trochanteric burisitis

[alophysio]

Hi SigMik,

Thanks for your posts above. I agree with what you write.

However from a practical point of view, i am not sure that most physios would be able to challenge themselves into thinking they weren't making much difference and protect the patient from the doubt. It is the very fact that you challenge yourself and seek other approaches which allows to you be an excellent clinician.

Whoever said that the placebo effect is not a valid effect to utilise?

Am i a fraud if i am confidently able to outline the "normal" recovery process and guide them along it?

I think it would be unethical of me to get the patient to rely on me to get better - i am not advocating that...

...however, my patients trust me, they believe i am caring and confident in knowing what to do for them (including NOT treating them if they don't need it or referring onto someone else who is better suited).

Your words and explanation of how you approach a problem functionally and taking into account all the systems possibly involved is to be commended. I wish there were more physios out there who were more like you...

...unfortunately, the gap between knowledge and clinical practice and the ability to implement effectively what we believe is the main problem that i see.

I know lots of physios who are pretty useless when it comes to knowledge - it is all undergrad stuff with minimal post-grad courses taken or active revision or reflection done...but they are awesome physios because they inspire confidence and trust in their patients, as well as not making them worse. I learned this lesson early on and i have never forgotten - it is not about how good you are at assessment and diagnosis, it is how good you are at being confident, competent, and communicative with your patients.

As for muscle imbalances, it is merely a phrase you describe (probably inadequately) the idea that a particular area is overactive or underactive or excessive shortened or lengthened - which neatly summarises the things we assess (because we know the different things we are assessing) but perhaps gets used too loosely by people who mean it to be "something wrong" with your muscles.

As for DrDamien's comment - his description of your approach from a neurological perspective would be a little inaccurate would it not? It would seem to me that you have emphasised the neurological aspects in this discussion (and probably others because it is quite often lacking) butwouldn't your approach be a truly neuromusculoskeletal approach - what we all should be doing?

Anyway, it is good to see you on the forum and your particular point of view is very welcome here and no doubt sorely needed ")

CHeers

[SigMik]

Dear Alophysio,

I am truly grateful and, flattered, of your constructive feedback. These are words and genuine, reflective thoughts clinicians don't get to hear too often from fellow colleagues, especially not when working in a busy private out-patient practice like I do. So again, thank you for that.

However from a practical point of view, i am not sure that most physios would be able to challenge themselves into thinking they weren't making much difference and protect the patient from the doubt. It is the very fact that you challenge yourself and seek other approaches which allows to you be an excellent clinician.

I see your point, and from a sound pedagogical perspective, I do agree. But I've also challenged myself and sought other approaches, and thought I was an excellent clinician. But what did I challenge? What did I do with those other approaches more than expanding my technical repertoire? My comment about how I never believe that the patient is improving because of what I do, is just a mental and brutal reminder that is back of my head - to never assume anything and try to prove to myself and equally as important, to the patient that what we just did, made both clinical and functional sense. There is so many good advices to give and I find this harsh reminder to make me think twice about what advice I give. Also clinically with techniques, it has helped me to identify which technique has the better effect over the other at an earlier stage. Call it Murphy's Law... Or even better - Ziggy's Law of Manual Treatment...

Whoever said that the placebo effect is not a valid effect to utilise?

WHO said the placebo effects is not a valid effect to ulilise??? Certainly not me I hope!!! It is a matter of identifying how much effect do my particular intervention, have BEOYND the placebo effect! This also accounts for the other possible effects of improvement as I mentioned. Placebo is the therapists best friend, just as the dog is for the Man! I have some colleagues, who get a bit puffed up, when I talk about the placebo effect, and I do not understand why.................... It is to my greatest delight that the latest decade have started to shed light on the actual biochemical process of placebo, by means of fMRI and such = LOVELY!! To me such a picture is more beautiful than a snapshot from the Hubble telescope!! It is a beautiful endogenous, potent, reality modulating opioid drug, I'd change my NMS title for a placebo-therapist accreditation anytime! Getting a bit carried away here, I could probably write a religiously loaded article about the placebo effect, but I'll save that for another time.

My point being, from the context in my previous comment where I mentioned placebo, is that in this MIST of all potential natural, unnatural, magical wish-wash and other logical causes for a patient to improve within a treatment, it is important not to assume anything, but to use sound clinical reasoning as a means to navigate safely. I hope you see where I'm coming from.

Am i a fraud if i am confidently able to outline the "normal" recovery process and guide them along it?

Not at al. In fact, I think this is the area where I have improved most, to suggest a possible prognosis, based on age, general health, psychosocial factors, pathology, stage, stability, natural history of conditions, treatment-response, etc, etc, etc and so on. It is an important skill for physiotherapists to develop, as this will make us stronger as a profession, and will add to the identity our profession is struggling with. I hope I'll continue this "improvement" as it also helps me sleep better and let go of those I am not able to help.

The gap between knowledge and clinical practice and the ability to implement effectively what we believe is the main problem that i see.

Well, I'm still working on that gap. I used to have great knowledge, and I've always been confident as a practitioner. It was a difficult process for me to realize and admit that clinical reasoning is the bridge in between.

As for muscle imbalances, it is merely a phrase you describe (probably inadequately) the idea that a particular area is overactive or underactive or excessive shortened or lengthened - which neatly summarises the things we assess (because we know the different things we are assessing) but perhaps gets used too loosely by people who mean it to be "something wrong" with your muscles.

I think I see your point here, and am not even really sure if I know what I tried to say... But what I think I tried to say, is that I've seen people looking like the Hunchback of Notre Dame and repeatedly asked them "are you sure you've never had any problems with your shoulders?" in which they replied a simple "no". Repeatedly. I'm very well aware of Shirley A. Sahrmann's work about diagnosis and treatment of movement impairment syndromes. I think my main problem here, is that I'm not able to link observations of tonic/phasic postures, overactive/underactive and so on - to clinical evidence. I mean, I do observe these situations, but have problems in concluding on a causality. It's a lovely concept, it's all very logical, for me as a therapist and often to the patients, but I just find it so much easier to treat and re-assess. Treat and re-assess. Treat and re-assess. So what are we doing to a tight muscle? Stretch. Or MET/hold-relax. Is that tight muscle really a comparable sign, worth of treatment?

Then I came over what I consider as sound work by Joseph Threlkeld, Patrick de Deyne, Mitchell, Feland, Ballantyn, Fryer, I could go on. METs and hold/relax only seem to alter the perception of stiffness, therefore after a few reps, people are able to tolerate more stiffness/stretch. That's good. But no real muscle change really. And what about the biomechanical mechanisms (visco-elastic behaviour issues), neurological mechanisms (no reciprocal or autogenic inhibition present) and even what happens on cellular and molecular levels? If stretched, the muscle will respond (in addition to release of insulin-like growth factors) with myofibrillogenesis = addition of sarcomeres. Is this likely to happen within one treatment session? Will I be able to prove this change from observing a tight muscle, stretch one muscle to improve the muscle imbalance? What really happened when I stretched that muscle? But true as you say, all this "stuff", probably gets used too loosely by therapists who mean this to be "something wrong" with your muscles...

As for DrDamien's comment - his description of your approach from a neurological perspective would be a little inaccurate would it not? It would seem to me that you have emphasised the neurological aspects in this discussion (and probably others because it is quite often lacking) but wouldn't your approach be a truly neuromusculoskeletal approach - what we all should be doing?

I don't know. I'm not sure. We'll all have our areas of interest, and there are definitely many roads to Rome. I only take on board the findings from recent neuroscience, about pain perception (in reality, perception of anything) and cognitive aspects. The importance of mindfulness, being present, focused on movement - rather than pain. Both pain and movement is neuro, isn't it? That's what we all should be concerned about, or not? But it's is really a true pain in the #*$& sometimes, as Damien correctly points out, it's time consuming and I've become more to terms that it needs a different level of patient compliance. Or communication from my part. I'm seldom able to get people with "fix-my-car" attitude a lot better. But I've just started on this "stuff". I'm curious of where I'll be in say 5-10 years as a therapist.

Your words and explanation of how you approach a problem functionally and taking into account all the systems possibly involved is to be commended. I wish there were more physios out there who were more like you... Anyway, it is good to see you on the forum and your particular point of view is very welcome here and no doubt sorely needed ")

Thank you again. Your comments made my day.

Kind regards,
Sigurd Mikkelsen