THE BETWEEN THE EARS BIT IN YOUR REPLY, WOULD SHOW CLEARLY A LACK OF
UNDERSTANDING OF THE WHOLE ISSUE.....I AM IN NO WAY REFERRING TO THE
DUALISTIC APPROACH (DESCARTES) ADVOCATED HISTORICALLY BY MANY IN THE MEDICAL
PROFESSION (IE IF YOU CANT SEE IT THEN THE PATIENTS MAD!)....i AM TRYING TO
INTEGRATE INTO MY PRACTISE A GOOD UNDERSTANDING OF PAIN MECHANISMS AND THE
INFLUENCE OF OTHER FACTORS ON THEM.....THAT THESE IDEAS ARE NOT FULLY
UNDERSTOOD, OR USED OUT OF CONTEXT, IS NOT REALLY MY CONCERN....
FOR ANY MORE ON THIS READ SOME OF L. GIFFORDS WORK ON RSD (CRPS) ETC.....IN
THE TOPICAL ISSUES OF PAIN STUFF...DIFFERENCES BETWEEN PROXIMAL AND
EVOLUTIONARY THINKING...INTERESTING STUFF!

cHEERS

sAM bOWDEN






>From: Frank Conijn <[log in to unmask]>
>Reply-To: - for physiotherapists in education and practice
><[log in to unmask]>
>To: [log in to unmask]
>Subject: Re: LBP & neuro signs dilemma [Sam]
>Date: Sat, 1 Feb 2003 05:40:07 +0100
>
>Sam,
>
>You: "My concerns lie firstly with such an obviously mechanical approach."
>Me: If you mean that versus a biochemical approach (in which the mechanical
>aspect is if no or little relevance), I can assure you that McKenzie pays
>due attention to that aspect in his books! In fact, on more than one
>occasion in the McKenzie clinical discussion group the group came to the
>conclusion that a certain patient probably had a primarily biochemically
>determined complaint versus a mechanically determined one.
>
>If you mean that versus a behavioural appoach, you're in deep trouble. Not
>so much with me, but with the state of affairs concerning science, and
>therefore concerning EBP/EBM. I've extensively studied the general
>behavioural approach, but cannot distill a practical method that can
>generally be applied to patients with physical complaints. McCracken & Turk
>seem to share my conclusion in a recent review (1). The major problem is
>that 95% of the studies finding a correlation between psychosocial
>variables and physical pain/disability (so what's new?????) do <not>
>determine which comes first.
>
>If you ever had one patient with a RSD, who, as in my case, was a joyful,
>sports-minded and socially happy women before she underwent the arthroscopy
>a couple of years ago, and is now in a wheelchair due to the subsequent
>rapidly developing RSD, with recent suicidal(!) thoughts because she could
>do practically nothing anymore of what she loved to do, you'll understand
>my drift.
>
>We have to be very careful with labelling patients with (chronic)
>complaints as "between the ears".
>
>I <fully> acknowledge the influence of psychosocial variables in (reported)
>physical complaints. The evidence when it comes to Workers' Compensation is
><overwhelming> (2). But that is just one variable. What do we know about
>the others? Why is it that more elderly patients seek help for not being
>able to walk longer distances because of increasingly radiating LBP, and
>young and middle-aged patients usually tell that the LBP is the worst when
>they stand up, but the pain decreases when they walk a while? Where is the
>behaviour model that explains that, based on (if it were only
>circumstantial) evidence? McKenzie offers an an (at least acceptable)
>explanation for it, based on extensive (be it circumstantial) evidence.
>
>You: "I do think it is dangerous for a junior physio to concentrate so
>fully on one aspect of our practise, so early in his/her career".
>Me: I'd say: we're <physical> therapists. We need to know everything there
>is to know about the biomedical approach. We also need to know those
>aspects of the psychosocial side of the story that have been established as
>being clearly correlated with physical complaints. I.e.: the psychosocial
>red or reddish flags. But that's it, for now. A behavioural therapist
>should know everything there is to know about the psychosocial side of the
>story. A behavioural therapist should also know about those aspects of
>biomedical aspects that have been established as being clearly correlated
>with behavioural complaints. The "referee" as to which patient should go
>where, at first, is the general practitioner. If s/he does his/her work
>well, <we> can focus on the primarily biomedical aspects.
>
>In short: I think Ben, assuming he whole-heartedly chose the profession of
>physical therapist, should learn as much as possible about the biomedical
>approach as possible. And <especially>, should be given a workable model
>that has (<uniquely>) been proven to be reliable in terms of diagnosis,
>includes almost all subtherapies (with the last one probably to come), and
>can count on a large amount of circumstantial evidence to prove its
>validity. If we were to send him to therapist-teachers or a school that
>know(s) only one or two sides of the biomedical story, he will be deprived
>of teachers that can teach him a multi-faceted biomedical model with a
>logical model as to when to do what. Guru or no guru (in fact, the literal
>translation of 'guru' is: teacher).
>
>Folks who suggest he should invent the wheel himself should by a bike.
>They're available.
>
>
>References:
>1. McCracken LM, Turk DC, Behavioral and Cognitive-Behavioral Treatment for
>Chronic Pain: Outcome, Predictors of Outcome, and Treatment Process. Spine
>2002; 27(22):2564-2573.
>2. Conijn FJJ, The BPS Model. Physical Therapist's Literature Update 2001;
>1(5): Editorial (www.ptlitup.com | Archive & Search | Editorial March 2001
>[free]).
>
>
>
>----- Oorspronkelijk bericht -----
>Van: Sam Bowden
>Aan: [log in to unmask]
>Verzonden: zondag 26 januari 2003 9:34
>Onderwerp: Re: LBP & neuro signs dilemma
>
>
>Frank thankyou for your reply,
>
>I have no wish to criticise an approach unduly (and hope that i'm not) but
>simply see problems with some peoples understanding/application of the
>approach( That i have experienced the same concerns with accredited PT's
>concerns me even more!). There are by all accounts useful aspects in the
>assessment, and I would hope that I have tried to identify them and apply
>them within my own work.....
>
>My concerns lie firstly with such an obviously mechanical approach. In
>view of recent advances in understanding pain processes/chronic
>pain,/influence of other factors, any approach (whether guru led as in
>this case or not) that relies so heavily on mechanics would be of concern
>for that matter. I appreciate that the approach attempts to (soften)be
>more inclusive of other ideas...but somehow it always sounds to me like
>everything else gets tagged on the end when the purist aproach doesn't
>quite work?
>
>Issues regarding Physio preferences, might I think revolve more around
>considerable marketing brilliance (one of the first courses I knew about,
>where you had to take parts in an order, and if you left it too long you
>had to start again)! No problem with that, except it always feels that
>conversion to the way is really the only way? Remember the average
>practitioner qualifies, realises they weren't taught the whole truth and
>nothing but the truth, and then somebody offers them a nice recipe- and
>even better it has some evidence behind it....maybe this illustrates a
>lack of decent research fullstop, as opposed to anything more?
>
>I'm certainly not advocating applying hot packs, massage and some SWD OR
>ignoring a McKenzie approach,but I do think it is dangerous for a junior
>physio to concentrate so fully on one aspect of our practise , so early in
>his/her career.
>
>Sam Bowden


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