As Physical Therapists, we interact with our patients in many different ways.  We talk to our patients.  We touch our patients.  We teach our patients.  In doing this, we provide a significant amount of “input” to their individualized nervous systems.

But despite many of us grasping this idea, I feel we are plagued by the “search for the holy grail“.  What I mean is we all want to have an edge.  We all want to find that modality that is superior to the other.  We all want to boast about our superior outcomes utilizing that modality and we all want to downplay any argument that suggests the possibility that that modality is simply just another modality.


I am going to be quite blunt here:  I do not think there is a superior modality in the treatment of pain.

That stated, I do think we can be quite successful in the treatment of pain…by simply understanding that there are two forms of input we provide (these are the variables that need manipulated in the complex equation of treating pain).  And sometimes those modalities assist us in providing the necessary equation of input.  But the equation is dependent on the person in front of us.

1. Clinician Directed Input: This is the input that is provided by the clinician.   This type of input includes the clinicians hands; their confidence; their words; their appearance; etc.

None of us interact with our patients in a one-dimensional manner.  We all interact in a multitude of ways, to attempt to convince our patient’s nervous system, that the actual (or potential) threat to their tissues is diminishing (in simplistic terms, this is what we do).   In this, I suspect a bit of theatrics come into play, which varies based upon the patient in front of us (which is ok.  Its humanistic.).   This complex series of inputs eventually leads to some form of outcome  (which confuses me why we spend so much time tightly controlling for internal validity in RCTs—or perform so many RCTs looking at all of these different forms of input in isolation without accounting for things such as examiner’s equipoise).

Every bit of interaction matters.

2. Non-Clinician Directed Input:  This is the input that is provided to the patients nervous system that is not directly related to the clinicians interaction.  It involves the sounds in the clinic; the lighting;  the grimacing of another patient on a plinth.

We have all been in situations which have made us feel comfortable and uncomfortable.   When a patient comes in your door, in pain, they need to enter a clinical environment that is not threatening.   We need to understand which patients perceive the gym as beneficial; and which patients view it as scary.  We do not want to create a “haunted house effect”, making the patient even more fearful of moving (because they don’t know what that piece of equipment is).   We need to understand that the environment in which we treat, may be just as valuable as the tools which we use.

These concepts are part of the MIP (Motivation, Input, Plan) algorithm which myself and Dr. Francois developed a couple of years ago.   We have lectured on this idea at national conferences, it is taught within our residency and fellowship programs.   I want you, to help me in further developing the concept of input—in the comment section: lets discuss this idea further, provide me with some clinical examples or even provide some references for research supporting OR refuting our idea.  Let’s begin a discussion and determine if this search for the holy grail is really necessary…

-Joe B


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