WEBVTT

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Hi, I am Amy McDevitt,

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and I am going to be

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interviewing Paul Minkin

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today for our hands-on,

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hands-off podcast.

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So this is our newer AOMT podcast.

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So I'm really excited to

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have Paul as a guest.

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Paul is a professor at

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Hawaii Pacific University in Hawaii.

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And we actually had the

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pleasure of working

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together for almost 13

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years at the University of Colorado.

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And so Paul has been

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publishing in the area of

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manual therapy and

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orthopedics for many years

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and is quite well known in

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the AOMT community.

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But I'm going to turn it

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over to Paul to talk a

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little bit more about himself.

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And then I want you to just

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tell our listeners a little

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bit about yourself and what

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you like to do and what

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some of your interests are.

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So I'm going to hand it over to you, Paul.

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All right.

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Thanks, Amy.

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Well, thanks for inviting me.

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I'm excited to be here and, you know,

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privileged to be a part of AOMT overall,

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the organization that's

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done so much for my career overall.

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So, you know, talk about yourself.

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That's always a challenging

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question overall, you know,

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kind of on a spiritual

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journey as of late.

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So, you know,

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labeling myself as this or

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that or that kind of thing

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kind of seems shallow and fake.

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But, you know, just...

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I'm a human being who's

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trying to be the best husband, father,

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physical therapist,

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professor that I can be.

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You know, I've been on a long journey.

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I've just celebrated 30

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years of being a physical therapist.

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So I've maintained,

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I've stayed clinically

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active for those whole 30 years and,

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and been in academia for 20 years.

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And, uh,

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Enjoyed my time at the

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University of Colorado and

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retired from there with a pension,

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which was pretty exciting.

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And now I'm teaching at a

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new hybrid program in Hawaii,

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which is just amazing overall.

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Our students are so diverse

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and hungry for knowledge

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and that type of thing.

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So it's been an interesting

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transition from brick and

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mortar to more of a hybrid

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education model.

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But I'm loving every minute of it.

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And I'm a firm believer in

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the approach overall.

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Yeah, yeah.

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That's great.

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And so you've been at Hawaii

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Pacific for how long?

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Two years?

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Two years.

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Yeah.

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Just celebrated two years,

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if you can remember that.

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Wow.

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Well,

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what we decided to talk about today

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with you,

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and part of this was your choice,

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was patient expectations.

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I know personally,

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you and I have had many

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conversations about this,

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just because we both

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believe that it has such an

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incredible influence on what we're doing.

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And so

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I'm going to kind of back us

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up and I would just love to

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hear your thoughts on just

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explain to the listeners a

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little bit about what

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patient expectations are, I guess,

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from a definitional

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standpoint and how they are

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really a critical piece in

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potentially influencing outcomes.

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So I just want to hear a

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little bit about what your thoughts are.

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Yeah.

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So patient expectations are

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kind of the beliefs and

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anticipated benefits that

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patients have regarding the

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interaction that they have

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with their healthcare provider,

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the outcomes,

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the quality of care they might receive.

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So when patients have

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positive expectations,

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they're more likely to

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engage actively in their therapy.

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It can help reduce their pain overall.

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They're more likely to be

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adherent to their home program.

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And it

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there's pretty good evidence

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that it can improve their

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pain and their function in the long run.

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So really the patient's

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expectations are framed by

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a lot of different things overall,

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but they're such a powerful

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part of the treatment,

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especially in physical therapy,

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that if we don't pay attention to them,

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we're missing a huge part

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of the therapeutic alliance

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and the care package.

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And you were saying just a

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moment ago that there's

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multiple things that feed

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into patient expectation.

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So based on your many years

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in clinical practice,

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what do you think are some

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of those elements or

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influences that are going

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to influence what patients

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are actually expecting when

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they come to us for

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physical therapy or manual therapy care?

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Well,

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the important thing is to remember

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that every patient is a

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human being with this

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complex milieu of past

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experiences and education,

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what they believe about

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themselves and others,

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what they've heard from their family,

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their friends and Dr.

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Google and that type of thing.

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It's also strongly

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correlated with their worldview.

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Are they optimistic by nature?

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Are they pessimistic by nature?

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So the interesting thing is

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that these expectations

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that the patients come in with

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which again can come from

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many different avenues,

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those can be changed by a

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positive healthcare interaction,

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forming a good therapeutic

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alliance with your patient

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and that type of thing.

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So you never know what's in

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the soup of that individual,

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what led to those expectations.

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It could have been something

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they heard or something

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they read or something they experienced,

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but really exploring that I

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think is a key part of what

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we do as healthcare providers.

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And so with that being said,

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what are some of those key

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things that you think we

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need to do from like the

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moment we start interacting

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with that patient, that human?

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What are some of the first

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couple of things that

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you're going to do to try

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to glean how to meet them

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where they're at in terms

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of expectations?

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Well, the first thing, I mean,

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I love Peter O'Sullivan's, you know,

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tell me your story,

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kind of just listen to the

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patient and where they've been.

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and the journey they've been

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on since this condition came on.

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It may be something that

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just started two days ago,

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or it may be something

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they've been dealing with

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for decades overall.

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So just listening to that

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patient and being present for them,

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really tuning in and kind

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of letting them tell their story.

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The research is pretty clear

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that in most healthcare interactions,

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the patient is interrupted

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before they get to complete

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their opening statement.

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you know, hear what they have to say.

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And that helps you start to

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understand what their

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expectations might be.

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You know, if they come in and say, well,

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I saw this provider and

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they told me this and I saw

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this provider and I told

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they told me that nothing's been working.

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You can kind of really start to hear

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You know,

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the frustration and being able to

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empathize with that individual.

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That's, that's really, you know,

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where it starts overall.

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And then I'll ask them,

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what are your expectations

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from treatment?

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What are your specific goals?

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Patient centered?

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What, what do you want to be able to do?

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What are you not able to do now?

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And what do you want to be able to do?

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Um, and then asking them what,

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what they think is going on.

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Maybe they've heard five,

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five different stories from

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five different providers.

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And maybe they have a set

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idea of what they think is going on,

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or maybe they have no idea

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and they're looking to you

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for guidance overall.

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So really exploring those expectations.

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And again,

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it's based on their past experiences.

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And then, you know, things emerge that are,

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you know, in your opinion,

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potentially detrimental.

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to the improvement of the individual,

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that's where you can start

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to use some of the

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motivational interviewing things and say,

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is it okay if I share with

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you some information about

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back pain or neck pain or

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that belief or that type of thing?

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Yeah.

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I had a conversation with

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students similar to what

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you're saying just the other day.

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And we were talking about,

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one of the associated

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faculty used this word,

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some of our patients have

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become medicalized.

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They bounced around between

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so many providers and

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they've heard all these different

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kind of stories about why

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they are in pain or what

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they need to do next,

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or you're not going to get

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better unless you do this or this.

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And so we were talking in

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class about just those

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challenges of sometimes

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trying to undo a lot of

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what's been done for

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individuals that are kind

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of just moving through the system.

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And then you see harmful

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things on social media on top of it.

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So what are

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What are some of your

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thoughts or strategies?

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Like how do you undo the

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things that have negatively

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influenced patients and

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change their expectation

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for what they might get out

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of care with you?

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yeah as you and I know that

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that is one of the most

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challenging patients to

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treat is the one that comes

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in and says you know my

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chiropractor or my physical

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therapist told me my sacrum

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is out or my l5 is out and

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I need you to put it back

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in and they've got six or

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they're all six six yeah

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Yeah.

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And those patients are

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really challenging because

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they had a previous

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experience where maybe it was positive.

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Maybe they did see a

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physical therapist or a

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chiropractor who did a

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manipulation and they heard

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a pop and all of a sudden

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they felt better and they

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were back doing what they want to do.

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And they're bringing that

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expectation into the treatment.

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And those are the really

00:08:50.030 --> 00:08:52.711
challenging patients, I think, to treat,

00:08:52.772 --> 00:08:55.072
especially if they're fixated on

00:08:55.782 --> 00:08:56.042
you know,

00:08:56.062 --> 00:08:58.243
I'm broken or I'm out of

00:08:58.283 --> 00:09:00.104
alignment and I need you to

00:09:00.423 --> 00:09:02.043
fix me and make me better.

00:09:02.124 --> 00:09:03.085
So, you know,

00:09:03.105 --> 00:09:04.865
I really try and engage them

00:09:04.924 --> 00:09:06.245
with the current best evidence,

00:09:06.306 --> 00:09:07.725
try and hear where they're coming from,

00:09:07.745 --> 00:09:09.807
but also encourage an

00:09:09.927 --> 00:09:11.307
active approach that, you know,

00:09:12.248 --> 00:09:13.648
there's things that I can do,

00:09:13.727 --> 00:09:15.609
but the most important part

00:09:15.649 --> 00:09:16.649
of this relationship in

00:09:16.688 --> 00:09:18.149
your recovery is what you do.

00:09:18.836 --> 00:09:19.037
Yep.

00:09:19.418 --> 00:09:19.618
Yep.

00:09:20.278 --> 00:09:22.341
And you mentioned Peter O'Sullivan earlier,

00:09:22.360 --> 00:09:25.163
and I followed a lot of his work in it.

00:09:25.323 --> 00:09:27.206
And he really does a beautiful job,

00:09:27.225 --> 00:09:29.067
I think, of dialing into, you know,

00:09:29.488 --> 00:09:30.808
in some of the things that

00:09:30.828 --> 00:09:32.250
he's published on cognitive

00:09:32.270 --> 00:09:32.991
functional therapy,

00:09:33.032 --> 00:09:34.852
really having the patient

00:09:35.313 --> 00:09:37.255
learn and be active in the process.

00:09:38.397 --> 00:09:40.239
So I think that's also really important.

00:09:41.528 --> 00:09:43.451
You talked about using best evidence.

00:09:43.471 --> 00:09:44.852
So before we talk about best

00:09:44.932 --> 00:09:45.833
evidence of what

00:09:46.313 --> 00:09:47.535
interventions and what the

00:09:47.576 --> 00:09:48.537
plan of care should look

00:09:48.557 --> 00:09:49.418
like for the patient,

00:09:50.458 --> 00:09:52.081
what is some of the current

00:09:52.301 --> 00:09:53.982
best evidence surrounding

00:09:54.043 --> 00:09:55.244
patient expectations?

00:09:55.303 --> 00:09:56.625
What does that look like right now?

00:09:58.325 --> 00:09:58.504
Well,

00:09:58.544 --> 00:10:01.306
there's an overwhelming amount of

00:10:01.346 --> 00:10:02.645
evidence from both medicine

00:10:02.725 --> 00:10:05.187
and in physical therapy that, you know,

00:10:05.287 --> 00:10:07.548
if a patient has a positive expectation,

00:10:07.648 --> 00:10:08.988
whether that was influenced

00:10:09.048 --> 00:10:10.388
by the healthcare provider or not,

00:10:10.447 --> 00:10:11.849
that's going to impact their outcomes.

00:10:13.068 --> 00:10:15.450
So really, you know,

00:10:15.870 --> 00:10:16.970
some of Joel Bialoski's

00:10:17.009 --> 00:10:19.051
work where they used manipulation,

00:10:19.091 --> 00:10:19.910
let's say, and they said,

00:10:20.625 --> 00:10:20.846
you know,

00:10:20.885 --> 00:10:22.447
this is a technique that we think

00:10:22.488 --> 00:10:23.668
will improve your back pain,

00:10:23.769 --> 00:10:24.970
or we think this is a

00:10:25.009 --> 00:10:25.750
technique that we don't

00:10:25.811 --> 00:10:27.152
know if it will help your back pain,

00:10:27.172 --> 00:10:28.513
or this is a technique that

00:10:29.053 --> 00:10:31.196
we think may make your back pain worse,

00:10:31.436 --> 00:10:32.317
you know,

00:10:33.057 --> 00:10:35.559
that framing to the patient

00:10:35.720 --> 00:10:37.802
actually impacted the outcome.

00:10:37.881 --> 00:10:38.022
So

00:10:38.940 --> 00:10:40.400
The evidence is pretty clear

00:10:40.441 --> 00:10:41.682
that if a patient has a

00:10:41.741 --> 00:10:44.462
positive or a negative expectation,

00:10:45.083 --> 00:10:46.965
and that's not modified,

00:10:47.004 --> 00:10:48.586
let's say on a negative side,

00:10:48.625 --> 00:10:49.706
a negative expectation,

00:10:49.745 --> 00:10:50.746
if that's not modified,

00:10:51.206 --> 00:10:52.427
their outcomes are not

00:10:52.467 --> 00:10:54.688
going to be as good as if you potentially

00:10:55.821 --> 00:10:57.582
change those expectations.

00:10:57.643 --> 00:10:58.565
And I hate to use the word

00:10:58.764 --> 00:11:00.547
manipulate their expectations,

00:11:00.626 --> 00:11:02.708
but that's really what we want to do.

00:11:02.729 --> 00:11:04.431
We want to sell the evidence

00:11:04.650 --> 00:11:06.572
that this treatment will

00:11:06.613 --> 00:11:09.496
likely make you better and

00:11:09.716 --> 00:11:12.820
kind of reframe the

00:11:12.919 --> 00:11:14.101
treatment that you're delivering,

00:11:14.121 --> 00:11:14.962
making sure you're very

00:11:15.102 --> 00:11:16.865
clear about it and

00:11:17.679 --> 00:11:17.980
Uh, you know,

00:11:18.000 --> 00:11:19.400
that that's the challenging

00:11:19.500 --> 00:11:20.341
part a lot of times,

00:11:20.422 --> 00:11:22.062
but you have to kind of

00:11:22.503 --> 00:11:23.864
present to the patient, okay,

00:11:23.884 --> 00:11:25.625
this is what my exam showed me.

00:11:25.644 --> 00:11:27.125
And you need to stay away from saying,

00:11:27.706 --> 00:11:27.927
you know,

00:11:27.966 --> 00:11:29.006
you're out of alignment or you

00:11:29.027 --> 00:11:31.349
have bad posture, all those words that,

00:11:31.568 --> 00:11:34.990
that harm kind of thing and say, you know,

00:11:35.030 --> 00:11:36.511
this is what I found in my exam.

00:11:37.475 --> 00:11:38.336
This is what the current

00:11:38.375 --> 00:11:39.495
best evidence says about

00:11:39.576 --> 00:11:41.136
treating those findings.

00:11:41.977 --> 00:11:43.198
And we published a paper

00:11:43.239 --> 00:11:44.399
called the Healthcare Buffet,

00:11:44.438 --> 00:11:45.840
where we kind of present to your patient,

00:11:45.879 --> 00:11:46.081
well,

00:11:46.660 --> 00:11:47.841
evidence shows we could use some

00:11:47.861 --> 00:11:50.363
manual therapy, we could do some exercise,

00:11:50.423 --> 00:11:53.424
you could do some aerobic conditioning,

00:11:53.465 --> 00:11:54.326
those type of things.

00:11:54.385 --> 00:11:55.647
We could work on some pain

00:11:55.687 --> 00:11:56.826
science education,

00:11:57.327 --> 00:11:58.187
we could work on some

00:11:58.227 --> 00:11:59.528
relaxation techniques,

00:11:59.609 --> 00:12:00.610
and those would probably

00:12:00.669 --> 00:12:02.591
all benefit you or any of

00:12:02.630 --> 00:12:03.792
those of interest to you.

00:12:04.412 --> 00:12:05.052
And that whole

00:12:06.474 --> 00:12:07.475
patient-centered care and

00:12:07.514 --> 00:12:08.495
shared decision-making,

00:12:08.515 --> 00:12:09.537
you actually put the

00:12:10.357 --> 00:12:11.919
evidence in front of the patient and say,

00:12:12.340 --> 00:12:13.740
what aligns with kind of

00:12:13.782 --> 00:12:14.721
your world belief?

00:12:14.802 --> 00:12:15.903
What do you think would give

00:12:15.943 --> 00:12:16.924
you the best outcome?

00:12:17.465 --> 00:12:18.907
And then let them choose,

00:12:19.067 --> 00:12:20.727
and then you proceed together as a team.

00:12:21.288 --> 00:12:21.629
Yeah.

00:12:22.309 --> 00:12:22.549
Yeah.

00:12:22.990 --> 00:12:24.432
I like that approach.

00:12:24.491 --> 00:12:26.114
I think it makes total sense,

00:12:26.173 --> 00:12:27.315
especially on the heels of

00:12:27.807 --> 00:12:28.567
kind of all this kind of

00:12:28.606 --> 00:12:29.707
contemporary and updated

00:12:29.748 --> 00:12:30.687
information that's coming

00:12:30.768 --> 00:12:31.768
out about patient-centered

00:12:31.788 --> 00:12:33.128
care and why that's so important.

00:12:34.068 --> 00:12:34.908
But I think it's hard,

00:12:35.009 --> 00:12:36.528
as at least you and I both

00:12:36.629 --> 00:12:37.950
educate entry-level students,

00:12:37.990 --> 00:12:40.549
I think it's hard for us to

00:12:41.471 --> 00:12:43.171
help them see that you have

00:12:43.191 --> 00:12:44.591
to kind of lay out the options.

00:12:44.630 --> 00:12:46.172
It's not all on you, actually.

00:12:46.371 --> 00:12:47.871
It's got to be on the patient, too.

00:12:47.892 --> 00:12:50.072
So how do you

00:12:50.748 --> 00:12:52.288
You said there's evidence in

00:12:52.328 --> 00:12:54.731
certain regions that

00:12:55.852 --> 00:12:56.854
positive expectations

00:12:56.913 --> 00:12:58.394
anyway might drive outcomes

00:12:58.455 --> 00:12:59.995
in terms of like a manual

00:13:00.015 --> 00:13:00.956
therapy intervention.

00:13:01.017 --> 00:13:02.958
How do you measure that type of a thing?

00:13:03.019 --> 00:13:04.159
So for those listeners that

00:13:04.780 --> 00:13:06.402
aren't necessarily as familiar with it,

00:13:07.062 --> 00:13:09.065
what does expectation research look like?

00:13:09.125 --> 00:13:10.326
What are you actually measuring?

00:13:12.096 --> 00:13:12.296
Yeah,

00:13:12.355 --> 00:13:14.096
we ask the patient their past

00:13:14.157 --> 00:13:15.797
experience with certain treatments.

00:13:16.357 --> 00:13:17.758
We ask them specifically,

00:13:17.817 --> 00:13:19.418
do you think that exercise

00:13:19.458 --> 00:13:20.399
will help your condition?

00:13:20.438 --> 00:13:21.178
Do you think that

00:13:22.519 --> 00:13:24.660
manipulation or manual

00:13:24.681 --> 00:13:26.120
therapy will help your condition?

00:13:26.221 --> 00:13:27.181
Do you think that stretching

00:13:27.201 --> 00:13:28.261
would help your condition?

00:13:28.682 --> 00:13:29.642
And we give them kind of a

00:13:29.701 --> 00:13:31.423
Likert scale for when not

00:13:31.462 --> 00:13:32.743
likely or very likely or

00:13:33.083 --> 00:13:33.764
those kind of things.

00:13:34.583 --> 00:13:36.424
uh and so we kind of assess

00:13:36.485 --> 00:13:37.865
their expectations prior to

00:13:37.905 --> 00:13:39.586
treatment and we can look

00:13:39.625 --> 00:13:40.547
at whatever treatment they

00:13:40.567 --> 00:13:42.307
received in that research

00:13:42.467 --> 00:13:43.668
and see if their

00:13:43.748 --> 00:13:44.989
expectations correlated

00:13:45.068 --> 00:13:46.769
with the outcomes overall

00:13:46.929 --> 00:13:47.970
and you know you and I

00:13:48.029 --> 00:13:49.551
published a few things and

00:13:50.270 --> 00:13:52.471
and um with uh josh cleland

00:13:52.511 --> 00:13:53.712
and joel bylosky and mark

00:13:53.753 --> 00:13:55.894
bishop we published on neck

00:13:55.953 --> 00:13:57.534
pain and back pain and

00:13:57.634 --> 00:13:58.615
shoulder pain and uh

00:14:00.916 --> 00:14:01.756
There's probably a few that

00:14:01.777 --> 00:14:03.038
I'm missing overall,

00:14:03.078 --> 00:14:04.900
but it comes in with the

00:14:04.980 --> 00:14:06.042
expectation that the

00:14:06.081 --> 00:14:06.682
treatment that they're

00:14:06.702 --> 00:14:09.105
going to receive will help them.

00:14:09.385 --> 00:14:10.787
Their outcomes are better.

00:14:10.927 --> 00:14:12.328
And the other thing I wanted

00:14:12.349 --> 00:14:14.091
to talk about with you is, you know,

00:14:14.110 --> 00:14:15.133
you get these patients in

00:14:15.153 --> 00:14:16.313
these studies and they know

00:14:16.374 --> 00:14:18.035
that it's a manual therapy study.

00:14:18.056 --> 00:14:19.717
Maybe it's a randomized controlled trial.

00:14:20.373 --> 00:14:21.673
and the randomization occurs

00:14:21.832 --> 00:14:23.234
and we open the envelope and we say,

00:14:23.274 --> 00:14:24.114
you're in the exercise

00:14:24.153 --> 00:14:25.514
group or you're in the control group,

00:14:25.554 --> 00:14:26.335
you can see them,

00:14:26.514 --> 00:14:27.455
the ones that have this

00:14:27.514 --> 00:14:28.696
really high expectation

00:14:28.735 --> 00:14:30.635
that manual therapy is gonna help,

00:14:30.676 --> 00:14:34.677
they kind of deflate a little bit.

00:14:35.658 --> 00:14:38.359
And there are healthcare

00:14:38.399 --> 00:14:39.938
seekers and that kind of

00:14:39.958 --> 00:14:40.720
thing that will actually

00:14:40.779 --> 00:14:43.519
look for studies where they

00:14:43.539 --> 00:14:44.780
can get the treatment that

00:14:44.821 --> 00:14:45.900
they really strongly

00:14:45.961 --> 00:14:47.241
believe in and that type of thing.

00:14:48.856 --> 00:14:50.258
clinical research is really

00:14:50.337 --> 00:14:53.159
hard to be able to take a

00:14:53.279 --> 00:14:55.881
naive patient and deliver

00:14:56.221 --> 00:14:57.743
two different types of

00:14:58.023 --> 00:14:59.323
treatment to see which one

00:14:59.563 --> 00:15:01.205
is superior because these

00:15:01.264 --> 00:15:02.326
patient expectations,

00:15:02.566 --> 00:15:03.966
every patient coming in has

00:15:04.467 --> 00:15:06.528
some thought or belief about, you know,

00:15:06.589 --> 00:15:07.210
what they're going to

00:15:07.250 --> 00:15:08.289
receive and what they think

00:15:08.330 --> 00:15:08.850
will help them.

00:15:08.890 --> 00:15:10.751
And if it doesn't match what

00:15:10.792 --> 00:15:11.913
they think will help them,

00:15:12.173 --> 00:15:12.993
their outcomes are not

00:15:13.033 --> 00:15:13.673
going to be as good.

00:15:14.174 --> 00:15:14.434
Yeah.

00:15:14.815 --> 00:15:15.056
Yeah.

00:15:15.375 --> 00:15:15.956
It's interesting.

00:15:15.995 --> 00:15:16.996
I think that's the perfect

00:15:17.076 --> 00:15:18.618
example of when we see it

00:15:18.738 --> 00:15:21.059
because our hands are tied

00:15:21.100 --> 00:15:21.940
and we're forced to be

00:15:22.000 --> 00:15:23.221
prescriptive because we're

00:15:23.260 --> 00:15:24.761
in a clinical research environment.

00:15:25.442 --> 00:15:26.802
But what's amazing is you

00:15:26.842 --> 00:15:27.783
get to the clinic and you

00:15:27.803 --> 00:15:29.024
actually get to tell the patient,

00:15:29.044 --> 00:15:30.105
these are all the options.

00:15:30.586 --> 00:15:31.326
Like you were saying,

00:15:31.466 --> 00:15:32.047
what did you call it?

00:15:32.067 --> 00:15:32.927
A healthcare buffet?

00:15:32.947 --> 00:15:33.508
Yeah.

00:15:33.528 --> 00:15:34.288
Healthcare buffet.

00:15:34.467 --> 00:15:36.590
Like you go to an Asian

00:15:36.629 --> 00:15:37.549
restaurant or something and

00:15:37.570 --> 00:15:38.831
there's all this stuff that

00:15:38.870 --> 00:15:39.692
you can choose from.

00:15:39.731 --> 00:15:39.951
Right.

00:15:40.172 --> 00:15:41.812
And some, some you like,

00:15:41.932 --> 00:15:42.614
some you don't like.

00:15:42.874 --> 00:15:42.994
Yeah.

00:15:43.682 --> 00:15:45.082
But I like that analogy

00:15:45.123 --> 00:15:46.124
because in the clinic it's

00:15:46.163 --> 00:15:47.083
just different and the

00:15:47.124 --> 00:15:48.504
patients can choose or

00:15:48.565 --> 00:15:49.784
prioritize what they what

00:15:49.804 --> 00:15:51.164
they want to do if you're

00:15:51.184 --> 00:15:52.145
kind of exercising that

00:15:52.285 --> 00:15:54.145
that shared decision making model.

00:15:55.687 --> 00:15:56.606
So you talked a little bit

00:15:56.647 --> 00:15:57.547
about some of the studies

00:15:57.586 --> 00:15:58.447
that were done in the past,

00:15:58.488 --> 00:16:00.148
and that was I think it was interesting.

00:16:00.168 --> 00:16:01.349
I remember when you and I

00:16:01.389 --> 00:16:02.308
were kind of looking at

00:16:02.741 --> 00:16:03.842
the patient expectation

00:16:03.863 --> 00:16:05.183
information from the lumbar

00:16:05.203 --> 00:16:06.565
spine and the neck and the shoulder,

00:16:07.184 --> 00:16:08.166
all those figures looked

00:16:08.206 --> 00:16:09.267
very much the same.

00:16:09.386 --> 00:16:11.769
So do you think that's fair

00:16:11.928 --> 00:16:13.090
to say that you would

00:16:13.289 --> 00:16:14.551
probably see the same

00:16:14.951 --> 00:16:17.133
patient expectations in

00:16:17.192 --> 00:16:18.073
terms of influencing

00:16:18.173 --> 00:16:19.534
outcomes in other regions

00:16:19.595 --> 00:16:21.235
like the foot and ankle and

00:16:21.255 --> 00:16:23.477
the knee and across

00:16:23.518 --> 00:16:24.578
orthopedic conditions?

00:16:26.000 --> 00:16:26.379
Yeah,

00:16:26.399 --> 00:16:29.062
I think there's very few exceptions

00:16:29.201 --> 00:16:29.623
to that.

00:16:30.381 --> 00:16:31.201
the studies that have

00:16:31.363 --> 00:16:33.003
explored expectations where

00:16:33.023 --> 00:16:34.303
if a patient had a positive

00:16:34.504 --> 00:16:35.464
expectation for that

00:16:35.504 --> 00:16:36.365
treatment and they received

00:16:36.404 --> 00:16:36.884
that treatment,

00:16:36.924 --> 00:16:37.926
that the outcomes were not

00:16:38.505 --> 00:16:40.787
better compared to the alternative.

00:16:40.947 --> 00:16:42.847
And we've seen it in other

00:16:42.888 --> 00:16:45.229
conditions as well, headaches, migraines,

00:16:45.548 --> 00:16:46.750
irritable bowel syndrome,

00:16:46.789 --> 00:16:48.510
all kinds of different medical treatments,

00:16:48.571 --> 00:16:49.291
that type of thing.

00:16:50.051 --> 00:16:52.091
And as I said before,

00:16:52.131 --> 00:16:52.952
the interesting thing about

00:16:52.972 --> 00:16:54.153
those patient expectations

00:16:54.212 --> 00:16:55.313
is you can mold those

00:16:56.009 --> 00:16:57.129
the patient can come in and

00:16:57.149 --> 00:16:58.250
they can maybe have a

00:16:58.429 --> 00:16:59.551
neutral or a negative

00:16:59.591 --> 00:17:00.951
expectation about a treatment,

00:17:01.051 --> 00:17:02.610
but through a good

00:17:02.650 --> 00:17:03.831
therapeutic alliance where

00:17:03.850 --> 00:17:06.711
you really connect with that patient,

00:17:06.731 --> 00:17:08.092
get to know them as a human being,

00:17:08.132 --> 00:17:09.592
know that you're in this as a team,

00:17:10.393 --> 00:17:12.032
can share the evidence with them and say,

00:17:12.053 --> 00:17:12.752
you know,

00:17:12.772 --> 00:17:13.813
the research shows this

00:17:13.873 --> 00:17:16.273
intervention would probably help you.

00:17:16.354 --> 00:17:17.413
What are your thoughts on that?

00:17:17.473 --> 00:17:18.433
You can actually change

00:17:18.473 --> 00:17:19.334
their expectations.

00:17:19.374 --> 00:17:21.334
And when you do change their expectations,

00:17:21.354 --> 00:17:22.474
their outcomes improve.

00:17:22.934 --> 00:17:23.795
Yeah, yeah.

00:17:24.625 --> 00:17:26.406
So I have a question, it's related,

00:17:26.487 --> 00:17:28.489
but on a slightly different topic,

00:17:29.329 --> 00:17:29.509
you know,

00:17:29.550 --> 00:17:30.652
there's a lot of information

00:17:30.672 --> 00:17:31.813
that's come out about

00:17:32.053 --> 00:17:33.734
placebo and nocebo and,

00:17:34.476 --> 00:17:36.898
and patients might have an expectation.

00:17:37.019 --> 00:17:37.398
Oh gosh,

00:17:37.419 --> 00:17:39.401
there's that little thumbs up

00:17:39.442 --> 00:17:40.241
thing that I didn't mean

00:17:40.261 --> 00:17:41.463
for that to happen.

00:17:43.007 --> 00:17:44.728
Tell me how placebo effect

00:17:44.847 --> 00:17:46.808
and expectations kind of

00:17:46.910 --> 00:17:48.309
collide when it comes to

00:17:48.390 --> 00:17:49.391
clinical practice,

00:17:49.510 --> 00:17:50.791
or even what does some of

00:17:50.811 --> 00:17:52.093
the research say about

00:17:52.532 --> 00:17:54.233
placebo and expectations?

00:17:54.273 --> 00:17:55.154
What does that even mean?

00:17:55.904 --> 00:17:58.527
Yeah, so placebo effect, well,

00:17:58.567 --> 00:18:00.948
placebo is a supposedly

00:18:01.167 --> 00:18:02.028
inactive treatment.

00:18:02.068 --> 00:18:04.309
That could be a pill with sugar in it,

00:18:04.390 --> 00:18:05.330
or it could be a sham

00:18:05.351 --> 00:18:06.951
manipulation or something like that.

00:18:06.971 --> 00:18:09.492
The placebo effect is what happens,

00:18:09.512 --> 00:18:10.313
you know,

00:18:10.333 --> 00:18:11.273
the physiological or

00:18:11.334 --> 00:18:13.575
psychological changes in a

00:18:13.615 --> 00:18:14.496
patient's condition

00:18:14.556 --> 00:18:16.297
resulting from the belief that

00:18:16.576 --> 00:18:17.938
that they're receiving an

00:18:17.978 --> 00:18:18.838
effective treatment.

00:18:18.959 --> 00:18:20.220
So even if that treatment

00:18:20.319 --> 00:18:22.461
has no therapeutic value,

00:18:22.521 --> 00:18:24.363
so patient expectations are

00:18:24.383 --> 00:18:25.584
a part of placebo,

00:18:25.624 --> 00:18:27.506
but they're not all of it overall.

00:18:27.746 --> 00:18:29.146
So, so you,

00:18:29.346 --> 00:18:30.647
you can change a patient's

00:18:30.708 --> 00:18:32.210
expectation and improve

00:18:32.289 --> 00:18:34.411
potentially the placebo effect.

00:18:34.531 --> 00:18:36.053
But you know,

00:18:36.073 --> 00:18:38.253
a lot of people get confused

00:18:38.375 --> 00:18:40.355
on placebo versus control

00:18:40.476 --> 00:18:41.616
and that type of thing.

00:18:41.656 --> 00:18:43.618
So a placebo can be a control and,

00:18:44.239 --> 00:18:45.859
You have a no treatment

00:18:45.920 --> 00:18:46.900
control where patients

00:18:46.940 --> 00:18:48.060
don't receive any treatment.

00:18:48.601 --> 00:18:50.661
But the state of the art in

00:18:50.701 --> 00:18:52.602
medicine is to compare the

00:18:52.761 --> 00:18:54.303
active treatment to a

00:18:55.182 --> 00:18:56.223
similar treatment that the

00:18:56.243 --> 00:18:58.443
patient thinks is going to

00:18:58.503 --> 00:19:00.085
benefit them overall, whether

00:19:00.702 --> 00:19:01.584
you know,

00:19:01.903 --> 00:19:04.184
it actually has some therapeutic

00:19:04.204 --> 00:19:05.165
value or not.

00:19:05.586 --> 00:19:07.366
And then we know that the

00:19:07.406 --> 00:19:09.667
placebo effect is around 30 to 35%.

00:19:09.667 --> 00:19:12.549
If patients think that they

00:19:12.589 --> 00:19:14.590
are actively receiving a

00:19:14.810 --> 00:19:15.790
treatment or doing

00:19:15.891 --> 00:19:17.592
something that will make them better,

00:19:17.632 --> 00:19:19.432
that we will see improvements in that.

00:19:19.512 --> 00:19:21.954
So the bar is really, does the,

00:19:22.615 --> 00:19:23.395
treatment that you're

00:19:23.415 --> 00:19:25.498
investigating exceed that

00:19:25.617 --> 00:19:27.799
bar of 30 to 35% will

00:19:27.859 --> 00:19:30.682
improve with the placebo

00:19:31.443 --> 00:19:33.425
and to actually show that

00:19:33.586 --> 00:19:34.906
it made a significant difference.

00:19:35.548 --> 00:19:37.549
So it almost seems like you'd have to have,

00:19:38.611 --> 00:19:39.912
if we're getting granular,

00:19:39.932 --> 00:19:40.613
you'd have to have your

00:19:40.633 --> 00:19:42.674
experimental group, a sham group,

00:19:42.795 --> 00:19:44.115
and then a true control

00:19:44.155 --> 00:19:45.356
where nothing is happening

00:19:45.376 --> 00:19:46.798
in order to maybe sort that out.

00:19:47.983 --> 00:19:48.203
Yeah,

00:19:48.223 --> 00:19:49.625
because natural history is such a

00:19:49.684 --> 00:19:50.365
powerful thing.

00:19:51.445 --> 00:19:54.247
Even in patients with chronic pain overall,

00:19:54.287 --> 00:19:56.008
there is an ebb and a flow

00:19:56.087 --> 00:19:57.788
to it and kind of a natural

00:19:57.827 --> 00:19:58.608
history overall.

00:19:58.669 --> 00:20:01.150
So you really, you know, it is nice,

00:20:01.250 --> 00:20:03.490
like in our study where we

00:20:03.510 --> 00:20:04.191
looked at thoracic

00:20:04.211 --> 00:20:05.291
manipulation for patients

00:20:05.352 --> 00:20:06.531
with cervicogenic headaches.

00:20:06.592 --> 00:20:07.833
We had those patients come in.

00:20:07.873 --> 00:20:08.993
We did the baseline data.

00:20:09.074 --> 00:20:09.953
The ones that got the

00:20:09.993 --> 00:20:11.835
control got no treatment for four weeks.

00:20:12.522 --> 00:20:13.943
And they stayed the same, right?

00:20:13.963 --> 00:20:14.684
Yeah, yeah.

00:20:15.105 --> 00:20:16.446
And they'd had headaches, I think, what,

00:20:16.487 --> 00:20:17.847
for an average of five years?

00:20:18.347 --> 00:20:20.590
Yeah, our average was 10 and a half years.

00:20:20.611 --> 00:20:22.192
10 and a half years of headaches.

00:20:23.512 --> 00:20:25.515
And so the group that got the control,

00:20:25.595 --> 00:20:26.476
which was no treatment,

00:20:26.635 --> 00:20:28.478
they just sat idle for four weeks.

00:20:29.077 --> 00:20:30.480
But it was a crossover study.

00:20:30.680 --> 00:20:32.842
So we wanted to deliver the

00:20:32.922 --> 00:20:34.163
thoracic manipulation to

00:20:34.282 --> 00:20:35.203
one group while the other

00:20:35.243 --> 00:20:36.664
group sat on the sidelines.

00:20:37.519 --> 00:20:38.519
And then after four weeks,

00:20:38.579 --> 00:20:39.460
they entered the game.

00:20:39.480 --> 00:20:40.240
We did the thoracic

00:20:40.280 --> 00:20:41.280
manipulation and the

00:20:42.020 --> 00:20:43.941
improvements almost exactly

00:20:44.020 --> 00:20:45.101
mirrored each other overall.

00:20:45.320 --> 00:20:46.642
So that kind of proves that

00:20:47.362 --> 00:20:48.362
what we did in the

00:20:48.442 --> 00:20:49.602
intervention made a

00:20:49.642 --> 00:20:50.382
difference in these

00:20:50.442 --> 00:20:51.162
patients who had had

00:20:51.221 --> 00:20:52.383
symptoms for 10 years.

00:20:53.042 --> 00:20:54.202
And we had that control

00:20:54.242 --> 00:20:55.363
group where no treatment

00:20:55.403 --> 00:20:57.104
was delivered and they

00:20:57.144 --> 00:20:58.483
didn't change at all.

00:20:58.663 --> 00:20:58.884
Yeah.

00:20:59.564 --> 00:20:59.763
Yeah.

00:20:59.784 --> 00:21:00.703
And I'm wondering, you know,

00:21:00.824 --> 00:21:01.503
things like that,

00:21:01.564 --> 00:21:02.625
it's hard to know how much

00:21:03.125 --> 00:21:05.085
natural history for something that's been

00:21:05.748 --> 00:21:06.867
occurring in an individual

00:21:06.907 --> 00:21:08.308
for 10 years as opposed to

00:21:08.388 --> 00:21:09.489
two months is also probably

00:21:09.509 --> 00:21:10.289
going to look different.

00:21:11.170 --> 00:21:12.589
It just occurred to me, Paul,

00:21:12.631 --> 00:21:13.631
that we actually gathered

00:21:13.671 --> 00:21:15.090
patient expectation data,

00:21:15.491 --> 00:21:17.172
but we never did anything with it.

00:21:17.832 --> 00:21:20.113
So maybe this is the impetus

00:21:20.133 --> 00:21:21.554
for us to do a secondary

00:21:21.594 --> 00:21:22.673
analysis of some of that

00:21:22.733 --> 00:21:23.894
data for individuals with

00:21:23.914 --> 00:21:24.914
cervicogenic headache.

00:21:25.234 --> 00:21:27.355
Yeah, yeah.

00:21:28.193 --> 00:21:30.394
So what are some of the

00:21:30.575 --> 00:21:31.715
thoughts you have on, like,

00:21:31.756 --> 00:21:33.497
I would love for you to share with people,

00:21:34.018 --> 00:21:34.597
what's the link?

00:21:34.637 --> 00:21:35.818
What is the language that

00:21:35.858 --> 00:21:36.999
you would use if someone

00:21:37.038 --> 00:21:38.440
has a negative expectation?

00:21:38.519 --> 00:21:39.740
So I'm talking about that

00:21:39.780 --> 00:21:41.241
patient that comes in and they're like,

00:21:41.281 --> 00:21:42.762
my brother, you know, went to PT.

00:21:42.803 --> 00:21:43.682
It wasn't helpful.

00:21:44.223 --> 00:21:46.404
I'm not even sure if this is going to help,

00:21:46.525 --> 00:21:48.506
but I can't get, you know,

00:21:48.705 --> 00:21:50.326
an injection until I do six

00:21:50.366 --> 00:21:51.647
weeks of physical therapy

00:21:51.688 --> 00:21:52.828
or I can't do this or that,

00:21:53.009 --> 00:21:53.970
or I don't know.

00:21:54.069 --> 00:21:54.450
How do you.

00:21:55.136 --> 00:21:56.040
I have my own ideas,

00:21:56.082 --> 00:21:57.125
but I want to hear your thoughts.

00:21:57.186 --> 00:21:58.352
How do you realign those?

00:21:58.412 --> 00:21:59.778
What are the words that you use?

00:22:02.009 --> 00:22:03.148
uh well that's challenging

00:22:03.368 --> 00:22:06.490
and it's it's um you know

00:22:06.549 --> 00:22:07.630
every every patient is

00:22:07.670 --> 00:22:08.550
different like in the

00:22:08.730 --> 00:22:09.730
situation with the brother

00:22:09.750 --> 00:22:11.131
had a bad experience maybe

00:22:11.171 --> 00:22:12.090
explore that a little bit

00:22:12.131 --> 00:22:14.731
more but uh you know maybe

00:22:14.771 --> 00:22:15.751
there was some other

00:22:15.811 --> 00:22:17.113
variable in there that that

00:22:17.153 --> 00:22:18.153
affected the outcome

00:22:18.252 --> 00:22:19.913
overall but you know really

00:22:19.932 --> 00:22:21.173
I try and bring it back to

00:22:21.212 --> 00:22:22.334
the patient this is your

00:22:22.394 --> 00:22:23.273
life this is your

00:22:23.334 --> 00:22:24.634
experience this is what the

00:22:24.653 --> 00:22:25.835
current best evidence says

00:22:25.894 --> 00:22:26.694
this is what my uh

00:22:28.672 --> 00:22:29.972
expert clinical judgment

00:22:30.133 --> 00:22:33.134
says would probably benefit you overall.

00:22:33.674 --> 00:22:34.596
And if you bring that

00:22:34.675 --> 00:22:36.616
negative expectation into

00:22:36.737 --> 00:22:38.917
this therapeutic relationship,

00:22:39.298 --> 00:22:40.479
it will impact your outcomes.

00:22:40.499 --> 00:22:43.060
So I'll give them papers.

00:22:43.121 --> 00:22:44.261
I'll let them read papers.

00:22:44.321 --> 00:22:46.282
I'll send them to websites

00:22:46.323 --> 00:22:47.483
that I trust where they can

00:22:47.564 --> 00:22:49.085
explore the intervention

00:22:49.105 --> 00:22:49.984
that we're talking about,

00:22:50.746 --> 00:22:51.866
that maybe we can start to

00:22:51.946 --> 00:22:53.807
reshape that expectation

00:22:53.907 --> 00:22:55.348
from the brother's bad

00:22:55.388 --> 00:22:56.368
experience or whatever.

00:22:56.388 --> 00:22:57.089
Yeah.

00:22:57.537 --> 00:22:57.777
you know,

00:22:57.997 --> 00:23:00.357
bring them around to maybe a more

00:23:00.417 --> 00:23:01.898
neutral or more positive

00:23:02.019 --> 00:23:03.680
type of an expectation overall.

00:23:03.740 --> 00:23:04.961
But, you know, again,

00:23:05.000 --> 00:23:05.921
you have to value the

00:23:06.280 --> 00:23:07.261
patient's experience,

00:23:07.362 --> 00:23:09.423
but you have to bring it back to them.

00:23:09.643 --> 00:23:10.403
This is your life.

00:23:10.443 --> 00:23:11.423
This is your story.

00:23:12.183 --> 00:23:14.345
This is, I think, will help you.

00:23:15.026 --> 00:23:17.067
And then, you know, if you can change that,

00:23:17.086 --> 00:23:18.448
I think you can bring them

00:23:18.788 --> 00:23:20.648
around to that position.

00:23:21.689 --> 00:23:24.671
So for some of our listeners

00:23:24.711 --> 00:23:25.550
that are maybe a little bit

00:23:25.611 --> 00:23:27.211
earlier in their education or training,

00:23:27.728 --> 00:23:28.608
Would you say this is

00:23:28.628 --> 00:23:29.288
something that you're

00:23:29.368 --> 00:23:30.930
constantly and dynamically

00:23:30.990 --> 00:23:32.631
doing throughout your interactions?

00:23:32.711 --> 00:23:34.432
Or do you believe you kind

00:23:34.472 --> 00:23:35.353
of deliver a little bit of

00:23:35.393 --> 00:23:37.694
bolus of information in the

00:23:37.734 --> 00:23:38.996
beginning in terms of

00:23:39.056 --> 00:23:40.916
trying to change expectations?

00:23:42.861 --> 00:23:43.721
Yeah, that's a good question.

00:23:43.741 --> 00:23:45.523
That really gets into our bias, right?

00:23:45.683 --> 00:23:47.125
A lot of us are strongly

00:23:47.185 --> 00:23:48.407
opinionated about what we

00:23:48.428 --> 00:23:49.709
do and why we do it and

00:23:50.430 --> 00:23:51.511
look at social media and

00:23:51.612 --> 00:23:52.593
all the manual therapy,

00:23:52.653 --> 00:23:53.875
love it or hate it kind of

00:23:53.934 --> 00:23:54.875
things overall.

00:23:54.915 --> 00:23:56.377
So we do have to present it

00:23:56.498 --> 00:23:58.500
in an unbiased fashion and not try to

00:23:59.260 --> 00:24:00.962
persuade patients or talk

00:24:01.002 --> 00:24:02.625
them into a treatment that

00:24:02.704 --> 00:24:06.789
maybe they are not interested in overall.

00:24:06.849 --> 00:24:10.032
But it is challenging,

00:24:10.094 --> 00:24:11.996
but trying to just present

00:24:12.076 --> 00:24:14.298
it in a factual basis and

00:24:14.337 --> 00:24:15.559
then really involve the

00:24:15.599 --> 00:24:17.182
patient and listen to them.

00:24:17.521 --> 00:24:18.462
What are your thoughts on this?

00:24:19.263 --> 00:24:20.545
of them will say you know

00:24:21.125 --> 00:24:22.227
manipulation is a prime

00:24:22.247 --> 00:24:23.106
example cervical

00:24:23.147 --> 00:24:24.167
manipulation while my

00:24:24.769 --> 00:24:25.910
cousin's sister's brother

00:24:25.970 --> 00:24:26.911
got manipulated by a

00:24:26.971 --> 00:24:27.912
chiropractor and had a

00:24:27.951 --> 00:24:29.133
stroke and crashed into a

00:24:29.173 --> 00:24:30.294
ditch and things like that

00:24:30.334 --> 00:24:31.375
that's that's probably a

00:24:31.414 --> 00:24:32.155
patient that you're not

00:24:32.175 --> 00:24:33.336
going to bring around to

00:24:33.836 --> 00:24:35.538
letting them letting you do

00:24:36.159 --> 00:24:38.060
a cervical manipulation on

00:24:38.101 --> 00:24:40.202
them overall so there are some

00:24:40.782 --> 00:24:42.324
barriers to expectation,

00:24:42.364 --> 00:24:43.324
I would say overall.

00:24:43.364 --> 00:24:44.663
But in general,

00:24:44.703 --> 00:24:46.065
if you can start to reframe

00:24:46.424 --> 00:24:48.085
whatever their expectation is,

00:24:48.144 --> 00:24:49.486
if it's on that negative side,

00:24:50.506 --> 00:24:51.986
you can bring them around.

00:24:52.026 --> 00:24:53.307
But if you can't,

00:24:53.586 --> 00:24:55.106
then move on to something else.

00:24:55.728 --> 00:24:56.028
Yeah.

00:24:56.688 --> 00:24:58.847
And so how are you in the

00:24:58.887 --> 00:25:01.568
context of being an entry level educator?

00:25:01.808 --> 00:25:03.509
How are you kind of

00:25:03.609 --> 00:25:04.809
sprinkling some of this

00:25:04.930 --> 00:25:06.411
content in with your students?

00:25:06.451 --> 00:25:07.431
How are you helping them to

00:25:08.018 --> 00:25:09.199
to understand that this is

00:25:09.278 --> 00:25:10.680
another component of how we

00:25:10.700 --> 00:25:13.101
need to interact with our patients?

00:25:14.701 --> 00:25:15.082
Yeah.

00:25:15.241 --> 00:25:17.683
So, you know,

00:25:17.864 --> 00:25:19.565
I really emphasize that

00:25:19.704 --> 00:25:21.086
therapeutic alliance with

00:25:21.125 --> 00:25:22.546
patients and being present

00:25:22.666 --> 00:25:23.307
for your patients.

00:25:23.976 --> 00:25:24.875
Most of our students,

00:25:24.935 --> 00:25:25.855
when they're sitting in

00:25:25.895 --> 00:25:26.556
front of a patient,

00:25:26.576 --> 00:25:27.737
they've got their heads

00:25:27.797 --> 00:25:29.317
going in a thousand different directions.

00:25:29.336 --> 00:25:30.797
They've got a checklist in front of them.

00:25:31.196 --> 00:25:32.196
They don't even make eye

00:25:32.238 --> 00:25:33.637
contact with the patient.

00:25:34.617 --> 00:25:35.657
Or they've got their tablet

00:25:35.678 --> 00:25:36.637
or their computer up and

00:25:36.678 --> 00:25:37.778
they're documenting while

00:25:37.818 --> 00:25:38.838
the patient is talking.

00:25:38.878 --> 00:25:40.419
And I really try to get them

00:25:40.578 --> 00:25:42.058
out of that mode where they

00:25:42.078 --> 00:25:43.940
can be with that other human being,

00:25:44.019 --> 00:25:46.140
look them in the eye, talk to them.

00:25:46.180 --> 00:25:47.700
And I've always told my students,

00:25:47.720 --> 00:25:48.559
you've heard me say this,

00:25:48.599 --> 00:25:49.701
that your interaction may

00:25:49.800 --> 00:25:51.340
outweigh your intervention, right?

00:25:51.760 --> 00:25:52.000
I mean,

00:25:52.080 --> 00:25:53.401
we've got all these studies that

00:25:53.441 --> 00:25:54.582
show that manual therapy

00:25:55.201 --> 00:25:56.761
helps maybe a little bit in

00:25:56.781 --> 00:25:57.442
the short term.

00:25:58.022 --> 00:25:59.823
But if you look that patient in the eye,

00:25:59.883 --> 00:26:01.262
get to know them as a human being,

00:26:01.962 --> 00:26:04.743
really invest in them as a

00:26:04.784 --> 00:26:05.743
healthcare provider,

00:26:06.384 --> 00:26:07.605
that will likely have a

00:26:07.664 --> 00:26:09.184
better effect on the

00:26:09.285 --> 00:26:10.566
outcome of your treatment

00:26:10.766 --> 00:26:11.885
than any treatment we can

00:26:11.905 --> 00:26:13.205
throw at our patients overall.

00:26:13.705 --> 00:26:14.006
Yeah.

00:26:14.886 --> 00:26:15.027
Yeah.

00:26:15.047 --> 00:26:16.886
And I think it's exciting to see that,

00:26:18.207 --> 00:26:18.446
you know,

00:26:18.487 --> 00:26:20.548
there's work being done now to really

00:26:21.468 --> 00:26:22.608
try to figure out how to

00:26:22.648 --> 00:26:25.871
better harness that shared

00:26:26.290 --> 00:26:27.991
contextual piece.

00:26:28.112 --> 00:26:29.051
It's not all about,

00:26:29.673 --> 00:26:30.492
it's interesting because I

00:26:30.532 --> 00:26:31.153
think we're starting,

00:26:31.173 --> 00:26:32.094
I hope we're starting to

00:26:32.134 --> 00:26:33.015
move away from the fact

00:26:33.055 --> 00:26:34.675
that we think all of our interventions,

00:26:34.736 --> 00:26:35.816
whether it's manual therapy

00:26:35.836 --> 00:26:37.758
or exercise or what drive the outcomes,

00:26:38.377 --> 00:26:40.038
it's so much bigger than that, including

00:26:40.458 --> 00:26:40.678
you know,

00:26:40.698 --> 00:26:43.159
our topic here today of expectations,

00:26:43.239 --> 00:26:44.940
but also of some of these

00:26:44.980 --> 00:26:45.941
shared mechanisms.

00:26:46.201 --> 00:26:47.121
So I think it'll be

00:26:47.181 --> 00:26:48.781
interesting to see what

00:26:48.862 --> 00:26:50.363
more we learn about how

00:26:50.423 --> 00:26:51.564
that really needs to be a

00:26:51.624 --> 00:26:52.604
big player in the

00:26:52.663 --> 00:26:54.704
intervention outside of just, you know,

00:26:55.266 --> 00:26:57.207
exercise and manual therapy, for example.

00:27:00.147 --> 00:27:00.667
Yeah.

00:27:00.768 --> 00:27:02.348
What are some things that are kind of,

00:27:02.749 --> 00:27:05.250
I don't know, when you've done lectures,

00:27:05.310 --> 00:27:05.711
I know,

00:27:06.250 --> 00:27:08.251
in various places and in Europe on

00:27:08.291 --> 00:27:09.313
patient expectations,

00:27:10.224 --> 00:27:11.146
What are some of the biggest

00:27:11.186 --> 00:27:12.147
things that your audience

00:27:12.208 --> 00:27:13.550
tends to be curious about?

00:27:13.651 --> 00:27:14.451
Or what are some of the

00:27:14.491 --> 00:27:17.037
things that maybe continue

00:27:17.096 --> 00:27:21.183
to interest you about this topic?

00:27:21.263 --> 00:27:22.105
Or what are some things that

00:27:22.144 --> 00:27:23.988
surprise you maybe about this topic?

00:27:26.516 --> 00:27:26.776
Well,

00:27:26.796 --> 00:27:29.277
I think the big thing is just not

00:27:29.557 --> 00:27:30.977
paying attention to the

00:27:30.997 --> 00:27:31.978
fact that patients have

00:27:32.038 --> 00:27:33.678
expectations and that you

00:27:33.798 --> 00:27:35.239
can explore those and that

00:27:35.278 --> 00:27:35.959
you could potentially

00:27:35.999 --> 00:27:37.720
modify those expectations.

00:27:37.819 --> 00:27:38.019
I mean,

00:27:38.039 --> 00:27:39.539
that was eye-opening to a lot of

00:27:39.579 --> 00:27:41.520
people that I give this talk to,

00:27:41.560 --> 00:27:42.161
and they say, well,

00:27:42.381 --> 00:27:44.942
isn't that deceptive if you tell them,

00:27:45.061 --> 00:27:45.301
you know,

00:27:45.362 --> 00:27:46.623
this manipulation will make you

00:27:46.663 --> 00:27:47.063
feel better?

00:27:47.083 --> 00:27:47.923
If you're sharing...

00:27:48.426 --> 00:27:49.428
current best evidence and

00:27:49.468 --> 00:27:51.888
you can back it up with research, then,

00:27:51.909 --> 00:27:53.769
you know, it's not deceptive at all.

00:27:54.910 --> 00:27:55.210
You know,

00:27:55.411 --> 00:27:57.131
and then harnessing the placebo effect.

00:27:57.271 --> 00:27:58.932
I openly embrace the placebo

00:27:58.971 --> 00:28:00.173
effect in physical therapy.

00:28:00.192 --> 00:28:01.094
I think it's a huge

00:28:01.173 --> 00:28:02.213
component of what we do,

00:28:02.273 --> 00:28:04.515
whether it's manual therapy or exercise.

00:28:04.595 --> 00:28:05.875
And I will tell patients that.

00:28:06.435 --> 00:28:06.675
I mean,

00:28:06.695 --> 00:28:08.856
the new research out on open label

00:28:08.917 --> 00:28:10.577
placebo, where you tell the patient,

00:28:10.617 --> 00:28:10.778
I mean,

00:28:10.798 --> 00:28:13.039
there's one great study on chronic

00:28:13.079 --> 00:28:13.640
low back pain

00:28:14.563 --> 00:28:16.405
who these individuals had had pain for,

00:28:16.425 --> 00:28:18.849
I think, five years at a minimum.

00:28:19.530 --> 00:28:21.173
And they gave them a placebo and they said,

00:28:21.212 --> 00:28:23.396
there's no active substance in this pill.

00:28:24.183 --> 00:28:25.664
But in research studies,

00:28:25.744 --> 00:28:26.786
it has shown that people

00:28:26.806 --> 00:28:28.567
who take this pill have an

00:28:28.627 --> 00:28:29.627
improvement in their pain

00:28:29.667 --> 00:28:30.568
and their function and that

00:28:30.608 --> 00:28:31.150
type of thing.

00:28:31.210 --> 00:28:33.330
So they're very open about

00:28:33.371 --> 00:28:35.252
the fact that this is a placebo.

00:28:35.853 --> 00:28:37.295
And they saw significant

00:28:37.434 --> 00:28:38.335
improvements in those

00:28:38.394 --> 00:28:39.115
individuals and they

00:28:39.175 --> 00:28:40.876
tracked them out to five years.

00:28:40.896 --> 00:28:43.298
And that was maintained out to five years.

00:28:43.398 --> 00:28:45.040
And, you know, at the end of the study,

00:28:45.740 --> 00:28:48.163
When they stopped giving them the placebo,

00:28:48.182 --> 00:28:49.364
a lot of these patients would say,

00:28:49.844 --> 00:28:51.425
where can I get a prescription for that?

00:28:51.546 --> 00:28:52.506
Where can I buy that?

00:28:52.666 --> 00:28:55.048
And you tell them it's just a sugar pill,

00:28:55.127 --> 00:28:55.269
right?

00:28:55.288 --> 00:28:56.189
There's nothing in it,

00:28:56.288 --> 00:28:58.171
but they want to keep taking it.

00:28:58.191 --> 00:28:59.112
And there's something about

00:28:59.172 --> 00:29:01.653
that doing something active

00:29:01.712 --> 00:29:02.273
for your health.

00:29:02.374 --> 00:29:03.954
Maybe when they're taking that pill,

00:29:03.994 --> 00:29:04.715
they're thinking, well,

00:29:04.736 --> 00:29:05.696
maybe I should walk a

00:29:05.737 --> 00:29:06.717
little bit more today or

00:29:06.757 --> 00:29:07.817
maybe I should eat a little

00:29:07.837 --> 00:29:08.538
bit better today.

00:29:09.239 --> 00:29:11.079
or maybe I should get more sleep.

00:29:11.220 --> 00:29:14.361
They take a more active role

00:29:14.681 --> 00:29:15.701
in their recovery just

00:29:15.741 --> 00:29:16.662
because they're doing

00:29:16.741 --> 00:29:17.842
something they think has

00:29:18.382 --> 00:29:20.403
potential therapeutic value overall.

00:29:20.423 --> 00:29:22.483
I tell my patients that.

00:29:22.884 --> 00:29:24.525
There may be a placebo effect in this,

00:29:24.565 --> 00:29:25.285
but we know that the

00:29:25.325 --> 00:29:26.865
placebo effect is very powerful.

00:29:26.885 --> 00:29:28.726
It's getting your brain on

00:29:29.507 --> 00:29:31.487
board with this plan of

00:29:31.547 --> 00:29:32.728
care that we're going to be

00:29:32.748 --> 00:29:34.347
doing and that will improve

00:29:35.169 --> 00:29:35.749
your outcomes.

00:29:36.448 --> 00:29:36.728
Wow.

00:29:37.008 --> 00:29:38.048
So you're saying maybe it

00:29:38.627 --> 00:29:40.588
boils down to like the

00:29:40.648 --> 00:29:43.028
ritual of taking a pill and

00:29:43.068 --> 00:29:43.910
maybe something that's

00:29:43.950 --> 00:29:44.970
happening in the present

00:29:45.009 --> 00:29:45.769
when they're doing that?

00:29:46.369 --> 00:29:46.609
Yeah.

00:29:46.950 --> 00:29:47.130
Yeah.

00:29:47.269 --> 00:29:47.529
I mean,

00:29:48.010 --> 00:29:49.151
just the fact that the patient

00:29:49.230 --> 00:29:50.770
every day is taking that

00:29:50.830 --> 00:29:52.352
pill because that was key

00:29:52.392 --> 00:29:53.652
in that placebo study,

00:29:53.672 --> 00:29:54.991
that open label placebo.

00:29:55.392 --> 00:29:56.192
And they've done it near

00:29:56.392 --> 00:29:57.673
irritable bowel syndrome too.

00:29:57.853 --> 00:29:58.792
Exact same thing.

00:30:00.233 --> 00:30:01.815
where they told the patient,

00:30:01.855 --> 00:30:03.496
you have to take this every

00:30:03.536 --> 00:30:04.457
day and you have to

00:30:04.576 --> 00:30:06.278
document that and that type of thing.

00:30:06.377 --> 00:30:08.038
So the ritual of doing

00:30:08.159 --> 00:30:10.140
something every day that

00:30:10.940 --> 00:30:12.721
may help with their back

00:30:12.760 --> 00:30:13.521
pain or their irritable

00:30:13.541 --> 00:30:14.923
bowel syndrome and that kind of thing,

00:30:15.442 --> 00:30:16.864
I think just shifts their

00:30:16.884 --> 00:30:18.304
mindset overall that, hey,

00:30:18.364 --> 00:30:19.244
maybe I'm not going to eat

00:30:19.265 --> 00:30:20.365
that cheeseburger for lunch.

00:30:20.425 --> 00:30:21.586
Maybe I'll get a salad or

00:30:21.625 --> 00:30:22.787
maybe I'll go for a walk

00:30:22.886 --> 00:30:24.307
instead of sitting on my

00:30:24.347 --> 00:30:26.229
phone on social media for

00:30:26.249 --> 00:30:27.710
the entire hour overall.

00:30:27.789 --> 00:30:27.930
So-

00:30:30.021 --> 00:30:30.221
Yeah,

00:30:30.261 --> 00:30:31.863
I think that that research is so

00:30:32.063 --> 00:30:32.682
interesting.

00:30:33.963 --> 00:30:34.943
And I think it's important

00:30:34.963 --> 00:30:36.484
for us to think about that component too,

00:30:36.505 --> 00:30:37.265
that some of what we're

00:30:37.285 --> 00:30:39.405
doing is probably tapping into placebo.

00:30:40.006 --> 00:30:40.865
So what do you do?

00:30:40.885 --> 00:30:43.767
I love the scenarios of like, you know,

00:30:43.826 --> 00:30:44.587
you get a patient that

00:30:44.627 --> 00:30:45.567
comes in the clinic and

00:30:46.505 --> 00:30:47.645
they're dead set on the fact

00:30:47.685 --> 00:30:48.705
that ultrasound is gonna

00:30:48.945 --> 00:30:49.727
help their neck pain.

00:30:49.807 --> 00:30:50.007
I mean,

00:30:50.027 --> 00:30:52.728
I've seen those patients and you have to,

00:30:53.068 --> 00:30:54.249
how do you kind of rectify

00:30:54.269 --> 00:30:56.329
that disconnect between, you know,

00:30:56.671 --> 00:30:57.691
it actually kind of kills

00:30:57.730 --> 00:30:58.771
me to plug the machine in

00:30:58.791 --> 00:30:59.652
and actually do this,

00:31:00.212 --> 00:31:01.133
but yet the patient is

00:31:01.173 --> 00:31:02.054
saying that they're

00:31:02.074 --> 00:31:03.354
expecting that it's gonna help.

00:31:04.255 --> 00:31:05.394
What's your response to that

00:31:05.414 --> 00:31:06.236
and how do you manage that?

00:31:07.315 --> 00:31:08.055
Yeah, that's interesting.

00:31:08.076 --> 00:31:10.376
I remember I was talking to John Childs.

00:31:10.416 --> 00:31:12.858
This was like 20 years ago

00:31:12.898 --> 00:31:15.420
or so and asked him that exact question.

00:31:15.599 --> 00:31:16.580
The patient comes in and said,

00:31:16.621 --> 00:31:17.922
last time I hurt my back,

00:31:17.961 --> 00:31:19.563
I had ultrasound and it really helped.

00:31:20.143 --> 00:31:23.506
And he said, do the ultrasound.

00:31:23.685 --> 00:31:25.126
That's their expectation.

00:31:25.207 --> 00:31:28.328
And I've tried the contrary where I'll say,

00:31:28.388 --> 00:31:29.470
the evidence shows that

00:31:29.529 --> 00:31:30.450
ultrasound is not very

00:31:30.509 --> 00:31:31.671
beneficial for back pain,

00:31:32.211 --> 00:31:33.632
probably won't help you a whole lot.

00:31:33.791 --> 00:31:35.933
And then that creates a little bit of

00:31:36.655 --> 00:31:37.916
adversarial relationship.

00:31:39.038 --> 00:31:40.259
This is my experience.

00:31:40.378 --> 00:31:41.180
This helped me.

00:31:41.619 --> 00:31:42.441
And you're telling me that

00:31:42.461 --> 00:31:43.260
you're not going to do it

00:31:43.340 --> 00:31:44.721
because there's not a study

00:31:44.761 --> 00:31:46.083
that shows that it helped me.

00:31:46.103 --> 00:31:46.743
Right.

00:31:47.044 --> 00:31:47.663
Yeah.

00:31:47.724 --> 00:31:51.146
So I will embrace those things.

00:31:51.426 --> 00:31:52.567
I may share a little bit of

00:31:52.627 --> 00:31:53.469
knowledge about the

00:31:54.038 --> 00:31:55.159
the benefit of ultrasound.

00:31:55.200 --> 00:31:56.160
But, you know,

00:31:56.200 --> 00:31:57.460
the other important thing is

00:31:57.520 --> 00:31:58.901
while you're doing that ultrasound,

00:31:58.921 --> 00:31:59.922
you can be educating the

00:31:59.942 --> 00:32:02.082
patient and do some science education,

00:32:02.122 --> 00:32:02.942
or you can talk to them

00:32:03.002 --> 00:32:04.544
about activity modification

00:32:04.663 --> 00:32:06.604
or reinforcing their home

00:32:06.644 --> 00:32:07.924
exercise program or the

00:32:08.085 --> 00:32:09.246
overall plan of care and

00:32:09.286 --> 00:32:09.806
that kind of thing.

00:32:09.826 --> 00:32:11.707
So it's not really wasted time.

00:32:11.906 --> 00:32:13.027
And who knows, maybe it,

00:32:13.547 --> 00:32:14.428
maybe it does help them.

00:32:14.688 --> 00:32:16.048
So, you know, I try not to,

00:32:18.355 --> 00:32:19.517
poo-poo too much on

00:32:19.557 --> 00:32:21.218
patients' positive expectations.

00:32:21.337 --> 00:32:23.138
If something in the past helped them,

00:32:23.618 --> 00:32:24.299
by all means,

00:32:24.819 --> 00:32:25.579
unless it was something

00:32:25.619 --> 00:32:29.323
harmful to their health,

00:32:29.383 --> 00:32:31.183
drinking too much or using

00:32:31.223 --> 00:32:33.085
drugs or things like that, opioids,

00:32:33.144 --> 00:32:33.805
that kind of thing,

00:32:34.326 --> 00:32:35.987
that's a different discussion overall.

00:32:36.027 --> 00:32:36.886
But if it's something that

00:32:36.926 --> 00:32:39.608
has no potential harm overall,

00:32:39.669 --> 00:32:41.069
then I fully embrace that.

00:32:41.589 --> 00:32:41.769
Yeah.

00:32:41.789 --> 00:32:43.711
And I think what's also hard

00:32:43.730 --> 00:32:45.132
for us to swallow sometimes,

00:32:45.192 --> 00:32:46.432
I've had experiences where

00:32:47.078 --> 00:32:49.221
patients absolutely 100%

00:32:49.221 --> 00:32:50.382
have the expectation that,

00:32:50.902 --> 00:32:51.843
that they should have or

00:32:51.883 --> 00:32:52.502
move forward with the

00:32:52.563 --> 00:32:54.064
surgery that I don't

00:32:54.104 --> 00:32:55.164
believe they necessarily

00:32:55.224 --> 00:32:56.685
have objective findings to

00:32:56.767 --> 00:32:58.087
support the need for that.

00:32:58.948 --> 00:32:59.888
But I'm telling you,

00:32:59.949 --> 00:33:01.230
it's hard to talk a patient

00:33:01.430 --> 00:33:02.570
out of a surgery that

00:33:02.611 --> 00:33:04.392
they're convinced that they need to have.

00:33:04.972 --> 00:33:06.134
So I believe that's another

00:33:06.294 --> 00:33:08.275
avenue where I just, I tread lightly.

00:33:08.295 --> 00:33:10.938
I present information and research, but,

00:33:11.238 --> 00:33:11.337
um,

00:33:11.894 --> 00:33:12.134
you know,

00:33:12.194 --> 00:33:13.621
surrounding what some of the

00:33:13.661 --> 00:33:14.625
outcomes are with some of

00:33:14.664 --> 00:33:16.310
these orthopedic surgeries.

00:33:16.351 --> 00:33:17.114
How do you handle that?

00:33:18.055 --> 00:33:18.234
Well,

00:33:18.255 --> 00:33:19.715
a lot of those situations are driven

00:33:19.915 --> 00:33:21.636
by the surgeon,

00:33:21.977 --> 00:33:23.238
where it's not just the

00:33:23.258 --> 00:33:24.699
patient who absolutely believes it.

00:33:24.739 --> 00:33:25.920
The surgeon has told them

00:33:25.960 --> 00:33:27.401
they absolutely need this

00:33:27.461 --> 00:33:29.382
surgery to get back to function.

00:33:29.422 --> 00:33:30.803
And that's where we can present.

00:33:31.363 --> 00:33:33.243
Let's take lumbar stenosis, for example,

00:33:33.284 --> 00:33:35.865
the main stenosis study

00:33:35.885 --> 00:33:37.006
that tracked patients out

00:33:37.006 --> 00:33:38.967
10 years who had surgery,

00:33:39.307 --> 00:33:41.048
lumbar fusion versus not.

00:33:41.229 --> 00:33:42.529
And they looked exactly the

00:33:42.569 --> 00:33:43.470
same out to 10 years.

00:33:43.509 --> 00:33:44.590
You can present some of that.

00:33:45.191 --> 00:33:46.271
information to patients.

00:33:46.352 --> 00:33:46.451
Now,

00:33:46.471 --> 00:33:48.253
if there's a clear indication for surgery,

00:33:48.273 --> 00:33:48.835
you know,

00:33:48.875 --> 00:33:49.674
they've got progressive

00:33:49.694 --> 00:33:52.817
neurologic deficits or a

00:33:53.259 --> 00:33:54.440
spondylolisthesis that's

00:33:54.500 --> 00:33:55.820
unstable or something like that,

00:33:55.861 --> 00:33:57.643
that's a different story overall.

00:33:57.702 --> 00:34:01.326
But that is where I will try to, you know,

00:34:01.445 --> 00:34:02.708
counteract what they may

00:34:02.748 --> 00:34:04.028
have heard from another provider.

00:34:04.068 --> 00:34:04.189
Well,

00:34:04.826 --> 00:34:05.807
that provider told you

00:34:05.866 --> 00:34:06.708
absolutely need this

00:34:06.748 --> 00:34:08.449
surgery to get back to what

00:34:08.469 --> 00:34:09.048
you need to do.

00:34:09.108 --> 00:34:10.590
I'm telling you from personal experience,

00:34:10.630 --> 00:34:11.590
I've seen patients just

00:34:11.610 --> 00:34:12.530
like you who have gotten

00:34:12.570 --> 00:34:13.951
back without doing that surgery.

00:34:14.490 --> 00:34:16.172
So I tell them, give me six weeks,

00:34:16.572 --> 00:34:17.333
give me six weeks.

00:34:17.393 --> 00:34:18.213
And if you're not where you

00:34:18.233 --> 00:34:19.233
want to be in six weeks,

00:34:19.934 --> 00:34:21.393
after I've done all the

00:34:21.434 --> 00:34:22.815
patient education and maybe

00:34:22.875 --> 00:34:24.675
some manipulation of their expectations,

00:34:25.556 --> 00:34:26.175
if you're not where you

00:34:26.195 --> 00:34:27.657
want to be in six weeks, by all means,

00:34:27.936 --> 00:34:29.838
you can, you can go get that surgery.

00:34:30.358 --> 00:34:30.597
Yeah.

00:34:30.938 --> 00:34:31.159
Yeah.

00:34:31.659 --> 00:34:31.778
So,

00:34:32.489 --> 00:34:33.990
From the clinical perspective,

00:34:34.010 --> 00:34:35.211
because I know you treat

00:34:35.271 --> 00:34:36.594
weekly up at Wardenburg at

00:34:36.653 --> 00:34:37.635
University of Colorado and

00:34:37.655 --> 00:34:38.715
their student health center,

00:34:39.217 --> 00:34:40.878
do you capture any patient

00:34:40.918 --> 00:34:44.123
expectation material or

00:34:44.282 --> 00:34:46.925
through intake paperwork or

00:34:46.945 --> 00:34:47.606
anything like that?

00:34:47.746 --> 00:34:49.048
Or do you pretty much try to

00:34:49.088 --> 00:34:49.628
garner what their

00:34:49.668 --> 00:34:50.771
expectations are in that

00:34:50.851 --> 00:34:51.672
initial encounter?

00:34:53.103 --> 00:34:54.422
Yeah, that's really challenging.

00:34:54.443 --> 00:34:57.224
I mean, patients get form fatigue, right?

00:34:57.264 --> 00:34:58.724
They have to fill up so much

00:34:58.824 --> 00:35:00.005
paperwork at their initial

00:35:00.025 --> 00:35:01.184
appointment that we don't

00:35:01.284 --> 00:35:03.666
routinely assess for expectations.

00:35:03.766 --> 00:35:05.266
But that's part of my

00:35:05.407 --> 00:35:06.887
subjective interview that

00:35:07.327 --> 00:35:09.188
I'll be asking them about it.

00:35:09.248 --> 00:35:09.467
You know,

00:35:09.507 --> 00:35:10.788
what kind of treatment have you had?

00:35:10.827 --> 00:35:11.708
What do you think is going

00:35:11.827 --> 00:35:13.228
on with your back pain?

00:35:13.268 --> 00:35:14.329
What do you think will help

00:35:14.588 --> 00:35:15.369
with your back pain?

00:35:15.389 --> 00:35:16.150
Those type of things.

00:35:16.210 --> 00:35:16.389
Yeah.

00:35:17.190 --> 00:35:18.471
Do it more informally.

00:35:18.710 --> 00:35:18.891
You know,

00:35:18.911 --> 00:35:20.092
it would be ideal if we could

00:35:20.132 --> 00:35:21.132
have a standardized.

00:35:21.873 --> 00:35:22.512
The other thing about the

00:35:22.572 --> 00:35:23.693
expectation literature is

00:35:23.833 --> 00:35:24.855
there's no one form.

00:35:24.894 --> 00:35:26.175
I mean, I did a,

00:35:27.016 --> 00:35:27.896
I looked at a systematic

00:35:27.936 --> 00:35:29.257
review where there were 19

00:35:29.257 --> 00:35:31.318
different patient expectation forms.

00:35:31.518 --> 00:35:32.818
I mean, yeah.

00:35:32.900 --> 00:35:33.960
Which one do you use?

00:35:34.179 --> 00:35:36.521
You know, so, so again,

00:35:36.842 --> 00:35:38.362
I tend to do it more informally,

00:35:38.402 --> 00:35:39.302
but I do think you can

00:35:39.342 --> 00:35:40.403
glean a lot of information

00:35:40.463 --> 00:35:41.664
just from asking the patient.

00:35:42.405 --> 00:35:42.644
Yeah.

00:35:43.286 --> 00:35:43.365
Okay.

00:35:43.385 --> 00:35:43.485
Okay.

00:35:44.418 --> 00:35:44.557
Um,

00:35:44.697 --> 00:35:46.838
I've kind of two more questions and

00:35:46.878 --> 00:35:47.619
then I'm just kind of

00:35:47.719 --> 00:35:49.159
eyeing those guitars behind you.

00:35:49.219 --> 00:35:49.739
And I don't know,

00:35:49.798 --> 00:35:50.699
I might try to twist your

00:35:50.739 --> 00:35:51.498
arm to play a little.

00:35:52.280 --> 00:35:54.400
All right.

00:35:54.500 --> 00:35:55.480
That'll be for another one.

00:35:55.960 --> 00:35:58.960
So in terms of, of, um, where's,

00:35:59.561 --> 00:36:00.221
what's the future of

00:36:00.280 --> 00:36:01.360
expectation research?

00:36:01.380 --> 00:36:01.521
Like,

00:36:02.222 --> 00:36:04.422
are you kind of privy to what that

00:36:04.481 --> 00:36:06.041
next layer is now that we

00:36:06.081 --> 00:36:07.802
know that expectations can

00:36:07.842 --> 00:36:09.302
influence outcomes, especially with

00:36:10.570 --> 00:36:12.231
You know, people with musculoskeletal pain,

00:36:12.751 --> 00:36:14.293
is there anything on the horizon for us?

00:36:15.606 --> 00:36:16.545
that you're aware of?

00:36:16.726 --> 00:36:16.905
Well,

00:36:17.166 --> 00:36:19.867
I think the interesting thing will be

00:36:20.047 --> 00:36:21.807
pragmatic clinical trials

00:36:21.907 --> 00:36:23.748
where you kind of let the

00:36:24.347 --> 00:36:26.829
clinician explore

00:36:26.889 --> 00:36:28.949
expectations and then maybe

00:36:29.250 --> 00:36:31.449
make some suggestions to

00:36:31.489 --> 00:36:32.311
the patient and that kind

00:36:32.351 --> 00:36:33.331
of thing versus a more

00:36:33.391 --> 00:36:34.271
prescriptive kind of

00:36:34.331 --> 00:36:35.110
approach where you just

00:36:35.150 --> 00:36:36.632
deliver the treatment.

00:36:36.652 --> 00:36:38.811
I mean, that's been done to some extent,

00:36:38.891 --> 00:36:41.092
but really embracing that placebo effect

00:36:42.653 --> 00:36:44.815
And then, you know, potentially exploring,

00:36:45.436 --> 00:36:45.695
you know,

00:36:46.257 --> 00:36:48.318
the effect of placebo in

00:36:49.099 --> 00:36:50.539
physical therapy itself, because,

00:36:50.581 --> 00:36:50.820
you know,

00:36:50.840 --> 00:36:53.902
we hate to think that some or

00:36:53.963 --> 00:36:55.043
much of what we do is

00:36:55.103 --> 00:36:57.186
actually placebo effect, but it is.

00:36:57.405 --> 00:37:00.309
I mean, going into that placebo effect,

00:37:00.369 --> 00:37:01.989
again, that's the, you know,

00:37:02.574 --> 00:37:03.795
the patient changes their

00:37:03.835 --> 00:37:05.175
thinking or their

00:37:05.215 --> 00:37:06.036
psychology or their

00:37:06.056 --> 00:37:07.956
physiology based on their

00:37:08.056 --> 00:37:09.036
expectations and their

00:37:09.077 --> 00:37:10.617
thoughts of what's going on,

00:37:10.657 --> 00:37:12.739
if we can change that overall.

00:37:12.838 --> 00:37:14.278
And Joel Bialoski has done a

00:37:14.318 --> 00:37:17.161
lot of really good work on that front.

00:37:17.201 --> 00:37:18.360
But I think just embracing

00:37:18.400 --> 00:37:19.181
the whole package,

00:37:19.882 --> 00:37:20.922
because we have all these

00:37:20.943 --> 00:37:21.742
studies coming out,

00:37:21.802 --> 00:37:24.003
let's say on back pain that shows that

00:37:25.121 --> 00:37:27.382
there's no one clear exercise, you know,

00:37:27.443 --> 00:37:30.003
specific versus global or

00:37:30.324 --> 00:37:31.503
local versus global and

00:37:31.543 --> 00:37:32.264
those kind of things.

00:37:32.344 --> 00:37:34.065
And the key thing that comes

00:37:34.105 --> 00:37:34.826
out of those research,

00:37:34.865 --> 00:37:36.206
and same thing in manual therapy too,

00:37:36.226 --> 00:37:37.327
it doesn't matter the

00:37:37.407 --> 00:37:38.686
exercise or the technique,

00:37:38.726 --> 00:37:40.027
it's getting the patient doing,

00:37:40.067 --> 00:37:41.547
which goes back to that

00:37:41.788 --> 00:37:43.309
whole ritual thing that

00:37:43.329 --> 00:37:44.208
they're actually doing

00:37:44.268 --> 00:37:46.349
something that may improve their health.

00:37:46.570 --> 00:37:48.771
Maybe that's the important thing.

00:37:48.811 --> 00:37:49.831
It doesn't matter

00:37:50.318 --> 00:37:53.960
how the movement system

00:37:54.001 --> 00:37:54.981
people are gonna hate this,

00:37:55.081 --> 00:37:56.443
but it doesn't matter how

00:37:56.523 --> 00:37:57.864
specific our movement

00:37:57.903 --> 00:38:00.565
analysis is and our exercise prescription,

00:38:00.666 --> 00:38:01.425
which is a whole nother

00:38:01.447 --> 00:38:03.427
topic that PTs suck at,

00:38:03.547 --> 00:38:07.050
but maybe it's just getting

00:38:07.070 --> 00:38:07.751
the patient moving.

00:38:08.820 --> 00:38:09.820
Exercise will help you.

00:38:09.880 --> 00:38:10.922
What do you like to do?

00:38:11.003 --> 00:38:12.304
What can you do at home?

00:38:12.385 --> 00:38:13.646
So many times we prescribe

00:38:13.706 --> 00:38:14.827
exercises that the patient

00:38:14.867 --> 00:38:15.949
either can't do or is not

00:38:16.068 --> 00:38:18.130
interested in doing at home.

00:38:18.211 --> 00:38:20.954
So just getting, embracing, you know,

00:38:20.994 --> 00:38:22.657
what they will actually do.

00:38:22.677 --> 00:38:23.978
And that's where

00:38:24.018 --> 00:38:24.980
motivational interviewing

00:38:25.019 --> 00:38:25.721
can really come in.

00:38:26.677 --> 00:38:27.757
how likely are you to do

00:38:27.818 --> 00:38:29.318
this exercise program that

00:38:29.338 --> 00:38:30.478
we just talked about today

00:38:30.518 --> 00:38:32.958
and kind of moving in that direction.

00:38:33.059 --> 00:38:34.820
So I'd like to see physical

00:38:34.860 --> 00:38:35.860
therapy research start to

00:38:35.940 --> 00:38:37.420
embrace all of these things

00:38:37.581 --> 00:38:39.262
and to include therapeutic

00:38:39.282 --> 00:38:40.942
alliance and the patient expectations,

00:38:41.001 --> 00:38:41.902
as well as current best

00:38:41.963 --> 00:38:44.143
evidence on exercise and

00:38:44.563 --> 00:38:45.864
manual therapy and those

00:38:45.923 --> 00:38:47.184
kinds of things and kind of

00:38:47.204 --> 00:38:48.885
look at the whole package together.

00:38:48.905 --> 00:38:53.306
And then the other thing that John Childs

00:38:54.059 --> 00:38:55.599
told me we need to stop

00:38:55.679 --> 00:38:56.900
comparing one PT

00:38:56.920 --> 00:38:58.722
intervention to another PT intervention.

00:38:58.762 --> 00:39:00.302
We need to start comparing

00:39:00.422 --> 00:39:01.704
what we do as a profession

00:39:01.804 --> 00:39:03.025
from the initial

00:39:04.518 --> 00:39:05.840
second that we interact with

00:39:05.860 --> 00:39:08.501
that patient until we end

00:39:08.561 --> 00:39:09.802
that episode of care,

00:39:10.041 --> 00:39:11.322
compare that to what

00:39:11.802 --> 00:39:13.143
orthopedic surgeons do or

00:39:13.184 --> 00:39:14.724
that kind of thing and give

00:39:14.744 --> 00:39:15.804
them the whole package

00:39:15.864 --> 00:39:16.746
rather than just breaking

00:39:16.786 --> 00:39:17.786
it down and saying, oh wait,

00:39:17.905 --> 00:39:19.387
what does this manual technique do?

00:39:19.427 --> 00:39:20.668
Or what does this stretch do?

00:39:20.708 --> 00:39:22.809
Or what does this exercise do?

00:39:23.329 --> 00:39:24.530
Use the whole package and

00:39:24.590 --> 00:39:25.550
compare it to other

00:39:25.650 --> 00:39:26.911
standards of care for that

00:39:26.951 --> 00:39:28.751
condition to prove that our

00:39:28.811 --> 00:39:29.853
profession has a better

00:39:29.952 --> 00:39:32.153
answer in most situations to

00:39:32.813 --> 00:39:34.856
you know, the medical model, if you will.

00:39:35.416 --> 00:39:36.737
Yeah, I couldn't agree with you more.

00:39:36.878 --> 00:39:38.619
And some of the, you know,

00:39:38.699 --> 00:39:41.882
kind of details of what we're missing.

00:39:41.922 --> 00:39:43.003
And I know, I mean,

00:39:43.023 --> 00:39:43.885
you and I have been working

00:39:44.045 --> 00:39:45.726
with a bigger group on a

00:39:46.827 --> 00:39:47.907
neck pain clinical practice

00:39:47.929 --> 00:39:48.708
guideline revision.

00:39:48.748 --> 00:39:49.550
And one of the things that

00:39:49.630 --> 00:39:50.570
we've struggled with as a

00:39:50.610 --> 00:39:51.431
group is we can't,

00:39:51.931 --> 00:39:53.172
no one's reporting dosing.

00:39:53.554 --> 00:39:54.474
They're doing menotherapy,

00:39:54.494 --> 00:39:55.215
but we don't know what it

00:39:55.335 --> 00:39:56.777
is because it's not well-defined.

00:39:57.346 --> 00:39:58.666
But I love that idea of

00:39:58.726 --> 00:40:02.228
taking more of like a meta view, I guess,

00:40:02.407 --> 00:40:03.887
of what we're doing from

00:40:03.967 --> 00:40:06.088
beginning to end in, you know,

00:40:06.108 --> 00:40:07.429
an episode of care instead

00:40:07.489 --> 00:40:08.710
of trying to dial into

00:40:08.750 --> 00:40:10.150
these minutial details,

00:40:10.170 --> 00:40:11.030
because we don't have

00:40:11.130 --> 00:40:12.331
answers for dosing for

00:40:12.411 --> 00:40:13.670
exercise or manotherapy.

00:40:13.710 --> 00:40:16.092
We're actually doing a, you know,

00:40:16.231 --> 00:40:17.132
we're lost.

00:40:17.331 --> 00:40:18.333
I think we don't, you know,

00:40:18.353 --> 00:40:19.753
we think that manotherapy

00:40:19.773 --> 00:40:20.932
holds all this power,

00:40:20.992 --> 00:40:22.213
but we know that the

00:40:22.253 --> 00:40:23.554
multimodal approach is best,

00:40:23.614 --> 00:40:24.554
but we still don't know how

00:40:24.614 --> 00:40:26.054
much is the right amount.

00:40:26.532 --> 00:40:27.753
So I love that concept of

00:40:27.793 --> 00:40:29.596
maybe thinking about, you know,

00:40:29.715 --> 00:40:30.797
looking at the forest and

00:40:30.836 --> 00:40:31.878
not so much being in the

00:40:31.938 --> 00:40:33.039
trees and trying to figure

00:40:33.099 --> 00:40:35.340
out how we measure up to

00:40:35.360 --> 00:40:37.121
what's happening in other

00:40:37.262 --> 00:40:38.583
avenues of health care.

00:40:39.244 --> 00:40:39.324
Yeah.

00:40:39.344 --> 00:40:40.525
And that's what if you

00:40:40.545 --> 00:40:41.525
haven't read any of Julie

00:40:41.565 --> 00:40:43.327
Fritz's most recent work,

00:40:43.367 --> 00:40:44.867
that she's kind of taken

00:40:44.889 --> 00:40:45.809
that 20,000 for you.

00:40:45.929 --> 00:40:46.210
You know,

00:40:46.710 --> 00:40:49.172
it doesn't matter what you do in a,

00:40:49.192 --> 00:40:50.052
you know,

00:40:50.702 --> 00:40:53.806
from treatment to treatment, what you do,

00:40:53.905 --> 00:40:55.086
it's kind of stepping back.

00:40:55.166 --> 00:40:56.628
Is it more of an active approach?

00:40:56.708 --> 00:40:58.929
Are you using current best evidence?

00:40:59.010 --> 00:41:00.170
Are you educating the

00:41:00.190 --> 00:41:01.231
patient and that kind of

00:41:01.251 --> 00:41:03.032
thing and looking at the whole package?

00:41:03.052 --> 00:41:04.114
Because what we do as

00:41:04.173 --> 00:41:06.657
physical therapists is not

00:41:06.737 --> 00:41:08.398
manual therapy or exercise

00:41:08.538 --> 00:41:09.239
or this kind of thing.

00:41:09.278 --> 00:41:10.239
It's a whole package,

00:41:10.300 --> 00:41:12.661
which those soft skills are

00:41:12.742 --> 00:41:13.943
such a huge part of.

00:41:14.523 --> 00:41:14.802
Yeah.

00:41:14.943 --> 00:41:15.923
And those are the things

00:41:15.943 --> 00:41:17.585
that I think as educators

00:41:17.626 --> 00:41:18.867
are the most challenging for us

00:41:19.487 --> 00:41:20.648
to figure out it's kind of

00:41:20.688 --> 00:41:22.170
that affective domain of learning.

00:41:22.230 --> 00:41:24.592
How do we keep scaffolding

00:41:24.612 --> 00:41:26.494
that in to the curriculum?

00:41:26.534 --> 00:41:27.835
So our students really

00:41:27.875 --> 00:41:28.775
appreciate that as a

00:41:28.835 --> 00:41:31.237
skillset and not just their

00:41:31.318 --> 00:41:33.059
perceived need to develop

00:41:33.079 --> 00:41:33.940
psychomotor skills.

00:41:34.041 --> 00:41:35.081
Cause I think some of the

00:41:35.121 --> 00:41:36.163
other ones are equally,

00:41:36.182 --> 00:41:37.123
if not more important.

00:41:37.264 --> 00:41:38.304
And I think patient

00:41:38.344 --> 00:41:39.646
expectation is a part of that.

00:41:40.806 --> 00:41:41.588
Okay, so top,

00:41:42.108 --> 00:41:43.668
Top two or three things that

00:41:43.789 --> 00:41:45.208
you as we kind of wrap up

00:41:45.248 --> 00:41:46.309
our conversation that you

00:41:46.349 --> 00:41:49.610
want our listeners to think about,

00:41:49.670 --> 00:41:50.791
whether they're educators

00:41:50.871 --> 00:41:52.932
or clinicians or students

00:41:53.052 --> 00:41:55.054
or residents or fellows in training.

00:41:55.094 --> 00:41:56.755
Give me like a top two to

00:41:56.795 --> 00:41:58.135
three things that you want

00:41:58.175 --> 00:41:59.516
people to walk away remembering.

00:42:02.387 --> 00:42:02.628
Well,

00:42:02.949 --> 00:42:05.452
I think just acknowledging that the

00:42:05.512 --> 00:42:06.393
person sitting in front of

00:42:06.413 --> 00:42:07.894
you is a human being that's

00:42:08.096 --> 00:42:09.456
bringing a lot of things to

00:42:09.496 --> 00:42:11.159
the table that you know nothing about.

00:42:11.280 --> 00:42:12.882
So exploring that a little

00:42:12.902 --> 00:42:15.905
bit and finding out what they believe,

00:42:16.005 --> 00:42:17.748
what they think, what they've heard,

00:42:18.088 --> 00:42:18.849
those kind of things.

00:42:19.521 --> 00:42:20.623
And then trying to tailor

00:42:20.643 --> 00:42:22.844
your treatment approach to

00:42:22.885 --> 00:42:24.726
that individual human being

00:42:24.806 --> 00:42:25.746
who's sitting in front of you.

00:42:26.547 --> 00:42:29.050
I like to say to patients,

00:42:29.070 --> 00:42:30.231
the good news is you're in

00:42:30.271 --> 00:42:30.931
the right place.

00:42:31.612 --> 00:42:34.114
I see this a lot.

00:42:34.134 --> 00:42:34.875
There's current best

00:42:34.954 --> 00:42:36.556
evidence that shows that we

00:42:36.576 --> 00:42:37.637
can make some improvements

00:42:37.836 --> 00:42:39.599
in this area overall.

00:42:40.559 --> 00:42:42.699
just really involving them in the,

00:42:43.019 --> 00:42:45.681
the overall shared decision-making,

00:42:45.740 --> 00:42:46.300
that type of thing,

00:42:46.340 --> 00:42:48.442
involving your patient in their,

00:42:48.641 --> 00:42:50.262
their plan of care overall.

00:42:50.762 --> 00:42:51.501
And then, you know,

00:42:51.541 --> 00:42:53.422
moving forward with them as a team,

00:42:53.483 --> 00:42:54.523
rather than you being the

00:42:54.563 --> 00:42:55.682
dictator and saying, you know,

00:42:55.702 --> 00:42:56.682
this is what we're going to do.

00:42:56.782 --> 00:42:57.603
And today we're going to do

00:42:57.643 --> 00:42:59.264
this and that type of thing.

00:43:00.603 --> 00:43:01.384
And then again, that,

00:43:01.543 --> 00:43:02.563
that therapeutic alliance,

00:43:02.623 --> 00:43:03.523
just getting to know who

00:43:03.543 --> 00:43:06.385
your patients are before you, you know,

00:43:07.172 --> 00:43:09.275
enter that relationship with

00:43:09.315 --> 00:43:11.275
them is so powerful.

00:43:11.476 --> 00:43:11.695
I mean,

00:43:11.715 --> 00:43:13.097
talking to them about their kids or

00:43:13.137 --> 00:43:14.478
their dog or things like that.

00:43:14.579 --> 00:43:14.898
I mean,

00:43:15.278 --> 00:43:16.780
that has such therapeutic value

00:43:16.800 --> 00:43:18.300
that we can't really put a finger on,

00:43:18.360 --> 00:43:19.722
but just having that,

00:43:20.103 --> 00:43:22.224
that interaction with the

00:43:22.244 --> 00:43:23.585
human being that's in front of you.

00:43:24.166 --> 00:43:24.346
Yeah.

00:43:25.065 --> 00:43:25.306
Okay.

00:43:26.527 --> 00:43:28.088
Um, what book are you currently reading?

00:43:28.108 --> 00:43:32.070
I didn't put that on the list,

00:43:32.090 --> 00:43:33.793
so sorry to spring that one on you.

00:43:34.012 --> 00:43:34.393
Yeah.

00:43:34.652 --> 00:43:34.952
Yeah.

00:43:35.414 --> 00:43:35.494
Um,

00:43:36.297 --> 00:43:37.938
I am reading this book

00:43:38.018 --> 00:43:39.278
called The Holographic

00:43:39.398 --> 00:43:40.978
Universe right now that

00:43:41.119 --> 00:43:42.739
kind of explores

00:43:42.998 --> 00:43:44.699
spirituality and quantum

00:43:44.760 --> 00:43:45.980
physics at the same time.

00:43:47.019 --> 00:43:49.320
We always hear we're all connected, right?

00:43:49.400 --> 00:43:50.141
Everything's connected.

00:43:50.181 --> 00:43:51.681
Well, on a physical level,

00:43:51.701 --> 00:43:54.021
at the quantum physics level, it's true.

00:43:54.481 --> 00:43:57.902
And so it's just interesting

00:43:57.942 --> 00:43:59.262
to kind of explore that.

00:44:00.422 --> 00:44:01.302
And how did you get there?

00:44:01.362 --> 00:44:02.342
How did you find that book?

00:44:02.402 --> 00:44:03.503
Was that a recommendation or?

00:44:04.693 --> 00:44:04.893
Yeah,

00:44:05.293 --> 00:44:06.414
I think it was another book that I

00:44:06.474 --> 00:44:08.735
read that was kind of talking about,

00:44:08.896 --> 00:44:09.137
you know,

00:44:09.476 --> 00:44:11.797
when you get down to that

00:44:12.097 --> 00:44:13.659
quantum level overall,

00:44:13.719 --> 00:44:15.940
how everything is connected and, you know,

00:44:15.980 --> 00:44:17.721
the whole wave particle duality thing,

00:44:18.422 --> 00:44:20.222
you know, is it a wave?

00:44:20.282 --> 00:44:20.983
Is it a particle?

00:44:21.003 --> 00:44:22.403
As soon as you start to observe it,

00:44:22.443 --> 00:44:23.043
things change,

00:44:23.083 --> 00:44:24.005
which is what happens in

00:44:24.085 --> 00:44:24.965
our patients too.

00:44:25.005 --> 00:44:26.846
When you pay attention to them, you know,

00:44:26.905 --> 00:44:28.146
things change overall.

00:44:28.186 --> 00:44:28.387
Yeah.

00:44:29.568 --> 00:44:30.467
Well, Paul,

00:44:30.507 --> 00:44:31.887
I just want to thank you on

00:44:31.949 --> 00:44:32.708
behalf of the AMT

00:44:32.768 --> 00:44:34.168
organization and myself for

00:44:34.208 --> 00:44:35.248
taking the time to talk to

00:44:35.329 --> 00:44:36.188
us a little bit more about

00:44:36.248 --> 00:44:37.329
patient expectations.

00:44:37.409 --> 00:44:41.070
And I think why we value you

00:44:41.230 --> 00:44:43.210
as a member of AMT and as

00:44:43.251 --> 00:44:45.831
an educator is you're in all of it.

00:44:45.931 --> 00:44:48.532
You're in the educational piece,

00:44:48.751 --> 00:44:50.411
you are in clinical practice,

00:44:51.152 --> 00:44:52.333
and you're doing research.

00:44:52.393 --> 00:44:53.072
And so I think

00:44:54.385 --> 00:44:55.987
listening to you, it just, you,

00:44:56.166 --> 00:44:57.909
you so eloquently kind of

00:44:57.989 --> 00:44:59.329
weave all of this together

00:44:59.409 --> 00:45:00.231
because you're doing all

00:45:00.271 --> 00:45:01.351
those things concurrently.

00:45:01.431 --> 00:45:04.313
And I highly value that, that about you.

00:45:04.414 --> 00:45:06.436
So I appreciate, you know,

00:45:06.476 --> 00:45:07.336
hearing your insights and

00:45:07.376 --> 00:45:08.157
having you share a little

00:45:08.197 --> 00:45:09.699
bit more with us about this topic.

00:45:10.378 --> 00:45:10.719
All right.

00:45:10.800 --> 00:45:11.239
Well, thanks.

00:45:11.320 --> 00:45:12.121
It's been a pleasure, Amy.

00:45:12.641 --> 00:45:12.902
Okay.

00:45:12.961 --> 00:45:13.242
Thank you.