Join us in this insightful episode of the "Hands On / Hands Off" podcast as we dive deep into the world of manual therapy and orthopedics with Dr. Paul Mintken, a renowned professor at Hawaii Pacific University. With over a decade of experience and a robust publication record, Dr. Mintken shares his expertise on patient expectations in manual therapy. We explore the nuances of managing these expectations in clinical practice and the latest research in the field. Whether you're a seasoned therapist or a student eager to learn, this episode offers valuable takeaways for everyone in the physical therapy and orthopedic community.
Key Points Discussed:
Introduction to Dr. Paul Mintken and his extensive background in physical therapy and academia.
The role of patient expectations in manual therapy and their impact on treatment outcomes.
Insights into Dr. Mintken’s research in orthopedics and manual therapy.
The professional journey and collaboration between Amy McDevitt and Paul Mintken.
Special Guest:
Dr. Paul Mintken, Professor at Hawaii Pacific University.
00:00:03 --> 00:00:05 Hi, I am Amy McDevitt,
00:00:05 --> 00:00:06 and I am going to be
00:00:07 --> 00:00:08 interviewing Paul Minkin
00:00:08 --> 00:00:11 today for our hands-on,
00:00:11 --> 00:00:12 hands-off podcast.
00:00:12 --> 00:00:16 So this is our newer AOMT podcast.
00:00:16 --> 00:00:17 So I'm really excited to
00:00:17 --> 00:00:18 have Paul as a guest.
00:00:19 --> 00:00:20 Paul is a professor at
00:00:20 --> 00:00:23 Hawaii Pacific University in Hawaii.
00:00:24 --> 00:00:25 And we actually had the
00:00:25 --> 00:00:25 pleasure of working
00:00:25 --> 00:00:28 together for almost 13
00:00:28 --> 00:00:30 years at the University of Colorado.
00:00:30 --> 00:00:31 And so Paul has been
00:00:32 --> 00:00:34 publishing in the area of
00:00:34 --> 00:00:35 manual therapy and
00:00:35 --> 00:00:37 orthopedics for many years
00:00:37 --> 00:00:38 and is quite well known in
00:00:38 --> 00:00:39 the AOMT community.
00:00:39 --> 00:00:40 But I'm going to turn it
00:00:40 --> 00:00:41 over to Paul to talk a
00:00:41 --> 00:00:42 little bit more about himself.
00:00:42 --> 00:00:43 And then I want you to just
00:00:43 --> 00:00:45 tell our listeners a little
00:00:45 --> 00:00:46 bit about yourself and what
00:00:46 --> 00:00:47 you like to do and what
00:00:47 --> 00:00:48 some of your interests are.
00:00:48 --> 00:00:49 So I'm going to hand it over to you, Paul.
00:00:51 --> 00:00:51 All right.
00:00:51 --> 00:00:51 Thanks, Amy.
00:00:52 --> 00:00:53 Well, thanks for inviting me.
00:00:53 --> 00:00:55 I'm excited to be here and, you know,
00:00:57 --> 00:00:59 privileged to be a part of AOMT overall,
00:00:59 --> 00:01:00 the organization that's
00:01:00 --> 00:01:03 done so much for my career overall.
00:01:03 --> 00:01:06 So, you know, talk about yourself.
00:01:06 --> 00:01:08 That's always a challenging
00:01:08 --> 00:01:09 question overall, you know,
00:01:10 --> 00:01:11 kind of on a spiritual
00:01:11 --> 00:01:12 journey as of late.
00:01:12 --> 00:01:13 So, you know,
00:01:13 --> 00:01:15 labeling myself as this or
00:01:15 --> 00:01:16 that or that kind of thing
00:01:16 --> 00:01:19 kind of seems shallow and fake.
00:01:19 --> 00:01:21 But, you know, just...
00:01:21 --> 00:01:23 I'm a human being who's
00:01:23 --> 00:01:25 trying to be the best husband, father,
00:01:26 --> 00:01:27 physical therapist,
00:01:27 --> 00:01:29 professor that I can be.
00:01:29 --> 00:01:30 You know, I've been on a long journey.
00:01:31 --> 00:01:32 I've just celebrated 30
00:01:32 --> 00:01:34 years of being a physical therapist.
00:01:34 --> 00:01:36 So I've maintained,
00:01:36 --> 00:01:38 I've stayed clinically
00:01:38 --> 00:01:40 active for those whole 30 years and,
00:01:40 --> 00:01:42 and been in academia for 20 years.
00:01:43 --> 00:01:43 And, uh,
00:01:44 --> 00:01:45 Enjoyed my time at the
00:01:45 --> 00:01:46 University of Colorado and
00:01:46 --> 00:01:48 retired from there with a pension,
00:01:48 --> 00:01:49 which was pretty exciting.
00:01:49 --> 00:01:51 And now I'm teaching at a
00:01:51 --> 00:01:52 new hybrid program in Hawaii,
00:01:52 --> 00:01:54 which is just amazing overall.
00:01:54 --> 00:01:57 Our students are so diverse
00:01:57 --> 00:01:59 and hungry for knowledge
00:01:59 --> 00:02:00 and that type of thing.
00:02:00 --> 00:02:02 So it's been an interesting
00:02:02 --> 00:02:03 transition from brick and
00:02:03 --> 00:02:04 mortar to more of a hybrid
00:02:05 --> 00:02:05 education model.
00:02:06 --> 00:02:08 But I'm loving every minute of it.
00:02:08 --> 00:02:09 And I'm a firm believer in
00:02:11 --> 00:02:11 the approach overall.
00:02:12 --> 00:02:13 Yeah, yeah.
00:02:13 --> 00:02:14 That's great.
00:02:14 --> 00:02:15 And so you've been at Hawaii
00:02:15 --> 00:02:16 Pacific for how long?
00:02:16 --> 00:02:17 Two years?
00:02:17 --> 00:02:17 Two years.
00:02:17 --> 00:02:18 Yeah.
00:02:18 --> 00:02:19 Just celebrated two years,
00:02:19 --> 00:02:20 if you can remember that.
00:02:20 --> 00:02:20 Wow.
00:02:21 --> 00:02:21 Well,
00:02:21 --> 00:02:24 what we decided to talk about today
00:02:24 --> 00:02:24 with you,
00:02:24 --> 00:02:26 and part of this was your choice,
00:02:26 --> 00:02:27 was patient expectations.
00:02:28 --> 00:02:29 I know personally,
00:02:29 --> 00:02:30 you and I have had many
00:02:30 --> 00:02:31 conversations about this,
00:02:32 --> 00:02:33 just because we both
00:02:33 --> 00:02:34 believe that it has such an
00:02:35 --> 00:02:36 incredible influence on what we're doing.
00:02:37 --> 00:02:37 And so
00:02:38 --> 00:02:39 I'm going to kind of back us
00:02:39 --> 00:02:40 up and I would just love to
00:02:40 --> 00:02:42 hear your thoughts on just
00:02:42 --> 00:02:44 explain to the listeners a
00:02:44 --> 00:02:45 little bit about what
00:02:45 --> 00:02:47 patient expectations are, I guess,
00:02:47 --> 00:02:48 from a definitional
00:02:48 --> 00:02:51 standpoint and how they are
00:02:51 --> 00:02:52 really a critical piece in
00:02:53 --> 00:02:54 potentially influencing outcomes.
00:02:54 --> 00:02:55 So I just want to hear a
00:02:55 --> 00:02:57 little bit about what your thoughts are.
00:02:58 --> 00:02:58 Yeah.
00:02:58 --> 00:03:00 So patient expectations are
00:03:00 --> 00:03:01 kind of the beliefs and
00:03:01 --> 00:03:03 anticipated benefits that
00:03:03 --> 00:03:06 patients have regarding the
00:03:06 --> 00:03:07 interaction that they have
00:03:07 --> 00:03:08 with their healthcare provider,
00:03:08 --> 00:03:09 the outcomes,
00:03:10 --> 00:03:11 the quality of care they might receive.
00:03:13 --> 00:03:14 So when patients have
00:03:15 --> 00:03:16 positive expectations,
00:03:16 --> 00:03:17 they're more likely to
00:03:17 --> 00:03:19 engage actively in their therapy.
00:03:19 --> 00:03:23 It can help reduce their pain overall.
00:03:23 --> 00:03:25 They're more likely to be
00:03:25 --> 00:03:27 adherent to their home program.
00:03:27 --> 00:03:27 And it
00:03:28 --> 00:03:29 there's pretty good evidence
00:03:29 --> 00:03:30 that it can improve their
00:03:30 --> 00:03:33 pain and their function in the long run.
00:03:33 --> 00:03:37 So really the patient's
00:03:37 --> 00:03:39 expectations are framed by
00:03:39 --> 00:03:41 a lot of different things overall,
00:03:41 --> 00:03:42 but they're such a powerful
00:03:43 --> 00:03:44 part of the treatment,
00:03:44 --> 00:03:45 especially in physical therapy,
00:03:46 --> 00:03:48 that if we don't pay attention to them,
00:03:49 --> 00:03:50 we're missing a huge part
00:03:50 --> 00:03:52 of the therapeutic alliance
00:03:52 --> 00:03:53 and the care package.
00:03:54 --> 00:03:55 And you were saying just a
00:03:55 --> 00:03:56 moment ago that there's
00:03:56 --> 00:03:57 multiple things that feed
00:03:57 --> 00:03:58 into patient expectation.
00:03:58 --> 00:04:00 So based on your many years
00:04:00 --> 00:04:01 in clinical practice,
00:04:01 --> 00:04:02 what do you think are some
00:04:02 --> 00:04:04 of those elements or
00:04:04 --> 00:04:05 influences that are going
00:04:05 --> 00:04:07 to influence what patients
00:04:07 --> 00:04:08 are actually expecting when
00:04:09 --> 00:04:10 they come to us for
00:04:10 --> 00:04:12 physical therapy or manual therapy care?
00:04:13 --> 00:04:13 Well,
00:04:13 --> 00:04:15 the important thing is to remember
00:04:15 --> 00:04:17 that every patient is a
00:04:17 --> 00:04:18 human being with this
00:04:18 --> 00:04:20 complex milieu of past
00:04:20 --> 00:04:22 experiences and education,
00:04:22 --> 00:04:23 what they believe about
00:04:23 --> 00:04:24 themselves and others,
00:04:24 --> 00:04:26 what they've heard from their family,
00:04:26 --> 00:04:27 their friends and Dr.
00:04:27 --> 00:04:30 Google and that type of thing.
00:04:30 --> 00:04:31 It's also strongly
00:04:31 --> 00:04:32 correlated with their worldview.
00:04:32 --> 00:04:34 Are they optimistic by nature?
00:04:34 --> 00:04:35 Are they pessimistic by nature?
00:04:35 --> 00:04:37 So the interesting thing is
00:04:38 --> 00:04:39 that these expectations
00:04:39 --> 00:04:40 that the patients come in with
00:04:41 --> 00:04:42 which again can come from
00:04:42 --> 00:04:44 many different avenues,
00:04:44 --> 00:04:46 those can be changed by a
00:04:46 --> 00:04:49 positive healthcare interaction,
00:04:49 --> 00:04:51 forming a good therapeutic
00:04:51 --> 00:04:52 alliance with your patient
00:04:52 --> 00:04:53 and that type of thing.
00:04:53 --> 00:04:56 So you never know what's in
00:04:56 --> 00:04:57 the soup of that individual,
00:04:57 --> 00:04:59 what led to those expectations.
00:04:59 --> 00:05:00 It could have been something
00:05:00 --> 00:05:01 they heard or something
00:05:01 --> 00:05:03 they read or something they experienced,
00:05:04 --> 00:05:05 but really exploring that I
00:05:05 --> 00:05:07 think is a key part of what
00:05:07 --> 00:05:08 we do as healthcare providers.
00:05:09 --> 00:05:10 And so with that being said,
00:05:10 --> 00:05:11 what are some of those key
00:05:11 --> 00:05:12 things that you think we
00:05:12 --> 00:05:13 need to do from like the
00:05:13 --> 00:05:15 moment we start interacting
00:05:15 --> 00:05:17 with that patient, that human?
00:05:17 --> 00:05:19 What are some of the first
00:05:19 --> 00:05:20 couple of things that
00:05:20 --> 00:05:21 you're going to do to try
00:05:21 --> 00:05:23 to glean how to meet them
00:05:23 --> 00:05:24 where they're at in terms
00:05:24 --> 00:05:24 of expectations?
00:05:26 --> 00:05:27 Well, the first thing, I mean,
00:05:27 --> 00:05:32 I love Peter O'Sullivan's, you know,
00:05:32 --> 00:05:33 tell me your story,
00:05:33 --> 00:05:34 kind of just listen to the
00:05:34 --> 00:05:35 patient and where they've been.
00:05:36 --> 00:05:37 and the journey they've been
00:05:38 --> 00:05:40 on since this condition came on.
00:05:40 --> 00:05:41 It may be something that
00:05:41 --> 00:05:42 just started two days ago,
00:05:42 --> 00:05:42 or it may be something
00:05:42 --> 00:05:43 they've been dealing with
00:05:43 --> 00:05:45 for decades overall.
00:05:45 --> 00:05:47 So just listening to that
00:05:47 --> 00:05:49 patient and being present for them,
00:05:49 --> 00:05:51 really tuning in and kind
00:05:51 --> 00:05:54 of letting them tell their story.
00:05:54 --> 00:05:55 The research is pretty clear
00:05:55 --> 00:05:57 that in most healthcare interactions,
00:05:58 --> 00:05:59 the patient is interrupted
00:05:59 --> 00:06:01 before they get to complete
00:06:01 --> 00:06:02 their opening statement.
00:06:03 --> 00:06:05 you know, hear what they have to say.
00:06:05 --> 00:06:06 And that helps you start to
00:06:06 --> 00:06:08 understand what their
00:06:08 --> 00:06:09 expectations might be.
00:06:09 --> 00:06:10 You know, if they come in and say, well,
00:06:10 --> 00:06:11 I saw this provider and
00:06:12 --> 00:06:13 they told me this and I saw
00:06:13 --> 00:06:14 this provider and I told
00:06:14 --> 00:06:16 they told me that nothing's been working.
00:06:16 --> 00:06:18 You can kind of really start to hear
00:06:19 --> 00:06:19 You know,
00:06:19 --> 00:06:21 the frustration and being able to
00:06:21 --> 00:06:23 empathize with that individual.
00:06:23 --> 00:06:24 That's, that's really, you know,
00:06:25 --> 00:06:26 where it starts overall.
00:06:26 --> 00:06:27 And then I'll ask them,
00:06:27 --> 00:06:28 what are your expectations
00:06:28 --> 00:06:29 from treatment?
00:06:29 --> 00:06:30 What are your specific goals?
00:06:30 --> 00:06:31 Patient centered?
00:06:31 --> 00:06:33 What, what do you want to be able to do?
00:06:33 --> 00:06:34 What are you not able to do now?
00:06:35 --> 00:06:36 And what do you want to be able to do?
00:06:36 --> 00:06:38 Um, and then asking them what,
00:06:39 --> 00:06:40 what they think is going on.
00:06:40 --> 00:06:41 Maybe they've heard five,
00:06:41 --> 00:06:43 five different stories from
00:06:43 --> 00:06:44 five different providers.
00:06:45 --> 00:06:48 And maybe they have a set
00:06:48 --> 00:06:49 idea of what they think is going on,
00:06:49 --> 00:06:50 or maybe they have no idea
00:06:51 --> 00:06:51 and they're looking to you
00:06:51 --> 00:06:53 for guidance overall.
00:06:53 --> 00:06:56 So really exploring those expectations.
00:06:56 --> 00:06:57 And again,
00:06:57 --> 00:06:59 it's based on their past experiences.
00:06:59 --> 00:07:01 And then, you know, things emerge that are,
00:07:02 --> 00:07:03 you know, in your opinion,
00:07:04 --> 00:07:06 potentially detrimental.
00:07:06 --> 00:07:07 to the improvement of the individual,
00:07:08 --> 00:07:08 that's where you can start
00:07:09 --> 00:07:09 to use some of the
00:07:09 --> 00:07:11 motivational interviewing things and say,
00:07:11 --> 00:07:12 is it okay if I share with
00:07:12 --> 00:07:13 you some information about
00:07:14 --> 00:07:15 back pain or neck pain or
00:07:16 --> 00:07:18 that belief or that type of thing?
00:07:19 --> 00:07:19 Yeah.
00:07:19 --> 00:07:21 I had a conversation with
00:07:21 --> 00:07:23 students similar to what
00:07:23 --> 00:07:24 you're saying just the other day.
00:07:24 --> 00:07:25 And we were talking about,
00:07:25 --> 00:07:26 one of the associated
00:07:26 --> 00:07:27 faculty used this word,
00:07:28 --> 00:07:29 some of our patients have
00:07:29 --> 00:07:30 become medicalized.
00:07:30 --> 00:07:31 They bounced around between
00:07:31 --> 00:07:32 so many providers and
00:07:32 --> 00:07:34 they've heard all these different
00:07:34 --> 00:07:37 kind of stories about why
00:07:37 --> 00:07:38 they are in pain or what
00:07:38 --> 00:07:39 they need to do next,
00:07:39 --> 00:07:40 or you're not going to get
00:07:40 --> 00:07:41 better unless you do this or this.
00:07:42 --> 00:07:43 And so we were talking in
00:07:43 --> 00:07:44 class about just those
00:07:44 --> 00:07:45 challenges of sometimes
00:07:46 --> 00:07:49 trying to undo a lot of
00:07:49 --> 00:07:50 what's been done for
00:07:50 --> 00:07:51 individuals that are kind
00:07:51 --> 00:07:53 of just moving through the system.
00:07:53 --> 00:07:55 And then you see harmful
00:07:55 --> 00:07:57 things on social media on top of it.
00:07:57 --> 00:07:57 So what are
00:07:58 --> 00:07:58 What are some of your
00:07:58 --> 00:07:59 thoughts or strategies?
00:07:59 --> 00:08:02 Like how do you undo the
00:08:02 --> 00:08:03 things that have negatively
00:08:03 --> 00:08:04 influenced patients and
00:08:04 --> 00:08:06 change their expectation
00:08:06 --> 00:08:07 for what they might get out
00:08:07 --> 00:08:08 of care with you?
00:08:10 --> 00:08:11 yeah as you and I know that
00:08:11 --> 00:08:12 that is one of the most
00:08:12 --> 00:08:14 challenging patients to
00:08:14 --> 00:08:15 treat is the one that comes
00:08:15 --> 00:08:17 in and says you know my
00:08:17 --> 00:08:18 chiropractor or my physical
00:08:18 --> 00:08:20 therapist told me my sacrum
00:08:20 --> 00:08:23 is out or my l5 is out and
00:08:23 --> 00:08:24 I need you to put it back
00:08:24 --> 00:08:25 in and they've got six or
00:08:25 --> 00:08:28 they're all six six yeah
00:08:29 --> 00:08:29 Yeah.
00:08:29 --> 00:08:31 And those patients are
00:08:31 --> 00:08:32 really challenging because
00:08:32 --> 00:08:34 they had a previous
00:08:34 --> 00:08:35 experience where maybe it was positive.
00:08:35 --> 00:08:36 Maybe they did see a
00:08:36 --> 00:08:37 physical therapist or a
00:08:37 --> 00:08:38 chiropractor who did a
00:08:38 --> 00:08:39 manipulation and they heard
00:08:39 --> 00:08:41 a pop and all of a sudden
00:08:41 --> 00:08:42 they felt better and they
00:08:42 --> 00:08:44 were back doing what they want to do.
00:08:44 --> 00:08:45 And they're bringing that
00:08:45 --> 00:08:47 expectation into the treatment.
00:08:48 --> 00:08:49 And those are the really
00:08:50 --> 00:08:52 challenging patients, I think, to treat,
00:08:52 --> 00:08:55 especially if they're fixated on
00:08:55 --> 00:08:56 you know,
00:08:56 --> 00:08:58 I'm broken or I'm out of
00:08:58 --> 00:09:00 alignment and I need you to
00:09:00 --> 00:09:02 fix me and make me better.
00:09:02 --> 00:09:03 So, you know,
00:09:03 --> 00:09:04 I really try and engage them
00:09:04 --> 00:09:06 with the current best evidence,
00:09:06 --> 00:09:07 try and hear where they're coming from,
00:09:07 --> 00:09:09 but also encourage an
00:09:09 --> 00:09:11 active approach that, you know,
00:09:12 --> 00:09:13 there's things that I can do,
00:09:13 --> 00:09:15 but the most important part
00:09:15 --> 00:09:16 of this relationship in
00:09:16 --> 00:09:18 your recovery is what you do.
00:09:18 --> 00:09:19 Yep.
00:09:19 --> 00:09:19 Yep.
00:09:20 --> 00:09:22 And you mentioned Peter O'Sullivan earlier,
00:09:22 --> 00:09:25 and I followed a lot of his work in it.
00:09:25 --> 00:09:27 And he really does a beautiful job,
00:09:27 --> 00:09:29 I think, of dialing into, you know,
00:09:29 --> 00:09:30 in some of the things that
00:09:30 --> 00:09:32 he's published on cognitive
00:09:32 --> 00:09:32 functional therapy,
00:09:33 --> 00:09:34 really having the patient
00:09:35 --> 00:09:37 learn and be active in the process.
00:09:38 --> 00:09:40 So I think that's also really important.
00:09:41 --> 00:09:43 You talked about using best evidence.
00:09:43 --> 00:09:44 So before we talk about best
00:09:44 --> 00:09:45 evidence of what
00:09:46 --> 00:09:47 interventions and what the
00:09:47 --> 00:09:48 plan of care should look
00:09:48 --> 00:09:49 like for the patient,
00:09:50 --> 00:09:52 what is some of the current
00:09:52 --> 00:09:53 best evidence surrounding
00:09:54 --> 00:09:55 patient expectations?
00:09:55 --> 00:09:56 What does that look like right now?
00:09:58 --> 00:09:58 Well,
00:09:58 --> 00:10:01 there's an overwhelming amount of
00:10:01 --> 00:10:02 evidence from both medicine
00:10:02 --> 00:10:05 and in physical therapy that, you know,
00:10:05 --> 00:10:07 if a patient has a positive expectation,
00:10:07 --> 00:10:08 whether that was influenced
00:10:09 --> 00:10:10 by the healthcare provider or not,
00:10:10 --> 00:10:11 that's going to impact their outcomes.
00:10:13 --> 00:10:15 So really, you know,
00:10:15 --> 00:10:16 some of Joel Bialoski's
00:10:17 --> 00:10:19 work where they used manipulation,
00:10:19 --> 00:10:19 let's say, and they said,
00:10:20 --> 00:10:20 you know,
00:10:20 --> 00:10:22 this is a technique that we think
00:10:22 --> 00:10:23 will improve your back pain,
00:10:23 --> 00:10:24 or we think this is a
00:10:25 --> 00:10:25 technique that we don't
00:10:25 --> 00:10:27 know if it will help your back pain,
00:10:27 --> 00:10:28 or this is a technique that
00:10:29 --> 00:10:31 we think may make your back pain worse,
00:10:31 --> 00:10:32 you know,
00:10:33 --> 00:10:35 that framing to the patient
00:10:35 --> 00:10:37 actually impacted the outcome.
00:10:37 --> 00:10:38 So
00:10:38 --> 00:10:40 The evidence is pretty clear
00:10:40 --> 00:10:41 that if a patient has a
00:10:41 --> 00:10:44 positive or a negative expectation,
00:10:45 --> 00:10:46 and that's not modified,
00:10:47 --> 00:10:48 let's say on a negative side,
00:10:48 --> 00:10:49 a negative expectation,
00:10:49 --> 00:10:50 if that's not modified,
00:10:51 --> 00:10:52 their outcomes are not
00:10:52 --> 00:10:54 going to be as good as if you potentially
00:10:55 --> 00:10:57 change those expectations.
00:10:57 --> 00:10:58 And I hate to use the word
00:10:58 --> 00:11:00 manipulate their expectations,
00:11:00 --> 00:11:02 but that's really what we want to do.
00:11:02 --> 00:11:04 We want to sell the evidence
00:11:04 --> 00:11:06 that this treatment will
00:11:06 --> 00:11:09 likely make you better and
00:11:09 --> 00:11:12 kind of reframe the
00:11:12 --> 00:11:14 treatment that you're delivering,
00:11:14 --> 00:11:14 making sure you're very
00:11:15 --> 00:11:16 clear about it and
00:11:17 --> 00:11:17 Uh, you know,
00:11:18 --> 00:11:19 that that's the challenging
00:11:19 --> 00:11:20 part a lot of times,
00:11:20 --> 00:11:22 but you have to kind of
00:11:22 --> 00:11:23 present to the patient, okay,
00:11:23 --> 00:11:25 this is what my exam showed me.
00:11:25 --> 00:11:27 And you need to stay away from saying,
00:11:27 --> 00:11:27 you know,
00:11:27 --> 00:11:29 you're out of alignment or you
00:11:29 --> 00:11:31 have bad posture, all those words that,
00:11:31 --> 00:11:34 that harm kind of thing and say, you know,
00:11:35 --> 00:11:36 this is what I found in my exam.
00:11:37 --> 00:11:38 This is what the current
00:11:38 --> 00:11:39 best evidence says about
00:11:39 --> 00:11:41 treating those findings.
00:11:41 --> 00:11:43 And we published a paper
00:11:43 --> 00:11:44 called the Healthcare Buffet,
00:11:44 --> 00:11:45 where we kind of present to your patient,
00:11:45 --> 00:11:46 well,
00:11:46 --> 00:11:47 evidence shows we could use some
00:11:47 --> 00:11:50 manual therapy, we could do some exercise,
00:11:50 --> 00:11:53 you could do some aerobic conditioning,
00:11:53 --> 00:11:54 those type of things.
00:11:54 --> 00:11:55 We could work on some pain
00:11:55 --> 00:11:56 science education,
00:11:57 --> 00:11:58 we could work on some
00:11:58 --> 00:11:59 relaxation techniques,
00:11:59 --> 00:12:00 and those would probably
00:12:00 --> 00:12:02 all benefit you or any of
00:12:02 --> 00:12:03 those of interest to you.
00:12:04 --> 00:12:05 And that whole
00:12:06 --> 00:12:07 patient-centered care and
00:12:07 --> 00:12:08 shared decision-making,
00:12:08 --> 00:12:09 you actually put the
00:12:10 --> 00:12:11 evidence in front of the patient and say,
00:12:12 --> 00:12:13 what aligns with kind of
00:12:13 --> 00:12:14 your world belief?
00:12:14 --> 00:12:15 What do you think would give
00:12:15 --> 00:12:16 you the best outcome?
00:12:17 --> 00:12:18 And then let them choose,
00:12:19 --> 00:12:20 and then you proceed together as a team.
00:12:21 --> 00:12:21 Yeah.
00:12:22 --> 00:12:22 Yeah.
00:12:22 --> 00:12:24 I like that approach.
00:12:24 --> 00:12:26 I think it makes total sense,
00:12:26 --> 00:12:27 especially on the heels of
00:12:27 --> 00:12:28 kind of all this kind of
00:12:28 --> 00:12:29 contemporary and updated
00:12:29 --> 00:12:30 information that's coming
00:12:30 --> 00:12:31 out about patient-centered
00:12:31 --> 00:12:33 care and why that's so important.
00:12:34 --> 00:12:34 But I think it's hard,
00:12:35 --> 00:12:36 as at least you and I both
00:12:36 --> 00:12:37 educate entry-level students,
00:12:37 --> 00:12:40 I think it's hard for us to
00:12:41 --> 00:12:43 help them see that you have
00:12:43 --> 00:12:44 to kind of lay out the options.
00:12:44 --> 00:12:46 It's not all on you, actually.
00:12:46 --> 00:12:47 It's got to be on the patient, too.
00:12:47 --> 00:12:50 So how do you
00:12:50 --> 00:12:52 You said there's evidence in
00:12:52 --> 00:12:54 certain regions that
00:12:55 --> 00:12:56 positive expectations
00:12:56 --> 00:12:58 anyway might drive outcomes
00:12:58 --> 00:12:59 in terms of like a manual
00:13:00 --> 00:13:00 therapy intervention.
00:13:01 --> 00:13:02 How do you measure that type of a thing?
00:13:03 --> 00:13:04 So for those listeners that
00:13:04 --> 00:13:06 aren't necessarily as familiar with it,
00:13:07 --> 00:13:09 what does expectation research look like?
00:13:09 --> 00:13:10 What are you actually measuring?
00:13:12 --> 00:13:12 Yeah,
00:13:12 --> 00:13:14 we ask the patient their past
00:13:14 --> 00:13:15 experience with certain treatments.
00:13:16 --> 00:13:17 We ask them specifically,
00:13:17 --> 00:13:19 do you think that exercise
00:13:19 --> 00:13:20 will help your condition?
00:13:20 --> 00:13:21 Do you think that
00:13:22 --> 00:13:24 manipulation or manual
00:13:24 --> 00:13:26 therapy will help your condition?
00:13:26 --> 00:13:27 Do you think that stretching
00:13:27 --> 00:13:28 would help your condition?
00:13:28 --> 00:13:29 And we give them kind of a
00:13:29 --> 00:13:31 Likert scale for when not
00:13:31 --> 00:13:32 likely or very likely or
00:13:33 --> 00:13:33 those kind of things.
00:13:34 --> 00:13:36 uh and so we kind of assess
00:13:36 --> 00:13:37 their expectations prior to
00:13:37 --> 00:13:39 treatment and we can look
00:13:39 --> 00:13:40 at whatever treatment they
00:13:40 --> 00:13:42 received in that research
00:13:42 --> 00:13:43 and see if their
00:13:43 --> 00:13:44 expectations correlated
00:13:45 --> 00:13:46 with the outcomes overall
00:13:46 --> 00:13:47 and you know you and I
00:13:48 --> 00:13:49 published a few things and
00:13:50 --> 00:13:52 and um with uh josh cleland
00:13:52 --> 00:13:53 and joel bylosky and mark
00:13:53 --> 00:13:55 bishop we published on neck
00:13:55 --> 00:13:57 pain and back pain and
00:13:57 --> 00:13:58 shoulder pain and uh
00:14:00 --> 00:14:01 There's probably a few that
00:14:01 --> 00:14:03 I'm missing overall,
00:14:03 --> 00:14:04 but it comes in with the
00:14:04 --> 00:14:06 expectation that the
00:14:06 --> 00:14:06 treatment that they're
00:14:06 --> 00:14:09 going to receive will help them.
00:14:09 --> 00:14:10 Their outcomes are better.
00:14:10 --> 00:14:12 And the other thing I wanted
00:14:12 --> 00:14:14 to talk about with you is, you know,
00:14:14 --> 00:14:15 you get these patients in
00:14:15 --> 00:14:16 these studies and they know
00:14:16 --> 00:14:18 that it's a manual therapy study.
00:14:18 --> 00:14:19 Maybe it's a randomized controlled trial.
00:14:20 --> 00:14:21 and the randomization occurs
00:14:21 --> 00:14:23 and we open the envelope and we say,
00:14:23 --> 00:14:24 you're in the exercise
00:14:24 --> 00:14:25 group or you're in the control group,
00:14:25 --> 00:14:26 you can see them,
00:14:26 --> 00:14:27 the ones that have this
00:14:27 --> 00:14:28 really high expectation
00:14:28 --> 00:14:30 that manual therapy is gonna help,
00:14:30 --> 00:14:34 they kind of deflate a little bit.
00:14:35 --> 00:14:38 And there are healthcare
00:14:38 --> 00:14:39 seekers and that kind of
00:14:39 --> 00:14:40 thing that will actually
00:14:40 --> 00:14:43 look for studies where they
00:14:43 --> 00:14:44 can get the treatment that
00:14:44 --> 00:14:45 they really strongly
00:14:45 --> 00:14:47 believe in and that type of thing.
00:14:48 --> 00:14:50 clinical research is really
00:14:50 --> 00:14:53 hard to be able to take a
00:14:53 --> 00:14:55 naive patient and deliver
00:14:56 --> 00:14:57 two different types of
00:14:58 --> 00:14:59 treatment to see which one
00:14:59 --> 00:15:01 is superior because these
00:15:01 --> 00:15:02 patient expectations,
00:15:02 --> 00:15:03 every patient coming in has
00:15:04 --> 00:15:06 some thought or belief about, you know,
00:15:06 --> 00:15:07 what they're going to
00:15:07 --> 00:15:08 receive and what they think
00:15:08 --> 00:15:08 will help them.
00:15:08 --> 00:15:10 And if it doesn't match what
00:15:10 --> 00:15:11 they think will help them,
00:15:12 --> 00:15:12 their outcomes are not
00:15:13 --> 00:15:13 going to be as good.
00:15:14 --> 00:15:14 Yeah.
00:15:14 --> 00:15:15 Yeah.
00:15:15 --> 00:15:15 It's interesting.
00:15:15 --> 00:15:16 I think that's the perfect
00:15:17 --> 00:15:18 example of when we see it
00:15:18 --> 00:15:21 because our hands are tied
00:15:21 --> 00:15:21 and we're forced to be
00:15:22 --> 00:15:23 prescriptive because we're
00:15:23 --> 00:15:24 in a clinical research environment.
00:15:25 --> 00:15:26 But what's amazing is you
00:15:26 --> 00:15:27 get to the clinic and you
00:15:27 --> 00:15:29 actually get to tell the patient,
00:15:29 --> 00:15:30 these are all the options.
00:15:30 --> 00:15:31 Like you were saying,
00:15:31 --> 00:15:32 what did you call it?
00:15:32 --> 00:15:32 A healthcare buffet?
00:15:32 --> 00:15:33 Yeah.
00:15:33 --> 00:15:34 Healthcare buffet.
00:15:34 --> 00:15:36 Like you go to an Asian
00:15:36 --> 00:15:37 restaurant or something and
00:15:37 --> 00:15:38 there's all this stuff that
00:15:38 --> 00:15:39 you can choose from.
00:15:39 --> 00:15:39 Right.
00:15:40 --> 00:15:41 And some, some you like,
00:15:41 --> 00:15:42 some you don't like.
00:15:42 --> 00:15:42 Yeah.
00:15:43 --> 00:15:45 But I like that analogy
00:15:45 --> 00:15:46 because in the clinic it's
00:15:46 --> 00:15:47 just different and the
00:15:47 --> 00:15:48 patients can choose or
00:15:48 --> 00:15:49 prioritize what they what
00:15:49 --> 00:15:51 they want to do if you're
00:15:51 --> 00:15:52 kind of exercising that
00:15:52 --> 00:15:54 that shared decision making model.
00:15:55 --> 00:15:56 So you talked a little bit
00:15:56 --> 00:15:57 about some of the studies
00:15:57 --> 00:15:58 that were done in the past,
00:15:58 --> 00:16:00 and that was I think it was interesting.
00:16:00 --> 00:16:01 I remember when you and I
00:16:01 --> 00:16:02 were kind of looking at
00:16:02 --> 00:16:03 the patient expectation
00:16:03 --> 00:16:05 information from the lumbar
00:16:05 --> 00:16:06 spine and the neck and the shoulder,
00:16:07 --> 00:16:08 all those figures looked
00:16:08 --> 00:16:09 very much the same.
00:16:09 --> 00:16:11 So do you think that's fair
00:16:11 --> 00:16:13 to say that you would
00:16:13 --> 00:16:14 probably see the same
00:16:14 --> 00:16:17 patient expectations in
00:16:17 --> 00:16:18 terms of influencing
00:16:18 --> 00:16:19 outcomes in other regions
00:16:19 --> 00:16:21 like the foot and ankle and
00:16:21 --> 00:16:23 the knee and across
00:16:23 --> 00:16:24 orthopedic conditions?
00:16:26 --> 00:16:26 Yeah,
00:16:26 --> 00:16:29 I think there's very few exceptions
00:16:29 --> 00:16:29 to that.
00:16:30 --> 00:16:31 the studies that have
00:16:31 --> 00:16:33 explored expectations where
00:16:33 --> 00:16:34 if a patient had a positive
00:16:34 --> 00:16:35 expectation for that
00:16:35 --> 00:16:36 treatment and they received
00:16:36 --> 00:16:36 that treatment,
00:16:36 --> 00:16:37 that the outcomes were not
00:16:38 --> 00:16:40 better compared to the alternative.
00:16:40 --> 00:16:42 And we've seen it in other
00:16:42 --> 00:16:45 conditions as well, headaches, migraines,
00:16:45 --> 00:16:46 irritable bowel syndrome,
00:16:46 --> 00:16:48 all kinds of different medical treatments,
00:16:48 --> 00:16:49 that type of thing.
00:16:50 --> 00:16:52 And as I said before,
00:16:52 --> 00:16:52 the interesting thing about
00:16:52 --> 00:16:54 those patient expectations
00:16:54 --> 00:16:55 is you can mold those
00:16:56 --> 00:16:57 the patient can come in and
00:16:57 --> 00:16:58 they can maybe have a
00:16:58 --> 00:16:59 neutral or a negative
00:16:59 --> 00:17:00 expectation about a treatment,
00:17:01 --> 00:17:02 but through a good
00:17:02 --> 00:17:03 therapeutic alliance where
00:17:03 --> 00:17:06 you really connect with that patient,
00:17:06 --> 00:17:08 get to know them as a human being,
00:17:08 --> 00:17:09 know that you're in this as a team,
00:17:10 --> 00:17:12 can share the evidence with them and say,
00:17:12 --> 00:17:12 you know,
00:17:12 --> 00:17:13 the research shows this
00:17:13 --> 00:17:16 intervention would probably help you.
00:17:16 --> 00:17:17 What are your thoughts on that?
00:17:17 --> 00:17:18 You can actually change
00:17:18 --> 00:17:19 their expectations.
00:17:19 --> 00:17:21 And when you do change their expectations,
00:17:21 --> 00:17:22 their outcomes improve.
00:17:22 --> 00:17:23 Yeah, yeah.
00:17:24 --> 00:17:26 So I have a question, it's related,
00:17:26 --> 00:17:28 but on a slightly different topic,
00:17:29 --> 00:17:29 you know,
00:17:29 --> 00:17:30 there's a lot of information
00:17:30 --> 00:17:31 that's come out about
00:17:32 --> 00:17:33 placebo and nocebo and,
00:17:34 --> 00:17:36 and patients might have an expectation.
00:17:37 --> 00:17:37 Oh gosh,
00:17:37 --> 00:17:39 there's that little thumbs up
00:17:39 --> 00:17:40 thing that I didn't mean
00:17:40 --> 00:17:41 for that to happen.
00:17:43 --> 00:17:44 Tell me how placebo effect
00:17:44 --> 00:17:46 and expectations kind of
00:17:46 --> 00:17:48 collide when it comes to
00:17:48 --> 00:17:49 clinical practice,
00:17:49 --> 00:17:50 or even what does some of
00:17:50 --> 00:17:52 the research say about
00:17:52 --> 00:17:54 placebo and expectations?
00:17:54 --> 00:17:55 What does that even mean?
00:17:55 --> 00:17:58 Yeah, so placebo effect, well,
00:17:58 --> 00:18:00 placebo is a supposedly
00:18:01 --> 00:18:02 inactive treatment.
00:18:02 --> 00:18:04 That could be a pill with sugar in it,
00:18:04 --> 00:18:05 or it could be a sham
00:18:05 --> 00:18:06 manipulation or something like that.
00:18:06 --> 00:18:09 The placebo effect is what happens,
00:18:09 --> 00:18:10 you know,
00:18:10 --> 00:18:11 the physiological or
00:18:11 --> 00:18:13 psychological changes in a
00:18:13 --> 00:18:14 patient's condition
00:18:14 --> 00:18:16 resulting from the belief that
00:18:16 --> 00:18:17 that they're receiving an
00:18:17 --> 00:18:18 effective treatment.
00:18:18 --> 00:18:20 So even if that treatment
00:18:20 --> 00:18:22 has no therapeutic value,
00:18:22 --> 00:18:24 so patient expectations are
00:18:24 --> 00:18:25 a part of placebo,
00:18:25 --> 00:18:27 but they're not all of it overall.
00:18:27 --> 00:18:29 So, so you,
00:18:29 --> 00:18:30 you can change a patient's
00:18:30 --> 00:18:32 expectation and improve
00:18:32 --> 00:18:34 potentially the placebo effect.
00:18:34 --> 00:18:36 But you know,
00:18:36 --> 00:18:38 a lot of people get confused
00:18:38 --> 00:18:40 on placebo versus control
00:18:40 --> 00:18:41 and that type of thing.
00:18:41 --> 00:18:43 So a placebo can be a control and,
00:18:44 --> 00:18:45 You have a no treatment
00:18:45 --> 00:18:46 control where patients
00:18:46 --> 00:18:48 don't receive any treatment.
00:18:48 --> 00:18:50 But the state of the art in
00:18:50 --> 00:18:52 medicine is to compare the
00:18:52 --> 00:18:54 active treatment to a
00:18:55 --> 00:18:56 similar treatment that the
00:18:56 --> 00:18:58 patient thinks is going to
00:18:58 --> 00:19:00 benefit them overall, whether
00:19:00 --> 00:19:01 you know,
00:19:01 --> 00:19:04 it actually has some therapeutic
00:19:04 --> 00:19:05 value or not.
00:19:05 --> 00:19:07 And then we know that the
00:19:07 --> 00:19:09 placebo effect is around 30 to 35%.
00:19:09 --> 00:19:12 If patients think that they
00:19:12 --> 00:19:14 are actively receiving a
00:19:14 --> 00:19:15 treatment or doing
00:19:15 --> 00:19:17 something that will make them better,
00:19:17 --> 00:19:19 that we will see improvements in that.
00:19:19 --> 00:19:21 So the bar is really, does the,
00:19:22 --> 00:19:23 treatment that you're
00:19:23 --> 00:19:25 investigating exceed that
00:19:25 --> 00:19:27 bar of 30 to 35% will
00:19:27 --> 00:19:30 improve with the placebo
00:19:31 --> 00:19:33 and to actually show that
00:19:33 --> 00:19:34 it made a significant difference.
00:19:35 --> 00:19:37 So it almost seems like you'd have to have,
00:19:38 --> 00:19:39 if we're getting granular,
00:19:39 --> 00:19:40 you'd have to have your
00:19:40 --> 00:19:42 experimental group, a sham group,
00:19:42 --> 00:19:44 and then a true control
00:19:44 --> 00:19:45 where nothing is happening
00:19:45 --> 00:19:46 in order to maybe sort that out.
00:19:47 --> 00:19:48 Yeah,
00:19:48 --> 00:19:49 because natural history is such a
00:19:49 --> 00:19:50 powerful thing.
00:19:51 --> 00:19:54 Even in patients with chronic pain overall,
00:19:54 --> 00:19:56 there is an ebb and a flow
00:19:56 --> 00:19:57 to it and kind of a natural
00:19:57 --> 00:19:58 history overall.
00:19:58 --> 00:20:01 So you really, you know, it is nice,
00:20:01 --> 00:20:03 like in our study where we
00:20:03 --> 00:20:04 looked at thoracic
00:20:04 --> 00:20:05 manipulation for patients
00:20:05 --> 00:20:06 with cervicogenic headaches.
00:20:06 --> 00:20:07 We had those patients come in.
00:20:07 --> 00:20:08 We did the baseline data.
00:20:09 --> 00:20:09 The ones that got the
00:20:09 --> 00:20:11 control got no treatment for four weeks.
00:20:12 --> 00:20:13 And they stayed the same, right?
00:20:13 --> 00:20:14 Yeah, yeah.
00:20:15 --> 00:20:16 And they'd had headaches, I think, what,
00:20:16 --> 00:20:17 for an average of five years?
00:20:18 --> 00:20:20 Yeah, our average was 10 and a half years.
00:20:20 --> 00:20:22 10 and a half years of headaches.
00:20:23 --> 00:20:25 And so the group that got the control,
00:20:25 --> 00:20:26 which was no treatment,
00:20:26 --> 00:20:28 they just sat idle for four weeks.
00:20:29 --> 00:20:30 But it was a crossover study.
00:20:30 --> 00:20:32 So we wanted to deliver the
00:20:32 --> 00:20:34 thoracic manipulation to
00:20:34 --> 00:20:35 one group while the other
00:20:35 --> 00:20:36 group sat on the sidelines.
00:20:37 --> 00:20:38 And then after four weeks,
00:20:38 --> 00:20:39 they entered the game.
00:20:39 --> 00:20:40 We did the thoracic
00:20:40 --> 00:20:41 manipulation and the
00:20:42 --> 00:20:43 improvements almost exactly
00:20:44 --> 00:20:45 mirrored each other overall.
00:20:45 --> 00:20:46 So that kind of proves that
00:20:47 --> 00:20:48 what we did in the
00:20:48 --> 00:20:49 intervention made a
00:20:49 --> 00:20:50 difference in these
00:20:50 --> 00:20:51 patients who had had
00:20:51 --> 00:20:52 symptoms for 10 years.
00:20:53 --> 00:20:54 And we had that control
00:20:54 --> 00:20:55 group where no treatment
00:20:55 --> 00:20:57 was delivered and they
00:20:57 --> 00:20:58 didn't change at all.
00:20:58 --> 00:20:58 Yeah.
00:20:59 --> 00:20:59 Yeah.
00:20:59 --> 00:21:00 And I'm wondering, you know,
00:21:00 --> 00:21:01 things like that,
00:21:01 --> 00:21:02 it's hard to know how much
00:21:03 --> 00:21:05 natural history for something that's been
00:21:05 --> 00:21:06 occurring in an individual
00:21:06 --> 00:21:08 for 10 years as opposed to
00:21:08 --> 00:21:09 two months is also probably
00:21:09 --> 00:21:10 going to look different.
00:21:11 --> 00:21:12 It just occurred to me, Paul,
00:21:12 --> 00:21:13 that we actually gathered
00:21:13 --> 00:21:15 patient expectation data,
00:21:15 --> 00:21:17 but we never did anything with it.
00:21:17 --> 00:21:20 So maybe this is the impetus
00:21:20 --> 00:21:21 for us to do a secondary
00:21:21 --> 00:21:22 analysis of some of that
00:21:22 --> 00:21:23 data for individuals with
00:21:23 --> 00:21:24 cervicogenic headache.
00:21:25 --> 00:21:27 Yeah, yeah.
00:21:28 --> 00:21:30 So what are some of the
00:21:30 --> 00:21:31 thoughts you have on, like,
00:21:31 --> 00:21:33 I would love for you to share with people,
00:21:34 --> 00:21:34 what's the link?
00:21:34 --> 00:21:35 What is the language that
00:21:35 --> 00:21:36 you would use if someone
00:21:37 --> 00:21:38 has a negative expectation?
00:21:38 --> 00:21:39 So I'm talking about that
00:21:39 --> 00:21:41 patient that comes in and they're like,
00:21:41 --> 00:21:42 my brother, you know, went to PT.
00:21:42 --> 00:21:43 It wasn't helpful.
00:21:44 --> 00:21:46 I'm not even sure if this is going to help,
00:21:46 --> 00:21:48 but I can't get, you know,
00:21:48 --> 00:21:50 an injection until I do six
00:21:50 --> 00:21:51 weeks of physical therapy
00:21:51 --> 00:21:52 or I can't do this or that,
00:21:53 --> 00:21:53 or I don't know.
00:21:54 --> 00:21:54 How do you.
00:21:55 --> 00:21:56 I have my own ideas,
00:21:56 --> 00:21:57 but I want to hear your thoughts.
00:21:57 --> 00:21:58 How do you realign those?
00:21:58 --> 00:21:59 What are the words that you use?
00:22:02 --> 00:22:03 uh well that's challenging
00:22:03 --> 00:22:06 and it's it's um you know
00:22:06 --> 00:22:07 every every patient is
00:22:07 --> 00:22:08 different like in the
00:22:08 --> 00:22:09 situation with the brother
00:22:09 --> 00:22:11 had a bad experience maybe
00:22:11 --> 00:22:12 explore that a little bit
00:22:12 --> 00:22:14 more but uh you know maybe
00:22:14 --> 00:22:15 there was some other
00:22:15 --> 00:22:17 variable in there that that
00:22:17 --> 00:22:18 affected the outcome
00:22:18 --> 00:22:19 overall but you know really
00:22:19 --> 00:22:21 I try and bring it back to
00:22:21 --> 00:22:22 the patient this is your
00:22:22 --> 00:22:23 life this is your
00:22:23 --> 00:22:24 experience this is what the
00:22:24 --> 00:22:25 current best evidence says
00:22:25 --> 00:22:26 this is what my uh
00:22:28 --> 00:22:29 expert clinical judgment
00:22:30 --> 00:22:33 says would probably benefit you overall.
00:22:33 --> 00:22:34 And if you bring that
00:22:34 --> 00:22:36 negative expectation into
00:22:36 --> 00:22:38 this therapeutic relationship,
00:22:39 --> 00:22:40 it will impact your outcomes.
00:22:40 --> 00:22:43 So I'll give them papers.
00:22:43 --> 00:22:44 I'll let them read papers.
00:22:44 --> 00:22:46 I'll send them to websites
00:22:46 --> 00:22:47 that I trust where they can
00:22:47 --> 00:22:49 explore the intervention
00:22:49 --> 00:22:49 that we're talking about,
00:22:50 --> 00:22:51 that maybe we can start to
00:22:51 --> 00:22:53 reshape that expectation
00:22:53 --> 00:22:55 from the brother's bad
00:22:55 --> 00:22:56 experience or whatever.
00:22:56 --> 00:22:57 Yeah.
00:22:57 --> 00:22:57 you know,
00:22:57 --> 00:23:00 bring them around to maybe a more
00:23:00 --> 00:23:01 neutral or more positive
00:23:02 --> 00:23:03 type of an expectation overall.
00:23:03 --> 00:23:04 But, you know, again,
00:23:05 --> 00:23:05 you have to value the
00:23:06 --> 00:23:07 patient's experience,
00:23:07 --> 00:23:09 but you have to bring it back to them.
00:23:09 --> 00:23:10 This is your life.
00:23:10 --> 00:23:11 This is your story.
00:23:12 --> 00:23:14 This is, I think, will help you.
00:23:15 --> 00:23:17 And then, you know, if you can change that,
00:23:17 --> 00:23:18 I think you can bring them
00:23:18 --> 00:23:20 around to that position.
00:23:21 --> 00:23:24 So for some of our listeners
00:23:24 --> 00:23:25 that are maybe a little bit
00:23:25 --> 00:23:27 earlier in their education or training,
00:23:27 --> 00:23:28 Would you say this is
00:23:28 --> 00:23:29 something that you're
00:23:29 --> 00:23:30 constantly and dynamically
00:23:30 --> 00:23:32 doing throughout your interactions?
00:23:32 --> 00:23:34 Or do you believe you kind
00:23:34 --> 00:23:35 of deliver a little bit of
00:23:35 --> 00:23:37 bolus of information in the
00:23:37 --> 00:23:38 beginning in terms of
00:23:39 --> 00:23:40 trying to change expectations?
00:23:42 --> 00:23:43 Yeah, that's a good question.
00:23:43 --> 00:23:45 That really gets into our bias, right?
00:23:45 --> 00:23:47 A lot of us are strongly
00:23:47 --> 00:23:48 opinionated about what we
00:23:48 --> 00:23:49 do and why we do it and
00:23:50 --> 00:23:51 look at social media and
00:23:51 --> 00:23:52 all the manual therapy,
00:23:52 --> 00:23:53 love it or hate it kind of
00:23:53 --> 00:23:54 things overall.
00:23:54 --> 00:23:56 So we do have to present it
00:23:56 --> 00:23:58 in an unbiased fashion and not try to
00:23:59 --> 00:24:00 persuade patients or talk
00:24:01 --> 00:24:02 them into a treatment that
00:24:02 --> 00:24:06 maybe they are not interested in overall.
00:24:06 --> 00:24:10 But it is challenging,
00:24:10 --> 00:24:11 but trying to just present
00:24:12 --> 00:24:14 it in a factual basis and
00:24:14 --> 00:24:15 then really involve the
00:24:15 --> 00:24:17 patient and listen to them.
00:24:17 --> 00:24:18 What are your thoughts on this?
00:24:19 --> 00:24:20 of them will say you know
00:24:21 --> 00:24:22 manipulation is a prime
00:24:22 --> 00:24:23 example cervical
00:24:23 --> 00:24:24 manipulation while my
00:24:24 --> 00:24:25 cousin's sister's brother
00:24:25 --> 00:24:26 got manipulated by a
00:24:26 --> 00:24:27 chiropractor and had a
00:24:27 --> 00:24:29 stroke and crashed into a
00:24:29 --> 00:24:30 ditch and things like that
00:24:30 --> 00:24:31 that's that's probably a
00:24:31 --> 00:24:32 patient that you're not
00:24:32 --> 00:24:33 going to bring around to
00:24:33 --> 00:24:35 letting them letting you do
00:24:36 --> 00:24:38 a cervical manipulation on
00:24:38 --> 00:24:40 them overall so there are some
00:24:40 --> 00:24:42 barriers to expectation,
00:24:42 --> 00:24:43 I would say overall.
00:24:43 --> 00:24:44 But in general,
00:24:44 --> 00:24:46 if you can start to reframe
00:24:46 --> 00:24:48 whatever their expectation is,
00:24:48 --> 00:24:49 if it's on that negative side,
00:24:50 --> 00:24:51 you can bring them around.
00:24:52 --> 00:24:53 But if you can't,
00:24:53 --> 00:24:55 then move on to something else.
00:24:55 --> 00:24:56 Yeah.
00:24:56 --> 00:24:58 And so how are you in the
00:24:58 --> 00:25:01 context of being an entry level educator?
00:25:01 --> 00:25:03 How are you kind of
00:25:03 --> 00:25:04 sprinkling some of this
00:25:04 --> 00:25:06 content in with your students?
00:25:06 --> 00:25:07 How are you helping them to
00:25:08 --> 00:25:09 to understand that this is
00:25:09 --> 00:25:10 another component of how we
00:25:10 --> 00:25:13 need to interact with our patients?
00:25:14 --> 00:25:15 Yeah.
00:25:15 --> 00:25:17 So, you know,
00:25:17 --> 00:25:19 I really emphasize that
00:25:19 --> 00:25:21 therapeutic alliance with
00:25:21 --> 00:25:22 patients and being present
00:25:22 --> 00:25:23 for your patients.
00:25:23 --> 00:25:24 Most of our students,
00:25:24 --> 00:25:25 when they're sitting in
00:25:25 --> 00:25:26 front of a patient,
00:25:26 --> 00:25:27 they've got their heads
00:25:27 --> 00:25:29 going in a thousand different directions.
00:25:29 --> 00:25:30 They've got a checklist in front of them.
00:25:31 --> 00:25:32 They don't even make eye
00:25:32 --> 00:25:33 contact with the patient.
00:25:34 --> 00:25:35 Or they've got their tablet
00:25:35 --> 00:25:36 or their computer up and
00:25:36 --> 00:25:37 they're documenting while
00:25:37 --> 00:25:38 the patient is talking.
00:25:38 --> 00:25:40 And I really try to get them
00:25:40 --> 00:25:42 out of that mode where they
00:25:42 --> 00:25:43 can be with that other human being,
00:25:44 --> 00:25:46 look them in the eye, talk to them.
00:25:46 --> 00:25:47 And I've always told my students,
00:25:47 --> 00:25:48 you've heard me say this,
00:25:48 --> 00:25:49 that your interaction may
00:25:49 --> 00:25:51 outweigh your intervention, right?
00:25:51 --> 00:25:52 I mean,
00:25:52 --> 00:25:53 we've got all these studies that
00:25:53 --> 00:25:54 show that manual therapy
00:25:55 --> 00:25:56 helps maybe a little bit in
00:25:56 --> 00:25:57 the short term.
00:25:58 --> 00:25:59 But if you look that patient in the eye,
00:25:59 --> 00:26:01 get to know them as a human being,
00:26:01 --> 00:26:04 really invest in them as a
00:26:04 --> 00:26:05 healthcare provider,
00:26:06 --> 00:26:07 that will likely have a
00:26:07 --> 00:26:09 better effect on the
00:26:09 --> 00:26:10 outcome of your treatment
00:26:10 --> 00:26:11 than any treatment we can
00:26:11 --> 00:26:13 throw at our patients overall.
00:26:13 --> 00:26:14 Yeah.
00:26:14 --> 00:26:15 Yeah.
00:26:15 --> 00:26:16 And I think it's exciting to see that,
00:26:18 --> 00:26:18 you know,
00:26:18 --> 00:26:20 there's work being done now to really
00:26:21 --> 00:26:22 try to figure out how to
00:26:22 --> 00:26:25 better harness that shared
00:26:26 --> 00:26:27 contextual piece.
00:26:28 --> 00:26:29 It's not all about,
00:26:29 --> 00:26:30 it's interesting because I
00:26:30 --> 00:26:31 think we're starting,
00:26:31 --> 00:26:32 I hope we're starting to
00:26:32 --> 00:26:33 move away from the fact
00:26:33 --> 00:26:34 that we think all of our interventions,
00:26:34 --> 00:26:35 whether it's manual therapy
00:26:35 --> 00:26:37 or exercise or what drive the outcomes,
00:26:38 --> 00:26:40 it's so much bigger than that, including
00:26:40 --> 00:26:40 you know,
00:26:40 --> 00:26:43 our topic here today of expectations,
00:26:43 --> 00:26:44 but also of some of these
00:26:44 --> 00:26:45 shared mechanisms.
00:26:46 --> 00:26:47 So I think it'll be
00:26:47 --> 00:26:48 interesting to see what
00:26:48 --> 00:26:50 more we learn about how
00:26:50 --> 00:26:51 that really needs to be a
00:26:51 --> 00:26:52 big player in the
00:26:52 --> 00:26:54 intervention outside of just, you know,
00:26:55 --> 00:26:57 exercise and manual therapy, for example.
00:27:00 --> 00:27:00 Yeah.
00:27:00 --> 00:27:02 What are some things that are kind of,
00:27:02 --> 00:27:05 I don't know, when you've done lectures,
00:27:05 --> 00:27:05 I know,
00:27:06 --> 00:27:08 in various places and in Europe on
00:27:08 --> 00:27:09 patient expectations,
00:27:10 --> 00:27:11 What are some of the biggest
00:27:11 --> 00:27:12 things that your audience
00:27:12 --> 00:27:13 tends to be curious about?
00:27:13 --> 00:27:14 Or what are some of the
00:27:14 --> 00:27:17 things that maybe continue
00:27:17 --> 00:27:21 to interest you about this topic?
00:27:21 --> 00:27:22 Or what are some things that
00:27:22 --> 00:27:23 surprise you maybe about this topic?
00:27:26 --> 00:27:26 Well,
00:27:26 --> 00:27:29 I think the big thing is just not
00:27:29 --> 00:27:30 paying attention to the
00:27:30 --> 00:27:31 fact that patients have
00:27:32 --> 00:27:33 expectations and that you
00:27:33 --> 00:27:35 can explore those and that
00:27:35 --> 00:27:35 you could potentially
00:27:35 --> 00:27:37 modify those expectations.
00:27:37 --> 00:27:38 I mean,
00:27:38 --> 00:27:39 that was eye-opening to a lot of
00:27:39 --> 00:27:41 people that I give this talk to,
00:27:41 --> 00:27:42 and they say, well,
00:27:42 --> 00:27:44 isn't that deceptive if you tell them,
00:27:45 --> 00:27:45 you know,
00:27:45 --> 00:27:46 this manipulation will make you
00:27:46 --> 00:27:47 feel better?
00:27:47 --> 00:27:47 If you're sharing...
00:27:48 --> 00:27:49 current best evidence and
00:27:49 --> 00:27:51 you can back it up with research, then,
00:27:51 --> 00:27:53 you know, it's not deceptive at all.
00:27:54 --> 00:27:55 You know,
00:27:55 --> 00:27:57 and then harnessing the placebo effect.
00:27:57 --> 00:27:58 I openly embrace the placebo
00:27:58 --> 00:28:00 effect in physical therapy.
00:28:00 --> 00:28:01 I think it's a huge
00:28:01 --> 00:28:02 component of what we do,
00:28:02 --> 00:28:04 whether it's manual therapy or exercise.
00:28:04 --> 00:28:05 And I will tell patients that.
00:28:06 --> 00:28:06 I mean,
00:28:06 --> 00:28:08 the new research out on open label
00:28:08 --> 00:28:10 placebo, where you tell the patient,
00:28:10 --> 00:28:10 I mean,
00:28:10 --> 00:28:13 there's one great study on chronic
00:28:13 --> 00:28:13 low back pain
00:28:14 --> 00:28:16 who these individuals had had pain for,
00:28:16 --> 00:28:18 I think, five years at a minimum.
00:28:19 --> 00:28:21 And they gave them a placebo and they said,
00:28:21 --> 00:28:23 there's no active substance in this pill.
00:28:24 --> 00:28:25 But in research studies,
00:28:25 --> 00:28:26 it has shown that people
00:28:26 --> 00:28:28 who take this pill have an
00:28:28 --> 00:28:29 improvement in their pain
00:28:29 --> 00:28:30 and their function and that
00:28:30 --> 00:28:31 type of thing.
00:28:31 --> 00:28:33 So they're very open about
00:28:33 --> 00:28:35 the fact that this is a placebo.
00:28:35 --> 00:28:37 And they saw significant
00:28:37 --> 00:28:38 improvements in those
00:28:38 --> 00:28:39 individuals and they
00:28:39 --> 00:28:40 tracked them out to five years.
00:28:40 --> 00:28:43 And that was maintained out to five years.
00:28:43 --> 00:28:45 And, you know, at the end of the study,
00:28:45 --> 00:28:48 When they stopped giving them the placebo,
00:28:48 --> 00:28:49 a lot of these patients would say,
00:28:49 --> 00:28:51 where can I get a prescription for that?
00:28:51 --> 00:28:52 Where can I buy that?
00:28:52 --> 00:28:55 And you tell them it's just a sugar pill,
00:28:55 --> 00:28:55 right?
00:28:55 --> 00:28:56 There's nothing in it,
00:28:56 --> 00:28:58 but they want to keep taking it.
00:28:58 --> 00:28:59 And there's something about
00:28:59 --> 00:29:01 that doing something active
00:29:01 --> 00:29:02 for your health.
00:29:02 --> 00:29:03 Maybe when they're taking that pill,
00:29:03 --> 00:29:04 they're thinking, well,
00:29:04 --> 00:29:05 maybe I should walk a
00:29:05 --> 00:29:06 little bit more today or
00:29:06 --> 00:29:07 maybe I should eat a little
00:29:07 --> 00:29:08 bit better today.
00:29:09 --> 00:29:11 or maybe I should get more sleep.
00:29:11 --> 00:29:14 They take a more active role
00:29:14 --> 00:29:15 in their recovery just
00:29:15 --> 00:29:16 because they're doing
00:29:16 --> 00:29:17 something they think has
00:29:18 --> 00:29:20 potential therapeutic value overall.
00:29:20 --> 00:29:22 I tell my patients that.
00:29:22 --> 00:29:24 There may be a placebo effect in this,
00:29:24 --> 00:29:25 but we know that the
00:29:25 --> 00:29:26 placebo effect is very powerful.
00:29:26 --> 00:29:28 It's getting your brain on
00:29:29 --> 00:29:31 board with this plan of
00:29:31 --> 00:29:32 care that we're going to be
00:29:32 --> 00:29:34 doing and that will improve
00:29:35 --> 00:29:35 your outcomes.
00:29:36 --> 00:29:36 Wow.
00:29:37 --> 00:29:38 So you're saying maybe it
00:29:38 --> 00:29:40 boils down to like the
00:29:40 --> 00:29:43 ritual of taking a pill and
00:29:43 --> 00:29:43 maybe something that's
00:29:43 --> 00:29:44 happening in the present
00:29:45 --> 00:29:45 when they're doing that?
00:29:46 --> 00:29:46 Yeah.
00:29:46 --> 00:29:47 Yeah.
00:29:47 --> 00:29:47 I mean,
00:29:48 --> 00:29:49 just the fact that the patient
00:29:49 --> 00:29:50 every day is taking that
00:29:50 --> 00:29:52 pill because that was key
00:29:52 --> 00:29:53 in that placebo study,
00:29:53 --> 00:29:54 that open label placebo.
00:29:55 --> 00:29:56 And they've done it near
00:29:56 --> 00:29:57 irritable bowel syndrome too.
00:29:57 --> 00:29:58 Exact same thing.
00:30:00 --> 00:30:01 where they told the patient,
00:30:01 --> 00:30:03 you have to take this every
00:30:03 --> 00:30:04 day and you have to
00:30:04 --> 00:30:06 document that and that type of thing.
00:30:06 --> 00:30:08 So the ritual of doing
00:30:08 --> 00:30:10 something every day that
00:30:10 --> 00:30:12 may help with their back
00:30:12 --> 00:30:13 pain or their irritable
00:30:13 --> 00:30:14 bowel syndrome and that kind of thing,
00:30:15 --> 00:30:16 I think just shifts their
00:30:16 --> 00:30:18 mindset overall that, hey,
00:30:18 --> 00:30:19 maybe I'm not going to eat
00:30:19 --> 00:30:20 that cheeseburger for lunch.
00:30:20 --> 00:30:21 Maybe I'll get a salad or
00:30:21 --> 00:30:22 maybe I'll go for a walk
00:30:22 --> 00:30:24 instead of sitting on my
00:30:24 --> 00:30:26 phone on social media for
00:30:26 --> 00:30:27 the entire hour overall.
00:30:27 --> 00:30:27 So-
00:30:30 --> 00:30:30 Yeah,
00:30:30 --> 00:30:31 I think that that research is so
00:30:32 --> 00:30:32 interesting.
00:30:33 --> 00:30:34 And I think it's important
00:30:34 --> 00:30:36 for us to think about that component too,
00:30:36 --> 00:30:37 that some of what we're
00:30:37 --> 00:30:39 doing is probably tapping into placebo.
00:30:40 --> 00:30:40 So what do you do?
00:30:40 --> 00:30:43 I love the scenarios of like, you know,
00:30:43 --> 00:30:44 you get a patient that
00:30:44 --> 00:30:45 comes in the clinic and
00:30:46 --> 00:30:47 they're dead set on the fact
00:30:47 --> 00:30:48 that ultrasound is gonna
00:30:48 --> 00:30:49 help their neck pain.
00:30:49 --> 00:30:50 I mean,
00:30:50 --> 00:30:52 I've seen those patients and you have to,
00:30:53 --> 00:30:54 how do you kind of rectify
00:30:54 --> 00:30:56 that disconnect between, you know,
00:30:56 --> 00:30:57 it actually kind of kills
00:30:57 --> 00:30:58 me to plug the machine in
00:30:58 --> 00:30:59 and actually do this,
00:31:00 --> 00:31:01 but yet the patient is
00:31:01 --> 00:31:02 saying that they're
00:31:02 --> 00:31:03 expecting that it's gonna help.
00:31:04 --> 00:31:05 What's your response to that
00:31:05 --> 00:31:06 and how do you manage that?
00:31:07 --> 00:31:08 Yeah, that's interesting.
00:31:08 --> 00:31:10 I remember I was talking to John Childs.
00:31:10 --> 00:31:12 This was like 20 years ago
00:31:12 --> 00:31:15 or so and asked him that exact question.
00:31:15 --> 00:31:16 The patient comes in and said,
00:31:16 --> 00:31:17 last time I hurt my back,
00:31:17 --> 00:31:19 I had ultrasound and it really helped.
00:31:20 --> 00:31:23 And he said, do the ultrasound.
00:31:23 --> 00:31:25 That's their expectation.
00:31:25 --> 00:31:28 And I've tried the contrary where I'll say,
00:31:28 --> 00:31:29 the evidence shows that
00:31:29 --> 00:31:30 ultrasound is not very
00:31:30 --> 00:31:31 beneficial for back pain,
00:31:32 --> 00:31:33 probably won't help you a whole lot.
00:31:33 --> 00:31:35 And then that creates a little bit of
00:31:36 --> 00:31:37 adversarial relationship.
00:31:39 --> 00:31:40 This is my experience.
00:31:40 --> 00:31:41 This helped me.
00:31:41 --> 00:31:42 And you're telling me that
00:31:42 --> 00:31:43 you're not going to do it
00:31:43 --> 00:31:44 because there's not a study
00:31:44 --> 00:31:46 that shows that it helped me.
00:31:46 --> 00:31:46 Right.
00:31:47 --> 00:31:47 Yeah.
00:31:47 --> 00:31:51 So I will embrace those things.
00:31:51 --> 00:31:52 I may share a little bit of
00:31:52 --> 00:31:53 knowledge about the
00:31:54 --> 00:31:55 the benefit of ultrasound.
00:31:55 --> 00:31:56 But, you know,
00:31:56 --> 00:31:57 the other important thing is
00:31:57 --> 00:31:58 while you're doing that ultrasound,
00:31:58 --> 00:31:59 you can be educating the
00:31:59 --> 00:32:02 patient and do some science education,
00:32:02 --> 00:32:02 or you can talk to them
00:32:03 --> 00:32:04 about activity modification
00:32:04 --> 00:32:06 or reinforcing their home
00:32:06 --> 00:32:07 exercise program or the
00:32:08 --> 00:32:09 overall plan of care and
00:32:09 --> 00:32:09 that kind of thing.
00:32:09 --> 00:32:11 So it's not really wasted time.
00:32:11 --> 00:32:13 And who knows, maybe it,
00:32:13 --> 00:32:14 maybe it does help them.
00:32:14 --> 00:32:16 So, you know, I try not to,
00:32:18 --> 00:32:19 poo-poo too much on
00:32:19 --> 00:32:21 patients' positive expectations.
00:32:21 --> 00:32:23 If something in the past helped them,
00:32:23 --> 00:32:24 by all means,
00:32:24 --> 00:32:25 unless it was something
00:32:25 --> 00:32:29 harmful to their health,
00:32:29 --> 00:32:31 drinking too much or using
00:32:31 --> 00:32:33 drugs or things like that, opioids,
00:32:33 --> 00:32:33 that kind of thing,
00:32:34 --> 00:32:35 that's a different discussion overall.
00:32:36 --> 00:32:36 But if it's something that
00:32:36 --> 00:32:39 has no potential harm overall,
00:32:39 --> 00:32:41 then I fully embrace that.
00:32:41 --> 00:32:41 Yeah.
00:32:41 --> 00:32:43 And I think what's also hard
00:32:43 --> 00:32:45 for us to swallow sometimes,
00:32:45 --> 00:32:46 I've had experiences where
00:32:47 --> 00:32:49 patients absolutely 100%
00:32:49 --> 00:32:50 have the expectation that,
00:32:50 --> 00:32:51 that they should have or
00:32:51 --> 00:32:52 move forward with the
00:32:52 --> 00:32:54 surgery that I don't
00:32:54 --> 00:32:55 believe they necessarily
00:32:55 --> 00:32:56 have objective findings to
00:32:56 --> 00:32:58 support the need for that.
00:32:58 --> 00:32:59 But I'm telling you,
00:32:59 --> 00:33:01 it's hard to talk a patient
00:33:01 --> 00:33:02 out of a surgery that
00:33:02 --> 00:33:04 they're convinced that they need to have.
00:33:04 --> 00:33:06 So I believe that's another
00:33:06 --> 00:33:08 avenue where I just, I tread lightly.
00:33:08 --> 00:33:10 I present information and research, but,
00:33:11 --> 00:33:11 um,
00:33:11 --> 00:33:12 you know,
00:33:12 --> 00:33:13 surrounding what some of the
00:33:13 --> 00:33:14 outcomes are with some of
00:33:14 --> 00:33:16 these orthopedic surgeries.
00:33:16 --> 00:33:17 How do you handle that?
00:33:18 --> 00:33:18 Well,
00:33:18 --> 00:33:19 a lot of those situations are driven
00:33:19 --> 00:33:21 by the surgeon,
00:33:21 --> 00:33:23 where it's not just the
00:33:23 --> 00:33:24 patient who absolutely believes it.
00:33:24 --> 00:33:25 The surgeon has told them
00:33:25 --> 00:33:27 they absolutely need this
00:33:27 --> 00:33:29 surgery to get back to function.
00:33:29 --> 00:33:30 And that's where we can present.
00:33:31 --> 00:33:33 Let's take lumbar stenosis, for example,
00:33:33 --> 00:33:35 the main stenosis study
00:33:35 --> 00:33:37 that tracked patients out
00:33:37 --> 00:33:38 10 years who had surgery,
00:33:39 --> 00:33:41 lumbar fusion versus not.
00:33:41 --> 00:33:42 And they looked exactly the
00:33:42 --> 00:33:43 same out to 10 years.
00:33:43 --> 00:33:44 You can present some of that.
00:33:45 --> 00:33:46 information to patients.
00:33:46 --> 00:33:46 Now,
00:33:46 --> 00:33:48 if there's a clear indication for surgery,
00:33:48 --> 00:33:48 you know,
00:33:48 --> 00:33:49 they've got progressive
00:33:49 --> 00:33:52 neurologic deficits or a
00:33:53 --> 00:33:54 spondylolisthesis that's
00:33:54 --> 00:33:55 unstable or something like that,
00:33:55 --> 00:33:57 that's a different story overall.
00:33:57 --> 00:34:01 But that is where I will try to, you know,
00:34:01 --> 00:34:02 counteract what they may
00:34:02 --> 00:34:04 have heard from another provider.
00:34:04 --> 00:34:04 Well,
00:34:04 --> 00:34:05 that provider told you
00:34:05 --> 00:34:06 absolutely need this
00:34:06 --> 00:34:08 surgery to get back to what
00:34:08 --> 00:34:09 you need to do.
00:34:09 --> 00:34:10 I'm telling you from personal experience,
00:34:10 --> 00:34:11 I've seen patients just
00:34:11 --> 00:34:12 like you who have gotten
00:34:12 --> 00:34:13 back without doing that surgery.
00:34:14 --> 00:34:16 So I tell them, give me six weeks,
00:34:16 --> 00:34:17 give me six weeks.
00:34:17 --> 00:34:18 And if you're not where you
00:34:18 --> 00:34:19 want to be in six weeks,
00:34:19 --> 00:34:21 after I've done all the
00:34:21 --> 00:34:22 patient education and maybe
00:34:22 --> 00:34:24 some manipulation of their expectations,
00:34:25 --> 00:34:26 if you're not where you
00:34:26 --> 00:34:27 want to be in six weeks, by all means,
00:34:27 --> 00:34:29 you can, you can go get that surgery.
00:34:30 --> 00:34:30 Yeah.
00:34:30 --> 00:34:31 Yeah.
00:34:31 --> 00:34:31 So,
00:34:32 --> 00:34:33 From the clinical perspective,
00:34:34 --> 00:34:35 because I know you treat
00:34:35 --> 00:34:36 weekly up at Wardenburg at
00:34:36 --> 00:34:37 University of Colorado and
00:34:37 --> 00:34:38 their student health center,
00:34:39 --> 00:34:40 do you capture any patient
00:34:40 --> 00:34:44 expectation material or
00:34:44 --> 00:34:46 through intake paperwork or
00:34:46 --> 00:34:47 anything like that?
00:34:47 --> 00:34:49 Or do you pretty much try to
00:34:49 --> 00:34:49 garner what their
00:34:49 --> 00:34:50 expectations are in that
00:34:50 --> 00:34:51 initial encounter?
00:34:53 --> 00:34:54 Yeah, that's really challenging.
00:34:54 --> 00:34:57 I mean, patients get form fatigue, right?
00:34:57 --> 00:34:58 They have to fill up so much
00:34:58 --> 00:35:00 paperwork at their initial
00:35:00 --> 00:35:01 appointment that we don't
00:35:01 --> 00:35:03 routinely assess for expectations.
00:35:03 --> 00:35:05 But that's part of my
00:35:05 --> 00:35:06 subjective interview that
00:35:07 --> 00:35:09 I'll be asking them about it.
00:35:09 --> 00:35:09 You know,
00:35:09 --> 00:35:10 what kind of treatment have you had?
00:35:10 --> 00:35:11 What do you think is going
00:35:11 --> 00:35:13 on with your back pain?
00:35:13 --> 00:35:14 What do you think will help
00:35:14 --> 00:35:15 with your back pain?
00:35:15 --> 00:35:16 Those type of things.
00:35:16 --> 00:35:16 Yeah.
00:35:17 --> 00:35:18 Do it more informally.
00:35:18 --> 00:35:18 You know,
00:35:18 --> 00:35:20 it would be ideal if we could
00:35:20 --> 00:35:21 have a standardized.
00:35:21 --> 00:35:22 The other thing about the
00:35:22 --> 00:35:23 expectation literature is
00:35:23 --> 00:35:24 there's no one form.
00:35:24 --> 00:35:26 I mean, I did a,
00:35:27 --> 00:35:27 I looked at a systematic
00:35:27 --> 00:35:29 review where there were 19
00:35:29 --> 00:35:31 different patient expectation forms.
00:35:31 --> 00:35:32 I mean, yeah.
00:35:32 --> 00:35:33 Which one do you use?
00:35:34 --> 00:35:36 You know, so, so again,
00:35:36 --> 00:35:38 I tend to do it more informally,
00:35:38 --> 00:35:39 but I do think you can
00:35:39 --> 00:35:40 glean a lot of information
00:35:40 --> 00:35:41 just from asking the patient.
00:35:42 --> 00:35:42 Yeah.
00:35:43 --> 00:35:43 Okay.
00:35:43 --> 00:35:43 Okay.
00:35:44 --> 00:35:44 Um,
00:35:44 --> 00:35:46 I've kind of two more questions and
00:35:46 --> 00:35:47 then I'm just kind of
00:35:47 --> 00:35:49 eyeing those guitars behind you.
00:35:49 --> 00:35:49 And I don't know,
00:35:49 --> 00:35:50 I might try to twist your
00:35:50 --> 00:35:51 arm to play a little.
00:35:52 --> 00:35:54 All right.
00:35:54 --> 00:35:55 That'll be for another one.
00:35:55 --> 00:35:58 So in terms of, of, um, where's,
00:35:59 --> 00:36:00 what's the future of
00:36:00 --> 00:36:01 expectation research?
00:36:01 --> 00:36:01 Like,
00:36:02 --> 00:36:04 are you kind of privy to what that
00:36:04 --> 00:36:06 next layer is now that we
00:36:06 --> 00:36:07 know that expectations can
00:36:07 --> 00:36:09 influence outcomes, especially with
00:36:10 --> 00:36:12 You know, people with musculoskeletal pain,
00:36:12 --> 00:36:14 is there anything on the horizon for us?
00:36:15 --> 00:36:16 that you're aware of?
00:36:16 --> 00:36:16 Well,
00:36:17 --> 00:36:19 I think the interesting thing will be
00:36:20 --> 00:36:21 pragmatic clinical trials
00:36:21 --> 00:36:23 where you kind of let the
00:36:24 --> 00:36:26 clinician explore
00:36:26 --> 00:36:28 expectations and then maybe
00:36:29 --> 00:36:31 make some suggestions to
00:36:31 --> 00:36:32 the patient and that kind
00:36:32 --> 00:36:33 of thing versus a more
00:36:33 --> 00:36:34 prescriptive kind of
00:36:34 --> 00:36:35 approach where you just
00:36:35 --> 00:36:36 deliver the treatment.
00:36:36 --> 00:36:38 I mean, that's been done to some extent,
00:36:38 --> 00:36:41 but really embracing that placebo effect
00:36:42 --> 00:36:44 And then, you know, potentially exploring,
00:36:45 --> 00:36:45 you know,
00:36:46 --> 00:36:48 the effect of placebo in
00:36:49 --> 00:36:50 physical therapy itself, because,
00:36:50 --> 00:36:50 you know,
00:36:50 --> 00:36:53 we hate to think that some or
00:36:53 --> 00:36:55 much of what we do is
00:36:55 --> 00:36:57 actually placebo effect, but it is.
00:36:57 --> 00:37:00 I mean, going into that placebo effect,
00:37:00 --> 00:37:01 again, that's the, you know,
00:37:02 --> 00:37:03 the patient changes their
00:37:03 --> 00:37:05 thinking or their
00:37:05 --> 00:37:06 psychology or their
00:37:06 --> 00:37:07 physiology based on their
00:37:08 --> 00:37:09 expectations and their
00:37:09 --> 00:37:10 thoughts of what's going on,
00:37:10 --> 00:37:12 if we can change that overall.
00:37:12 --> 00:37:14 And Joel Bialoski has done a
00:37:14 --> 00:37:17 lot of really good work on that front.
00:37:17 --> 00:37:18 But I think just embracing
00:37:18 --> 00:37:19 the whole package,
00:37:19 --> 00:37:20 because we have all these
00:37:20 --> 00:37:21 studies coming out,
00:37:21 --> 00:37:24 let's say on back pain that shows that
00:37:25 --> 00:37:27 there's no one clear exercise, you know,
00:37:27 --> 00:37:30 specific versus global or
00:37:30 --> 00:37:31 local versus global and
00:37:31 --> 00:37:32 those kind of things.
00:37:32 --> 00:37:34 And the key thing that comes
00:37:34 --> 00:37:34 out of those research,
00:37:34 --> 00:37:36 and same thing in manual therapy too,
00:37:36 --> 00:37:37 it doesn't matter the
00:37:37 --> 00:37:38 exercise or the technique,
00:37:38 --> 00:37:40 it's getting the patient doing,
00:37:40 --> 00:37:41 which goes back to that
00:37:41 --> 00:37:43 whole ritual thing that
00:37:43 --> 00:37:44 they're actually doing
00:37:44 --> 00:37:46 something that may improve their health.
00:37:46 --> 00:37:48 Maybe that's the important thing.
00:37:48 --> 00:37:49 It doesn't matter
00:37:50 --> 00:37:53 how the movement system
00:37:54 --> 00:37:54 people are gonna hate this,
00:37:55 --> 00:37:56 but it doesn't matter how
00:37:56 --> 00:37:57 specific our movement
00:37:57 --> 00:38:00 analysis is and our exercise prescription,
00:38:00 --> 00:38:01 which is a whole nother
00:38:01 --> 00:38:03 topic that PTs suck at,
00:38:03 --> 00:38:07 but maybe it's just getting
00:38:07 --> 00:38:07 the patient moving.
00:38:08 --> 00:38:09 Exercise will help you.
00:38:09 --> 00:38:10 What do you like to do?
00:38:11 --> 00:38:12 What can you do at home?
00:38:12 --> 00:38:13 So many times we prescribe
00:38:13 --> 00:38:14 exercises that the patient
00:38:14 --> 00:38:15 either can't do or is not
00:38:16 --> 00:38:18 interested in doing at home.
00:38:18 --> 00:38:20 So just getting, embracing, you know,
00:38:20 --> 00:38:22 what they will actually do.
00:38:22 --> 00:38:23 And that's where
00:38:24 --> 00:38:24 motivational interviewing
00:38:25 --> 00:38:25 can really come in.
00:38:26 --> 00:38:27 how likely are you to do
00:38:27 --> 00:38:29 this exercise program that
00:38:29 --> 00:38:30 we just talked about today
00:38:30 --> 00:38:32 and kind of moving in that direction.
00:38:33 --> 00:38:34 So I'd like to see physical
00:38:34 --> 00:38:35 therapy research start to
00:38:35 --> 00:38:37 embrace all of these things
00:38:37 --> 00:38:39 and to include therapeutic
00:38:39 --> 00:38:40 alliance and the patient expectations,
00:38:41 --> 00:38:41 as well as current best
00:38:41 --> 00:38:44 evidence on exercise and
00:38:44 --> 00:38:45 manual therapy and those
00:38:45 --> 00:38:47 kinds of things and kind of
00:38:47 --> 00:38:48 look at the whole package together.
00:38:48 --> 00:38:53 And then the other thing that John Childs
00:38:54 --> 00:38:55 told me we need to stop
00:38:55 --> 00:38:56 comparing one PT
00:38:56 --> 00:38:58 intervention to another PT intervention.
00:38:58 --> 00:39:00 We need to start comparing
00:39:00 --> 00:39:01 what we do as a profession
00:39:01 --> 00:39:03 from the initial
00:39:04 --> 00:39:05 second that we interact with
00:39:05 --> 00:39:08 that patient until we end
00:39:08 --> 00:39:09 that episode of care,
00:39:10 --> 00:39:11 compare that to what
00:39:11 --> 00:39:13 orthopedic surgeons do or
00:39:13 --> 00:39:14 that kind of thing and give
00:39:14 --> 00:39:15 them the whole package
00:39:15 --> 00:39:16 rather than just breaking
00:39:16 --> 00:39:17 it down and saying, oh wait,
00:39:17 --> 00:39:19 what does this manual technique do?
00:39:19 --> 00:39:20 Or what does this stretch do?
00:39:20 --> 00:39:22 Or what does this exercise do?
00:39:23 --> 00:39:24 Use the whole package and
00:39:24 --> 00:39:25 compare it to other
00:39:25 --> 00:39:26 standards of care for that
00:39:26 --> 00:39:28 condition to prove that our
00:39:28 --> 00:39:29 profession has a better
00:39:29 --> 00:39:32 answer in most situations to
00:39:32 --> 00:39:34 you know, the medical model, if you will.
00:39:35 --> 00:39:36 Yeah, I couldn't agree with you more.
00:39:36 --> 00:39:38 And some of the, you know,
00:39:38 --> 00:39:41 kind of details of what we're missing.
00:39:41 --> 00:39:43 And I know, I mean,
00:39:43 --> 00:39:43 you and I have been working
00:39:44 --> 00:39:45 with a bigger group on a
00:39:46 --> 00:39:47 neck pain clinical practice
00:39:47 --> 00:39:48 guideline revision.
00:39:48 --> 00:39:49 And one of the things that
00:39:49 --> 00:39:50 we've struggled with as a
00:39:50 --> 00:39:51 group is we can't,
00:39:51 --> 00:39:53 no one's reporting dosing.
00:39:53 --> 00:39:54 They're doing menotherapy,
00:39:54 --> 00:39:55 but we don't know what it
00:39:55 --> 00:39:56 is because it's not well-defined.
00:39:57 --> 00:39:58 But I love that idea of
00:39:58 --> 00:40:02 taking more of like a meta view, I guess,
00:40:02 --> 00:40:03 of what we're doing from
00:40:03 --> 00:40:06 beginning to end in, you know,
00:40:06 --> 00:40:07 an episode of care instead
00:40:07 --> 00:40:08 of trying to dial into
00:40:08 --> 00:40:10 these minutial details,
00:40:10 --> 00:40:11 because we don't have
00:40:11 --> 00:40:12 answers for dosing for
00:40:12 --> 00:40:13 exercise or manotherapy.
00:40:13 --> 00:40:16 We're actually doing a, you know,
00:40:16 --> 00:40:17 we're lost.
00:40:17 --> 00:40:18 I think we don't, you know,
00:40:18 --> 00:40:19 we think that manotherapy
00:40:19 --> 00:40:20 holds all this power,
00:40:20 --> 00:40:22 but we know that the
00:40:22 --> 00:40:23 multimodal approach is best,
00:40:23 --> 00:40:24 but we still don't know how
00:40:24 --> 00:40:26 much is the right amount.
00:40:26 --> 00:40:27 So I love that concept of
00:40:27 --> 00:40:29 maybe thinking about, you know,
00:40:29 --> 00:40:30 looking at the forest and
00:40:30 --> 00:40:31 not so much being in the
00:40:31 --> 00:40:33 trees and trying to figure
00:40:33 --> 00:40:35 out how we measure up to
00:40:35 --> 00:40:37 what's happening in other
00:40:37 --> 00:40:38 avenues of health care.
00:40:39 --> 00:40:39 Yeah.
00:40:39 --> 00:40:40 And that's what if you
00:40:40 --> 00:40:41 haven't read any of Julie
00:40:41 --> 00:40:43 Fritz's most recent work,
00:40:43 --> 00:40:44 that she's kind of taken
00:40:44 --> 00:40:45 that 20 for you.
00:40:45 --> 00:40:46 You know,
00:40:46 --> 00:40:49 it doesn't matter what you do in a,
00:40:49 --> 00:40:50 you know,
00:40:50 --> 00:40:53 from treatment to treatment, what you do,
00:40:53 --> 00:40:55 it's kind of stepping back.
00:40:55 --> 00:40:56 Is it more of an active approach?
00:40:56 --> 00:40:58 Are you using current best evidence?
00:40:59 --> 00:41:00 Are you educating the
00:41:00 --> 00:41:01 patient and that kind of
00:41:01 --> 00:41:03 thing and looking at the whole package?
00:41:03 --> 00:41:04 Because what we do as
00:41:04 --> 00:41:06 physical therapists is not
00:41:06 --> 00:41:08 manual therapy or exercise
00:41:08 --> 00:41:09 or this kind of thing.
00:41:09 --> 00:41:10 It's a whole package,
00:41:10 --> 00:41:12 which those soft skills are
00:41:12 --> 00:41:13 such a huge part of.
00:41:14 --> 00:41:14 Yeah.
00:41:14 --> 00:41:15 And those are the things
00:41:15 --> 00:41:17 that I think as educators
00:41:17 --> 00:41:18 are the most challenging for us
00:41:19 --> 00:41:20 to figure out it's kind of
00:41:20 --> 00:41:22 that affective domain of learning.
00:41:22 --> 00:41:24 How do we keep scaffolding
00:41:24 --> 00:41:26 that in to the curriculum?
00:41:26 --> 00:41:27 So our students really
00:41:27 --> 00:41:28 appreciate that as a
00:41:28 --> 00:41:31 skillset and not just their
00:41:31 --> 00:41:33 perceived need to develop
00:41:33 --> 00:41:33 psychomotor skills.
00:41:34 --> 00:41:35 Cause I think some of the
00:41:35 --> 00:41:36 other ones are equally,
00:41:36 --> 00:41:37 if not more important.
00:41:37 --> 00:41:38 And I think patient
00:41:38 --> 00:41:39 expectation is a part of that.
00:41:40 --> 00:41:41 Okay, so top,
00:41:42 --> 00:41:43 Top two or three things that
00:41:43 --> 00:41:45 you as we kind of wrap up
00:41:45 --> 00:41:46 our conversation that you
00:41:46 --> 00:41:49 want our listeners to think about,
00:41:49 --> 00:41:50 whether they're educators
00:41:50 --> 00:41:52 or clinicians or students
00:41:53 --> 00:41:55 or residents or fellows in training.
00:41:55 --> 00:41:56 Give me like a top two to
00:41:56 --> 00:41:58 three things that you want
00:41:58 --> 00:41:59 people to walk away remembering.
00:42:02 --> 00:42:02 Well,
00:42:02 --> 00:42:05 I think just acknowledging that the
00:42:05 --> 00:42:06 person sitting in front of
00:42:06 --> 00:42:07 you is a human being that's
00:42:08 --> 00:42:09 bringing a lot of things to
00:42:09 --> 00:42:11 the table that you know nothing about.
00:42:11 --> 00:42:12 So exploring that a little
00:42:12 --> 00:42:15 bit and finding out what they believe,
00:42:16 --> 00:42:17 what they think, what they've heard,
00:42:18 --> 00:42:18 those kind of things.
00:42:19 --> 00:42:20 And then trying to tailor
00:42:20 --> 00:42:22 your treatment approach to
00:42:22 --> 00:42:24 that individual human being
00:42:24 --> 00:42:25 who's sitting in front of you.
00:42:26 --> 00:42:29 I like to say to patients,
00:42:29 --> 00:42:30 the good news is you're in
00:42:30 --> 00:42:30 the right place.
00:42:31 --> 00:42:34 I see this a lot.
00:42:34 --> 00:42:34 There's current best
00:42:34 --> 00:42:36 evidence that shows that we
00:42:36 --> 00:42:37 can make some improvements
00:42:37 --> 00:42:39 in this area overall.
00:42:40 --> 00:42:42 just really involving them in the,
00:42:43 --> 00:42:45 the overall shared decision-making,
00:42:45 --> 00:42:46 that type of thing,
00:42:46 --> 00:42:48 involving your patient in their,
00:42:48 --> 00:42:50 their plan of care overall.
00:42:50 --> 00:42:51 And then, you know,
00:42:51 --> 00:42:53 moving forward with them as a team,
00:42:53 --> 00:42:54 rather than you being the
00:42:54 --> 00:42:55 dictator and saying, you know,
00:42:55 --> 00:42:56 this is what we're going to do.
00:42:56 --> 00:42:57 And today we're going to do
00:42:57 --> 00:42:59 this and that type of thing.
00:43:00 --> 00:43:01 And then again, that,
00:43:01 --> 00:43:02 that therapeutic alliance,
00:43:02 --> 00:43:03 just getting to know who
00:43:03 --> 00:43:06 your patients are before you, you know,
00:43:07 --> 00:43:09 enter that relationship with
00:43:09 --> 00:43:11 them is so powerful.
00:43:11 --> 00:43:11 I mean,
00:43:11 --> 00:43:13 talking to them about their kids or
00:43:13 --> 00:43:14 their dog or things like that.
00:43:14 --> 00:43:14 I mean,
00:43:15 --> 00:43:16 that has such therapeutic value
00:43:16 --> 00:43:18 that we can't really put a finger on,
00:43:18 --> 00:43:19 but just having that,
00:43:20 --> 00:43:22 that interaction with the
00:43:22 --> 00:43:23 human being that's in front of you.
00:43:24 --> 00:43:24 Yeah.
00:43:25 --> 00:43:25 Okay.
00:43:26 --> 00:43:28 Um, what book are you currently reading?
00:43:28 --> 00:43:32 I didn't put that on the list,
00:43:32 --> 00:43:33 so sorry to spring that one on you.
00:43:34 --> 00:43:34 Yeah.
00:43:34 --> 00:43:34 Yeah.
00:43:35 --> 00:43:35 Um,
00:43:36 --> 00:43:37 I am reading this book
00:43:38 --> 00:43:39 called The Holographic
00:43:39 --> 00:43:40 Universe right now that
00:43:41 --> 00:43:42 kind of explores
00:43:42 --> 00:43:44 spirituality and quantum
00:43:44 --> 00:43:45 physics at the same time.
00:43:47 --> 00:43:49 We always hear we're all connected, right?
00:43:49 --> 00:43:50 Everything's connected.
00:43:50 --> 00:43:51 Well, on a physical level,
00:43:51 --> 00:43:54 at the quantum physics level, it's true.
00:43:54 --> 00:43:57 And so it's just interesting
00:43:57 --> 00:43:59 to kind of explore that.
00:44:00 --> 00:44:01 And how did you get there?
00:44:01 --> 00:44:02 How did you find that book?
00:44:02 --> 00:44:03 Was that a recommendation or?
00:44:04 --> 00:44:04 Yeah,
00:44:05 --> 00:44:06 I think it was another book that I
00:44:06 --> 00:44:08 read that was kind of talking about,
00:44:08 --> 00:44:09 you know,
00:44:09 --> 00:44:11 when you get down to that
00:44:12 --> 00:44:13 quantum level overall,
00:44:13 --> 00:44:15 how everything is connected and, you know,
00:44:15 --> 00:44:17 the whole wave particle duality thing,
00:44:18 --> 00:44:20 you know, is it a wave?
00:44:20 --> 00:44:20 Is it a particle?
00:44:21 --> 00:44:22 As soon as you start to observe it,
00:44:22 --> 00:44:23 things change,
00:44:23 --> 00:44:24 which is what happens in
00:44:24 --> 00:44:24 our patients too.
00:44:25 --> 00:44:26 When you pay attention to them, you know,
00:44:26 --> 00:44:28 things change overall.
00:44:28 --> 00:44:28 Yeah.
00:44:29 --> 00:44:30 Well, Paul,
00:44:30 --> 00:44:31 I just want to thank you on
00:44:31 --> 00:44:32 behalf of the AMT
00:44:32 --> 00:44:34 organization and myself for
00:44:34 --> 00:44:35 taking the time to talk to
00:44:35 --> 00:44:36 us a little bit more about
00:44:36 --> 00:44:37 patient expectations.
00:44:37 --> 00:44:41 And I think why we value you
00:44:41 --> 00:44:43 as a member of AMT and as
00:44:43 --> 00:44:45 an educator is you're in all of it.
00:44:45 --> 00:44:48 You're in the educational piece,
00:44:48 --> 00:44:50 you are in clinical practice,
00:44:51 --> 00:44:52 and you're doing research.
00:44:52 --> 00:44:53 And so I think
00:44:54 --> 00:44:55 listening to you, it just, you,
00:44:56 --> 00:44:57 you so eloquently kind of
00:44:57 --> 00:44:59 weave all of this together
00:44:59 --> 00:45:00 because you're doing all
00:45:00 --> 00:45:01 those things concurrently.
00:45:01 --> 00:45:04 And I highly value that, that about you.
00:45:04 --> 00:45:06 So I appreciate, you know,
00:45:06 --> 00:45:07 hearing your insights and
00:45:07 --> 00:45:08 having you share a little
00:45:08 --> 00:45:09 bit more with us about this topic.
00:45:10 --> 00:45:10 All right.
00:45:10 --> 00:45:11 Well, thanks.
00:45:11 --> 00:45:12 It's been a pleasure, Amy.
00:45:12 --> 00:45:12 Okay.
00:45:12 --> 00:45:13 Thank you.