would rather you go into a different profession. You need to learn proven or plausible foundations to your treatment interventions. Most of the research that is coming out with just about every manual therapy technique whether it is mobilization, manipulation, strain counter strain, myofascial release or what have you basically all says that it is NOT a mechanical effect. your thinking is what is valuable, not your metal tool that causes bruises, or the hickey creating cupping that Michael Phelps showed off in the Olympics, or kinesio taping, or dry needling etc . . .
 
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I do not doubt them specifically, I doubt my level of understanding of the basics of the subject, which is not a good foundation to read more advanced theories with the aim to explain them to others. I am basically interested to learn about other PT areas of specialization than chronic pain or neurorehabilitation.
Explain Pain, the first one is written primarily to the person IN pain so your level of understanding should be fine. The Supercharged version is a lot more difficult to understand.
 
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Out of respect for the nervous system, I do not think I would ever be able to have my own reasonable judgement on the subject, not being a neurologist or a neurophysiologist. I can only hope - perhaps - someday - to learn the current neurophysiological opinions on this matter in due time, by reading bits of their literature, but not sure I will ever comprehend it. I only speak for myself, I will not feel OK to explain people something I do not understand but have read a popular book on it.

What

Not going to argue with you since you are a PT, I am not one. As a student I am interested in learning marketable and useful skills because nobody is going to buy my way of thinking.

Go into sales

I do not doubt them specifically, I doubt my level of understanding of the basics of the subject, which is not a good foundation to read more advanced theories with the aim to explain them to others. I am basically interested to learn about other PT areas of specialization than chronic pain or neurorehabilitation.

I don't even know what you're really saying or what points you're trying to get across now. If you want to learn about subsections of physical therapy look up the sections from the American physical therapy association. There should be blurbs written there.

You've also thoroughly frustrated a member @truthseeker here who is probably the most level headed poster on this forum.

I would just stop the conversation as I think this is unintended annoyance being caused and you don't mean it.
 
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if you are going to simply think that you learn a toolbox full of techniques and sell them to people, I would rather you go into a different profession. You need to learn proven or plausible foundations to your treatment interventions. Most of the research that is coming out with just about every manual therapy technique whether it is mobilization, manipulation, strain counter strain, myofascial release or what have you basically all says that it is NOT a mechanical effect. your thinking is what is valuable, not your metal tool that causes bruises, or the hickey creating cupping that Michael Phelps showed off in the Olympics, or kinesio taping, or dry needling etc . . .

You are preaching to the choir, as a student you have to go through, internalize and reproduce at least the standards of care of the profession which are of course to certain extent are driven by evidence-based research, so it's never a problem and it is not a competitive edge when everyone claims to be an evidence-based practitioner, even every snake oil salesperson has some big theory to impress the public. Students generally may be even better in theories than many health care practitioners because we are fresh from the books, the right skills are a burning issue I would say. Cannot think anything at the moment regarding your example of manual therapy techniques, as I am currently puzzled about the balance between placebo/active treatment in different areas of physical therapy, I am afraid to find one day that passive manual treatments may be too close to a placebo camp, so I am not planning to go there more than my program demands from me. Sorry to see that we don't understand each other, but thank you for your attention to my frustrations.
 
Go into sales

I guess none will escape such a fate since every healthcare practitioner has to sell their services, their qualification, their cost-effectiveness, their patient communication skills, their keeping up to date with evidence based research, etc, trying to win a customer over the rivals.

I don't even know what you're really saying or what points you're trying to get across now. If you want to learn about subsections of physical therapy look up the sections from the American physical therapy association. There should be blurbs written there.

Wholeheartedly agree, we do not understand each other. I was interested in informal thoughts on placebo/active treatment balance in the treatments employed in other specialties than those one can learn from many online physio resources, e.g. outpatient MSK, a neuro theory of the abovementioned authors, medical imaging of the spine, placebo/nocebo.

You've also thoroughly frustrated a member @truthseeker here who is probably the most level headed poster on this forum.

I would just stop the conversation as I think this is unintended annoyance being caused and you don't mean it.

I would like to stop it as well. This is life, it happens people have different views and do not understand each other.
 
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