Episode 23: Do Expectations Shape Results? Mark Bishop

Whitney Lowe:

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Whitney Lowe:

So, good afternoon Til. Good to talk to you again today, and we have a great guest with us today. Who’s joining us today?

Til Luchau:

Mark Bishop is with us today. He is the most patient guest we’ve ever had. This has got to be take three or four through all of our technical problems. Mark, thanks for being here today.

Mark Bishop:

You’re welcome. I’m glad to be here.

Til Luchau:

You are a physiotherapist with more than 30 years of clinical and research experience in the area of rehabilitation of musculoskeletal pain disorders. Your work has focused predominantly on the mechanisms underpinning the efficacy and effectiveness of conservative interventions for pain especially in manual therapy and exercise.

Til Luchau:

You’re the current faculty member in the Department of Physical Therapy with affiliations in the Center for Pain Research and Behavioral Health and the Pain Research Intervention Center of Excellence at the University of Florida.

Til Luchau:

I met you at the San Diego Pain Summit last year 2019 where you were saying some pretty interesting things about contextual facts, about expectations, about patient, client preferences. I wanted to dive into that more because that’s an area that perks up my ears and gets me interested.

Til Luchau:

What else would you like our listeners to know about you and your background and your interests?

Mark Bishop:

Sure thanks Til. I think something that’s probably pertinent for the listeners is that I personally identify as a manual therapist that came from my entry level training and my wife Angel would agree. But what I took away from that degree was a very strong preference for manual differential diagnosis and treatment.

Mark Bishop:

I’d say I had always been pretty fascinated with that as a process and had the opportunity to go to Canada to learn some different styles of manual therapy. I’m very maintenance focused in my joint bias training in Australia.

Mark Bishop:

And in Canada had the chance to learn some of the muscle energy techniques, so slightly different version of things that I was doing in Australia.

Mark Bishop:

Then when I came to the US in the early ’90s, the people with whom I interacted with were heavily influenced by the osteopathic myofascial release theories and I had not experienced any of that and learnt some of those processes.

Mark Bishop:

But the thing that fascinated me clinically or frustrated depending on your perspective, was the fact that there was two groups of people who I was not able to help. That partly motivated the return to start studying these types of things, like what sort of factors could I learn about or study to help answer this question for myself about which techniques I should use for which people and when I should apply those.

Mark Bishop:

We started out studying particularly spinal manipulation when I first began studying manual therapies. We had the great good fortune to be collaborating with a group of clinical and health psychologists.

Mark Bishop:

It still makes me laugh to think about the director of the center looking at me and another physical therapist asking us why we thought the shoulder should be any different from let’s say the back or the knee.

Mark Bishop:

From his perspective, musculoskeletal pain was musculoskeletal pain and the anatomic location was not important. That was a bit confronting to my world view but it did get us thinking a little bit differently about how we were approaching some of our studies.

Mark Bishop:

A lot of the studies we were doing at that time, I’m going to say were periphery focused. We were looking at things like withdrawal reflexes and quantitative sensory things. It was the psychologist who really encouraged us to think a little bit differently about psychological factors in particular.

Mark Bishop:

At that time, I would say, I had a very dualistic view of this, that there was psychological factors, and that there were neurophysiological factors. The psychologists asked me, I remember why I thought that they were separate.

Mark Bishop:

If you thought anything part of your brain depolarized, so that had to be neurophysiology. That did get us thinking a little bit about this.

Til Luchau:

You’re saying that the thought itself is a neurophysiological phenomenon.

Mark Bishop:

Absolutely. But if something is happening in the cortex, that’s as neurophysiological as anything that we were measuring as far as nerve function or reflexes or anything like that.

Til Luchau:

The reframe you’re describing is a shift from being say, you said peripherally focused but focused on the body per se, to including what was happening in the brain in a non-dualistic way it sounds like. I want to hear about that.

Mark Bishop:

Yeah, absolutely. So, if I describe it like this saying that we were studying sensory input at the periphery and measuring things at the periphery, but what we were actually interested in is what the person was telling us.

Mark Bishop:

For you to tell me something, you get that sensory input, you process it in the cortex. You’re comparing the input to other previous inputs. You’re looking at some feedback loops through different parts of the brain. You’re processing it in areas all before you actually have to tell me about it.

Mark Bishop:

I guess to get completely amay, you’ve got to activate the speech motor centers and you’ve got to do all these things for you to tell me something. So, it has to be a complete system to get the output. That was a big change for us just looking at what was happening at the front or the back as far as reflexes were going to now really beginning to believe that the cortical aspects absolutely influenced everything that people were telling us.

Mark Bishop:

For example, in the context of expectation, if I talk about let’s say, an expectation that something bad might happen, maybe fear or anxiety about an intervention or in our case the pain we are actually going to cause potentially.

Til Luchau:

Maybe this treatment will hurt.

Mark Bishop:

Maybe this treatment will hurt. But if you have that your whole system, the gain in the system gets elevated because of the anxiety or fear and how that process is everywhere, and you’re more likely after you get a stimulus to tell me that it hurts.

Mark Bishop:

Now after you’ve experienced it and you’ve thought about it, if I give you that stimulus again at a different time and your anxiety about it has gone down, your response will likely be different even though the stimulus did not change.

Mark Bishop:

We use a lot of these standard stimuli usually something very, very hot. So, we’re able to control the stimulus and see the variability in what people are telling us based on what they happen to be thinking, and what’s some other things are going on.

Til Luchau:

Wait a minute. So, you’re using very, very hot things on your clients and you’re asking them if this hurts?

Mark Bishop:

Well this is in the research context. Some of the studies do include people that we’ve recruited from the clinic.

Til Luchau:

Yes.

Mark Bishop:

But this is in a research context not in clinical context.

Til Luchau:

Okay.

Mark Bishop:

I’d say that-

Til Luchau:

So, you’re saying I get predisposed by my expectations. If I think it’s going to hurt, you said the gain is raised, which if you’ve ever played an electric guitar you know what that is.

Til Luchau:

Otherwise, it means you’re more sensitive, you’re more likely to experience that as pain or report that as pain. Is that what you’re saying?

Mark Bishop:

Yes. Yes.

Til Luchau:

Okay.

Mark Bishop:

The opposite is true that if you’re expecting something to be good, you’re more likely to report either less pain or benefit from it. Even though the stimulus isn’t different test to test, there’s something about how you’re thinking about it that modifies how you process that stimulus and then what you say about it.

Mark Bishop:

So, when we get into the context of patient expectations for any sort of provider interaction, there’s some global expectations. For example, people coming to see providers usually if they have chosen to see that provider themselves, they often have an expectation that this is going to help me. I will get benefits.

Mark Bishop:

We’ve actually, when we’ve measured clinical samples seen that people have generally very high expectations that things are going to improve when they’ve actually chosen to go and see that provider.

Mark Bishop:

So, you have these general expectations. Actually you even have some more general expectations and the story that we tell is that’s like did I find parking, was the person at the front desk the way I expected, should I get an appointment when I wanted. Does Til’s office have what I would expect from someone of his skill. So, these are some background expectations.

Mark Bishop:

There’s expectations to benefit from the treatment in general, and then if it starts to get more and more focused to say people have specific expectations of the technique that you’re about to apply.

Mark Bishop:

Each of those expectations can influence what people are thinking about is happening to them, then let’s say Til’s come in with neck pain. He’s expecting the clinic to look a certain way. That meets his expectations. He’s generally expecting benefit from being to seek treatment for his neck.

Mark Bishop:

Then he receives a technique that he has high expectations is going to help him, chances are that he is going to report feeling better or a good outcome than someone who comes to see the provider. They don’t like the place. They didn’t like the provider. They’re not expecting much from treatment and then I do an intervention that is not what they expect to help them.

Mark Bishop:

Even if it’s the same intervention for the same condition, they may report or usually often report worse outcomes compared to the person with high expectations.

Til Luchau:

You’ve said you use two things here. Yeah, and Whitney you got something to throw in here too. But you’re talking both about what I expect, but also what I prefer.

Mark Bishop:

Yes. But they’re a little bit different. When we actually ask people these questions, people can expect a lot of benefit from a treatment that they don’t prefer.

Mark Bishop:

So, lots of people. Some people prefer and I put this on the PTs. They worked with folks with back or neck pain, people prefer maybe to get some heat, get some passive treatment, maybe that type of thing. But they expect exercise and manual therapy to help if that makes sense.

Whitney Lowe:

Okay. Yeah, yeah. I’m curious too, I’ve read in one of your other papers that was looking at some of the impacts of manual therapy on pain, there seems to be especially in a lot of the research, a focus on the biomechanical effects of some of these manual therapy interventions because they’re a little bit easier to measure.

Whitney Lowe:

I’m curious what you’ve run into and in terms of some of the significant challenges and difficulties of trying to measure something like expectation of benefit and its subsequent outcome of improving the outcomes of those type of treatments for the difficulty of making those accurate measurements that people can sort of hang their hat on.

Mark Bishop:

There’s a couple of things to unpack in there. A lot of mechanical theories that I learned about how the joint mobilizations were helping, some of those have not panned out exactly as were theorized as people are measuring things.

Mark Bishop:

For example, what I recall we’ll see when Joel responds to this, what I recall is being taught that I was specifically mobilizing a segment of the say surgical or lumbar spine. But what is seen is that we know that it’s multiple segments.

Mark Bishop:

So, if you’re mobilizing the spine, there’s multiple segments moving at once. If I do a thrust technique that force is transmitted across a lot of segments. So, we’re not quite as specific as we thought we were.

Mark Bishop:

Other challenges include the way we use force between people is quite different. That I might be using a very different force for you Whitney for example. We know we’re doing what could be potentially the same technique.

Mark Bishop:

So, there’s been a lot of work looking at the biomechanics that hasn’t supported the outcomes as quite as much as people theorize. That there are some sort of exceptions, Julie Fritz for example has some collaborators in Canada and they’ve built a very sophisticated way of measuring spinal stiffness.

Mark Bishop:

It turns out that that has some relationship to the outcome for some of the manual therapy for the lumbar spine. I don’t have the same sense of capacity as the robotic spinal stiffness device. But that is something biomechanical that does seem to be related.

Whitney Lowe:

I think in one of those other papers you had alluded to the idea that this made you think a lot more about the role of some of these other factors, some of these neurological factors and other psychological factors that you’re mentioning here as being far more prominent that we may have original thought in the beneficial outcomes. Is that correct?

Mark Bishop:

It is. I would say part of that was working in this research group with some collaborators in the physical therapy world. We have the American Academy of Orthopedic Manual Physical Therapy Center. A few of the people in our research group were fellows.

Mark Bishop:

We had someone from a chiropractic background who is part of their research group. We all did techniques differently. But our outcomes were very, very similar.

Mark Bishop:

So, when people have actually looked at comparing the, I think the last time I looked it was 270 different names, manual therapy philosophies that when philosophies and strategies are compared broadly head-to-head, there does not seem to be one particular philosophy that out classes the others as far as outcomes.

Mark Bishop:

Which, made us think that we’d all gone through the rigorous training to master out particular we’ll call it brand or area of manual therapy and we’d all been taught quite robustly that this is how it has to be and this is where things should go.

Mark Bishop:

But if people are all doing it differently for the same condition and getting similar outcomes, potentially there’s something else at work as well as whatever stress we’re putting in the tissue.

Mark Bishop:

Because, don’t get me wrong, we do stress the tissues. But there has to be something else that is helping contribute to the outcomes.

Mark Bishop:

That’s really what we began to focus on saying what were the common things across these practitioners who, I won’t speak for the others, but I think I’m pretty good at what I do. I suspect that some of the others also believe very strongly in themselves and so we’re looking at what commonalities across practitioners might help explain how we can have so many varied approaches with similar outcomes for the same conditions.

Whitney Lowe:

Okay. So, you’re saying if it isn’t the method, if the methods don’t seem to be sorting themselves out in terms of some being more effective than others, what are the practitioners bringing to the equation might be part of that difference?

Mark Bishop:

Yes. Yes. That was a big part of it. I know there’s efforts to subgroup that looks like some particular parts of different manual therapy disciplines work well for smaller subgroups.

Mark Bishop:

But on mass when we look broadly across management strategies, there has to be this path that’s from the practitioner but we started by focusing on the person in pain.

Mark Bishop:

What are the people in pain bringing to the interaction. We’ve spent a lot more time recently thinking about what you and I bring to the interaction and how that impacts things as well.

Mark Bishop:

What the patient is bringing, they’re bringing their beliefs, they’re bringing their expectations. As you said before, they’re bringing preferences.

Mark Bishop:

It turns out that at least some of the work we’ve done seems to suggest that the expectation that someone has before we even start is a stronger predictor of what they’ll tell you six months later, than which treatment they actually received. Which certainly got us thinking a lot.

Til Luchau:

What the client or patient thinks before they even come to you has a stronger correlation to how they’re doing six months later. What kinds of things, what do you mean what kind of things they would be thinking about?

Mark Bishop:

Yeah. This is where the psychometricians listening to the podcast will get a little bit angsty but we think yeah-

Til Luchau:

I think we have a lot of those by the way.

Mark Bishop:

Yeah. We simply asked people before they started treatment about their general expectation on full recovery. Do you expect you will be completely recovered in six months? Do you expect you will be moderately recovered in six months? The people who said that they would be completely recovered in six months before we’ve done anything, were the ones that had the largest change in outcome.

Whitney Lowe:

All right. So, the people that said they expected to recover had the largest change in outcome?

Mark Bishop:

Yes sir. That’s a very general expectation. That has got nothing to do with what we actually did. That’s got everything to do with what you think before you even get treatment. This is back to you probably don’t come to see me unless you expect something good from me.

Mark Bishop:

So, most people who were expecting the complete recovery by coming to see the PTs and the study, they reported the best recovery.

Whitney Lowe:

Another question again, back to sort of research methodologies and how we measure some of these things, because to me this is really fascinating about trying to figure out how we’re determining beneficial outcomes.

Whitney Lowe:

Back to this issue of looking at specific physiological effects of a treatment if it were that easy to measure those kinds of specific physiological parameters of a treatment when you talk about expectations. Let’s say somebody has expectations that either massage, or a manipulation, or a chiropractic treatment is going to help them.

Whitney Lowe:

If those treatments are relatively consistent from practitioner to practitioner because they’re specifically a manual or mechanical intervention, that seems a lot easier to evaluate than what we’re now learning which is that in many of these interventions and clinical scenarios, the personal interaction between the client or patient and therapist is a huge aspect of what makes that successful.

Whitney Lowe:

That seems like that’s particular challenging or difficult to isolate and then study. So, how do you all sort of look at that piece of it?

Mark Bishop:

Yes. There’s a couple of instruments that seem to be pretty good for measuring. One of the pieces you’re talking about, which is alliance. So, I’ll provide a client alliance with each other.

Mark Bishop:

But there’s no, and so I haven’t looked to see if there has been a particular tool that’s been recommended. But I know there’s been quite a few systematic reviews of all the different ways that people have measured expectation.

Til Luchau:

Sorry. Just to clarify, by instrument you mean a questionnaire or?

Mark Bishop:

Like survey, yes. Like a survey or something that the person can fill out. So, the measuring of expectations is done many, many different ways and to the best of my knowledge there’s not a standard recommendation saying okay, this is the most effective way to measure general expectations, specific expectations and that type of thing.

Mark Bishop:

Unfortunately, but I think one of the things we suggest to clinicians with whom we interact is not necessarily how you measure it, just make sure you measure it and include it in your management process.

Til Luchau:

Yeah. So, what about the role of client preferences. You’ve done some interesting publication on that, like your 2013 paper, patient expectations and benefit. We’re going to link that in the show notes.

Til Luchau:

You showed several interesting things. One of them being if I read it right, that patients ranked massage therapy pretty highly in terms of their expectation of benefit from that current episode of neck pain. Did I get that right and was that a surprise? Did you expect that?

Mark Bishop:

I don’t think we were surprised. I think we were surprised that manual therapy and exercise was so robustly represented in the expectations. I think it matched for our hypothesis pretty well that people wanted manual therapy for their neck pain.

Mark Bishop:

So, the two manual therapies I think we had manipulation and massage therapy and so it made sense to us that conceptually people would kind of put the two of those together.

Til Luchau:

I’m looking at the chart now, those were the two modalities that got the highest level of agreement about the intervention and helping them with this episode of neck pain massage and manipulation. Can you say for people who don’t know what manipulation would be, can you say something of what that is?

Mark Bishop:

Yes. Manipulation when I’m using that term is some people may be more familiar with thrust, joint techniques, or high velocity, low amplitude, joint techniques almost often associated with osteopathic and chiropractic providers.

Til Luchau:

Yeah. So, those were the two modalities out of whatever that is, eight or nine that you studied where people expected the most benefit.

Mark Bishop:

Yeah. I’ll tell you the thing that surprised us is we were kind of expecting some of the more passive modalities to be rated a bit higher. The fact that people who thought that exercise was going to be better than rest was I guess surprising and quite encouraging because in the study we were offering manual therapy and exercise as our treatment modalities. So, it kind of worked that people expected those to be effective.

Til Luchau:

One of your takeaways … Again, I’m remembering right from San Diego one of the things that sparked you on was trying to match clients and patients with a modality based on their expectations and then based on the practitioner preferences as well. Am I remembering that right?

Mark Bishop:

You are. You are. I have a colleague Joel Bialosky who has been doing some work there that’s not completed. So, doing some research to see if our theory actually works out.

Mark Bishop:

But we conceptualized it as a buffet. In that buffet is options under manual therapy. There’s options when you go through the menu for exercise and other things and the way we think about it is if the best treatment for neck pain, let’s say, is manual therapy and exercise, then the hooves may potentially to say, “Til it looks like manual therapy and exercise are really going to be the most effective ways to treat this, but we can do different types of manual therapy.

Mark Bishop:

So, I’m going to tell you about some of the types that I do really well and then you get to pick which one.”

Til Luchau:

You’re saying there is a strong research rationale for giving the patient a choice of modalities, giving a menu of options that work and letting them vote on which modality or method you’re going to use.

Mark Bishop:

Yeah. For me personally if there is no difference between me doing mobilization for your neck or manipulation for your neck or muscle energy technique for your neck, if I explain how each of those work to you, and I personally think the outcomes will probably be similar, then it’s no harm for you to say, “You know what, as the patient what I want is this one.”

Til Luchau:

Okay. Why don’t then we just ask our clients what they want and why don’t we just do it? Is there any downside to that at all?

Mark Bishop:

Yeah. I think the context around that, I’ll get to a different part of that question. But if in my opinion there is a best way to treat you, then part of the education would be to say, “Okay, this is the best options. These people who get these treatment programs seem to recover the fastest and have the best outcomes. So, this is what I recommend that we are going to do today.”

Mark Bishop:

That’s a little bit different than your question, which is the second part if the patient doesn’t want to do anything that I have suggested. You can say, “Well you know what, the only thing that I expect to help this is to have a hot pack and some ultrasound because last time my neck was sore what I got was a hot pack and ultrasound and my neck got much better.”

Mark Bishop:

So, the way that we have thought about that is to include that with the other package, and say, “You know what, that sounds like a great idea. I’m very happy to finish with those. Once we get through a couple of things up front, then we’ll make sure we finish with the hot pack and the ultrasound.”

Mark Bishop:

When I tell this sort of story to some people, one of the challenges with this surrounds billing and charges. So, it’s a little bit easier for me to advocate for that because my practice is pro bono at the university and our studies are not dependent on certain regulatory restrictions about how to charge and bill.

Mark Bishop:

So, I can do that but I understand some clinicians push back a little bit and say, “Well, that’s unethical. I can’t bill them for that.” That’s a slightly different conversation. If you take the billing part out of it, if I don’t think that there’s going to be any detriment, then certainly I would include that.

Mark Bishop:

The other part I would say though is do it on a time contingent basis so that the person is not expecting this other part of treatment to be the primary focus for how many times they come and say, “Yeah, we’re very happy to include that. I think that’s a great way to finish for the first two, maybe three sessions. Then we’ll re-assess and see where we are then.”

Til Luchau:

All right. What if it’s something that I don’t particularly believe in as the practitioner or enjoy doing or don’t think helps? Is there still a benefit in me doing it just because they do?

Mark Bishop:

Well, that gets to the provider stuff that even everyone who thinks they’re a great actor will convey that they don’t believe very strongly in what they’re doing.

Mark Bishop:

I haven’t done any of those studies but I’ve read a couple where clients and patients are able to pick out which providers are giving, particularly in research studies, the real treatment versus a placebo treatment just because of the way the person’s body language and interacting and stuff like that.

Mark Bishop:

So, if you don’t believe in it, then it’s going to be, I think, hard to get that extra piece, that benefit that if the patient believes it, they will still get that benefit from their belief, they just won’t get the added bonus of your belief positivity, confidence, and those type of things.

Whitney Lowe:

I’m curious to hear your opinion on this. I don’t think this was … I didn’t see this picked up at all in any of your other research. But in something like the massage therapy profession, which is a vast majority of our audience that we’re talking with, if we’re talking about expectations to benefit from that treatment and in that particular let’s call it a modality or approach of massage.

Whitney Lowe:

Massage might be administered by a physiotherapist with a great deal of academic education and high level of credentials, DPT or something like that, it could also be administered by an individual with just a very basic level of massage training who has very little formal academic training.

Whitney Lowe:

Might you see expectations from the client or patient change when they recognize who their practitioner is and they don’t … I’m assuming that if you have a great deal of confidence in the skill level, the demonstrated or perceived skill level, let’s say, of the practitioner that you’re working with and maybe you have never met this person before and that environment changes when you meet them and you see well they don’t have a lot of significant training, could that change the outcomes of your perception of effectiveness of your treatment at that point?

Mark Bishop:

It may indirectly. One of the things that you’re talking about is I think related within therapeutic alliance. One of the elements that people have identified as building therapeutic is the trust in the provider and the perceived, as you said, skill level of the provider.

Mark Bishop:

So, potentially yes if you walk into a place and the person has got their academic training and their clinical certifications and the pictures of the happy people on the wall who’ve signed with the thank you for a great job and all that type of stuff, that helps build the kind of confidence that our client has in you as a provider.

Mark Bishop:

I don’t know enough about it to give you an answer about the degree qualification. I think that whether you’re someone from the physical therapy background or massage therapy or osteopathy, for example, it’s potentially the same environment set up and that would be the healing context, the therapeutic environment around this.

Whitney Lowe:

Yeah, yeah. I’m thinking more in terms of talking about the degree and the academic qualifications, more about just the environment that gets set up there. Not specifically those particular educational programs but just the client or patient’s perception of this individual’s skill and capability levels that might be demonstrated by some of those things.

Mark Bishop:

Absolutely. I know there’s a couple of groups in the US that have began doing this and doing it very well. But one of the things is the first person with whom the client interacts is your expectation ambassador.

Whitney Lowe:

Yeah.

Mark Bishop:

Whoever that person interacts the first time has great potential to help set this context in motion. That, “Whitney yes we’ve got an appointment at the time that works, you are going to see Til. You’ll love Til. He is such a funny guy. He does great work. Everyone loves seeing him.”

Mark Bishop:

That even just those sort of comments can begin the person on the other end of the phone saying, “Good, good. I got to see Til. He’s the best in the clinic. This is going to be great.”

Whitney Lowe:

Yeah.

Mark Bishop:

Same with if friends or they don’t have to be friends, but if people are giving the good reports, these all help build that pre-contact expectation.

Mark Bishop:

Then once you get there, the therapeutic context has been shown to really influence alliance and client confidence and that type of thing. The trust and confidence that the patient and client has in the provider.

Whitney Lowe:

Yes. These are all … Go ahead Til. I was just going to say these are all things that we question I think how we go about training people appropriately for developing those kinds of things.

Whitney Lowe:

There’s I think a much greater emphasis needed in some of our training programs on the role of some of these factors which I think are significantly under emphasized in terms of their contribution to the outcomes.

Mark Bishop:

Yeah, I would agree. I think the metaphor that works for me is that I have never given treatment in a blacked out room, dressed all in black with a mask on, and the client unconscious.

Whitney Lowe:

Yeah.

Mark Bishop:

If the mechanical effects of treatment were all that mattered, then doing treatment that way would work just as well as what we’re talking about.

Til Luchau:

So, you’re saying you’ve never given a treatment where you tried to eliminate the context because a treatment in a dark room with you dressed in black is an interesting context in it of itself.

Mark Bishop:

Very true.

Whitney Lowe:

The masked man, there could be a lot of power in that.

Til Luchau:

Well that’s so candid in saying there’s always weather, there’s always a context you’re saying, there’s always some set of factors that creates the expectations or preferences or associations on both of our parts.

Mark Bishop:

Yeah. I have some great examples in the placebo literature from Benedetti’s group. The original design is quite old and it’s called I think Open Injection. In those studies, someone who is in pain, in a hospital randomized to two groups.

Mark Bishop:

One group has a health professional work walkup in a white coat. The person in the bed can see the injection going into the bag. And you get a great response after the injection.

Mark Bishop:

When you give the same injection from behind the screen so the person doesn’t know when it’s administered, in some drugs used for pain, not all, but in some drugs used for pain you actually eliminate the effectiveness. So, the effectiveness of that particular medication was all context.

Mark Bishop:

So, it’s an incredibly powerful path of the treatments that we have. The sociologists and I think it’s Verghese is a physician who studied some of this calling it the Bedside Ritual or the Therapeutic Ritual as part of setting the context for healing to occur.

Til Luchau:

Yeah, I read about this again that what you’re talking about the contextual effects, et cetera, are subjective only. Are they and does that even matter?

Mark Bishop:

Well, so I want to go back to if whatever you thought changed your neurophysiology. So, subjective just means to people that you thought it. I think that’s what people mean when they say subjective. You thought it and told me about it.

Mark Bishop:

But I can measure that and I can measure what you tell me quite accurately and repeatedly. So, it’s not a measurement issue, I think it’s people’s, this is an opinion, I think it’s people’s bias back to this dualism that if you thought about it and told me, that can’t be objective because I didn’t measure whatever it is.

Mark Bishop:

But you can measure these verbal responses very accurately. You can measure everything that I would, it just happens to be that what you’re measuring is the end result of a critical process.

Til Luchau:

Okay.

Mark Bishop:

So, to your point, I don’t think it matters. If I’m doing a treatment that seems to activate your endogenous capacity or modulate your own physiology and increase the inhibitory dampening in your spinal cord, good.

Mark Bishop:

Once again though, I don’t have to negotiate billing and regulatory things associated with that.

Til Luchau:

Yeah. Those things aside, there’s also the argument that people are coming to us for subjective reasons. So, maybe the subjective realm was the right target for our outcomes as well.

Mark Bishop:

Yes, yes. What’s the, I can’t remember that saying, I think at the pain summit we were at, one of the slides was when the person is complaining about pain, the treatment should focus on the pain.

Til Luchau:

Okay. Well okay. That makes me think that there is a portion of our listeners who see clients or patients whose focus may not be pain, maybe general self-care, relaxation and stress relief. Do you see any reason these things wouldn’t apply there as well?

Mark Bishop:

I can tell you they do apply. In fact, in exercise studies, expectation of benefit predicts performance improvement, confidence in the coach and expecting sort of alliance with the coach predicts performance improvement.

Mark Bishop:

So, the same things are at play and this is an example of, I think what people would truly think is peripheral physiology, your ability to run faster is influenced by your confidence in the training program and your expectation that you will run faster if you’re not expecting …

Mark Bishop:

What they think the mechanism is, that if I’m expecting this to work, when they get people exercising at consistent effort outputs and that type of thing, that the people with high expectations and benefit report lower exertion than people who don’t expect it to help.

Mark Bishop:

If I don’t expect it to help, it’s that old adage about if your head’s not in the game, you are not putting in the effort I think, is what it makes me think about. So exercise, for sure. I see no reason that if I go to see you expecting benefit in the forms of relaxation or stress relief, that I will experience more relaxation and stress relief unless you’re using a very hot thing for treatment.

Whitney Lowe:

Do you think there are specific things that we could focus on, for example Til and I are both educators. Are there specific things that we could focus on in educational programs both in our field and across multiple different professions to enhance the benefits of this piece of expectation for therapeutic outcomes?

Whitney Lowe:

What kinds of things, I know certainly it’s a soft skill and much more difficult to kind of to put in granular terms to what kinds of things we might really be able to focus on, to improve those outcomes.

Mark Bishop:

I think at the simplest level, going back I apologize I didn’t research any of the training for other professionals. But going back to, say for example, therapeutic communication, which used to be a standard class in every PT program everywhere.

Mark Bishop:

Then like you said, that got removed as people wanted more physiology and pharmacology and radiology, what are we going to get rid off? It’s just communication. We’ll eliminate that.

Mark Bishop:

What I think is learning how to communicate well is of imperative performance, I’d probably also suggest things that elements of motivational interviewing, not necessarily the whole formal training because that’s very intense.

Mark Bishop:

But making sure people are asking open ended questions and actually caring. I think one thing that came to mind recently is I ran into someone I’d seen as a patient, I don’t know, 20 years ago in a parking lot.

Mark Bishop:

We were catching up and she was complaining about a shoulder and how she was doing all this exercise and doing all this manual therapy it just wasn’t getting any better. I literally, I listened to her, this is what I remember, I listened to her and then said, “You know what, I have to go. I need you to just do a couple of these catch the rain exercises, feel it back there, just work on that for a week and we can talk later.”

Mark Bishop:

Then a week later I ran called her and she said, “I feel great. I have never felt so good. My shoulder is better.” When I asked her, she said I was the first person who actually let her tell me about her frustrations with what was going on and suggesting all changes.

Mark Bishop:

So, I’m not saying that I’m awesome because of that, but I think just episode of listening to her and saying, “Okay. I hear you’re really frustrated. There’s lots of different ways to do this. How about we just try this alternative?” That was enough for her to, I think, say thank you.

Til Luchau:

Yeah, a great example. And Whitney your question is great too because it has a lot of implications for say, entry level training for sure, and the pressure you’ve mentioned Mark about how those things are often the first things to get cut, the alliance skills, the listening skills, the communication skills.

Til Luchau:

But I’m thinking even at say the post-grad level, the people that are out there in the field working for a while we tend to think, yeah I got that, I know about that stuff, I’m a natural. I’ve been doing this for how many X decades.

Til Luchau:

There’s probably a whole other room for us to get better in terms of understanding the alliance and the contextual possibilities and the expectations involved too.

Mark Bishop:

I think so. I’m going to be PT specific again. I think there is a group of physical therapist who were trained in the, there was an era where we’re not going to ask about pain, we’re going to focus on function.

Mark Bishop:

So, there’s a group of PTs from the late ’90s who probably may not have been trained to think about these type of things in the same way. I think this is all opinion.

Mark Bishop:

The other thing that I think is interacting with providers when we are talking about this, is many people are still getting a very traditional explanation of pain as a symptom. People are talking to me about the gate theory and stuff like that and saying it’s a little bit more complex and there’s lots of things that play not just A-alpha and A-delta’s company and the C5-ers and top down inhibition.

Mark Bishop:

It is a little bit more complex and there has been a move that I’ve liked where people are beginning to understand a little bit more of the complexity of not only pain the symptom, but pain as a disease because once you get into working with people who have chronic pain, there’s lot of the whole marks that have all of the disease states in that situation, not just the symptom.

Til Luchau:

All right, pain as a disease in the chronic level and pain as an experience than anyone different symptom, it’s a whole person’s experience to say more than something that just happens at the periphery or on the body.

Til Luchau:

One more question I’ll make sure I get in before we wrap it up. What about COVID? How might that be well something that would influence the contextual factors but also the expectations or how do you think we need to be thinking about the rituals or the ways that ambassadors step in bringing people into our practice if we’re for the same clients. Any thoughts about that?

Mark Bishop:

Yeah. I would think that being very reassuring, the ambassador saying, “You know what? Do you have any concerns about coming to see us? Anything about COVID? Let me tell you about the protocol. So, we’re deep cleaning everything in between people and then you go and see Til. He will probably have a face shield on and a mask. Will that be okay?”

Mark Bishop:

Just kind of interacting with people I think to give them the before they get there, before they are lying on a table with their mask and you walk in and full PPE. I think setting the stage that this is what treatment would actually look like.

Mark Bishop:

Then my thought is that practitioners and providers may need to also be interacting with patients ahead of time, answering questions.

Til Luchau:

Yeah.

Mark Bishop:

Because nothing has changed in what we’re actually delivering. I just need to let you know that how we deliver it is just going to look a little bit different than if you were here before COVID. You’ll see that we are separating people and all that type of thing.

Mark Bishop:

So, people’s expectation of what it’s going to look like matches what they experience when they get there.

Til Luchau:

You’re saying we may need to be a little more proactive and a little more detail-oriented around setting the expectations and making sure those are outlined clearly ahead of time. Well Whitney, anything else you want to make sure you have a chance to ask?

Whitney Lowe:

No, I think we got into some fascinating territory here and I hope we maybe can have an opportunity to dig into some more of it later on.

Whitney Lowe:

But I think there’s some really significant things to think about in terms of going beyond the usual pictures of what it is that we think makes our work effective because these concepts and ideas around expectation and some of the other factors I think are sometimes undervalued in a lot of the approaches and perspectives that we have.

Whitney Lowe:

So, Mark just thank you so much for sharing your research and your perspective on this with us here.

Til Luchau:

Absolutely. Mark is there anything you want to leave us with? Any key thoughts or key points that you think we should be keeping in mind?

Mark Bishop:

Well if I was going to summarize, I’d say I think it’s important to think about what the person is expecting and to find out if they have specific expectations about a treatment or types of treatment.

Mark Bishop:

Then if you are able, and it does not interfere with your treatment plan, consider including elements that patients expect to help in to that decision making process when you’re pointing out the management strategy.

Mark Bishop:

I think engaging. There’s some patients that don’t want to be involved and just want you to tell, but unless you ask someone about that you may not know what the expectations are being included, the expectation for interventions, all those things.

Mark Bishop:

So, I think asking people about what they expect is useful to help you plan the right approach.

Til Luchau:

Yeah. That could be as simple as saying is there anything that you want to make sure we cover today? Anything you want to make sure that I do for example. That kind of question?

Mark Bishop:

Yes sir. Absolutely.

Til Luchau:

Excellent. Excellent advice. Well Mark where can people find out more about you and your work?

Mark Bishop:

I’d say the simplest place would be the PHHP.ufl.edu would be where you can find links to our lab there. That’s probably the simplest place for information. Periodically I’m on Twitter @PhysioBish.

Til Luchau:

We’ll put all this in the show notes too.

Mark Bishop:

The Center for Pain Research and Behavioral Health is at Painlab.org.

Til Luchau:

Okay, fantastic. Well thanks again for joining us Mark and thanks for the patients with the set up. But I’m glad we got to pick your brain on a couple of these really interesting topics.

Mark Bishop:

That was great. Thank you for the invitation. I enjoyed it.

Whitney Lowe:

Absolutely. Yeah good. We would like to say thank you to our sponsors and we also have this show is also being sponsored by Books of Discovery. We have a brief message from Andrew Bill the author of Trail Guide to the Body.

Andrew Bill:

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Andrew Bill:

Books of Discovery is proud to support the thinking practitioner and we’re offering a 15% discount when a listener enters thinking at the BooksofDiscovery.com checkout page. Enjoy the show.

Whitney Lowe:

And if you heard any of us drop a reference to something you’d like to learn a little bit more about, remember to visit our sites, check out all the studies and references that you heard about today as well as a full transcript for the show. Til, where can people find that information from you and information on the presentation here?

Til Luchau:

Information on our site is at Advanced_Trainings.com. How about you Whitney, where do they get it through you?

Whitney Lowe:

They can get it through us also over at the AcademyofClinicalMassage.com. If you will remember send us questions that you have or input on other things that you’d like to hear us talking about to [email protected] You can look for us on social. Where do people find you there on social, Til?

Til Luchau:

Just my name @TilLuchau. How about you?

Whitney Lowe:

Also the same thing for @WhitLowe on Twitter and also on social under my name as well.

Til Luchau:

Follow us on Spotify. Rate us on Apple Podcast or wherever else you listen. Tell a friend. Thanks Whitney, thanks Mark. Well see you everybody.

Whitney Lowe:

That sounds great. We’ll see you in two weeks. Thanks again Mark and everybody.

 

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