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Considering career as Physical therapist but having doubts with newfound TMS knowledge

Discussion in 'General Discussion Subforum' started by Kingkong, Mar 16, 2019.

  1. Kingkong

    Kingkong New Member

    I am in the midst of my jouney to subsiding my TMS. I am currently finishing reading the Great Pain Deception and it has brought massive amounts of clarity regarding TMS and the work that I need to do.

    I have a bachelors degree in sport science. And for many years have considered pursuing a masters in Physiotherapy/ physical therapy.
    Now, however, with my new found knowledge, I am questioning how easy it is for physiotherapists around the world to mislead patients. They are misleading them either due to not knowing about psychosomatic pain, or knowing about it and not disclosing the knowledge to "chronic pain patients" because repeat customers are their bread and butter. So I have a moral dilema in this regard.
    Next, lets say a patient comes with back pain or shoulder pain. The physiotherapist does not have time to ask the patient about their history and anxiety. Most physio clinics are fully booked and have no time for extra chitchat its like a conveyor. So how is the physiotherapist supposed to establish whether the pain is actually structural in nature or psychosomatic without having time to run "psychotherapy" shall we say. Not to mention that it is not their scope of practice. The pain could indeed be structural from lifting awkwardly or overworking of shoulder. Or it could be TMS. In onder to make a more accurate diagnosis a lot of questions need to be asked and there is simply not enough time for that. So of course physiotherapists treat all pain as if it were structural and the psychosomatic group only experience a short placebo treatment. It occured to me that when a patient comes repeatedly due to not improving I could just recommend the Great Pain Deception book and Dr. Sarno's books. But even then my boss might find out and get mad that I am driving away patients.
    So as you guys can see I am caught in a conflict of interest. Yes there are many patients with structural pain that I can help, which is why I want to enter the profession, and yes one of my purposes in life is to spread the knowledge on TMS and refer the books when neccessary but I feel due to the fast paced nature of the job I simply won't have the time to ask the neccesary questions to determine if the pain could be psychosomatic. And lets say a patient comes with back pain or shoulder pain that is TMS and I treat it with electrotherapy like most physios would, I have now ingrained in the patient that they have structural pain and I have now made their fate worse for many years to come, since the "physio" treated them with a modality and not psychotherapy.
    I have thought about just referring the books to most patients but then many would just stop coming and the clinic will lose business.

    So I am torn on whether or not to pursue this profession.

    I am also considering being an xray technologist instead which is not a bad alternative, just no patient interaction. Just robotic work.

    I am also considering personal training which can be very rewarding and I can educate clients on TMS, the problem, sourced from my trainer friends, is most clients are lazy and hardly see any results so its frustrating.

    And there is also career in psychotherapy, but I find it emotionally draining because again most clients are not willing to put in the work at home and many do not see results.

    Sorry for the long rant, just had to share that with you guys because my friends can't exactly relate to this.

    Thank you for listening and any advice would be appreciated.
    HattieNC likes this.
  2. JanAtheCPA

    JanAtheCPA Beloved Grand Eagle

    Hey @Kingkong , what an interesting and valid query! I'm going to give a shout-out to member @MindBodyPT (just doing that should alert her) so we can see what she says. I feel like she has discussed this here on the forum. There may be others here...

    I would like to think that there are more, or that there will be more, physical therapy clinics and practices that are working with mind-body techniques. If I had an injury now that needed PT, I would never go back to the "conveyor belt" clinic that is operated by my health plan - I would be looking for a mindbody-centric practice and pay for treatment myself.
  3. EileenS

    EileenS Well known member

    We need more physiotherapists like you that are going to do what needs to be done from a PT standpoint, but will recognize and try to help clients from a TMS perspective. I know MindBodyPT will be a big help to you in helping figure out when to suggest the TMS route and how. My husband is currently going to physio for his shoulder which had been getting worse for many years. The PT is doing physio treatments, but she also recognized that stress is contributing to his problem, so in addition to usual shoulder exercises she gave him breathing exercises to do. I was very impressed! PT's need to move efficiently when treating patients, but in my experience there is still lots of chitchat that happens when they are doing their treatments.
    JanAtheCPA likes this.
  4. Duggit

    Duggit Well known member

    That is not true of all physical therapists. You might want to acquaint yourself with the work of Australian physiotherapists Lorimer Moseley and David Butler. They both started their careers as traditional physical therapists but moved on their Explain Pain approach based on the biopsychosocial model of pain. “Bio” stands for biological contributors to pain; “psycho” stands for psychological contributors to pain; and “social” stands for social interactions that contribute to pain. The model has existed for more than four decades and has been widely taught in the healthcare disciplines but is misunderstood (according to Moseley & Butler) by most healthcare providers as pertaining to suffering rather than pain itself.

    Moseley & Butler's first book, Explain Pain (2nd edition 2015) was written for physical therapists and their patients. The second one, The Explain Pain Handbook (2017) was written for patients. The most recent one, Explain Pain Supercharged (2018), was written mainly for physical therapists. The last five of its ten chapters provide specific instruction for physical therapists on how to treat patients using the biopsychosocial model of pain.

    All that said, there is a video somewhere on the internet in which Moseley (who now sees patients only half a day per week because of his other responsibilities as as a prolific and high-profile pain science researcher) acknowledges that it can be difficult be to treat a patient with his approach when the patient has been told by his or her physician the problem is structural. If you watch some of his other internet videos, however, you will realize that he can be really charismatic and persuasive in explaining pain.
    JanAtheCPA likes this.
  5. Kingkong

    Kingkong New Member

    Thanks for the input guys! Really got me thinking.

    JanAtheCPA, thanks for the welcome. I actaully did not know there physical therapy clinics that work with mind-body techniques. I just did a google search for such clinics in my city Toronto, and nothing notable popped up. Maybe they are starting to make their appearance in the States. And I think that's awesome. I would love to volunteer in such a clinic and talk to the therapists.

    Thank you. I do have a strong desire to enter the profession and save people unnecessary suffering.
    I have volunteered at 2 physical therapy clinics. The first physical therapist, when I brought up the topic of mindbody and psychosomatic, I felt he wasn't interested in discussing it. He just said yes of course stress can add to pain and slow healing but he then quickly changed topics. The second one was open to discussing it. He said he knows about and recognizes psychosomatic pain but he said if he starts explaining it to patients, for many it will go over their heads. He said less than 10% of patients do the exercises he perscribes at home. And many people do experience a placebo treatment but he said that's quite alright because they still get their desired results. They did a study that showed many people experience placebo treatment from physio but their pain still diminishes from have a positive and reassuring experience with the physio and their conditioned response to heal. Also people that are told they experience placebo still continue to get benefit from the placebo treatment. :)
    And I have no issues with that aspect of the profession. My concern is placing the right diagnosis initually.
    For example, my father got 'frozen shoulder' on his birthday recently. He doesn't work physically. He was very stressed that day, received bad news regarding business, doesnt like social gatherings and being in the spotlight, and old age approaching.. to name a few factors. I am guessing its TMS. I told him that and explained his sources of stress and he listened but then chuckled in the end signifying that he didn't fully get it and not convinced with the diagnosis.
    Next day he got a cortisone shot at the hospital and it got worse that day. Next few days it improved. I told him I wonderd if it would have improved without the shot.
    So lets say my dad walked into my physio clinic as patient. And lets say the root is indeed TMS. On initial consultation I would assess the shoulder and it sure does overlap all the qualities of a partially torn rotator cuff. So I ask him some history questions, knowing my dad he will deny he is under stress and not disclose that to a physio. So with my given info I will probably document it as partially torn rotator. Use modalities on him, perhaps ultrasound and TENS, and in the meantime chitchat with him about stress and how it could be contributing. And he will be on his way, most likely will experience a placebo improvement from reduced stress about the shoulder.
    My point is TMS pain symptoms and structual pain symptoms often overlap and its not easy to differentiate right away. The therapist needs to ask questions that could reveal subconsious stress. The patient needs to be totally honest and even be able to recognize his own stress in order to talk about it. Dr. Sarno mentioned during TMS pain certain points on the body are overly sebsitive (it's the points at the traps, lower back, and upper buttocks). So the physiotherapist could palpitate those points, but it is not their scope of practice to identify (since this is not recognized as mainstream), and if the therapist makes an unconventional diagnosis such as TMS pain and documents it, he might get in trouble or legal trouble, since that is the scope of a psychologist or M.D.
    So this is what is bothering me. I want to help people, but I don't want to label a TMS patient with structural pain or vice versa. That could instantly condition the patient to believe the false diagnosis and will delay their healing. I won't sleep well at night pondering whether it could have been TMS but I treated it with a modality anyway because I am not a psychologist and didn't have the adequate time to ask about childhood and personality traits.
    I am thinking what I can do is perecrive The Great Pain Deception and Dr. Sarno's books to a lot of patients just in case. That way I pay my due dilligence and the rest is up to the patient.
    I am just thinking of ways physios can maximize their success while accomodating TMS. I read in a forum one physio posted that "a third of his clients will heal no matter what he does, one third he is actually able to help with his expertise, and one third will not improve no matter what (I wonder how many of these are TMS). So that makes sense. One third come with mild injuries and just need reassurance and a bit of treatment to improve. One third you actaully get to help, these would be mostly structural injuries I am assuming with a clear path of treatment like sprained ankle or post operation. And is it rewarding to help them. And one third will be tricky cases like "chronic back pain" I am assuming, which don't see progress. These are difficult to establish the right diagnosis for the reasons I listed, but I guess for this group I can prescribe the TMS books post session, and if they do their home work, some might be pleasantly surprised. And I can sleep well knowing I did whatever was in my power.

    EileenS, I wish your husband a quick recovery. And it warms me to hear his physio is precsribing deep breathing which is of course helpful. I applaud physios that have done their homework and accept the psychosomatic approach as well, or the biopsychosocial model as Duggit pointed out.
    Yes there is a bit of time for chitchat sometimes but it depends on the clinic. In some clinics physios see 2 or 3 parients at a time, which I am not a fan of, and are burdened with paperwork, so it is the physio assistants that do the chitchatting.
    A lot of clinics these days value quantity over quality and are not exactly interested in exploring how to treat TMS.

    that is very interesting. I will definitely look into those books. I will reply to you in more depth when I have more time and wheh I research those books a little
    Last edited: Mar 18, 2019
  6. Andy Bayliss

    Andy Bayliss TMS Coach & Beloved Grand Eagle

    Hi, Jumping in without reading all the thread simply to say that Dr. Schubiner uses physical therapy work to remobilize, move and assist physically to support recovery. Not as a pain treatment directly, but as support to re-engage with movement, increase activity. This is my understanding, at least.

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