#148 Musculoskeletal Treatment Pathways with Chad Cook

As we’ve interviewed expert clinicians on the podcast, clear trends have emerged. These clinicians have two things in common: 

1. They have a pretty set arc to their treatment sessions. 
2. They tend to work from “menus” of intervention options. 

I’m pretty sure they do this- because this is what they’ve discovered works. But, I’ve never really seen this approach studied or discussed in research…until now.

I was honestly flabbergasted to hear one of the most prominent rehab researchers in the world, talking about these two things, in his paper  Many Paths to Recovery: The Case for Treatment Pluralism. From what I understand, Dr. Cook gives these concepts some formal names: he calls those intervention menus ‘treatment pluralism‘—and he calls the components of the arc of a session ‘therapeutic ritual‘… driven by what researchers call contextual factors

In today’s episode, I can’t wait to dig deeper into this paper—and how our guest Dr. Chad Cook currently understands the factors that make therapy effective. 

This is an episode that could fundamentally change how you think about each patient encounter.  

See full course details here:
https://otpotential.com/continuing-education/course/msk-treatment-pathways 

See all OT CEU courses here:
https://otpotential.com/ceu-podcast-courses

Check our our live webinar schedule here:
https://otpotential.com/live-ot-ceu-webinars

Support the show by using the OTPOTENTIAL Medbridge Code:
https://otpotential.com/blog/promo-code-for-medbridge

Try 2 free OT Potential courses here:
https://otpotential.com/free-ot-ceus

Transcript

SPEAKER_00 0:00

As we've interviewed expert clinicians on the podcast, clear trends have emerged. These clinicians tend to have two things in common. First, they have a pretty set arc to their treatment sessions that they repeat with each client. And second, they tend to work from menus of treatment options, giving them flexibility in choosing the right intervention for the right patient at the right time. I'm pretty sure they do this because they've learned that this is what works. But I've never really seen this approach studied or discussed in research until now. I was honestly flabbergasted to hear one of the most prominent rehab researchers in the world, Dr. Chad Cook, talking about these two things in a paper he co-authored called Many Paths to Recovery: The Case for Treatment Pluralism. From what I understand, Dr. Cook gives these two concepts some formal names. He calls those treatment menus treatment pluralism. And he calls the components of that arc of the session treatment ritual, driven by what the researchers call contextual factors. In today's episode, I cannot wait to dig deeper into this paper and how our guest, Dr. Chad Cook, currently understands the factors that make therapy effective. This is an episode that could fundamentally change how you think about each patient encounter. And I can't wait to dive in. Welcome to the OT Potential Podcast. I'm your host, Sarah Lyon, OTRL, and I wanted to let you know that this podcast may qualify as continuing education for you. You are probably listening to this podcast on a free podcast platform. But to gain CEU credit, you will need to be a member of the OT Potential Club, our OT Continuing Education Platform. You can go to OTpotential.com to learn more. Okay, here we go. As I mentioned at the top, joining us today is Chad E. Cook, PT PhD, MBA, FAPTA. Dr. Cook is a clinical researcher, physical therapist, and professional advocate with a clinical care excellence and service history. His passions include refining and improving the patient examination process and validating tools used in day-to-day physical therapist practice. Dr. Cook has authored or co-authored four textbooks, published over 460 peer-reviewed manuscripts, and internationally lectured on orthopedic examination and treatment in over 40 countries. He currently serves as a professor of orthopedic surgery at Duke University School of Medicine, as well as the Director of Clinical Facilitation Research at the Department of Orthopedic Surgery and as the director of Duke's Center for Excellence in Manual and Manipulative Therapy. So without further ado, we will patch Chad into our live studio. Welcome to OT Potential, Chad. It's so great to have you.

SPEAKER_01 3:04

Thanks, Sarah. It's wonderful to be here. Thanks for that introduction.

SPEAKER_00 3:08

Absolutely. I cannot tell you how excited I am for this conversation. I almost feel like you are someone I've been searching for for like a decade because I started this podcast because I felt like I was just an okay average clinician. I went to school at NYU. I came back to work in rural Nebraska. I was by myself. I was seeing all kinds of patients. And I just felt like I was just okay at it. And I got really curious. I was like, what are the expert clinicians doing? And that led me to this podcast and getting to interview expert clinicians and really hear what their sessions look like, how they're thinking about treatment. And I was so surprised. I, as I was talking to people from all different practice areas, I felt like I just kept seeing these common themes emerge. That one, they had this like very clear arc to their sessions that they just repeated all the time. I did not do that when I was practicing. I was just like flying by the seat of my pants. Um, and two, they tend to function from what they called like their menu. Like they had these kind of set things that they could do with each patient, but they would choose strategically which ones to do with the patient. So I saw that trend like three years ago that came really clear. Um, and I started to look in the research of like, what do you call this? Is anyone studying this? Like, this feels really important. Like I'm seeing it in pelvic floor therapy and hand therapy and chronic conditions, they're all doing the same thing. And I just couldn't find any writing about it. Um, and then, like a month ago, I heard you on a podcast and I felt like you were kind of talking about these things, use but using words that I had never heard before. So today we're going to talk about your paper on treatment pluralism, um, which we'll define and we'll kind of bring back to what that looks like in clinical practice. So, to kick us off, I would just love to hear what is treatment pluralism and how did you become interested in it?

SPEAKER_01 5:27

So, treatment pluralism is the fact that there's no single way of recovery for every patient. That there are there are multiple roads to Lincoln, Nebraska. There's all these different ways that you can make the patient better, and there's no superior treatment technique. And it is somewhat shocking because I think, you know, you and I both went to professional programs and we were taught these are the best uh care processes, this is what you should do. But in reality, what happens outside those care processes processes, which you were talking about, are just important, just as important. So I got interested in this back in probably 2018, um, and published a paper with a clinical psychologist named Frank Keefe, and then a very talented psychologically informed practice PT named Stephen George. We published it in the British Journal of Sports Medicine, where we talked about the fact that most of the time you're going to get the same outcomes, even though you use different treatment techniques. And we tried to explain why in that particular case. So it was more of a uh mechanisms approach. Rather than describing what it means and what it is, we said this is probably why. And we were spitballing essentially. Uh, the most recent paper was in J O S P T with Jared Powell and Amy McDebitt. And in that case, we really mostly just described what is pluralism, what does it mean, and how it's actually a good thing.

SPEAKER_00 6:59

So your paper was about specifically about MSK treatment. And as I understand it, please correct this. It feels like you're loosely talking about uh like exercise approaches, manual therapy approaches, and you can kind of go either way and get about the same outcome. Is that a good summary of the paper?

SPEAKER_01 7:25

It is, but there you could actually toss in other treatment approaches with that too. Um, self-care management has similar outcomes to manual therapy and exercise. A psychologically informed approach or a talk-based therapy approach has a similar outcome as well when you look at trials. Um, so there are many different types. My world is definitely MSK. My neurological colleagues will tell me that they have a lot of situations that are very similar in to their care management too. But definitely it fits within muscle skeletal, and definitely how you're describing it is accurate.

SPEAKER_00 8:02

It does feel like I'm going to make you spitball a little bit right away. Um, you you're you're studying this in MSK, but I totally anecdotally from what I see looking across practice areas, it feels like this is a paper not just for people working in orthopedics. It feels like an approach that uh our neuro OTs, our pediatric OTs um can also think about. I even just did suicide prevention, uh, and it felt similar where there's multiple options that feel like they have similar effect sizes. Do you feel like this is a framework for therapists in other practice areas? Um, and have you thought about that?

SPEAKER_01 8:47

I do. And so I you're probably like me. When I treated patients and someone didn't get better or I didn't see the same results, I took it personally and I felt, okay, what did I do wrong? Or in other cases, I worked with a patient, I would use a set of techniques or an arc of techniques, and maybe with another one I'd do something different. And the results were often equivocal. And I was just really dumbfounded by that. How can it be that these two inherently completely different approaches can lead to the same overall outcome? I think it takes a lot of pressure off a given clinician. You know, there are close to two million biomedical articles published every year providing evidence about a, you know, a particular area. There's no way we can keep up with that much information. And I think it's as a practicing clinician, I think staying on top of the day-to-day clinical work and trying to stay on top of the literature, it's really a challenge. Pluralism allows us to recognize that there are probably a lot of different things that are going to be useful for this patient. You don't have to focus on one way, you don't have to go get certified in a particular method. There, there are many different things that are going to be beneficial.

SPEAKER_00 10:08

Feels like a way to free us from a lot of guilt as therapists. Like, I think I, uh as a generalist, uh would tend to do, of course, the stuff that was in my wheelhouse. So maybe I would choose like an exercise intervention, just like that's something I can do, it's safe. I'm not trained in manual techniques, and I would feel guilty to be like, oh, I know there's these other offerings, but I don't know how to do them. I have to stay within my wheelhouse. Um, and treatment pluralism kind of frees us from the guilt of that.

SPEAKER_01 10:41

It also frees us from the negativity that we see on social media, where people are pushing different techniques or a certain type of approach, or being uh, or people are berating others for using things like manual therapy or a treatment approach that somebody has found to be beneficial. The the truth is on the side of the individuals who understand pluralism. It's not on the side of the social media folks that are um pushing one way of care. Uh, can I tell you a quick funny story?

SPEAKER_00 11:12

Yeah.

SPEAKER_01 11:12

So about a week and a half ago, I was in Barcelona, I was speaking, and I talked about treatment pluralism a little bit and the the fact that you don't really need to do all of this uh, you know, huge continuum education, take eight courses to be certified in a given approach. You know, it's not going to make that big of a difference in your overall outcomes. And it was funny because afterwards, people, most people came up and said, I really appreciate you saying that. You know, that is relieving to know that I don't have to do that. But the people that were selling products, they didn't like that message very much. But but it is true. I mean, look, it expertise is never a wrong thing, but it isn't necessarily going to mean a person's overall outcomes are gonna be um better than another person. You mentioned at the very start that the average clinician, most clinicians, and there there are actually studies that look at this, about 80% of clinicians have the same overall outcomes. So most clinicians are average clinicians, and that's not a bad thing.

SPEAKER_00 12:17

This is already super helpful, just uh being able to think about therapy in this way. I'm also like, oh, it's okay that I'm an average clinician. That's most of us. I have lots of questions about what this means for our treatment sessions, how to choose the right interventions, is it a free-for-all? But I want to linger a little bit just on writing this paper. Um, I want to say the full name of the paper out loud. The paper is Many Paths to Recovery: The Case for Treatment Pluralism. And it was co-authored by Jared Powell and Amy McDevitt and yourself. It was published in the Journal of Orthopedic and Sports Physical Therapy, and it came out online on June 1st, 2026. I would just love to hear a little bit more about the experience of uh writing this paper. It's still pretty fresh, but what stands out to you as you look at it and think about it now?

SPEAKER_01 13:16

A lot. Uh, first of all, shout out to J O S P T for um being interested in the paper. They're they they're very forward-thinking as a journal, and they have viewpoints that you know it's almost like a white paper. They're they're completely okay with an apypical paper coming out. So, Jared Powell, who is an extremely talented uh Australian uh researcher and clinician, he just finished his PhD a couple years ago. He's a young fellow. Also, um, he's the host of the shoulder physio podcast, which is a great podcast if individuals are interested in shoulder treatments. He reached out to Amy and me and he said, I know you guys do a lot of work on shared mechanisms. I'd like to actually tie that in with treatment pluralism and you know, have you guys involved in the product. Amy is a um clinician researcher from the University of Colorado. She's a physical therapist. Uh Amy's like a free-spirited kind of hip hippie type, just super fun, great person, good thinker. So the three of us said, Yeah, let's do it. This sounds like a great idea. Sarah, I gotta tell you, usually when you publish a paper, you have, you know, somebody saying something negative about it, or you know, somebody on social media is saying this is garbage or whatever. It has been nothing but positive. Uh, I think it's been, you know, like we were talking about, it's been somewhat relieving that people can read about this and recognize that it there is not one way of doing something. There are many ways, and that the research actually supports that. So that's that's the backstory behind it. We basically wanted to get the message out. I think Jared became interested in it because he started looking at the role of strength gains in the shoulder toward overall outcomes, and there is not a relationship with that, which is completely the opposite of what we learned as we, you know, as we were trained. Um, so it has to be something else. And it it has to be many other things. So uh that's the backstory behind it. It was kind of a uh good timing, I think, for for the paper.

SPEAKER_00 15:25

I've already seen in the comments what you said the reaction to the paper was was this feeling of relief. Um, I'm as you're talking, I'm thinking about the commercial influences that we do have as therapists, where we are being sold different trainings, the idea on social media that there's one right way and this is superior. And it is relieving to see a paper like this to reaffirm what a lot of us really see in practice, that there are many paths, and focusing on that patient in front of you and trying to figure out what's the right path for them still feels like the best approach. You've done so much research, uh, 450 articles. I just can't even wrap my mind around that. I'd love to get a little nerdy for just a little bit and talk about uh what this has looked like in your research, um, what the trials andor just papers that you've written related to this, what have those looked like and what's the trends as a researcher that you see on treatment pluralism?

SPEAKER_01 16:30

Yeah, so we've done, I've been part of 20 trials. A lot of them I was the primary investigator on, others I was just either an analyst or a co-investigator or something. And what is probably stunning is that out of 20 trials that I've been on where we compared one treatment to another, 19 were null trials where there was no difference between the two groups. So even in situations where we would take seemingly completely different interventions, or most recent one where we compared manual therapy to exercise, exact same outcomes, uh, which suggests that there is heavy pluralism, even in a uh a well-controlled clinical trial. The one instance where we did find a difference was probably the weakest overall design, the one that we had the least amount of quality control, because it there were multiple sites, many even in South America that were gathering data for us. So we we didn't have you know really strong oversight on that. Recently, with instead of answering, is there a difference? we've been trying to figure out why. Um so we've been doing a lot of mechanisms-based research. And and in mechanisms-based research, you basically look at the underlying reasons why people are changing or why are we seeing these outcomes. We do what's happening physiologically, what's happening, happening psychologically. And what's interesting is we're finding the same thing, that even on the physiology side or the psychology side, we're getting the same in the where different inputs are are leading to the same overall physiological or psychological outcome, meaning that the reason behind the change seems to come to a common metric, and that common metric is what influences outcomes. And that's been relieving too.

SPEAKER_00 18:22

I'm so curious about what you're saying. That I have to admit is the part of the paper that I read this paragraph like multiple times, and it was about shared mechanisms. So I would love for you to explain this to me even further. So, in the paper, if you're loosely talking about uh exercise, manual therapy, a self-management program, you're saying that there is a shared way that these three things work. And I in the paper you say shared mechanisms are the underlying processes, pathways, or factors common across multiple conditions, treatments, or phenomena. What does that mean? How is a self-management program doing the same thing as manual therapy? Um, they feel fundamentally different to me.

SPEAKER_01 19:17

It's a great question. And if you don't mind, I'm gonna deconstruct it and maybe give an example. Um, I've used an example in the past, and I think that's been probably been the most helpful. So we know that selected interventions have specific mechanisms. In other words, the way they work is specific to the intervention itself. Exercise increases cross-bridges, it increases power, it does a number of things. And we believe that that increase in power is what leads to improvements and outcomes. It's not always the case, but that's its specific mechanisms. Manual therapy, we know, actually has a very strong pain modulatory effect. It influences the uh biomarkers associated with pain. And it's been studied numerous times, and it does that exactly. So it's very different specifically than exercise. Two very different specific mechanisms. They both have shared mechanisms, though. And those shared mechanisms are things such as belief and patient preference and how it influences the way a person thinks and how it frees them up to get back to activity and how they believe they're improving overall. Those are more psychologically oriented, but we know those are strong influencers toward overall outcome. And if you don't mind, I'll give you an example. So I had frozen shoulder after a shingle shot, and I was going in and I and I tried to do all the PT things to help it out. And I knew that I needed to stretch it and strengthen it and keep the mobility up, but it just kept getting worse. And it it kept getting worse for over a year, and it got to the point where I was really struggling with it. So I talked to an orthopedic surgeon. I said, Can you give me a cortisone shot? I really need a cortisone shot. I think that's gonna really help. And he set up the appointment, went in to see him. I go in and he goes, When did you last have your COVID booster? And I said, Well, like two weeks ago. He said, Well, I can't give you your shot yet. You have to wait another month for that. So I had to wait another month for that. And I'm and I'm really needing that shot. I finally got the cortisone shot, and there was a dramatic improvement in my shoulder. Now, the specific mechanisms of cortisone, right? It pushes all the fluid out of the area and it stops the neuroimmune response. But it typically works a little bit slower than being instantaneous. I had instantaneous pain reduction after the cortisone shop. And I had improved mobility. That is from shared mechanisms. That's because I believe that's what I needed. It's because that's what I wanted, and that was my preference. And I've been really pushing for that. So that's what we mean by shared mechanisms, the piece that checks the box on what that patient thinks and believes they need, and then that allows them to improve and move forward. Does that help?

SPEAKER_00 22:19

Yeah, it's reminding me of um I have a hand therapist I love having back to the podcast because she's so good at describing her treatment process. And I asked her recently, I was like, what was the moment that you felt like you went from an average to an expert clinician? And she said, and I was assuming it was going to be some kind of training, something she learned. And she said, It was when I started saying to my patients, I can help you with this. But she just had the confidence in herself, and it sound, and now as I'm hearing you talking, I'm like, she set expectations, and that is a powerful thing in our sessions. I have like a million questions about this. I want to drill like linger though on this like no superior interventions piece, like that we're seeing kind of equal outcomes. I just frankly, I think of I have a bias. I think of exercise. I'm like, the patient is very active in it, their motivation has to be high. I think of manual therapy. I'm like, it's more passive. Um, I don't see the translation to that that gets incorporated to their routine. Why aren't there superior interventions? Like it just feels to me like some should actually be a little better. Why do you think we're seeing these same outcomes?

SPEAKER_01 23:52

I think partly is because what we see is active and passive as something that you can divide is actually overlaps a lot in how it's manifested in clinical practice. There, if you talk to any manual therapist, they don't just do manual therapy. They actually incorporate manual therapy into the exercise. And it's part of you know incorporating movement or reducing pain during movement or other elements. So that part of it, I think, has a blended approach. Uh, even chiropractors now who used to live only in the passive sphere of care have incorporated exercise and active movements and such into that. There's a lot of shared mechanisms because active movements can also relieve pain very similarly to passive movements. So I think there's some overlap there, which is why we don't see superiority in trials that compare the two in any area of the body, um, is because there's so so many shared uh mechanisms with respect to that. And even our recent neck trial, we found the same thing. There was no superiority for the neck for chronic neck pain, whether a person got a uh manual therapy approach or an exercise-based approach. So that part I've kind of given up on expecting to see differences, even though that we would think lifestyle-wise, anything more self-management oriented will be better for the olivar oligum. I think part of that, Sarah, is that patients fail to follow through in many cases. We know that as soon as the pain subsides, they stop doing their programming. And then lifestyle medicine and then behavioral change is a really hard thing to do as a patient. It's a real a real challenge and they don't always follow through with it. So that may be one of the reasons we don't see great success on that either.

SPEAKER_00 25:43

So if all from the set of uh like study treatment interventions, if the effect is the same, why does it mat why does tailoring it matter at all? Like, should I just do the same thing with every patient, get good at, get good at one thing? And I'm even listening to you, and I'm like, could I just have my patients come and juggle? Like, could I get like outside of the realm of evidence-based and still see an effect? Um, why does tailoring matter or does it?

SPEAKER_01 26:19

That is the best question of the day, I think. Because you would think if that if nothing matters, then do anything. And but it's but that's actually not the case. Um it it what's important is to set up the guide rails of evidence-based care. So we have options that we can use, and we know these options actually have meaningful overall effects that can influence outcomes. That is that part has been studied. Now, what's key is uh two things, I think. The first is even with efficacious treatments like selected medications or exercise or manual therapy or psychologically informed care, some people respond well to that, whereas some people do not. People have variable outcomes. Now, some people um really gravitate to more towards self-management and exercise, others, that's not going to help them. And we've seen that in the literature. There are variations in the way that people respond to treatments. That is very clear. That said, it's incumbent upon us to identify those approaches that are best for that patient out of our selection within those guide rails. That's called uh moderators. Let's find those moderators for that patient that are going to lead to improved outcomes. Now, you can't typically do that in a regular randomized trial because some people will do very well, some people will do poorly, but we only look at averages, average treatment effects. So, any randomized trial, there are always people that do very well with the intervention they receive. There are some that don't. It may be that the treatment in the other arm would have been better for that person who received care in the um experimental group, even if its mean or average score is higher than that comparator. So looking only at average treatment effects doesn't allow us to understand individualized treatment effects. That's why tailoring is still important. That's why it's still important to talk to your patient to find out what are your beliefs, what are your thoughts? Have anybody talked to you about what you think you need with this particular condition? What have you used in the past that is really meaningful to you that has seemed to be helpful? Um, finding those things that tie a patient into their beliefs and their preferences, but also match what you, as an expert clinician, thinks they need, that's true shared decision making. That's where tailoring can really make a difference. So it seems like it doesn't matter, but it actually does matter. Um, the key is, and the way I look at it, is we just have more choices than restrictions, like we thought we might have before. We have many choices, but the key is finding which choice is best for that patient.

SPEAKER_00 29:12

Someone made a question in the comments. I think trying to put our clients like loosely in buckets of like average clients that might respond well to multiple things. Uh, and then with their, there might be a bucket of clients who like might struggle with any of these or any intervention because they have so many confounding things going on. And then there might be a bucket that really responds to particular interventions, like someone who loves exercise might really take to exercise, or someone who might really take to manual therapy. Is that kind of the buckets you would think about as a therapist when you're thinking about our clients? Okay.

SPEAKER_01 29:59

Yeah. So whoever wrote that, well done. That that's a strong understanding of real-world patient management. There's not a regularity that we see with our patients, there's there's a lack of continuity and there's such a variability, um, which kind of makes our jobs interesting, but it's also frustrating. And without help on the research side, you know, in many cases, we're spitballing on what you know care matters the the most. It's considered a third-order question. If are there features about that patient that will predict what bucket they fall into? That's to me, is the holy grail of research moving forward. That's gonna be where we really make a difference. And we're really weak on that right now. We don't have a lot of literature that that tells us if this person has X at baseline, they're really gonna respond well with this particular approach. We're just doing those now. These are costly studies. There's the designs are really complicated. They're called uh treatment effect moderator designs. Um, you'll also hear this termed as heterogeny of treatment effects. Uh, so researchers will know that it means that you're gonna see all kinds of variable findings. And it's really up to us as researchers to help sort out those uh and and put those in, as your uh listener says, into buckets that allow us to more effectively treat patients. Yeah, well done on your uh listener there.

SPEAKER_00 31:26

Yeah, yeah, that's a really helpful um, I guess, like mental model for us to think about as we have patients coming into the door. I want to swing us a little bit to a phrase that I heard you use on a podcast, and it was honestly the moment when I was like, oh, I have to have Dr. Chad Cook on my podcast. You were talking about this paper, and you used a phrase that isn't actually in the paper. Um, but you were talking about something called therapeutic ritual. What is therapeutic ritual and how does it relate to what we're talking about today?

SPEAKER_01 32:06

So, I first of all, I'd have to give uh acknowledgement to my colleague who actually turned me onto this. And he he's a clinical psychologist. We've done a couple of papers together and we're on a grant together where we're comparing uh a touch-based therapy to a talk-based therapy because we believe they affect biomarkers the same way. Well, anyway, we were talking, I was telling him in the results of one of our recent trials and mentioned that everything was the same, everything, the outcomes were all the same, the average treatment effects, the average mechanisms were all the same. And he just laughed. And because he's found the same thing on talk-based care, no matter which type of talk-based therapy, it all has the same outcome. And he goes, Wouldn't it be funny, Chad, if it all just boiled down to therapeutic ritualism? And it was relatively new to me, too. I knew the premise behind it, but it it really turned me on to digging into this a little bit further. And if you think about it, I think the really good clinicians do this without thinking about it or without giving it a name. But it's basically giving permission and control and direction to our patients to recover. In other words, developing a ritual or a structure that they can own, where they go in and operate and know that they're managing their condition so that they can improve moving forward. So therapeutic ritualism is basically just giving power, empowering the patient to manage themselves and permission to improve overall. And we've seen it so many times, right? How many times have you seen a patient? No, I'm an mostly outpatient clinician. So I'll see a patient on one visit and they come back for the second visit and they're like, I'm already 75% better. And I'm like, what the heck did I do? I mean, I basically just told them, you know, you're gonna be fine. Here's what you need to do. This is what this means, this is why it's important. I have that process, that ritual is what allows that patient to mentally move forward and start the recovery process. It's something that is um more commonly seen in the psychological literature, but on in the rehab literature, we deal with it all the time.

SPEAKER_00 34:28

When I hear ritual, I'm thinking of like habitual acts that we do with each patient that based on what you're saying, like is influencing how they're feeling about the treatment. And when I'm thinking of clinicians I've talked to in the past, I think of these rituals as things like Rachel being telling every patient, I think I can help you. I know a lot of um therapists like even have a rhythm to their sessions where they usually open with something like a breathing exercise to like downgrade a patient or exercise to like boost their endorphins. And then I feel like expert clinicians spend more time than I did talking to their patients, like at the beginning, in like a consultative mode. Is that therapeutic ritual? It is like those habitual acts that we do with each patient.

SPEAKER_01 35:24

Habitual acts, priming, all of it is part of that therapeutic ritual. Framing, um, staging, all of it is part of the therapeutic ritual. Prior to going on, you and I were chatting about um, I used to treat in Florida, and we used to see a lot of the older folks would come in and they would do their yoga and they would go in the gym and do their exercises, and then they would go do aquatic therapy. And individually, those approaches have marginal effects. But if you add that into a pattern and a structure, and if that becomes the ritual that allows that person to control their osteoarthritis or their back pain or whatever, then that piece is has a much more powerful specific effect. So definitely all of those things are part of the therapeutic ritual. And I think our physician colleagues who refer to us actually recognize that because even when we often send a patient back, there's not much I can do with this individual. I think we're we've, you know, we we've gone the limit of what we're gonna do. And they refer them back anyway and saying they need that structure, they need that continuation, they need that formal process. That's part of the therapeutic ritual too. We don't like that part, but it's it's part of it.

SPEAKER_00 36:40

If you ever write more about this and there's a paper, please come back because I have like a billion questions specifically about therapeutic ritual. But I want to call out this really great question in the comments. There's so many smarties here. Um, someone is asking, well, then is therapy just a placebo effect? Like we're doing things to make you feel like you're going to be better and so you get a little better. Is that what you're saying?

SPEAKER_01 37:11

So another great comment. Um, do you mind can I do you mind if I deconstruct that for a second? Because placebo effect, I think a lot of people will think that's a bad word. And when in when in reality is not. Now, placebo, a placebo is some form of sham therapeutic intervention that has absolutely no effect. None. A placebo effect, though, is a catalytic effect, it's the enhancement of that interaction, of the way you explain it, uh, the way of what your patient believes, the building of it up so that it actually bumps up the overall outcome for an intervention that has an effect. So the placebo effect is good. It's just basically a contextual effect where you're you're really framing that intervention as something that they really need, and having a really professional back and forth with that patient so that they trust you and they believe in your judgment. Placebo, not good, worthless, meaningless. We use those in studies. We should not use interventions that are just placebos. But even an intervention we have that has a small effect, you can heighten that effect using the strategies for placebo effect. So, yes, we are using a placebo effect to uh improve our overall effect sizes of these interventions that we have, which are typically small to moderate by themselves. And that there's nothing wrong with that.

SPEAKER_00 38:44

Okay, so placebo in my mind is like you're giving people a sugar pill, that's bad. Placebo effect is shaping people's belief, and that's a driver and that's a good thing. Is that what you're saying? Okay. I'm just wondering about therapeutic alliance in here and wondering where that fits in this conversation, like is a therapeutic ritual, typically building a therapeutic alliance, and is that related to a placebo effect? Could you weave that concept in here with me? I feel like we're all used to that concept, but maybe not in this related to these concepts you're talking about.

SPEAKER_01 39:29

They're all connected. Uh so conceptually, a therapeutic ritual is the overarching element of that. A contextual factor are all of those things that influence the outcomes that aren't related to the treatment itself. It's more related to the encounter. Um, so a contextual factor might be how was parking? And how was the experience? How was the front office person? How was the biller? How was the uh person who walked the patient back? Were they polite to them? All of these things that influence that person's experience, which in turn influences the outcome. Therapeutic alliance is that relationship that we build with the patient that also has been shown to influence overall outcomes and is a contextual factor. Patient preferences is a contextual factor. Therapist preferences is actually a contextual factor. In 2012, we studied that. That can actually lead to significant improvements just by the preferences that the therapists have of the treatments that they give to the patients. So all of these things are contextual components. Um, I heard a term one time that I like extratherapeutic effect. All right. Beyond just the intervention, it has an extratherapeutic effect because of all the other ways, the way you frame it with the patient, the way that it's presented.

SPEAKER_00 40:49

I hope in a future research article of yours, there's a very helpful diagram that puts this all together for us. I feel like I need the visual of like therapeutic ritual, therapeutic alliance, placebo effect, and how they all interconnect to each other. This feels really, really important. It's leading me to this question of this feels like a very hard question, but I'm going to ask it. How much can we influence therapy with these things, with therapeutic ritual, with therapeutic alliance? Like the way you're talking, it's feeling like a main driver and feeling like something I should be really focused on in every single session. And as a new therapist, I was not focused on that. How much of a driver are these, this therapeutic ritual, therapeutic alliance?

SPEAKER_01 41:39

Yeah, it actually has been studied. And um, the the work has been done by they're a German group, and Saurasig is the uh Tobias Saurasig is the first author. It was his PhD work. And they actually looked at manipulating the context around the therapeutic encounter. In other words, where they were they enhanced the therapeutic alliance, where they really built the relationship, where they talked up the treatment versus more of a sterile interaction. How much did that actually influence the meaningful change in the overall outcome? Now that's a very controlled environment. Multiple studies looked at it, and it's about 15 to 20 percent of the overall clinically meaningful outcome. So it's not as big as what we might think. But keep in mind these are averages. So some people it's gonna affect a lot more, and some people it's gonna affect a lot less. And there are features of individuals that are more influenced by these contextual components, and they they tend to be the more open individuals, they they are more optimistic. You you will recognize these in your patients. These are people who want to work with you and want to improve. Uh, having those extra elements, enhancing it through a placebo effect, those folks, it's gonna make a big difference. Other folks, it may not make a difference at all. It depends. But 15 to 30 percent is typically uh what is known.

SPEAKER_00 43:06

15 to 30 percent is just the effect of me building that alliance and using that therapeutic ritual. That feels really big.

SPEAKER_01 43:19

You know what I say? Our effect sizes for a lot of our interventions are pretty small. So any any benefit, any additional improvement is incredibly welcomed in the way that we manage our patient. 15 to 30 percent is great. It's not 100%, like some people will say, oh, it's probably 100% of what you're doing, is that no, that's not true. That's not what the literature says. It's 15 to 30 percent. And the other meaningful recovery is coming from something else. It's coming from the specific effects of the intervention or the natural history, and the person just changes over time and they recover on their own. So there are other things that are leading to that too, but. Certainly 15 to 30% is nothing to sniff at.

SPEAKER_00 44:06

Thinking back to me starting my career as a just okay clinician, and I can say I wasn't focused on therapeutic ritual. I was like focused on like get my thing done, move on to the next patient, like shorter sessions. Um, and I had a pretty high dropout rate. Like people would see me like three sessions and then drop out. Do you think strengthening therapeutic alliance and therapeutic ritual would have helped me retain patients longer?

SPEAKER_01 44:37

For sure. Yeah. And in fact, that's been studied. Um actually we studied that. We we looked at the we we looked at the and we worked with a group um called Select and who actually had the foresight to measure the the experience of the patient when they when they came to uh outpatient clinical practice. And we had uh, I think 52,000 um patient um experiences for both PT and OT. And certainly those folks who had a poor experience, which encompassed a lot of these things that we've talked about today, those individuals had shorter overall visits and shorter overall stays and higher rates of dropouts, which is a big problem. And some people don't like to talk about that because they see that as a business piece, and it is. I don't see it as purely a business piece. I see that as fragmented care. And when you lose the ability to guide that person through their care process, then there's a greater chance that they're gonna have long-term issues with that. So fragmented care, anything that affects the continuity of care, we don't want that. So I I to answer your original question, absolutely. Yeah, absolutely. Better connection is is gonna allow that patient to stay with you and allow you to make to guide them to recovery better.

SPEAKER_00 46:02

I want to restate my takeaways for clinicians, and then I'll I have a separate question about continuing education, but for clinicians, I want to go back to, like I said, old me, I would I literally back in the day, I would have like jotted down what I wanted to do with each patient and I would go and do that. I had sort short sessions that were just focused on getting the thing done, and I would go patient to patient doing that. Now, hearing how other clinic, how more expert clinicians are practicing, hearing about your research, what I would do instead is I would think a lot about the arc of my session, about using that full 60 minutes. And I would devote like almost a third of it to therapeutic ritual therapeutic alliance building, like doing like a buy-in activity at the top, not being afraid to spend like five to 20 minutes that were more like consulting with the patient on like what's working well, what's not working. I know a lot of therapists use that time for like lifestyle thinking like with their lifestyle medicine lens to be like, oh, if you're not sleeping, let's talk about that and let's work on that. And then they move into that like 30 to 40 minutes of like doing the main thing that they wanted to do with that patient. And then really taking time to stick the landing at the end and making sure that we feel on the same page that the patient is going to come back. Is that how I should be processing? Oh, and on top of all that, that I'm also functioning from this kind of menu of like there are different options for almost all of our conditions, and I'm trying to match the right um option with the client. Is that my overall model of how I should be practicing? Anything you would critique there or add to that?

SPEAKER_01 48:07

I think that's the exact overall model of a good shared decision-making patient-centered care approach. Absolutely. Um, I'll just say that those pieces which you have broken out into segments, probably for learning and presenting state, it's more continuous in that care encounter. There's not a there's not a single point where therapy clients ends and or initiates or anything like that. It's just throughout. And that part of it is really important. A piece that I that you mentioned that I think is really important is this finding out what's meaningful to the patient and extracting that and and letting them know that they're heard on that. But your your patients want to know from you and what you believe as an expert clinician. So, you know, it isn't just about saying, yeah, whatever you want, we can do that, because we know that the research actually suggests you'll have worse outcomes if you do that. We we called that the smorgasborg approach, right? The golden corral approach to care. Um, it's not gonna lead to better outcomes because actually the patients discount the care when you do that. So it's important for you to follow up and say, I hear you mentioned that it's really important for you to learn strategies for sleep. I have some that I believe are going to be really meaningful for you. I think you need that. Let's find the ones that match what your belief system and preferences are and what you can do, and what I can actually provide, and what is meaningful for me as an expert provider. That's shared decision making. That's what's really important. So I love the fact that you mentioned that at the end. That's got to be a it's a it's a relationship. It is a commitment from both parties on that piece of it.

SPEAKER_00 49:57

I think there's two barriers to really piecing all those things together. One, our treatment reimbursement codes are all, they just feel focused on doing. Like, so you're you feel incentivized to get the patient in and just be doing. And we forget that we can also be reimbursed for patient education for sitting down and really like talking to that patient. And I think that's a big breakthrough that a lot of expert clinicians have is like that face-to-face time is just as valuable as doing the thing. I also think just in our programs overall, we don't talk about like the art, like putting together an arc of a session. Like we, I don't know, we're so focused on like the meat of the intervention, and we don't talk about the importance of that full arc. Um, do you agree with that?

SPEAKER_01 50:47

Oh, a thousand percent. We we teach treatments.

unknown 50:50

Yeah.

SPEAKER_01 50:50

And I'm in I'm in education. We teach, we teach somatosensory-based approaches, and here's how you do it. And we spend a whole lot of time, you know, here's how the technique is done right. Let's practice this. Instead of how do I present this? What is a meaningful response from that? What is a negative response from applying this? You know, how do you set this up for success? That part of it is what an expert clinician will learn over time, but really is not effectively taught as and you know, we we have this we kind of so I'm in the academic side, right? And I do teach a couple of courses, and we like to believe that what we teach our students is what really makes them turn out to be great clinicians. But we actually know when they go to their terminal clinical experiences and then they imprint upon their clinical instructor, that's where they learn really what it's like to be a great clinician. You know, what are the strategies to be a great clinician? Because they see the process of all of these things that they've learned. They see how it is built into practice. And if that CI or that educator can show the importance of the little things that, you know, one would say you can't build for those, but are technically the glue that uh really pulls all the interventions together, if they're really good at that, then that's gonna make a difference on the on the learners. That's gonna elevate somebody to be an expert clinician, I think. We used to call them cookie therapist um because they were always the patients were always bringing them things. Like they just loved their therapist. And it's like, what's going on over there? But it it, those are meaningful things. That's the the uh that's making that uh ritual a great experience for the patient.

SPEAKER_00 52:44

I only want to spend like two minutes on this next question, even though it's really important topic for another time. Um, someone asks, what's the best way to sort through evidence-based research when you are fresh out of college and unsure how to do this? Is there generally a way to find out what is evidence-based versus reading every single research article? I want to put that in my continuing education realm where I look at this and I'm like, with each condition, there's kind of there's like several, there tends to be several approaches that we know work. And what I hope to do as a continuing education provider is kind of standardize how we're presenting those options across conditions. Like I'm making uh pages like for uh pediatric sleep, carpal tunnel, where they kind of look the same. Like, here's the general assessments, here's the interventions that are studied to help us see like what are the options for each um condition. Is that generally the direction that we need to go?

SPEAKER_01 53:51

100%. And you know, I'm on the PT side, so they've have really had a lot of initiative lately to build clinical practice guidelines around um given uh body part impairments or or disease processes. And so I would start there. Um, so your listener, I would start with a if there's a clinical practice guideline, I'd start there. If there isn't one, I I would go to either a systematic review or meta-analysis that has pooled the data and looked at the quality of the data. And then I might, if that if that doesn't exist, then maybe move to a randomized trial or or something like that. I believe there's no possible way for busy clinicians to fully understand what the literature says. And we can't expect that. That's that's an unreasonable expectation. And even uh, I'm a full-time researcher, I cannot be expected to know all of the literature, even in the area that I'm uh that I focus on in my research, because there's just too much. So I I would definitely recommend starting with the summary and then working down. And what a really good clinician understands is those summary components, these guide rails of what you can do are starting points. And how you use those and that individual interaction with the patient is where the real sausage is made. That's really that's where the great clinician um excels because they know how to use that evidence for that particular patient that is individualized to that individual.

SPEAKER_00 55:24

This has all been so much fun. I'm sad we're so close to the end of our hour. I feel like I've been pursuing this question for a decade of like, how could I be better than an average clinician? And I so appreciate the research and the writing that you're doing it and giving us words to understand the trends that uh we've been seeing in our podcast discussions. We've touched on so many really important things today. What's the thought that you want to leave us with to keep top of mind for people?

SPEAKER_01 55:57

So I'll be real quick about it. I am a physical therapist, so you know, I was trained very much around biology, fix impairments. You do that, the patient's gonna do great. Excuse me, additional education around chronic pain management for two and a half years and learned a lot about psychology and learned about that the brain and the way people think and where they're at and how they frame things matter probably more so than what I thought the interventions were actually doing biologically to the patient. And if I can quote my son, who's actually a psychiatry resident in um uh Cedar Sinai in Manhattan, he said, Dad, psychology is biology. So all of these things that sound like softball stuff and wishy-washy, et cetera, probably less to an OT than a PT. PTs look at this and say, Yeah, I'm getting out of my comfort zone. But psychology is biology. If you change the way people think, if you change the way they approach something, biologically it changes things too. It is powerful. It has as much power as any of the interventions we do, and it should be considered um like a standard approach, I think, to the way we manage our patients.

SPEAKER_00 57:23

Chad, it was just such a true joy to hear from you today. Thank you for the work you're doing to uh just give language to the things that we're seeing in uh the clinic uh for making it so helpful um and applicable to just day-to-day practice. I hope we get to have more conversations, but thank you so much for your time today and what you've shared with us with us. I've just really appreciated this conversation.

SPEAKER_01 57:50

Well, I love the experience and congratulations. You have a great podcast. I was actually nervous coming on because usually I um some you're so polished and so well prepared. Um, I I really do appreciate it. Thanks for having me on.

SPEAKER_00 58:08

Thank you for joining us on the OT Potential podcast. To earn one hour of AOTA approved continuing education for your time today, you will need to sign in or sign up at OTPotential.com. Once you're in the OT Potential Club, you will find a five-question post-course quiz connected to this episode. When you pass the quiz with a score of 75% or higher, you will be able to download a PDF certificate that certifies your completion of this course. Okay, I want to thank you for joining us today, and we'll see you next time.