Sista 4-5 åren har Keith Waldron inspirerat och utmanat mig inom många aspekter av neuromuskuloskeletal smärta.
Slutligen bestämde jag mig för att få ner några av hans tankar på papper, blant annat om den biopsykosociala modellen och vilka olika metoder det fins där ute för att behandla patienter med smärta.
Intervjun är lång och på engelska, men full av nyttiga tankar!
Who are you?
My name is Keith P. Waldron, PT, DPT. I am a physiotherapist in the state of New York in the United States. I initially obtained my Master’s degree in Physical Therapy in 2000; I later returned to academia and earned my Doctorate in Physical Therapy in 2007.
Over the course of the last 17 years, I have worked in a variety of settings including public and private schools, outpatient clinics, and home care. Since 2012, I have provided physiotherapy care exclusively in the home, working jointly with skilled nursing, occupational therapy, and medical social service professionals to comprehensively address the patient’s medical and social needs (to the best of our respective abilities).
I also hope to finalize the formation of a private practice in June 2017 – my objective is to provide quality physiotherapy care in the home when insurance regulations cease to cover traditional home services.
How did your evolution as a therapist come about?
In some respects, my approach to physiotherapy care has nearly come full circle since I started practicing in 2000; I wager that someone watching me practice in 2001 may not see a significant difference in my approach today, although I am less playful with a patient who is 80 years old than I was with patients who were 3 years of age.
When I was working with children with developmental disabilities as a naive but confident new-grad, I already knew that the more a child liked me, the more they enjoyed “playing” with me, and the better I understood what motivated them, the stronger our relationship would be and the more likely I would be to successfully help them explore their environment and expand their mobility repertoire. In contrast, when I started working in the adult population, with patients with (primarily) neuromusculoskeletal complaints, my mindset shifted.
In my mind, if children had been unmolded clay, adults were broken pieces of pottery. I was no longer teaching; I was rehabilitating. I was fixing someone that was broken. Tears. Sprains. Strains. Ruptures. Tweaks. Problems. Derangements. Shifts. Syndromes. It was my job to treat and fix them all.
I made efforts to learn as much as I could afford. I attended a series of classes on a variety of techniques and theories including Myofascial Release, Muscle Energy Techniques, Postural Restoration, and Graston ASTM. I learned approaches developed by physio luminaries such as McKenzie and Maitland, as well as osteopaths such as Greenman. With each course, I learned more to do to patients and different ways to dissect, categorize, and envision their pathologies. With each course I got smarter and found new ways to help my patients. Nowadays, such therapists are considered eclectic. That is just a nice way of calling someone a physio-hoarder (hat-tip: Barrett Dorko).
In 2011, I was preparing to add Movement Impairments Syndromes to my already cluttered therapy closet. I made it through 46 pages of Sahrmann’s text before wondering, “Is this evidence-based?” A quick internet search later and I was scanning a web forum that had been previously unknown to me: SomaSimple. This is where I was first exposed to the concepts surrounding what has been referred to as “modern pain science”.
What are these concepts, and how did they change your understanding of painful complaints?
When I first started scanning through SomaSimple’s forums, I wasn’t sure what to make of it all – it just seemed like another group of people with their own (strong) opinions on things. The link I discovered on the site with information pertaining to Sahrmann was not favorable to her text or her hypotheses, but the random posters on that message board were no more credible than any other site that would have praised the same methods.
That being said, there was something that I read on SomaSimple that shook the bedrock on which all of my professional thinking pertaining to the treatment of pain was grounded. It wasn’t a long post, but it was a powerful one. The words were clear and pierced through me in a way no others have in my professional life.
“When the [patient’s] primary complaint is pain, the treatment for pain should be primary.” – Barrett Dorko
It was an “Ah-ha!”-moment for me, as I realized that I was trying to make joints more symmetrical in hopes that a person’s pain would go away. I was trying to make muscles stronger in hopes that a person’s pain would go away. I was trying to change the alignment of a skeleton (again) in hopes that a person’s pain would go away. To date, my treatment was targeting the wrong thing. I was working incredibly hard to address a variety of flaws that I found in an evaluation that may have had little to do with the patient’s actual complaint.
I quickly began absorbing thoughts, information, and ideas from Melzack and Wall. Moseley and Butler. Louis Gifford. I learned about the Neuromatrix and Anzio Beach. I learned about how Descartes tried his best, but got it all wrong. I learned about how there are no pain signals, only nociception – and it isn’t even necessary for a painful experience. I learned that pain is a defense mechanism, not necessarily an indication of a defect in the human organism. This has lead me further down the “rabbit-hole” into readings on neuroscience, placebo, embodied-cognition, predictive-processing, causality, emergence, and consciousness – none of which have directly helped me become a better therapist (I don’t think), but they have certainly helped me acquire a more nuanced and uncertain view of the subject before me.
And – I’m sorry, this is a long way to answer your question. Okay, I’ll try to condense it down. The concept that I learned was this: Pain is not a signal from peripheral tissues that is mediated by other factors in a person’s life. It often occurs in the absence of overt injury. Pain is best viewed – for me, anyway, as best I understand it today … it is a small aspect of a person’s conscious experience (to the best of our knowledge, an often predictive, but entirely neurological and emergent phenomenon) that initially evolved to defend that person from a threat, whatever that may be. Pain is something that we (as physios) don’t have access to – it is a subjective experience, a qualia, unique to one person – yet it is our job to treat it.
I mean, really – think about it for a moment. The brightest scientific and philosophical minds that the world has ever known don’t know the answer to Chalmers’ “hard problem”, and I had the hubris to be confident that I was going to make a person’s pain go away in their low back by having them do a some lumbar extensions every few hours? That if their pain didn’t go away, they must be a wimp, or faking it? That if their pain was severe, there must be something severely wrong with them? That if their pain was constant or long-standing, that I wasn’t likely to help them? Nah, I started to know better, and I started to see the patient with painful complaints through a whole new – hopefully more empathetic – lens.
Would you describe it as pain being “in the brain”, and if so, does this not just move the explanation one step further (now the pain is not from the muscles, but from the brain)?
No – I wouldn’t. And don’t get me wrong, it wasn’t long ago that I was “that-physio”. You know the one … the guy with the meme-like phrases. Pain is in the brain. Know pain, know gain. The issue isn’t the tissue. It was an exciting time to be learning how powerful and important an understanding of the nervous system was, and I wanted every one of my patients to know that they needed to reshape their own understanding of why they were suffering. There were more catch-phrases too, but I have stopped using them, so they are aren’t readily available to me at the moment.
But, no – nowadays, when I am working with patients with painful complaints (be their pains acute or chronic), I will complete a very thorough neuromusculoskeletal assessment to expressly point out all the many things that are “good” or “normal” for a patient. As I am able to show them all that is right, we can begin – over time – to have a conversation about defense vs defect. Maybe we talk one day about a grandchild who is a predictably cranky at the end of the night. Maybe another day I’ll share a story about by buddy’s school-aged son who was hitting his siblings with his new cast, although the bone was still broken beneath. Those sort of stories work well with patients with post-operative pain especially, probably because they are so relatable.
More often, though, it is most important to help the patient craft their own story (over time) that affords them an opportunity to view their pain from (perhaps) a more stoic, less fearful perspective. Maybe we talk about how their arthritis looks the same on radiograph on Monday as it does on Tuesday, yet some days hurt a lot more than others (“Is it really the arthritis that hurts?”). Or maybe we talk about stress responses and circumstance: how they don’t stress out if their automobile’s low-fuel light is illuminated when they are driving in town or close to home, but the same light might stress them out if they were on an isolated highway that they were unfamiliar with. Same stimulus, different response. Regardless, I try to help them understand that their personal experience of pain as a defense mechanism, and that there are ways that we can work together to potentially mediate their painful experience.
And please don’t think that I am disparaging Explain Pain or Therapeutic Neuroscience Education – nothing could be farther from the truth. Physios like myself have learned so much from Moseley, Butler, and Louw, and I find their work to be very interesting and compelling – but it isn’t what I do best. Perhaps it is my patients, but the problem is most likely in me. I probably didn’t practice enough, or wasn’t flexible enough. Maybe I needed a better accent, or more credibility. I don’t know. All I know is that I failed as much (or more) than I succeeded and I found that “painful yarns” (hat tip to Moseley – See! I do respect his stuff and his approach.) … but yeah, I find stories are far more palatable for my patients than outright education with handouts, a whiteboard, and the like. I usually don’t even mention the brain anymore.
One can see a change to explain the effects of our treatments not on a biomechanical change (such as the breaking of adhesions), but on “neurophysiological effects”, such as descending inhibition.
Do you feel that this is a step in the right direction, or is this problematic in some way?
I take it that you are speaking of primarily the neurophysiological effects of manual therapy interventions?
[audible sigh] So you’re taking us there, huh?
Okay. Yes, there is no doubt in my mind that a move away from a biomechanical explanation for the effects of manual therapy interventions is a step in the right direction. But – and this is a huge ‘but’ in my mind … BUT, there is also an inherent problem in this line of reasoning, because it is a necessary and intellectually honest step that firmly places us into a [metaphorical] corner where there is a bucket full of warm water and soap conveniently allowing us to “neuro-wash” every treatment technique that we have ever used, and many we have considered dismissing in the past. The “neurophysiological effects”-narrative effectively kills the requirement for biological plausibility when introducing new interventions. No biological plausibility? No problem!
Anything is a stimulus and literally anything can cause a change, even if only in the short-term. Cupping needn’t release fascia, it is a neuromodulatory experience. Scraping someone’s skin with a metal implement isn’t breaking adhesions, is it neuromodulatory. Tightly wrapping a limb with a bicycle tire inner-tube is neuromodulatory. Laterally stretching skin is neuromodulatory. Sticking a needle into painful tissue is neuromodulatory. Cracking the spine (pardon me, high-velocity thrust manipulation – that sounds far more professional) … cracks and pops are neuromodulatory. Heck, rubbing a facial tissue on your cheek is neuromodulatory. With a compelling narrative, any and all of the manual therapy tools and techniques at the physio’s disposal may provide short-term benefit to any given patient under specific (but as yet unknown) circumstances, and our colleagues will continue to become ever-more creative in the years ahead as they try to develop their own up-to-date, science-informed, neuromodulatory technique to market to an ever-increasingly large population of potential patients suffering with painful complaints. And sure, some will predictably have slightly larger but still modest effect sizes with an always small number of patients, but advocates will continue to push for more studies to find the best sub-groups of patients for their preferred method.
And it is all with the best of intentions, right? We are just looking for a “window of opportunity”, are we not? We are only looking for a chance to help the patient feel a little better for a brief moment in time, so they might move a little more, gain a little more confidence, do a little more at home, feel a little better, and begin on their path to recovery. Our pursuits are noble, after all, and we all think that we are good at what we do while most patients don’t improve nearly as much as we think.
We remember the folks who come back to our clinics for follow-ups and praise us for how much we helped them, not the ones who stopped coming in after 3 visits. You recall the guy who came in for a few weeks in 2015: he had a history of on/off-again low back pain that flares 2-3 times per year. That guy raved about how much better he felt after working with you and how much better you were than all the other physios in the past. They did things differently, and the effects never lasted. When you discharged him, he hadn’t felt that good in years and he never came back in again. What a success story he was – never mind that his history indicates that he most likely had another flair, and if you didn’t see him again, it’s probably because he went to a different physio.
And, yeah, I know that there are folks out there who are rock-star clinicians who get most of their patients better – until they work with a recently divorced 63-year-old Vietnam vet with ETOH, COPD, and DM who has been on worker’s compensation for the last 10 years due to complaints of chronic non-specific low back pain. Of course, this patient can improve too – but it will likely take a long time, a lot of energy, more downs than ups, and a genuine investment in providing humanistic care to a patient with a complex complaint. Which of course leads us to consider again how much better off he is with a physiotherapist who appreciates that a biomechanical view of this patient’s pain is an erroneous one and who is willing to take a wide-angle view of the patient.
Could you expand on what “humanistic care” is, and is it different from practising within a BPS (bio-psycho-social) framework?
To be honest, it is likely an exercise in semantics. Nonetheless, I think it is a very important exercise for physiotherapy to consider, because – and I understand that this is probably a minority position – classifying our care as a biopsychosocial approach is intellectually dangerous.
Whether we like it or not, moving from a biomedical to a biopsychosocial framework is a step in the right direction, but it remains both erroneous and reductive. Last year, I called it “a skyscraper favela in an earthquake zone held together with duct tape.” And I while I completely confess to a bit of hyperbole, I will stand by the intent of those words.
Historically, the biomedical framework unforgivingly chopped up persons into two dominant pieces: the physical body and the mind. Today we appreciate that the body and the mind are inseparable, but we still break up the person into similar arbitrary constituent parts for study and evaluation including the biological (formerly body), psychological (formerly mind, now acknowledging relatedness to biology), and sociological. See how smart we are? We added environment and culture! Now we’ll be good therapists, right?
And before anyone were to accuse me of an ad hom (folks don’t like to be called reductionists, even if it is only inferred), I am not arguing that those who claim to use a “BPS-approach” are horribly-evil reductionists – hell, we are all reductionists, and there are many tremendous wiser-than-me physios who I have a great amount of respect and admiration for who disagree with me. I also grant you that well-read and wise clinicians who have been practicing for many years, who are leaders in their field, or who are actively engaged on social media may very-well see a patient at a more meta- , rather than micro-, level. I would argue, though, that even in that instance, BPS is an inherently flawed term and explicitly invites [especially newer and inexperienced] clinicians to view their patient through a series of parallel myopic perspectives.
And while many may think that humanistic care is just the BPS-approach by a different name (and, depending on the clinician, that may be true) I prefer the term humanistic, because I think it more accurately portrays how we wish to interact with the person who seeks our care. Thinking of human-kind reminds us that we are social biological creatures. The notion of humanity is inclusive of a our history – the good and the bad. Human-ness is about relationships and interactions – all those that fail and those that succeed. Human experience cannot be separated from feelings and emotions, simultaneously affording us both hope and despair. It is our own humanity, as therapists, that allows us to empathize and have compassion and in turn provide authentic care. The term humanistic, then, serves as a firm semantic reminder that, while we necessarily practice reductionism when we evaluate and care for our patients, we need to make a conscious effort to always see the whole person – the human, with all our collective history, beliefs and experiences – seeking our care.
It sounds like the BPS framework is a good guide in our work with patients, would you agree?
Yes, I think so – it is an ultimately fallible guide, but it the best guide that we have available to us at this moment.
There is, understandably so, a huge focus on results in therapy. I just read this quote from a prominent therapist in the field: “”Some people need studies. Whatever, they don’t really mean shit to me. I need results. It’s all I care because I care about my patients and do what works.
If you get results with patients, then that is all that matters, no? Or is there more to “results” than meets the eye?
Ah, the nostalgia. Hooray for the 70s and 80s! Hooray for when we were helping our patients – except for when we weren’t. Hooray for gurus and their slanted views. Hooray for passive modalities and “therapeutic” ultrasound! Hail the days when I could do whatever I thought might help and could feel good doing it! And – oh! – our patients LOVED us for how helpful we were then too!
I couldn’t more strongly disagree with such ridiculously righteous views, which are an affront to scientific reasoning and set our profession back decades in thinking. The hubris to think that one is either ahead of the science, or that science simply doesn’t apply to them, is beyond reproach and is almost certainly fantastical whimsy at best, dishonest charlatanism at worst. Do they think that they care more about their patients than other therapists? Are they that much better than other physios who are more inclined to rigorously vet their interventions based on scientific literature?
I would wager that there are literally hundreds (if not thousands) of “emerging” interventions across the world at any given time – the likelihood of ANY of them resulting in greater efficacy than placebo in well controlled studies, or that their results would significantly improve on already-established interventions is infinitesimally small, yet everyone out there with a new or different idea thinks that theirs is the new and novel intervention that gets patients better more successfully than any other. In each instance, they think that they – or what they do – is somehow special. Each thinks that they are a some sort of rare physiotherapeutic unicorn; they may be remarkable steeds, but none possess the alicorn that they cherish. History tells us that it is far more likely that such a clinician’s patients get better because they have unknowingly or intuitively mastered patient interaction, engagement, and alliance (cough, cough, non-specific effects and placebo) rather than having discovered a yet-to-be-proven means of positively improving the patient’s physiology.
Do results matter? Of course they do, but everyone gets results. EV-ER-Y-ONE. The reality is that the worst physio in your district, town, or city has devoted patients who think they are the best. Consider what we know about statistical variances/outliers, or recall bias, or the implications of natural history, or regression to the mean, or non-specific effects. I’m sorry, but if – even with a considerable understanding of all those confounding variables – a physio tells you that they don’t need studies to inform them of the benefit of their chosen interventions, they are doing themselves and our profession a disservice (and maybe their patients too.)
There are a lot of different methods and systems marketed in physical therapy, for fresh graduates it is no doubt hard to separate the wheat from the chaff.
Do you have some good tips on how to spot bullshit, and what do you consider to be good sources of information?
I think so – but I completely acknowledge my own biases and strongly encourage students to be skeptical of my own recommendations or tips.
That being said, the first thing to do is discard any new or up-and-coming method or system that revolves around the thoughts or insights of a single, isolated person. Odds are they are wrong, and science will confirm if they aren’t over time.
Second, if the system or method revolves around the therapist’s acquisition of skills that result in what I call magic hands – hands that feel and do things that they can only master after many, many classes and hours upon hours of instruction/practice – be skeptical. I would posit that manual therapy courses (should they be something that a physio is indeed interested in) should focus on the process and thinking behind manual therapy, not somehow miraculously improving what your hands are capable of.
Third, beware any intervention that uses “-neuro-” in its name. Some organizations may very well be legit, and I am not at all aiming to disparage all interventions that reference neuroscience, but we have to admit to ourselves that it has become the cool-thing to do to reference neuroscience in nearly every course. Again, just be skeptical. I, for one, consider NOI Group to be an exception to this rule, but there are many others other there without the supporting evidence that Butler, Moseley, etc have. And if neuroscience is the it-thing, then it is certainly a wise marketing strategy to reference “neuro” to sound as science-like as possible, but I would be skeptical about how measured and scientific they are in their neuroscientific thinking.
Which ties into the fourth recommendation – if it sounds too good to be true, it most certainly is. There is not EVER going to be a panacea for all patients with painful complaints. All injuries cannot be prevented. Not gonna happen. Not in my lifetime and not in my grandkid’s lifetime. ANY course that advertises that their intervention helps every patient, or prevents most injuries, or eradicates all pains are being dishonest from the get-go and are to avoided.
And as for how to find good information – first and foremost read. It is virtually free. You can do it on your own schedule. Read enough to understand physiology and biology – it will help you laugh at bullshit, rather than be taken for an eventually embarrassing ride by the biologically implausible. Read about what interests you (and sometimes the stuff that doesn’t). Read about all the stuff that school didn’t teach you. Read about psychology. Read about socioeconomics and culture. Read about things like placebo, the scientific process, and patient interaction/motivational interviewing. Go online and watch relevant videos and lectures from leading figures in such fields. Engage with people on social media, or lurk and read what others are thinking and writing. Be an autodidact – forever learn, but learn with purpose, intent, and passion. Learn to better yourself – a better you is best for your patients.
Thank you so much for your time, Keith!
Where can people find out more about you?
As most of my extra-time is devoted to family and getting a new PT-practice off the ground, I spend less time on social media than I once did. That being said, I am often lurking on Twitter as @waldronphysio, and I would encourage anyone to reach out to me there if they felt compelled to do so. I am pretty good at responding in less than 24 hours, as I hope you would attest to. People should be warned though, if they follow me, I plan to use the platform to promote issues that impact my current patient population, with an emphasis on chronic conditions especially (e.g. COPD, CHF, Diabetes).
That’s not to say that I don’t RT materials from, or engage with, those who are more pain-science-focused in the twitter-sphere, my interests are simply a bit more varied now than they were in the past.