I am both excited and frustrated to embark on this journey with you. Excited, because I am deeply fascinated by training tools that employ sophisticated biomechanics in a manner appropriate to our physiology. Frustrated, because we should have learned all of this in our physical therapy training.

The irony is that high quality research has been, and continues to be, conducted on the subject of training intensely and to failure, typically using specialized equipment. And yet, this modern approach has become forgotten lore in the minds of most of my peers. Very few therapists that I meet can explain how an accommodating resistance curve is achieved through machine design, nor what its value might be. This bewildering lack of understanding has motivated me to write this series.

Now, the experienced reader is surely saying, “wait a moment, all of this has been written about before.” Of course, they are correct. Doug McGuff, Drew Baye, Skyler Tanner, and many others have clearly articulated the value of these techniques and tools that were originally pioneered by Arthur Jones and improved on by folks like Tyler Hobson, and I too am puzzled at my own need to reiterate these concepts. These proponents have made their case eloquently, and I doubt I’ll add much. My only hope is to increase the audience of their message.

And yet, as I mentioned, few of my peers are even aware that biomechanically sound machines exist, let alone what sets them apart from the chaff or how they should be employed. And so, simply to scratch my own itch, I will discusses the elements of good exercise machines, and how they can be employed in rehabilitation.

It is not my intention to argue against any other training method or tool, ‘functional’ or otherwise. This is not a treatise, an apologetic effort. Instead, it is simply an overview of some fascinating innovations that we, as physical therapists (and our peer professions) should be aware of. I am simply trying to pull machines back out of obscurity and into the awareness of the next generation of physios, so that we maximize the tools at our disposal. In a world dominated by pistol squats and turkish getups (both of which I perform and value), I want my peers to be aware of precisely what machines can offer their practice, and how to identify those machines that are worth while.

Stay tuned for a short series of posts in which I talk about:

• some of the reasons machines have failed to become more popular
• some of the common objections to machines, and my responses
• what machines are uniquely able to offer, supported by evidence
• how to identify machines that are appropriately designed
• some exciting new developments that are currently happening
• how this need not be a dichotomy – machines and ‘functional’ movement can (and should) happily co-exist.

Thanks for reading.

-Bryce Lee, DPT

Don’t watch this video of Lorimer Moseley explaining the placebo effect. If you do, you’re likely to find a lot of your assumptions challenged.

Ok, maybe watch it.

Alright, definitely watch it.

After you’re finished, you’re likely to find yourself in a bit of an ethical quandary. I mean, the placebo effect is powerful! So powerful that one could almost make a living administering nothing but interventions they knew were not clinically meaningful … Thank goodness no one does this.

Now, you’re different. You believe in ethics, and you also believe that using treatments that are no better than placebo undermines your profession and your own reputation. I think you’re right, but let’s think about this for a minute, because there’s a confounder you may not have considered.

I propose that trying to eliminate the placebo effect isn’t possible. I think that’s true because the moment a patient walks into a professional clinical environment, the placebo effect is at play. The same exact technique administered by the patient’s buddy on a gym floor will unavoidably have a different effect when performed by you in a clinic.

What’s more, the choice is rarely between a favorable placebo effect and no effect at all, as that would require a patient that was unconscious. Instead, reality forces us to choose between placebo and nocebo. Between confidence and uncertainty. If you decide to overly qualify your clinical reasoning to the patient, you’ll likely swing the pendulum too far. In your attempts to abolish any trace of placebo effect, you will come across as so uncertain in the efficacy of your treatment that your patient’s inevitable doubts will lead to a nocebo.

Clinician affect is a prime example. If you are confident in your treatment, and believe it will work, that is likely to come across and increase the efficacy of your treatment. The converse is true. If you are ultrasounding your patient’s ankle, and think it’s worthless, it is likely to BE worthless. If you paid attention during Moseley’s video above, he talks about how, when clinicians were told that the drug they were administering was placebo, the intervention was less effective, even when they were actually administering the real thing. In otherwords, clinician doubt had a nocebo effect and blunted the real effects of the intervention.

Clinician beliefs matter, and I think the safe play here is obvious. Select interventions you can be confident in, and you are likely to be maximizing the placebo effect. Even if you make some errors in your treatment selection, the confidence you exude, which can only come from sincerity, will benefit your patients. Further, the more research you do into what the evidence actually says, the more confident you will be in your choices.

Be honest with yourself and your patients, and you’ll likely be taking full advantage of the placebo effect in an ethical and responsible way.