Although there appears to be consensus that pysical therapy is an integral component of pain management centers, few physical therapists have received adequate training in clinical pain mechanisms and pain management strategies, which is somewhat remarkable considering that the chronic pain prevalence is estimated to range from 10% to 55%. The International Associaton for the Study of Pain (IASP) has developed a specific pain curriculum for occupational and physical therapy education (http://www.iasp-pain.org/ot-pt_toc.html), yet there is no evidence that htis or similar curricula are commonly taught in physical therapy academic programs. It should then come as no surprise that many phsyical therapists lack knowledge on pain managment and may not be all that interested in working with persons with chronic pain.

According to Wolff and colleages, 96% of orthopedic physical therapists prefer to work with patients who are not likely to have chronic pain. A search of the membership directory of the Orthopedic Section of the American Physical Therapy Association (APTA) suggests that its Pain Management Special Interest Group has less than 400 physical therapy members out of a total APTA membership of about 64,000, which equates to approximately 0.6 percent (from “members only” section of http://www.orthopt.org, accessed October 30, 2004). A similar search of the membership directory of the American Academy of Pain management suggests that there are less than 100 identifiable physical therapy members out of a total of approximately 6,000 members (less than 1.7 percent)(http://www.aapainmanage.org/search/MemberSearch.php, accessed October 30, 2004). The apparent lack of professional interest and insufficient education and knowledge in pain mechanisms and pain management strategies can create multiple challenges for physical therapiests to become effective pain management clinicians.

As for my impression that what I consider suitable protocols (i.e. “manual therapy” and “movement therapies” in the words of the above author) are much more common among chiros, it comes from searching for practitioners of any sort who had those skills, both in google searches and databases, and from noting the backgrounds of the authors of the articles I’ve read. It is an impression, but I believe it’s correct.

Sorry to be too slow getting back, I’ve been working on other things, and don’t like being sucked into debates. The reason I mentioned those protocols is because when I searched the archives of this blog for them, the only mention was disparaging – it appear that Dr. Novella considers them woo.

I personally have not had manipulation done, but based on comments I’ve read by chronic pain sufferers, manipulation gives them temporary relief – that’s called “pain management.”

I think it’s wonderful that you know those protocols you’ve mentioned, but the truth is they’re rare for PTs, (see the link I provided – written by a PT, I might add), and much more common for chiros.

My experience with PTs has been generally that their approach to everything revolves around weightlifting – which did make me a little stronger, but aggravated my symptoms. Ultimately I found I had to to do my own reading, experiment and self-treat.

I should note that I’d forgotten about one PT I saw who did manage to give me some relief, using an unusual technique involving arm manipulation as I held air in my lungs. This was a U.S.-educated PT I saw briefly in Taiwan, though unfortunately no other PT I described the technique to had any idea what it was, and by the time I managed to contact him again, it had been so many years that he himself couldn’t identify it… however, it strikes me as similar to a description of muscle energy technique as described in another article by the same PT who wrote the link I provided above. As it happens the only L.A. area PT I’m aware of who knows this technique is way the hell over in Beverly Hills; although there is a chiro who knows it fairly close to me. By this point I’m no longer interested in seeing any practitioner, though. I find the library more helpful.

Besides failed clinical trials are not “lack of evidence” but “evidence against”, and there are plenty of failed clinical trials for a whole host of common snake oil medicine.

http://www.theatlantic.com/life/archive/2011/06/evidence-not-anecdotes/240588/

This is, of course, utter nonsense. Mr. Freedman was completely unable to refute a single point I made. Instead, he posted a long, rambling, nearly incoherent angry comment, chock full of ad hominems and logical fallacies.

Yes – Lindor is wrong in his interpretation of the literature. That is largely what this whole controversy is about. We write about this exhaustively at SBM – proponents are trying to change the rules, they are cherry picking evidence, and they are misinterpreting the significance of research. But they have an appealing marketing strategy – it just doesn’t hold up to close scientific scrutiny. We do that – and then we get dismissed as closed minded and dogmatic. But that’s just part of the marketing strategy – and it unfortunately works. Freedman bought it.

Freedman claims he would pick you for his physician. A plug!

It seems that different people would respond to different placebos. If I were going to give you a placebo I’d go with an injection that caused mild discomfort. Am I right?
Some would do with a pill, others encouragement.
A mother’s kiss seems universal, but it’s not just any mother.

The factors that would determine what placebo was good for what person might include their education, profession, genetics, philosophy, sex, sexual orientation, religion,birthplace, age…
I’m not sure it would make sense to try to change any of those to make a placebo work. It seems one could just use the placebo that fit the situation– Some people would probably respond to touch better than pill- and vice-versa, for example.
Some people will respond to statements like “You are doing so well,” others might prefer, “We are healing the body,” others might respond to “Mumbo jumbo wombo tombo,”
I’m not sure the studies have been completed on this.
In the meantime, it seems pragmatic to go with what is seen to be working best, right?

I think that is what Freedman is trying to say here.

I acknowledge that the current demand requires a system that can provide more time with patients than the current system allows. There are ways to fix this – proposals that have already been made and to some extent incorporated. One mechanism is increased use of physician extenders – APRNs, LPNs, etc. Therefore you get the best of both worlds – the physician’s time (and therefore expense) is used efficiently, while the bulk of the time with the patient spent by a trained practitioners who specializes in patient education, preventive management, nutrition, and lifestyle risk factors.

But what if what a lot of patients want is to have more time with the person doing the diagnosis and prescribing the therapies? The impression I get is that what a lot of people want.

As a PT who has been educated in Feldenkrais, and trigger point therapy, and is trained in manips, and comes from a country where we use Tai Chi as a government funded falls prevention strategy. Let me point out a few things -

Feldenkrais is just motor relearning – not mysterious.

Trigger point therapy is just manual therapy – not mysterious.

Tai Chi is just slow controlled exercise – not mysterious.

Manipulation is no more effective than mobilisation of a specific vertebral segment – which all PTs are trained in.

As pointed out by Steve many times – If you strip off the woo and BS that underlies some of these interventions, they are very normal, standard, “Western medicine” approaches.

“…PTs are trained to focus on acute problems, and to deal with pain, if at all, as a symptom of an acute physical disability rather than as a problem in itself. This is the reason they typically are not interested in chronic pain. So I’m all in favor of reforming this aspect of physical therapy, but until that happens, chiros are going to necessary in order to fill that gap.”

What on earth makes you believe chiros are more equiped / better trained to deal with chronic pain??? (manipulation / mobilisation has only shown to be effective in acute pain – not chronic pain).

As pointed out I am trained in a number of the modalities you mention, however I don’t style myself a Chronic pain specialist. I don’t pretend to know it all, or be able to fix it all.
I (hope) I am professional enough to know where my expertise ends and a referral to our local pain clinic is indicated, I am not sure that the chiro theory of Life the Universe and Everything allows them the freedom to say – “I dunno, but I’m going to send you to someone who will know”.