Are You Music to Your Patient’s Ears?

It comes as no surprise that I am a large proponent of “pain science”.  The developments in our understanding of pain over the last few decades has been astounding.  It has moved our considerations and hypothesizing in regards to the patient in pain in front of us from the tissue hypothesized as the nociceptive driver into considerations of the central nervous system.

Science is what we use to develop and test theory that drives how we progress and grow as a profession or field.  It is not method of convenience that is used only when it is convenient for us.  It also is not perfect.  Science is constantly changing and adapting to new knowledge as it is developed.  Science gives us the best understanding of our realities by generating data  based on the best information available and our ability to consider, think, and experiment with the data we have around us.  To compare this to music, it is the understanding of notes, measures, chords, rhythms, compositions, and melodies that drive the creation of music.   It gives us the framework to understand all that goes into a clinical encounter and its resulting outcome or the music we make with the patient.

In my quest for knowledge in the physical therapy profession I have traveled the road of manual therapy training.  My early perceptions of manual therapy was that is was a method that required intensely skilled hands that could perceive small movement or positional faults, that if corrected with masterful technique, would relieve long-suffering patients of their pain and disability.   I spent the greater part of 9 years intensely pursuing the training in manual therapy that would move me to clinical mastery.   I would liken this to an obsessive pursuit of perfecting the ability to play the piano.

In the midst of my fellowship training I came across pain science as part of the curriculum.  It was truly a practice-shaking experience for me.  Initially I was a bit resistant to this information as it called into question a lot of what I was thinking in regards to a therapist-patient interaction and treatment outcome.   The piano was the star of the show and I was not going to give credit elsewhere.  This stirred up a huge motivation in me to prove the limitations of this model of thinking as at the time I felt the literature being published in this area made manual therapy an option and not a necessity.  This was a bit un-nerving as my practice prior to this knowledge was one that used the presence of a pulse to determine if manual therapy was indicated.    A strange thing  happened to me after graduating fellowship training and teaching pain science and manual therapy.  Throughout this time I poured through the works of Gifford, Butler, Moseley, Zusman, O’Sullivan, Louw, and others.    I was being told that maybe there were other instruments out there that patients responded to.  The obsession with technique performance was the piano yet there was a symphony playing along side me within each interaction.   My ears were biased to only hearing my preferred instrument.  I did not even see or hear the symphony around me.  It was an amazing “ear opening” experience.  It gave me a much wider appreciation of the instruments that are playing in the context of the patient encounter.  Of course I still love the piano, but strangely my playing of the piano, while still regular, is at an all time low.

Manual therapy can be a powerful way to modulate the nervous system’s protective behavior.  I feel it isn’t out of the question to consider that when a joint seems to be the predominate nociceptive factor in a patient’s presentation as determined by a thorough patient interview, red-flag screening, and physical examination that treatment of the joint is very helpful and very effective.  We can, and should, be arguing on the complexity of what drives the change and we know contextual factors will always be in play when we interact with a patient and produce a favorable outcome.  We cannot deny it plays a large role in a successful joint directed technique.   It would seem logical that patients who perceive a joint problem will seek a practitioner who addresses such problems, and when we meet the expectation of addressing the joint problem outcomes can follow regardless of the technique that the patient perceived addressed their issue.    There will always be people who love listening to the piano.  This is where comparable signs are powerful.  When we are able to reproduce the patient’s perceived issue and change it with a technique that targets this issue then there are a huge amounts of non-specific psychobiologic processes that positively move the patient in a great direction.  I would compare this to a person loving the piano and we find a way to play a concerto from their favorite musician.  They recognize it as their unique favorite song or melody.  They have witnessed you finding their pain and changing it.  This, coupled with a narrative that engenders a sense of safety can be extremely powerful.  This patient is coming back to hear you play and they are telling all their friends!

The problem occurs when we feel all patients in pain require only one narrative to help them.  When it comes to music it is apparent that we all have genres that suit our ears better than others.   Some music that sounds dreadful to us will be exactly what another person finds is the perfect melody to listen to and enjoy.  Manual therapy is one narrative or genre.  A lot of people seeking manual therapy are fervent manual therapy fans and find the narrative music to their ears.  They are primed for positive effect.  Enroll them into a research study and couple it with the Hawthorne effect and a lack of equipoise and you have good chance you will prove positive treatment effect.  We progress in the bias of our narrative by latching onto whatever literature supports our musical preference and avoid those that threaten it.   Our shelves become full of books on how to further the pursuit of becoming a master pianist and our continuing education becomes dedicated to furthering our piano playing abilities.

Some people will love the “click and stick” while some may think it’s nails on a chalkboard.  As practitioners it seems as though the best way to help the most people is to be able to offer a variety of music that will appeal to the most patients who consider and test out our services.   Like amazing new bands there often will be a huge surge in popularity that will have droves of people seeking the music.   In our profession we seem to regularly have “New Kids on the Block” that are all the rave that slowly fade when their music ceases to have the ability to satisfy our patient’s musical cravings.  As the rave continues we often destroy our enjoyment of the music by overplaying it over and over again until popularity wanes or the band eventually breaks up.  Sometimes we see these bands make a comeback, but they often lack the staying power of such bands as the Rolling Stones or my personal favorite, Pearl Jam.

So how does this relate to pain science?   Looking at pain science like another genre of music is so limiting to the aspiring musician or therapist.  Why not just call it science?   Why limit our understanding to just the piano and instead seek to understand the symphony? It gives us the knowledge on notes, chords, and arrangements that may suit different ears more than others.   It allows us to recognize all the other instruments that are playing in the context of the patient encounter.     It also allows us to adapt our music to the ever-changing preferences of our patients and as the plan of care progresses.  You cannot duck it when you encounter a patient in the clinic regardless of what setting you practice in or instrument you prefer to play.

There seems to be so much ambivalence to adopting this new science in our practice.  If often hear people declare me as part of the “pain science crowd”.   I have learned that there are some people who refuse to consider any other genre of music then their own which they prop up with outcomes and literature.  They are content only hearing the piano and are determined to play the same tune and play to their fan clubs or loyal followings.   We have research that is limited in considering the entire symphony of the patient encounter and in turn what drives someone to positively respond to our music.  By ignoring the other components of this positive response we limit our ability to please the ears of a wider audience.  We will always have a fan club of regular listeners but the wider audience are the patient’s who have stories or musical preferences that no one is asking about or listening to.  We will say we deserve to have everyone listen to our music or to #GetPT1st yet those on the outside will recognize our musical limitations and see we are not the solution with such biased views.  The recent article by Bialosky, Bishop, and Penza (1) discussed the consideration of placebo mechanisms in the response to manual therapy.  In the article it states:

Manual therapists should continue to pursue clinical excellence, while understanding that the hours spent perfecting individual approaches may result in better outcomes not strictly from precise application but rather from improved contextual factors related to reputation, confidence, and therapeutic alliance.

 To me this encapsulates the crossroads manual therapy finds itself standing at.  It likely would be helpful for clinicians to  consider the  possibility that patients may be responding to other instruments playing in the symphony of the patient encounter.  This consideration is often too threatening for some to consider especially when we are invested in or teaching others to be amazing pianists or technicians.   Maybe we will not need to take “manual therapy jedi level” courses and start emphasizing the soft skills that can have a powerful effect.  No one is saying we should not try to be good at playing the piano.  Healthcare demands we consider the symphony and I fear manual therapy will marginalize itself unless we make this consideration every time we lay our hands on a patient.  It may mean we have to challenge some sacred beliefs but if patient care is truly about the patient this should not be hard.

So as practitioners who have an open mind I urge you to consider pain science as simply science that informs everything we do in patient care from the way a front-desk coordinator greets a patient on the phone to how you explain and perform your masterful technique be it soft tissue, manipulative, exercise-based, myofascial, or whatever your preference is.  Let’s also consider the patient’s preferences (expectations) and instead of forcing our preferences upon a patient we consider alternatives that may suit their ear instead of ours.   A patient’s musical preference often changes over the plan of care and eventually we should be teaching them to make their own music and gain self-efficacy in their musical pursuits.

We can play music for a patient every encounter and they will enjoy music that day, but if we teach a patient to play their own music they will enjoy music for life.

  1.  Bialosky JE, Bishop MD, Penza CW. Placebo Mechanisms of Manual Therapy: A Sheep in Wolf’s Clothing? Journal of Orthopaedic & Sports Physical Therapy. 2017;47(5):301-304.
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.

  • Mark Kargela Tom Jennings says:

    Brilliant. Love the analogy and Pearl Jam!!

  • Mark Kargela Joel Dykstra says:

    I want to make a clever music analogy regarding “sub-grouping” here… A beautiful symphony cannot be played with just one instrument, a piano; even though the piano part can be played perfectly. (by the way, the missed notes of a less-than-perfectly played piano could potentially be drowned out if the other instruments in the symphony play their parts perfectly).
    So, the analogy might be if you want to please an audience (a patient) with the music they desire to hear (improved pain and function), and you have 12 bus loads of bands out back in the alley behind the theatre (various treatment interventions), you need to decide which band will most likely come in to give the audience what it wants (“needs”). So, first, you have to know your audience; what type of music is desired (sub-grouping), what band can come in and give the best chances of delivering the desired genre (Apply treatment A to group A, etc), then skillfully perform the works (guideline-based, science-based care). Then, of course, you’d be interested in the review (outcomes and outcomes reporting).
    If there are three each busloads of bluegrass bands, jazz bands, rock bands, and orchestras, you’d invite one of the orchestras in to play for the audience that desires a symphony. Then, after good data keeping, you could eventually learn which of the three orchestras is the best. The two points I am trying to make is that we can and should be sub-grouping (via some sub-grouping scheme), and that it is not all about what the patient “prefers”. Science defies popularity much of the time. Just because the rock band has the coolest bus and the biggest promises of a good time, doesn’t mean they are going to blow away the audience with a beautiful symphony. I do think that pain neuroscience is an instrument that all PTs need to “learn to play”. This is an unfamiliar instrument that most clinicians (including physicians) don’t even know how to hold yet.

    Maybe “pain neuroscience” isn’t an instrument, but rather, it is the rhythm, the chords, the synchronicity that are fundamental to any music.

    Sorry, if my analogy didn’t work out just right. Having some fun with it.


    • Mark Kargela Mark Kargela says:

      I think you can definitely see some commonalities among presentations but I still think trying to shove people into homogenous categories or subgroups of response to intervention is a tough task. There are so many variables in play with pain I find it hard to believe such sub groups exist. We want to make something extremely complex simple which I am not sure is possible. I think the keys to successful treatment are

      1. Address any existing nociceptive tissue contributions (if present)
      2. The practitioner must be confident and produce a convincing narrative to the patient
      3. The patient must be receptive to said narrative or the narrative must align with their culture, past experiences/learning, beliefs, and expectations
      4. The patient must be in a context in their life where change is possible – motivation, expectation, action

      Many treatments can fit this. The problem is when the narrative is out of line with biologic plausibility yet is convincing to the patient. This is why people will continue to seek getting their back’s realigned even though we know this is does not happen.

  • Mark Kargela Malcolm Innes says:

    I skipped over this the other week when I saw it, but really glad I’ve taken the time to read it in full just now.

    What an excellent piece of writing & completely fits all my biases of person centred care. Especially loved this bit.. “Let’s also consider the patient’s preferences (expectations) and instead of forcing our preferences upon a patient we consider alternatives that may suit their ear instead of ours.”

    & Thanks for the help just now btw with accessing my account on your website! Looking forward to the next instalment 🙂

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