Episode 1747 - Expectation and tissue healing

Dr. Justin Dunaway // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Spine Management & Pain Division lead faculty Justin Dunaway discusses new research regarding patient expectation & tissue healing.

Take a listen or check out our full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account.

JUSTIN DUNAWAY All right. Good morning, YouTube. Good morning, Instagram. Looks like the cameras are looking good. Okay, here we go, team. Welcome to PT on Ice, Clinical Tuesday. I am Justin Dunaway, lead faculty with Institute of Clinical Excellence. I teach in our Total Spine Thrust Manipulation courses and our eight-week Persistent Pain Comprehensive Management courses, which the newest cohort began this week. Still plenty of time to jump in if you're interested. Just coming back from a weekend in Bozeman, Montana, teaching Total Thrust at Excel PT with Jason London. Big shout out and thank you to that group for bringing me out. If you've never been to Bozeman, it's an absolutely beautiful town, totally worth your time to get out there and see it. All right, today's topic, expectation and tissue healing. This is an absolutely fascinating, fascinating study that came out in December of last year. I'd been on a bit of a hiatus from PT on ice, and when this study came out, I was super excited for the opportunity to jump back on the stage, and I knew that the first topic had to be talking about this stuff. So, I'm a bit of a nerd in the beliefs and expectations space. I think there's so much really cool evidence, some really cool, really intricate, fascinating studies that have been done. And we know that the way patients believe about their body, about tissue damage, what they know and understand about pain, and the expectations that can come from that can change pain, pain perception, motion, pain pressure threshold, all of that stuff. We know that patients' beliefs around interventions, they believe that this intervention can be helpful or harmful, they expect this intervention to help or hurt, will absolutely change their outcomes with that intervention. We have seen research that shows us that patients' beliefs aside, provider beliefs, If I believe in the intervention I'm about to give a patient, versus if I don't, that will change the outcomes of that intervention as well. We know that beliefs and expectations around exercise, when all things are held constant, when everything about the patients are held constant, when everything about exercise is held constant, we just look at beliefs, we know that beliefs around exercise as it relates to my job, how physical my job is. If I believe that my job is physical enough that it counts as exercise, it can actually have positive effects on blood pressure, resting heart rate, body composition, and weight. We know that when I think about my beliefs around exercise, it relates to my peers. All things being held equal, if I believe I exercise less than my peers, it actually has a negative effect longevity some really interesting cool research from Ellen Langer a handful of years ago but she took older adults put them in this this five-day retreat where where they set up the whole building to be like from 1952, all the shows for a certain month that year, all the pictures and the furniture and the magazines and news articles. And they were only allowed to talk about stuff from that year for five days. And then they had massive changes in all kinds of physiologic stuff. They had massive changes on disability and like six minute walk tests and things like that. And what's fascinating is they took a picture pre and post this five-day retreat and then had independent reviewers look at these pictures. And the independent reviewers rated the five-day post pictures as years younger than what they looked like when they went into the trial. So just incredible, fascinating stuff in the world of how powerful the mind-body connection is. Now there's this interesting new line of research that I just kinda stumbled on recently where the expectation variable that they start to play with is perceived time passage. So time is held constant, but in very creative ways they get patients to believe that more or less time has passed. One really interesting trial is they give subjects, they feed subjects, they measure blood glucose, they hold time constant, And then in some sessions, they make the subjects believe that more time has passed. Some subjects believe that less time has passed. And what you find is that blood glucose levels track better with perceived time passage than actual time passage. Another interesting trial is they took humans and they short sleep them, give them six hours of sleep and measure a bunch of cognitive tasks. And obviously you do worse when you're six hours asleep on cognitive tasks. But then in the second piece of that, they give you six hours of sleep but they make you believe that you got eight hours of sleep and a good night's sleep. And then that mitigates that and they actually do significantly better on those tasks. So that's kind of everything leading up to this point, but this study, and there's so much more, it's such a really cool body of literature in this space, but the study I want to talk about here came out in Nature, super well-respected journal, in December of last year, and it's called Physical Healing as a Function of Perceived Time, from Peter Engel and Ellen Langer. This is going to sound kind of nerdy because it is, but if researchers had baseball cards, I would have an Ellen Langer rookie card framed in my office. Her body of literature in this space over the last, since like 1970 to now, is just absolutely incredible and has really paved the way for everything about beliefs and expectations. So here's the premise of this study. And this study was mind-blowing. What they did is they brought subjects in. And subjects, they had three sessions. Each session was an hour long. Sat the subject down, put a cup on their forearm, just like a standard biofascial decompression therapy cup, put the cup on, gave it five pumps, left it on there pretty tight for 30 seconds, popped the cup off, took a picture immediately, and then had a timer on the wall for 28 minutes. At the end of the 28 minutes, took a second picture. And then during those 28 minutes, they had the subject, specific time intervals, rate their healing. Asked them a handful of questions, but this is basically about how much do you think it's healed, how red is it, how swollen is it, is it painful, blah, blah, blah. And then at the end of the 28 minutes, then they had just a random, unrelated task to kind of fill the rest of the hour. Like they watched TV and rated commercials and played a video game or things like that. So then the trial itself looked like this. When you came in, you were randomized into one of three scenarios. Scenario one, everything I just said, there's a 28-minute timer on the wall, pre and post, and they do the things. Scenario two, they come in, and there is a 14-minute timer on the wall. Now, they're in the room for 28 minutes, but the timer is altered, so it ticks down a bit slower. So even though I'm in here for 28 minutes, I believe I'm only in here for 14 minutes. Scenario three, timer on the wall. The timer is set for 56 minutes. Again, it's only 28 minutes long. It just ticks significantly faster. So at the end of that 28 minutes, I believe that I've spent 56 minutes in the room waiting by healing. Okay, so that's how the trial's set up. Really interesting way that they controlled for this, and they controlled for kind of the after-minute variables. I won't dive into that. But the outcomes, the outcomes are where it really gets neat. So the first piece of this outcome is not gonna be mind-blowing. The patients, or the subjects, when you've looked at their self-report of healing, what they believe happened is they looked at their arm each time, When they were in the 56-minute trial, when the timer ticks 56 minutes, even though it was only 28, they believed that more healing had taken place than when they were in the 28-minute room, and more healing took place in the 28-minute room than in the 14-minute room. I thought I was in the room longer. I feel like more healing occurred. Cool, but that's not mind-blowing. The mind-blowing piece is this. Those pre and post pictures, they sent those off to independent reviewers that didn't know anything about the trial. They just said, hey, take a look at these pairing of pictures and tell us which ones healed more, which ones kind of healed, which ones didn't heal nearly as much. And without a doubt, when looking at the pictures, the pictures that came from the 56-minute room, showed more healing than the pictures that came from the 28-minute rooms, and those showed more healing than the pictures that came from the 14-minute rooms. And again, remember that they were all 28 minutes. Every picture was taken pre and post 28 minutes. The only difference was how much time I perceived had passed. That is fascinating. What the conclusion of the trial was is basically that tissue healing Isn't just a function of time passage tissue healing time. That's still important, but that's not the only piece tissue healing is at least in part a function of Perceived time passage, but it's not really perceived time passage, right? It's it's me believing that more time had passed Really put me in a space where I believe that more healing has occurred and when I believed more healing occurred. I It did. Even though that was such a short trial, even though it was so acute, just believing in that space that my body was healing faster, it did. Now, this has massive implications in my head, from acute injuries through through tissue healing from surgeries. It doesn't matter if we're treating a patient that's got persistent 10-year centrally dominant pain, if I just rolled my ankle, if I was just in a car accident, if I just had an ACL reconstruction or anything along those lines. If tissue healing and tissue health is a piece of the puzzle, then my beliefs around my capacity for my tissues to heal or how quickly they're healing or what's going on in my body since that injury, that is gonna have a direct implication and direct effect on how quickly and how healthy those tissues can heal. I think that's the direction that this line of research is going. So what do we do with this information? What I'm not suggesting is that we start messing with the clocks in our clinic and bring people in for a 30 minute session, but make them feel like it was an hour or things like that. Although that's kind of interesting, right? And I think Dr. Langer, if you're listening, I think a really cool trial would be to take a whole bunch of humans Relatively untrained, you put them on a bike three times a week for the next six weeks at 30 minutes RPE of six, and a third of them believe they're on the bike for 15 minutes, a third believe they're on the bike for 30, a third believe they're on the bike for an hour, and I bet what you find is that the hour group outperforms everybody else. It's pretty fascinating, but… What I think that this means for us from a clinical perspective is that when we think about like patient education, we think about beliefs and expectations and things like that, we tend to focus on, importantly, but we tend to focus on teaching patients about pain. We tend to focus on trying to test, retest so they can show immediate improvements in the clinic. We try to get patients to kind of believe in the interventions that we're doing. But there's a space in the education, there's a space in whatever the patient's mindfulness practice is, there's a space in trying to get patients to really think about their tissue healing, thinking about their rate of tissue healing, thinking about the health of the stuff inside their body, and shifting that in a very positive direction. Because what Ellen showed us is that that is going to affect tissue healing. So at the end of the day, this is just another really cool facet of information in this mind-body connection space. And from a treatment perspective, we need to not just be thinking about having really good clinical reasoning, really good skills, and being able to really match the right intervention with the right hypothesis, with the right patient, things like that. But we've got to be thinking about the context in which our treatments occur. We've got to think a lot about where the patient's beliefs and expectations are about themselves, about their body, and the interactions they're having outside the clinic. The more work we can do to get the patient's mindset in a space that's positive, that's healthy, that is pro-healing, whether it's understanding pain, whether it's believing in the treatments we're about to do, whether it's really just understanding that they have a very, very powerful capacity for their tissues to heal and heal well and heal quickly. Those are the things that are really gonna drive outcomes forward. And I think that the novel piece of this study is that it's more than just about physiology, it's more than just about pain and pain perception. Now the belief piece also will actually affect, speed up, slow down the rate at which our tissues heal. Alright team, so again, absolutely mind-blowing study. Another really great piece of information, this mind-body connection. And thank you all for hanging out for the last 12 minutes. It was awesome to be back on the stage, chatting with you all. Hope to do it again very soon. Have an awesome day in the clinic.

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