Time to Change Your Filter?

The following is a quote from an article by Mark Jones (1) that was discussing implementing the biopsychosocial model in clinical practice:

No matter how much we may think we have an accurate sense of our practice, we are stymied by the fact that we are using our own interpretive filters to become aware of our own interpretive filters! . . . To some extent we are all prisoners trapped within the perceptual frameworks that determine how we view our experiences. A self-confirming cycle often develops whereby our uncritically accepted assumptions shape clinical actions which then serve only to confirm the truth of those assumptions.

Kory Zimney had a great post on pain competence that discussed some of the barriers to changing our perception of what we see and experience in the clinic.  Confirmation bias, cognitive dissonance, and unconscious incompetence are just a few of the issues we face when truly trying to change our interpretation of what is or is not creating change in our patients.

I have been a relatively well traveled therapist.  I have worked with therapists who have had a huge variety of backgrounds in training and experience that formed their interpretive filters. They may have had a variety of certifications or groups they identified with but they all had one thing in common. They ALL got outcomes.  How could this be? Some manipulated and some barely even touched.  Some used complex exercise equipment and others simply used the patient’s body.  How can clinicians who practice in such a polar opposite fashions ALL get outcomes?  Sure there were patients who failed with some and succeeded with others, but each clinician had a happy following of patients who gladly referred friends and family.

I think it is time in our profession we take a step back and try to look at the common ground that exists between us all.  Instead of creating more complex explanatory models, the next certification in xyz technique, method, or shiny tool, maybe we could pump the brakes a bit and put some serious thought into what we have in common and not what separates us.  Instead of surrounding ourselves with those who stroke our clinical ego, we consider putting our ego aside and consider and that maybe our way isn’t the only way. Could we all be supporting natural history of healing?  For those past healing time frames could we be producing a sense of safety and descending modulation that allows a person to regain confidence in movement?

Here are three commonalities (there are more) I think we all share that allows us all to get outcomes that often take a back seat to the shiny tool or certification letters after our names:

1.  Natural history of conditions

When patients see us they often are at or near the peak of symptoms and invariably they have no where else to go but in a direction of improvement.  Of course we as therapists should be there to educate people on tissue healing in a way that can engender confidence in the body and the necessity of movement.  Biomedicine often is not doing this.  We are the best health care professional to accompany people on their healing journey.  Let’s just stop letting xyz certification or xyz shiny tool take the credit the patient’s body deserves.  When you see outcomes here shelf your ego and make it be about the patient

2.  Confident explanatory models

Any explanatory model regardless of how ridiculous it may sound to those not trained in it or how ridiculous it may sound to those who don’t share the same belief system has the potential to create change.  This often can be based on nothing to do with the model itself, but has everything to do with the confidence and belief it creates in our patients.  A clinician can tell the patient, “I have found you have a dysfunction in gooblygook and this technique/tool is designed to fix gooblygook and will have you moving better in no time”.   Descending modulation of pain can have amazing effects on a patient’s pain and anything that gives the central nervous system a sense of confidence and safety can create impressive modulatory effects on pain.  More reason for us to put our egos aside and recognize models outside what you believe or practice can achieve the same modulatory effects.  It also should push us to examine whether we are all just modulating pain through different avenues in many cases.   Maybe we have all been neurologic PTs all along?

3.  Confident patient handling and touch

Our ability to touch is hugely powerful.  Whether we are claiming to assess and change cerebrospinal fluid flow, release emotions trapped in tissues, or do some other scientifically questionable technique we all have one thing in common.    We handle a patient in a way that creates a sense of caring/empathy and often produces relaxation and confidence.  Relaxation is a monumental challenge for some of our patients so being able to elicit it has the potential to have effects on the neurologic, immune, and endocrine systems.  No fancy wooey explanatory models or shiny tools needed here but simple confident and relaxing patient handling.  Anything that creates confidence and relaxation has the potential to tap into the same descending modulation that was discussed above.

Let's come together!

There are a lot of interventions and models of clinical interpretation that science is casting serious doubt upon yet they live strong in our profession because those who utilize them are trapped within the perceptual framework they were taught or paid for that gives them comfort.  We compound this by surrounding ourselves with like-minded people so we can maintain our belief by jumping on a self-confirming cycle where no one critically thinks about or questions our beliefs and clinical practice.  This allows us to continually give credit to our tools or belief systems and only strengthen them when in fact science may be screaming at us to give them some serious critical thought.  When the patient doesn’t respond to our beliefs or filters instead of blaming the patient maybe a serious look in the mirror is in order.

Clinical instructors and PT program instructors need to recognize their own filters and not simply force them upon their students.  Let’s teach students to think and not to simply be clones.  Our profession will never grow and become the sleeping giant Patrick Wall thought we were if we have a bunch of non-thinking clones out there reproducing interventions that have no basis in science.  The best thing that happened to me was to be instructed by Dan Vaughn at Grand Valley State University as he showed me that you need not camp out in one way of thinking but to consider other ways of intervening with patients.  Sure he had his foundation of training and beliefs he used in the clinic, but as a student I never felt pushed to adopt them myself.  He is a great example of what teaching our DPT students should look like.

There is a huge group of patients who the health care system (that includes us) is failing.  Our models that try to equate pain to tissue damage or faulty structure are horribly insufficient and often harmful.  We need to think twice before we tell a patient they have a deranged disc, a degenerative facet, a long leg, a rotated this, or (insert favorite structural problem here).  These models and their failing are what has created the alternative medicine industry.  I am not saying that all alternative medicine is bad, but if I have to hear another infomercial on the latest toxin-reducing ploy, miracle orthotic, or miracle back pain cure I may go crazy.  People living in persistent pain are the targets of every sketchy, scientifically-implausible miracle cure out there.  Strangely, if the sketchy, scientifically-implausible story or “sales pitch” is impressive enough in the patient’s eyes is has the ability to generate belief and safety in the patient and as a result an outcome can be achieved through descending modulation.  The subluxation story comes to mind here.  Of course the salesman will make it be about them and their bottom line rather than give credit to the patient’s nervous system in this scenario. This is why we never should simply believe in an intervention based on testimonials.   I am confident if we jumped in a time machine we could find testimonials on blood letting or other interventions that did not withstand the test of time and science.  Could we as a profession have some of these same issues that capitalize on desperation of these patients with a confident story or maybe a shiny tool?  This is an uncomfortable but necessary question.

A regular question a clinician should ask themselves is whether they are trapped in an interpretive filter that has blinded them to science.   Instead of avoiding someone who has critical thoughts toward the clinician’s filter they could engage them and embrace an opportunity to learn and grow and create a better filter.  It is healthy to move outside of the comfy confines of our perceived reality and see if our filter holds up to the scrutiny of science.

We need to stop trying to shape science to fit our interpretive filter.  Clinical research in our profession is rife with bias and interpretations of data that falls victim to our biased perception of the clinical world.  A critical eye is a must when consuming our research. When someone has a vested interest in creating a filter that sells a tool or a continuing education course we need to be skeptical over their interpretation of data.  Lastly if you come across an article that does not agree with your filter instead of throwing it in the trash you read further and seriously consider some adjustments to your filter.

If we make it be all about the patient then we should have no problem removing the interpretive filter we see our clinical worlds through and critically evaluating it.  The question is whether you are willing to inspect your filter.  Is it all about you or your patient?

  1. Jones M, Edwards I and Gifford LS 2002 Conceptual models for implementing biopsychosocial theory in clinical practice. Manual Therapy 7: 2-9

Mark Kargela

Mark has been practicing physical therapy since 2003. He spent the his career pursuing expertise in manual therapy treatments. When he recognized that manual therapy had limited success in chronic pain he began intense study of pain neuroscience and advanced training. He practices in Glendale, Arizona where he is a Clinical Assistant Professor and runs Midwestern University's Physical Therapy Institute. He also teaches nationally for Modern Pain Care and lectures across the country on spine care and persistent pain.