All aboard… the latest bandwagon!

We have all jumped onto a bandwagon at some point or other in our professional life. Come on admit it, if it wasn’t some electrotherapy gadget or something involving a needle, it was core stability or brightly coloured stretchy tape. Even my beloved exercise therapy isn’t immune from bandwagons with a recent epidemic for isometrics and of course eccentric exercises can cure all tendon issues.

However, recently there is a rather large and impressive bandwagon that many therapists seemed to have jumped onto (and I include myself here) and it seems to be gaining more momentum and speed, and if we are not careful it could, as bandwagons tend to do, completely run away from us.

What is this bandwagon?

Well it is the shift in the number of therapists learning more about the science of pain. Many therapists now have a far better understanding of this fasinating and complex area, and are slowly coming to the realisation that the traditional biomedical model and Descartes theory of pain = injury just doesn’t hold up to scrutiny or to the evidence base anymore. Many healthcare professionals now understand that pain isn’t only due to a tissue, joint, or nerve injury.

Many healthcare professionals are also now realising that we can no longer associate an individuals position, posture, occupation, or activity as a primary or sole factor for pain (source source source). Nor can we only blame so called biomechanic dysfunctions such as pronation as a cause for ankle, knee or hip pain (source source source). Nor scapula dyskinesia for shoulder pain (source source source), and I could go on and on presenting research paper after paper that blows ‘barn door’ size holes in many of the previously commonly held structural and biomechanical beliefs as a cause of injury, dysfunction, and pain.

More and more are now aware that many other factors other than posture, structure or biomechanics contribute to the sensation of pain thanks to the excellent work and research done by the likes of the NOI group, Body In Mind and the PainEd teams amongst many others.

Therapists now understand that pain…. 

  • isn’t nociception!
  • isn’t simply an input caused by tissue damage, but rather an output created by the brain.
  • doesn’t need tissue damage to be experienced 
  • and not all tissue damage will result in pain.

Up to my Limbic System in it!

I think it’s fair to say that in these last 10 years we have learnt more about pain and our nervous systems and produced more research on it and its role in the experience of pain than we have in our entire history of evolution, and I for one love learning as much as my poor brain can handle.

 

I’m up to my limbic system in papers about neuromodulation, nervi nervorum, ruffini endings, amygdala’s, prefrontal cortexes, glial cells and tripartite synapses. I’m trying to wade my way through the muddy swamp of the neural compexities that occur via touch, massage and manipulation. I’m reading about sensory afferent pathways, neurotags, cortical smudging, and the processes of diffuse noxious inhibitory control. I’m trying to get my grey matter around the other nuisances of pain such as sociology, psychology, mood states, contextual situations and past experiences, all in an effort to understand how I can better help those I see day in, day out who are in pain!

And there are thousands of other therapists all doing the same thing all over the world, and this has lead to the development of new methods of assessment and treatment for patients in persistant pain. Many therapists are now routinely assessing for the signs of central sensitisation, and have been trained to include new methods of assessment and treatment to those with persistent pain such as pain education, cognitive behavioural therapy and other self management strategies.

But… theres always a but!

As much as I myself encourage this biopsychosocial approach in the management of all patients, I think we also need to be careful to ensure that the pendulum doesn’t swing too far, and that the pain science bandwagon doesn’t go careering too fast, too quickly out of control, and start to loose sight of the bio in biopsychosocial

I will admit, I did, for a bit, loose the bio, when I started learning about pain science and I’m not alone. I have discussed this issue with other more experienced, more rationale, far brighter therapists than me who have said the same thing. And I have seen how this can negatively affect our patients when therapists rule out the tissue or the biomechanics too quickly, too easily just because a pain doesn’t seem to present or respond in the way, or in the time frame they think it should.

For example, I recently had a fit, healthy, active middle aged lady who told me her story of being quickly diagnosed with persistent pain by her physio and doctor after fracturing her fibula six months ago! She had the usual history of a broken ankle, fell down a step, went to A&E, had an x-ray, a simple undisplaced fibula fracture was diagnosed, she had her foot casted for a few weeks, had a follow up x-ray that confirmed union and was sent to physio for rehab. Simple, routine, nothing to it!

Well not quite, she tells me that she just could not get her foot and ankle going again due to the pain becoming worse and worse the more she tried. Over the following months she was told that she had CRPS and chronic pain and was referred to a pain management service where she was told she would need extensive cognitive rehabilitation and medications for it. 

However, not fully convinced she decided to seek a second opinion still feeling something just wasn’t right with her foot and, to cut a long story short, a large osteochondral defect was found with a small loose body within her ankle joint, a second operation was performed, and her pain is now much better and she is progressing well.

Unecessary surgery

Now this is just one example, and I’m sure, in fact I know, there are just as many, if not more patient stories that go the other way, eg patients in chronic persistant pain having unecessary surgery in a belief it would fix them only to find the pain is the same, or worse after!

But I just want to highlight that there are two sides to the pain coin, and that I have come across patients whose doctors and therapists have not fully considered or excluded that there maybe a structural or biomechanical factor for their pain.

I have also witnessed first hand some healthcare professionals using the ‘chronic pain’ tag simply because it is easier to ‘blame’ this than to exclude all the other possibilities! This is just lazy, sloppy, dangerous practice for which I have no tolerance for.

Monday Morning Syndrome

As awesome as the new advances and understanding into pain and neuro science are, I do think they have inadvertently become the new ‘cool kid’ in town that everyone whats to hang around with, the new skill everyone wants to demonstrate they are at using, showing how up to date they are with current research. This ‘cool kid factor’ is what, at times, makes some rush to diagnose and treat patients as persistent, non structural pain. 

Its a bit like ‘Monday morning syndrome’! You know the syndrome, it tends to strike after that super duper course you went on at the weekend with the latest guru, learning about the new thing. Then all of a sudden on Monday morning miraculously every patient you see just happens to have this thing that you just have been learning all about… how strange!

So in summary, lets not be too quick in diagnosing our patients with chronic, persistent non structural pain. Lets not be too quick in blaming the brain for getting it ‘wrong’. Lets remember that pain is our highly sophisticated alarm system of potential threat, that has been developed and honed through thousands of years of evolution and is pretty damn good at doing its job.

Yes ok, at times when this alarm system of potential threat does go ‘nuts’ or ‘squiffy’ or into ‘over drive’, but perhaps not as easily, nor as often as maybe some would like to think! Finally lets try not too loose sight of the bio in biopsychosocial, lets not let the pendulum swing too far one way and lets not let the pain science bandwagon run away from us all.

As always thanks for reading

Adam

 


51 thoughts on “All aboard… the latest bandwagon!

  1. Well said Adam. This reflects exactly what most physios are inclined in doing with patients lately. It is quite to easy to blame and point out contributing factors as source of pain and jump straight to conclusions around behaviour and mal adaptive patterns of movement. We still need an apropriate and full examination that looks to all possibilities to treat patients in a proper way. Vagner

  2. Good read again as well. Admittedly I have also jumped on this bandwagon but I choose to use this skill as a component of my treatment rather than the whole thing. Each skill we learn is important and unique as is each patient. Where we run into trouble is when we strictly use that one skill as the entire treatment without looking further.

    • Thanks TJ, think we all have been guilty of this, i know i have when i look back, but that’s exactly what critical thinking and clinical reasoning are there for, to keep u in check, as long as we have those ‘skills’ we can spot when the pendulum shifts too far one way

      Thanks again

      Adam

  3. I enjoyed reading your article. It has always been my belief that there are usually many factors involved in a person’s experience of pain and as hands on practitioners we are in a unique position to assist and facilitate the journey towards decreasing pain and improving the quality of life of our patients. In order to be in an effective partnership with our patients on this journey we must use all of our skills whether they are treating tissues, improving mindfulness, breathing and communicating effectively about pain, teaching exercises and addressing the many facets of pain and healing and put that into the multifactorial nature of their experience etc.

    Let us not underestimate or lose sight of the fact that as physiotherapists we are skilled practitioners in a caring profession ( or at least it is my belief that we must be caring in order to be effective). Being able to listen and then hear our patients, to acknowledge their experience and then provide a multi tiered level/ combination of treatment techniques, hands on and off, to assist them you will be doing the best you can for them in order to achieve the best possible outcome.

  4. Another thought provoking piece. Thank you.

    In regards to your case presentation, you concluded “This is just one example of not fully considering or ruling out structure as a cause of pain, and jumping too quickly, too easily on the ‘chronic pain’ bandwagon,….” Could you elaborate a bit more about “structure as a cause of pain”?
    Furthermore, IMHO, this kind of pain presentation is basically one of red flags and if a clinician reasons the scenario carefully and critically, the disaster would be avoidable.

    • Hi there

      The ‘structure’ causing ongoing pain and stiffness in this ankle case was a large talar dome osteochondral defect when the ankle was originally inverted, it need further surgery via a microfracture to help cover the exposed bone

      this is not a red flag case, red flags present with different symptoms to chronic or persistant pain but those do need to be considered and ruled out as well

      Thanks

      Adam

  5. I couldn’t agree more! Thanks for explaining this so well. I see this very regularly.

    I see patients from around the US (and abroad) with pelvic pain issues. They seek further evaluation and treatment after being told the pyschosicial part is the issue and it is likely centralized. I often find clear “bio” aspects that are missed. This creates two new pathways for treatment 1. Validation for the patient by someone who listened and touched. This typically has a large effect on treatment outcome 2. We can actually direct the appropriate care to the peripheral site – manual therapy, topical medicine, self-management education, etc. (The list goes on and often a multimodal approach works best).

    Cheers,
    Tracy Sher, MPT, CSCS
    http://www.sherpelvic.com
    http://www.pelvicguru.com

    • Hi Tracey

      Thanks for your comments and you make a great point in that both bio and psychosocial / neuro elements can be and often are combined in many cases

      Thanks again

      Adam

  6. I never jumped on the bandwagon in the first place! Pain is pain, and I see no need to make false distinctions. I treat an acute ankle sprain exactly the same way I would a 3 year “CRPS” patient.

    Cameron

    • Hi Cameron

      Well it must be nice (but hard work) being so perfect… 😉

      We all have followed a trend or jumped on a bandwagon at some point in our lives its human nature, and if you say you haven’t i have a hard time believing you

      I also find it interesting that you say pain is pain, when its clearly not, pain is very different from person to person and case to case, just for example neural nociception is different from bone nociception, which is different from inflammatory nociception, all different input nociceptions will produce different outputs felt as pain, and thats not to mention the difference in severity and irritability of each individuals perception of pain

      Finally i don’t for a second believe you treat a acute ankle sprain the same as a chronic CRPS case, they need a completely different approach and management

      • Adam,

        Your blog post warns about not jumping on the CRPS bandwagon and that’s the bandwagon I never jumped on.

        I don’t think the differentiation is necessary because even though the patient’s subjective experience is vastly different, the treatment need not be. So I do in fact treat all pain pretty much the same way (which is what I mean by “pain is pain”). I make a small allowance when treating someone with strong pain or inflammation, that’s all.

        You obviously have different treatments for different conditions. It’s not necessary.

        Cameron

        • Cameron

          I think u have completely missed the point of my blog, the CRPS was just an example of how some loose sight of the structure as a cause of pain and how I have seen some recently rush to jump on the chronic pain management approach, as well as a reflection of my own admission to to doing this in the past!

          And you have now gone from “I treat all pain the same” to “I treat all pretty much the same?”

          And are you honestly telling me you would approach and get someone who is highly irritable and sensitive with a high VAS doing exactly the same things as someone with low VAS and severity/irritability? Are you telling me you don’t change your approach for a chronic anxious apprehensive patient in pain compared to a indifferent not bothered to much about pain patient?

          If so I have a really hard time understanding that, why would you treat them the same when they are not the same?

          Pain is not the same for everybody, pain is unique to each individual and each case and management of it should be also unique, we need to taylor our approach rather than standardise it

  7. Hi Adam,

    Nice blog post and I do se where you are coming from. However a few issues spring to mind.

    I am not sure that the pendulum has swung very far at all. It is trendy these days to discuss pain within a biopsychosocial framework, however I am not aware of any data to say this is how clinicians are actually managing patients. To me it’s a case of talking the talk and not walking the walk.

    I do agree with Cameron’s point that pain is pain. You point out nociception originating in bone versus other structures etc. However they all scream “danger” to the CNS. It is the circumstances and context around this (beliefs etc) that will determine the output. So I do think “pain is pain” regardless of its location or label. The contributing factors will of course vary and this is where clinical skill counts to decipher this.

    As I mentioned, I do see you point with this post but in my experience the pendulum is still very much in favour of a biomedical approach to management regardless of how we might “talk” about pain.

    • Hi Derek

      Thanks for your comments

      I think pain specialists underestimate how many other therapists use or try to use pain ed and approaches in their practice, as you say no evidence or research out there apart from this that ive found http://prdupl02.ynet.co.il/ForumFiles_2/24823212.pdf perhaps this would be a good study to do?

      All I can do on my blog is comment on my own experience that I have in the past been guilty of jumping on the central sensitised reasoning bandwagon to quick and not fully exploring as many structural causes for nociception as perhaps I should have, and i have seen and heard of other similar cases

      I agree the biomedical paradigm is still the predominate one in most areas but the BSP model is growing in use and all i wished to do with the blog was highlight the bio in biopyschosocial is just as important as the other factors

      Cheers
      Adam

  8. Great Blog again, my colleague saw a patient today similar style history except pain around the buttock, turned out stress fracture in the pelvis. Lots of practitioners labelling ‘chronic pain’
    I really hope Cameron doesn’t really have a ‘one size fits all approach’. might as well have no approach and poke them with a stick

    • Thanks for your comments Jack, glad im not alone in hearing this kind of stuff happening from time to time, and as you say lets hope there really isn’t people out there using a standardised approach to people in pain, thats just mental IMO

  9. Good post. I too have jumped a bit onto the pain ed wagon, but I’d like to think with good, justifiable cause. The majority that I have learned regarding pain ed via ISPI (they dub it as Therapeutic Neuroscience Ed or TNE) has been in conjunction with the numerous manual therapy skills and exercises that can potentially be given depending on each patient (and their responses to each Rx). I have found this pain ed discussion of varying degrees and lengths a very valuable tool with a variety of patients on the acute, subacute, and chronic level. But it is just a tool in my toolbelt, and hopefully most others out there who are also jumping on this can recognize the utility of it being as such. I also hope they can recognize the futility of it’s overuse and improper use.

  10. (You can join this comment to my previous one if you like)
    One of point to consider – in no way should we be neglecting proper screening as well as taking a good subjective and objective on every patient regardless of how much we love pain ed. In fact, if someone is neglecting these parts of the exam as well as reassessing each time we see the patient and instead misguiding them to a pain ed direction of Rx only, I would contend the problem is not the pain ed Rx but the PT who likely had poor evaluation and assessment skills in the first place.

  11. Good advice to not jump on bandwagons. We should always be using crtical thinking and sound clinical reasoning with every patient and not just jumping on any bandwagon. We need to caution ourselves not to just label everything as central sensitization, just as we need to caution ourselves not to create some small biomechanical difference as the “cause” of someones pain. I cringe at the thought of what is meant “pain is pain.” We know pain is an emergent process of the brain that is a unique individual experience with congnitive, sensory and emotional aspects to it. Also we know pain and injury are not the same thing and both need attention from us as therapists.

    • Hi Kory

      Thanks for your comments, and I too cringe and am wide eyed and open mouthed that a physio thinks pain is pain and it all should be treated the same, does this mean a muscle injury is a muscle injury, a tendinopathy is a tendinopathy a fracture is a fracture etc etc

  12. Dear sanctimonious Adam, Jack and Kory,

    Thanks for your moral outrage. Very entertaining. Now can we get back to business? I get great outcomes using my one-size-fits-all approach (including for CRPS patients). Should I stop what I’m doing?

    Thanks for your concern 😉

    • There is absolutely no need for ad hom attacks Cameron, if you cannot debate logically, professionally and politely with those that question you then i shall delete your comments and block you from further discussion.

      Grow up!

      And yes I think you should ‘change’ what you are doing a standardised ‘one size fits all’ approach has consistently shown poor results in all areas eg back pain, OA, sub acromial pain etc etc

      You say you get great outcomes from this method, do you have evidence for this or is this your opinion and so your own bias (and ego) talking. Its well documented that patients who feel they are not given individualised personalised care and attention do not rate their treatment well.

      Perhaps if you adapt your approach I’m sure you will get better results

      As I said if you want to continue this debate, please do so but without the pathetic ad hom

      • Good luck with your blog and patients. Just a tip for you Adam – when you verbally abuse people for no reason, don’t cry foul when they bite back.

        • If you are referring to my light hearted albeit sarcastic quip about it being hard to be perfect with its cheeky little winky sign after 😉 as verbal abuse, then just a tip back to you Cameron, I think you may need to re evaluate your definition of abuse and perhaps stand down from hypervigilance a little

          Its a sham you cant expand on your ‘one size fits all’ treatment that is successful for you as i’m sure I and many others would love to know how to make our jobs easier and simpler by having just one approach that consistently works

  13. Cameron, I don’t know where you got moral outrage from. I simple stated I cringe at a statement such as you made because it does not seem to fit with modern neuroscience undrstanding of what pain is (I admit there is a lot about pain we don’t know, but I think we should agree that ‘pain is pain’ is not an accurate statement). Making an inacurate statement has nothing to do with ethics,morals or outcomes, its just an incorrect statement.

    I would not question your outcomes because I have no proof either way if they are good, bad or average, just your claim which I can not refute, nor do I need to.

    I would caution you as I do myself daily, that often times patients get better not necessarily because of me. What I do may have been sufficient to help them move out of a pain experience but it also may not have been neccessary. To me that mindset may get more the root of a BPS model then claiming it is bio or it is psychosocial when the reality is it always all of them.

  14. Adam,

    You can use that words “just plain mental” to describe other peoples’ work if you like, but I don’t have to play along.

    Good luck with your blog career.

    • Ok Cameron you’re very right here, that was poor from me and I apologise for that comment!

      If you accept this, I would still like to hear more about your ‘one size fits all’ approach as I am really having a hard time understanding how this works, lets take the ankle example, are you saying you would get someone with a 6 week old simple sprain doing the same exercises and movements and and give them the same advice and education as someone with a 3 year history of chronic CRPS ankle pain?

      Oh and please understand my blog isn’t a career opportunity rather just a hobby and past time of mine, my career is in clinical management of NMSK pain and injury

      Regards

      Adam

  15. Alright.

    Congruence (or deep authenticity) is the technique. As far as I know it was Carl Rogers who first described and researched this therapeutic mode of being. It requires a pysche which is largely free from personal shame + a high level of mindfulness combined. It is very hard skill to learn and apply, (depending on one’s starting point). When it is applied, the patient improves regardless of the physical or educational technique employed. When it is not applied, no patient improves, regardless of the physical or educational technique employed. And there’s shades of grey in between. This is my repeated clinical experience. So for me, congruence is the one and only technique I use, and I use it for everyone to the best of my ability. I use one or two physical modalities as ‘window dressing’ only (eg. interferential). I don’t count such ‘window dressing’ as techniques because these are just ‘fluff’ techniques which have been shown in studies to be ineffective in the treatment of pain and dysfunction.

    Most therapists already know what ‘being authentic’ means. But deep level (therapeutic) authenticity is something quite different. Most people maintain a reasonable level of authenticity through self-esteem, which is fine, but it’s not therapeutic. Therapeutic authenticity requires a different approach which is not reliant on self esteem.

    Cameron

    http://noijam.com/2014/06/10/congruence/

  16. Cameron, I think your thoughts on congruence are sound, just trying to figure out how you get ‘pain is pain’ out of that sme thinking pattern. Also with in that thinking should it not be a patient with CRPS as compared to a CRPS patient? It is this thinking and speaking, while may seem trivial in some regards to some, that speaks more to our thinking then we understand. It is a habit I am trying to break and see things in patient first language and the patient’s are first (which I think your congruence speaks to) as compared to the diagnosis or body part first.

    • Kory, ‘pain is pain’ was my way of saying that most of the diagnostic labels we use are unnecessary. So long as I know it’s not a condition requiring medical intervention, I can be happy enough with “well maybe it’s a muscle or ligament or whatever”. A diagnosis won’t change my treatment much anyway since I’m using mainly a psychological approach with some ‘fluff’ physical techniques as filler.

      Probably better to say a ‘patient with CPRS’, yeh. Personally I try to get out of the habit of using the word ‘patient’ at all. ‘Client’, ‘customer’ or just ‘Joe Bloggs’ works better. To think of myself as ‘healer’ and the person as ‘patient’ is just such a messed up frame to work within. There’s so many negative assumptions and implications involved with this. But that’s getting onto another topic.

      Cameron

      • Cameron, i don’t think anyone here is calling themselves or think themselves as healers and we are extremely aware of the non specific effects of our interventions and interactions. But to completely disregard the different mechanical and physiological properties of different connective tissue injuries and treat them all the same is border line neglect in my opinion, you state “maybe its a muscle or ligament or whatever it wont change my treatment” I find this shocking in this day and age of EBP, im all for a simplified approach but different tissue responds to different mechanical stress and loads and not to mention different levels of pain as such a different approach is needed for each person, no, or do you negate the effects of mechanotransduction and tensegrity?

        I am intrigued by the congruence theroy and will read more on this, thanks

      • Cameron, thanks for that clarification on your ‘pain is pain’ comment. I would agree with you that we have over medicalized many problems and in the context of your explanation I have have a better understanding of you ‘pain is pain’ statement. Sorry for the confusion, which can so easily happen in short typed exchanges on the internet. Thanks for the time to further explain.

        And yes, ‘Joe Bloggs’ is probably best and while ‘healer and patient’ labels are extensively messed up and another topic it is an important one that I’m not sure many therapist fully grasp and often play lip service to. With that, I understand Adam’s concern with BPS bandwagon bit, but it still concerns me that people are claiming practicing BPS and making it a bandwagon and not a deep understanding of all the components of a patient’s pain experience (of which congruence is a part of which you rightly point to).

  17. It’s the EBP that sent me on this path to find stuff that works.

    I think the aim of treatment should be reduction of pain and improvement of function. Physical techniques which create a mechanotransduction have very short-lived effects. Manipulation, mobilization, ultrasound, stretching, massage – these all create a real effect. But the effect lasts only minutes if done without a “therapist”. I’ve done a few experiments to determine this is the case. They are ‘fluff’, distraction from the real work which is always psychological.

    Different tissues may well respond differently to mechanical stress and load, but I don’t stress or load them.

    Cameron

    • I am not talking about the minimal to non existent effects on tissue that manual therapy or fluff as you call it, or as i call it human primate social grooming or placebo, I’m talking about the effects of movement and exercise has to create physical structural adaptation, as well as pain modulation.

      Its well known that exercise has hypo analgesic effects http://www.ncbi.nlm.nih.gov/pubmed/23141188 we just don’t know the best dose or method.

      So are you telling me you don’t advise those you see in pain or with injury to stress and load tissues for repair and maintenance and you dont give any exercise or movement advice and education and just use a psychosocial approach method with all your patients? Do you believe that the bio aspect has no role in pain or injury at all?

      I really am having a hard time understanding this or am I missing something?

      Adam

      • Healthy people (clients and non-clients) always tell me that exercise makes them feel good, so it doesn’t surprise me that there is a hypoalgesic effect, as per that meta-analysis. Clinically, it seems that clients with pain will benefit only if the exercising reinforces the idea that they aren’t damaging tissues (ie.by fear reduction rather than mechanotransduction). I’m not sure if the analysis addresses that point, but that’s my suspicion. It says sometimes it helps and sometimes it doesn’t for people with chronic pain. There are plenty of clients who have difficulty getting past the idea of tissue damage, even with ‘explain pain’ style education.

        For acute pain where there is tissue damage, I advise clients to increase movement as pain allows. But they are going to do that anyway whether I advise it or not, because it’s just common sense. Normal life requires movement and loading so I don’t feel like extra is necessary, but if they want to it’s fine by me.

        For chronic pain, I don’t tell them to exercise unless I think they are scared of moving or scared of tissue damage. But if someone is scared of tissue damage I think it’s easier and quicker to say “ok now do this movement” and when they hesitate and tense up, very confidently tell them “it’s ok even if it hurts a bit”.

        I believe the ‘bio’ can be altered with certain drugs – ones which act on the CNS – but that’s not my field. The effects of physical treatment on pain seem extremely short lived and the research backs this up.

        Cameron

        • I absolutely agree that many in pain have fear, anxiety and uncertainty regarding movement and it can be difficult to change their erroneous belief that they will do more damage if they move, but this is usually, in my humble opinion, due to a fault of many in the medical and therapy business telling patients incorrectly that they need to rest, when really they need to avoid too many painful movements

          Also it is well documented in chronic conditions that they need to move, and as you say “even if it hurts a bit” for example lets take a chronic tendinopathy doesn’t matter which one, there is host of research that shows that painful loading movements (self guided within realms of common sense) is needed to reduce pain and restore function even if the ‘pathology’ doesn’t seem to change the pain does, central neurological effects from loading not just structural I get that, but they have to move, not just have fluff or IF Rx, also the therapist will need to know which movements are suitable depending on the stage and location of the tendinopathy and so cannot simple give a one size fit all exercise or program.

          You also say that most will move as its common sense, this is true for some, but not many others in my experience, many need the ‘green light’ from the professional to move and do things and so again a tailored assessment and approach will highlight this, it now seems to me that your ‘one size fit all’ approach is anything but one size, i can see you make different choices based on different patient (sorry clients) presentations just in your last few comments, and I bet there are many many more.

          I think we have a similar outlook on the non specific neurological effects of all we do/say/poke etc, but its your notion of a one size fits all approach I really have a hard time understanding, and now discussing it a bit further with you, I don’t think you actually have one…

          Adam

  18. I am interested in the fact that Cameron said he uses a treatment just as filler! Why? That is unethical in the extreme, all interventions if causing any physiological or psychological response have a risk attached to them. If there is no reward you should absolutely not do it.

    If you have blinded trials of your congruence vs placebo i would be very interested to read them.

    Do you change your congruence approach to suit the patient or is this the same for everyone?

    • So long as you have the client’s best interest at heart, that’s all that matters. I don’t get hung up on morals and ethics. I find that defensive style of thinking a hindrance to good practice more than a help.

      Congruence requires an inner process (which is self directed and always the same). When this is achieved, one automatically pays attention to the client in a certain way. This ‘certain way’ is extremely adaptive, personal and ‘live’ (present moment). It’s not easy to do.

      Rogers has done most of the research on congruence. I don’t have such a paper for you

      What I’m saying is based on the application of what I have read in Rogers’ books and making very careful clinical observations and notes.

      Cameron

      • Cameron I am sure that the people who practiced trepanning or prescribe thalidomide had the ‘clients’ best interests at heart… I pay attention to my ‘clients’ by asking them questions and listening to the answer and completing a thorough assessment.

        Just out of interest how many sessions does it take for your congruence to work and what do you charge?

      • Cameron, this is extremely dodgy, dicey ground to tread and makes me feel uneasy when ever I hear a therapists say things like “I don’t get too hung up on the morals and ethics”

        We must remember we always have a duty to care to offer our patients the most effective, evidenced, honest and safe care, and this mean we have to give them all the possible options and information so that they may make an informed decision and so we gain their fully informed consent, if we just do what the patient wants and what makes them happy where do you draw the line, evidence based practice in therapy is essential for this exact reason.

        I sincerely do hope you do NOT do whatever a patient wants and you inform them what is BEST for them… sometimes when its NOT what they want to hear… or what you WANT to do…

        Adam

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