The Experience Wall
Mark Crislip over at the Science Based Medicine Blog wrote that “in my experience” are the three most dangerous words in medicine. I won’t go so far as to say they are the most dangerous words in the physical therapy world but I do think that they pose a threat. A common example of this danger is when physical therapists use “in my experience” to justify a particular treatment philosophy even though it is not supported by science. One examples of this is the use of palpation and movement tests to diagnosis and guide treatment of the SI joint. Despite a large body of evidence questioning the reliability and validity of this method I still see it used all the time. When trying to discuss this topic with believers, I often run into the experience wall. “The literature may say the s
upine to sit test doesn’t work but I know it is effective because my patients get better.” Or I will hear how the literature is biased, out of touch with clinical reality, not applicable to their patients etc….. Many of these criticisms of the literature have elements of truth, however we need to hold clinical experience to the same standard. It is easy to criticize the literature while blindly trusting our own experiences. It takes great effort to critically appraise our experience (and the experience of others), looking for bias and logical fallacies. If you are looking for more information on the limits of human experience I suggest you take a look at these book (this, this and this). Feel free to share other resources in the comments section.
To explore the dangers and pit falls of experience in more depth we first need to understand what experience is. Clinical experience is comprised of:
1) the perception of clinical events (seeing, hearing, feeling)
2) the memories of those events
3) the interpretations of those perceptions (cause and effect, etc).
For example, I examine a patient (looking, hearing and feeling) and determine he has an anteriorly rotated right innominate. I remember that I have seen several patients who look just like this and when treated with a specific MET they got better. After the treatment the patient improves so I conclude that I was correct in my diagnosis and the treatment was effective.
Unfortunately humans are prone to make mistakes in all three of the above categories. To make matters worse we rarely notice those errors so we become very confident in the accuracy of our experiences. As a result, experience can become a barrier to accepting new evidence especially if it goes against our beliefs.
In upcoming posts I will explore each of these three categories in more depth. Stay tuned!
Clinical Case 2: Parkinson’s “Earl”
I recently came into contact with patient who has a long-standing history of Parkinson’s disease. For the purposes of this discussion, let’s call him “Earl”. Earl has the typical shuffled gait pattern seen in those with “P” but what is unique is that he carries a flashlight wherever he goes. Earl states when he has difficulty initiating movement, he simply turns on the flashlight, and is then able to move again.
Now that we have defined this clinical case, how does this make sense? What is the neurophysiological connection between the light and movement? Is it placebo? Is the elicitation of the visual cortex triggering improved abilities to execute movements? What is happening here? Let’s discuss…
Boston
The following is a letter from George Coggeshall, the president of the Mass chapter of the APTA. I originally saw this letter posted here and felt it was worth sharing. Kudos to our colleagues in Massachusetts who assisted those injured in this terrible attack.
Massachusetts Chapter Responds After Boston Marathon Incident
A team of 70 Massachusetts Chapter members, stationed at the Boston Marathon finish line on April 15 when tragedy struck, stepped in despite a chaotic scene to help injured people. These physical therapists and physical therapist students from local colleges and universities helped provide exceptional care for the critically injured. While there were no APTA members hurt in the blast, there are members whose family and loved ones were among the more than 170 injured people Massachusetts Chapter President George Coggeshall, PT, DPT, expressed sincere thanks to those who aided the victims and everyone who reached out to the Massachusetts Chapter. “Thank you for your many emails and calls expressing your concerns, caring, compassion and love,” Coggeshall said. “We will do our best to follow the footsteps of those chapters who have survived adversity and tragedy.” If your members are interested in helping people affected by this tragic event, or your component would like to make a contribution, Gov Patrick and Mayor Menino have announced the formation of The One Fund Boston.
PTTV14: Movement and Pain
Tune -in this evening to therapydia.com at 9pm E to listen to Joseph Brence, Barrett Dorko, Eric Kruger and Tony Ingram discuss the relationship between movement and pain. Tweet us questions using #PTTV14
California Senate Say’s NO to SB381
Today was a victory for Physical Therapists. In an overwhelming decision, California’s congress voted to NO to support SB381 which would exclude Physical Therapists from the ability to manipulate.
The vote: Senators Price, Corbett, Block, Hill, Padilla & Galgiani said NO. Senator Yee was the sole YES.
Abstains – Hernandez, Wyland, Emmerson
This stated, this CRAP needs to stop NOW! I understand that professionally, we pose a major threat to chiropractors. But bills of this nature, without unsubstantiated cause, demonstrate a child-like behavior by a so-called professional organization. I recommend every PT and DC reads the below transcript and decides if this was necessary:
BILL ANALYSIS
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|Hearing Date:April 15, 2013 |Bill No:SB |
| |381 |
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SENATE COMMITTEE ON BUSINESS, PROFESSIONS
AND ECONOMIC DEVELOPMENT
Senator Curren D. Price, Jr., Chair
Bill No: SB 381Author:Yee
As Introduced: February 20, 2013 Fiscal:No
SUBJECT: Healing arts: chiropractic practice.
SUMMARY: Prohibits health care practitioners, other than
chiropractors, physicians, surgeons or osteopathic physicians, from
performing joint manipulation or joint adjustments.
Existing law:
1) Establishes the California Board of Chiropractic Examiners (BCE),
under the Department of Consumer Affairs (DCA), and authorizes the
BCE to license and regulate chiropractors. (Chiropractic Act of
1923 (CA), § 1 et seq.; Governor's Reorganization Plan No. 2 of
2012)
2) Authorizes a chiropractor to practice chiropractic as taught in
chiropractic school or college. (CA § 7)
3) Specifies the schedule of minimum education requirements to enable
any person to practice chiropractic in California includes: (CA §
5)
Group 1- Anatomy, including embryology and histology;
Group 2- Physiology;
Group 3- Biochemistry and clinical nutrition;
Group 4- Pathology and bacteriology;
Group 5- Public health, hygiene and sanitation;
Group 6- Diagnosis, dermatology, syphilology and geriatrics,
and radiological
technology, safety, and interpretation;
Group 7- Obstetrics and gynecology and pediatrics; and
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Group 8- Principles and practice of chiropractic, physical
therapy, psychiatry, and
office procedure.
4) Establishes the Medical Board of California (MBC), under the DCA,
and authorizes the MBC to license and regulate physicians and
surgeons. (BPC § 2000)
5) Establishes the Physical Therapy Board of California (PTB) under
the DCA, and authorizes the PTB to license and regulate physical
therapists and physical therapy assistants. (BPC § 2602)
6) Establishes the Osteopathic Medical Board of California (OMB),
under the MBC, and authorizes the OMB to license and regulate
osteopathic physicians. (BPC § 2450)
7) Establishes the Veterinary Medicine Board of California (VMB),
under the DCA, and authorizes the VMB to license and regulate
veterinarians. (BPC § 4800)
This bill:
1) Defines "joint manipulation" and "joint adjustment" as synonymous
terms that describe a method of skillful and beneficial treatment
where a person uses a direct thrust to move the joint of a patient
beyond its normal range of motion, but without exceeding the limits
of anatomical integrity, as taught in chiropractic schools or
colleges.
2) Prohibits a health care provider, other than a chiropractor,
physician, surgeon or osteopathic physician from performing joint
manipulation or adjustment.
3) Indicates that a health care practitioner who engages in the
unlawful practice of chiropractic is subject to their license being
revoked or suspended and/or other disciplinary action.
4) Specifies that the legislation will not prevent veterinarians from
practicing within the scope of their license.
5) Specifies that the legislation is not intended to restrict
providers working within their scope of practice from treating a
dislocated extremity joint.
FISCAL EFFECT: Unknown. This bill has been keyed "non-fiscal" by
Legislative Counsel.
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COMMENTS:
1.Purpose. This bill is sponsored by the California Chiropractic
Association (CCA) . According to the Author, there are currently
health care practitioners performing manipulations that should not
be, and that are doing so under the argument that their scope does
not say they cannot perform these procedures. Scope is about what
you can do, not what you cannot. There have been reports of
physical therapists performing these manipulations, and even when
reported to the Physical Therapy Board they are not being
reprimanded. This bill would clarify that it is unlawful for those
not trained and educated to perform these procedures. This bill is
needed to provide additional consumer protection against providers
who are currently operating outside their scope of practice by
performing manipulation.
2.Background.
a) Chiropractor Education, Training and Scope. Since 1923,
California has licensed chiropractors. Chiropractors are health
care practitioners who provide drug-free and non-surgical health
care. Based on the beliefs that the body has an inherent power
to heal itself and health depends on a properly-functioning
nervous system, chiropractic care focuses on adjustment of the
spinal column to remove hindrances to the nervous system.
Chiropractors earn a four year doctorate degree and participate
in a year long clinical internship. Chiropractors may also
pursue post graduate specialty training. The scope of practice
for chiropractors is defined in California Code of Regulations
Title 16 § 302:
1) A duly licensed chiropractor may manipulate and adjust the
spinal column
and other joints of the human body and in the process thereof
a chiropractor
may manipulate the muscle and connective tissue related
thereto.
2) As part of a course of chiropractic treatment, a duly
licensed chiropractor
may use all necessary mechanical, hygienic, and sanitary
measures incident to
the care of the body, including, but not limited to, air,
cold, diet, exercise, heat,
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light, massage, physical culture, rest, ultrasound, water, and
physical therapy
techniques in the course of chiropractic manipulations and/or
adjustments.
3) Other than as explicitly set forth in section 10(b) of the
Act, a duly licensed chiropractor may treat any condition,
disease, or injury in any patient, including
a pregnant woman, and may diagnose, so long as such treatment
or diagnosis
is done in a manner consistent with chiropractic methods and
techniques and
so long as such methods and treatment do not constitute the
practice of
medicine by exceeding the legal scope of chiropractic practice
as set forth in
this section. b) Physical Therapist Education, Training and Scope. Physical
therapists have been regulated in California since 1953.
Physical Therapists help restore function, improve mobility,
relieve pain and prevent or limit permanent physical disabilities
of patients with injuries or disease. They treat patients
including accident victims and individuals with disabling
conditions for back conditions, arthritis, head injuries, carpal
tunnel syndrome, hip fractures, as well as rehabilitation after
surgery, a serious injury or a stroke. Physical therapists
graduate from accredited physical therapist educational programs
that offer degrees at the master's degree level and above. A
physical therapist may also seek specialty certification offered
by the American Board of Physical Therapy Specialties. The scope
of practice for physical therapists is outlined in BPC § 2620 as
follows:
Physical therapy means the art and science of physical or
corrective
rehabilitation or of physical or corrective treatment of a
bodily or mental
condition of any person by the use of the physical,
chemical, and other
properties of heat, light, water, electricity, sound,
massage, and active, passive
and resistive exercise, and shall include physical therapy
evaluation, treatment planning, instruction and consultative
services. The use of roentgen rays and radioactive
materials, for diagnostic and therapeutic purposes, and the
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use of electricity for surgical purposes, including
cauterization, are not authorized
under the term 'physical therapy' as used in this chapter,
and a license issued pursuant to this chapter does not
authorize the diagnosis of a disease.
c) Grade 1-5 Exercises. According to information obtained from
the Physical Therapy Board and the Board of Chiropractic
Examiners, both physical therapists and chiropractors are trained
to utilize oscillatory and peripheral joint mobilization.
Peripheral joint mobilization is defined as mobilizing the joints
of the periphery or limbs. There is a grading system, created in
the mid 1900's, for completing a mobilization. The mobilization
technique used is based on the amount of available joint play.
Thus, the clinician must know what the total range is by
examination through passive movement. The first common
mobilization techniques are sustained joint play movements that
have three grades. These mobilizations aid in decreasing pain
and increasing mobility. Within these three grades the stretch
or hold is approximately five to seven seconds. A description of
the three grades include:
Grade 1. The clinician applies passive movement in a very
small range, approximately 15-25% of the available joint
play range.
Grade 2. Bone is passively moved in a moderate range to 50%
or half of the available joint play range.
Grade 3. Passive force by the clinician causes one bone to
move on the other to the end of the available joint play
range.
The other common mobilization technique is termed oscillatory
mobilization. Oscillatory mobilizations have five grades
associated with them. Grades one to two are used to help
decrease pain within a joint. Grades three to five are used to
increase mobility of joint play. Grade five mobilization is
called a manipulation. The following are grades for oscillatory
mobilizations:
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Grade 1. Slow oscillations within the first 20-25% of the
available joint play range.
Grade 2. Slow oscillations within 45-55% of the available
joint play range, or from the beginning to the middle of
available joint play range.
Grade 3. Slow oscillations from the middle of the available
joint play range to the end of available joint play range.
Grade 4. Slow oscillations at the end of the available
joint play range.
Grade 5. Bone is passively moved to the end-range, and a
fast thrust is performed. This technique is considered a
manipulation.
3. Attorney General Opinion. In 1976, California Attorney General
Evelle J. Younger was asked to provide an opinion regarding the
Chiropractic Act. One question asked, "Are there any circumstances
under which a physical therapist can manipulate or adjust the hard
tissue (i.e., the spine)? If so what are those circumstances?"
The Attorney General (AG) replied in his written legal opinion,
"Adjustment is not a term used in physical therapy. It is a
chiropractic word." He further stated, "?adjusting the spine by
hand for the curing of disease constitutes the practice of
chiropractic and under the Chiropractic Act is beyond the
permissive activity of a physical therapist?Therefore, we believe
that the adjustment and manipulation of "hard tissues," that is
bones and bone structures, is peculiarly a chiropractic technique
beyond the scope of authorized activity for a physical therapist."
4. Department of Consumer Affairs Opinion. In 1980, then Board of
Chiropractic Examiners Executive Secretary, Garrett Cuneo, sent a
letter to Richard Spohn, Director of Consumer Affairs at the DCA.
Mr. Cuneo posed the question, "Can physical therapists engage in
spinal manipulation which is the practice of chiropractic?" The
Chief Legal Counsel at DCA's Legal Office, Mr. Gus E. Skarakis,
received the letter and replied to Mr. Cuneo:
Mobilization of the spine and other joints through the use
of rotation and other
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physical pressure constitutes in our opinion the use of
physical properties
including passive exercise for the treatment of physical
conditions and is
specifically authorized in the physical therapist's scope of
practice. Therefore,
we do not believe that a physical therapist is practicing
beyond his or her legal scope of practice by utilizing such
technique? In our opinion the performance
of joint mobilization by a physical therapist is not the
adjustment and manipulation of hard tissues as a
chiropractic technique. We primarily view this controversy
not as a matter of legal interpretation, but an
interprofessional squabble, often referred to as a 'turf
battle.'
5.Confusion Regarding the Term "Manipulation." Though the AG and DCA
opinions specify that chiropractors manipulate hard tissue and
physical therapists utilize joint mobilization techniques, there
remains much confusion about the term "manipulation." Many physical
therapists describe their work as "physical therapy manipulation" or
"joint manipulation" which reportedly differs from "chiropractic
manipulation" of hard tissues. In addition, other professionals,
such as naturopathic doctors, dentists, veterinarians and physician
assistants use the term manipulation to describe some of the
techniques they use with their patients. In fact, naturopathic
doctors are also taught Grades 1-5 exercises during their training,
but are prohibited by California law from performing Grade 5
exercises in practice. Dentists manipulate the jaw when treating
Temporomandibular Joint Disorders (TMJ). Additionally, physicians
and surgeons specifically use the term manipulation to describe the
manual loosening a stuck joint often performed under sedation or
anesthesia. Thus, it becomes quite difficult to allow any one
profession to exclusively own or define the term.
6. Lack of Consumer Complaints. The CCA reports they have received
"hundreds" of complaints from the chiropractors they represent.
CCA purports that individual chiropractors report they see patients
who complain about receiving "manipulation" or "adjustments" from
professionals who are not licensed by the Board of Chiropractic
Examiners. In response, the CCA has forwarded these complaints to
the Physical Therapy Board (PTB). However, the CCA indicates that
the PTB reports that they never received such complaints. The CCA
is unable to provide any data regarding the number of complaints
received which were reportedly forwarded to the PTB.
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According to the PTB, however, their Consumer Protection Services
program rarely receives complaints that involve physical therapists
performing manipulation. Since 1990, there have only been 5
complaints against physical therapist(s) performing mobilization or
manipulation. The PTB indicates, "In all cases, the allegations
were not substantiated as the physical therapist(s) were deemed to
be practicing within a physical therapist's scope of practice.
Moreover, the 5 identified complaints were not submitted as a
result of patient harm, but rather by chiropractor(s) concerned
with the physical therapist(s) practicing outside their scope of
practice." Also, the Board of Chiropractic Examiners reports that there have
been no complaints on record of a licensed chiropractor reporting
that a licensed physical therapist in their practice setting is
performing manipulations. There have also been no consumer
complaints against physical therapists performing manipulations
received by the BCE.
Both the Physician Assistant Committee and the Massage Therapy
Council report that there have been no complaints on record of a
physician assistant or a massage therapist performing manipulation.
7.Arguments in Support. The Sponsor indicates, "Patients must be
adequately protected from unauthorized, unqualified and improper
application of manipulation or adjustment. By defining that only
doctors of chiropractic, physicians and surgeons and osteopathic
physicians and surgeons are allowed to perform joint manipulation or
spinal adjustment you are ensuring that patients seeking this form
of treatment receive it from providers best trained to perform it."
8.Arguments in Opposition. The Independent Physical Therapists of
California (IPTs) indicate physical therapists have been training
extensively to provide joint mobilization/manipulation. They note,
"Physical therapists have been performing manual therapy safely for
decades, including all degrees of joint mobilization/manipulation.
IPT recognizes that some patients with spinal disorders prefer to
seek care from chiropractors, some prefer acupuncture, some prefer
physical therapy and some may prefer medications, injections and
surgery. The physical therapy profession in California has never
attempted to restrain the trade of any of these health care
professions by attempting to pass legislation overturning the
legality of their treatment methods."
The California Naturopathic Doctors Association opposes the bill
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unless amended. They argue, "Naturopathic Doctors receive almost
400 hours of combined physical medicine joint manipulation in
California?In fact, joint manipulation classes are often taught at
naturopathic medical schools by Chiropractic Doctors?The lack of
inclusion of NDs in SB 381 would serve as an obstacle for the newly
opened Bastyr University California as it would prohibit
naturopathic medical students from the ability to learn and train
in joint manipulation, which is currently part of the required
curriculum at all naturopathic medical schools."
Mount St. Mary's College notes in their opposition letter, "MSMC
strongly opposes SB 381 because research on manipulation supports
physical therapists performing joint manipulation as among the
safest of all health care providers? The physical therapy
professional liability insurance program has not identified any
trends relative to manipulation that would indicate the procedure
presents a risk factor that should be considered in determining
professional liability rates for physical therapists. The
Legislature should require evidence of public harm or risk before
introducing legislation that restricts previously authorized
practice?further, graduates of physical therapy education programs
are required to be examined with respect to their knowledge of
joint manipulation in order to become licensed as a physical
therapist in California?Treatment interventions do NOT fall under
the exclusive domain of any one specific profession or group of
practitioners?SB 381 is an attempt to legislate clinical practice,
which is the purview of the Professional [licensing] Boards."
9.Policy Issues for Consideration. Though the Sponsor has stated that
the intent of the bill is to protect the public from all
unscrupulous professionals, there appears to be a specific focus on
restricting the professional activities of physical therapists as a
result of this legislation. For example, the Sponsor and Author's
office indicate in written materials submitted to the Committee,
"There have been reports of physical therapists performing these
manipulations, and even when reported to the Physical Therapy Board
they are not being reprimanded." However, the Physical Therapy
Board reports to the Committee that it has no record of such
complaints. The Sponsor also reports there have been "hundreds of
complaints" received from chiropractors that have been forwarded to
the Physical Therapy Board. However, the Sponsor is unable to
provide any data to substantiate these complaints. Moreover, when
the Committee checked with other licensing boards under the DCA,
including the Board of Chiropractic Examiners, the boards reported
little to no complaints from consumers or disciplinary action taken
against a licensee relating to the issue of manipulation or
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adjustment . If there are in fact consumers who complain to their
chiropractors about prior treatment from non-chiropractors, it is
plausible that these patients may not fully understand the
difference between the adjustment and manipulation of hard tissues
authorized for chiropractors and the mobilization and manipulation
of joints authorized for physical therapists to perform.
This appears to be a long-standing disagreement as evidenced by the
opinions dating back to 1976. Arguments from both sides seem to be
based on anecdotal evidence and discrepancies about semantics. As
noted in the 1980 DCA opinion, "We primarily view this controversy
not as a matter of legal interpretation, but an inter-professional
squabble, often referred to as a 'turf battle.'" Is making the
proposed changes in statute to define joint manipulation and
adjustment the appropriate avenue to take in order to clarify this
scope battle ?
As noted in the 1976 Attorney General opinion, "The definition
adopted by the Board of Chiropractic Examiners in section 302,
Title 16, California Administrative Code, reveals that physical
therapy and chiropractic each involve the use of physical agent
used by the other . We do not believe that this common use of
agents presents a major problem because a chiropractor is
prohibited by section 2630 from practicing physical therapy as such
and a physical therapist is prohibited by section 15 of the
Chiropractic Act from practicing chiropractic." As such, it
appears that the intent of the manipulations is what matters. The
intent of chiropractic manipulation of hard tissues, such as the
spine, is to cure disease. The intent of physical therapy
mobilization and manipulation is to provide physical or corrective
rehabilitation to reduce pain.
There obviously exists serious contention between the two
professions which has led to reactive stances regarding this
legislation. Perhaps the most judicious way to proceed is to
concede that both professions are concerned with consumer
protection, thus the specific activities of each profession need to
be clarified. Specifically, both chiropractors and physical
therapists are trained during their educational programs to perform
Grade 1-5 exercises, which has led to considerable confusion about
which profession is allowed to perform joint manipulation and joint
adjustments, specifically since Grade 5 is considered a
manipulation. The Committee may wish to consider whether it should
direct the Board of Chiropractic Examiners and the Physical Therapy
Board to collaborate and review the Grade 1-5 exercises to clarify,
according to each profession's scope of practice, if it is in fact
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appropriate for both professions to teach these exercises. If the
two Boards are unable to reach a conclusion, a legal opinion may
help to clarify this issue.
SUPPORT AND OPPOSITION:
Support:
California Chiropractic Association (Sponsor)
Los Angeles College of Chiropractic
65 letters from licensed chiropractors
21 letters from individuals
Oppose Unless Amended:
California Naturopathic Doctors Association
Opposition:
Independent Physical Therapists of California
Mount St. Mary's College
104 letters from licensed physical therapists
Over 300 letters from individuals
Consultant:Le Ondra Clark, Ph.D.
Dysfunctional Disabilty
Last weekend I loaded the wife and kids into the car and made the long trip to the sprawling metropolis of Fort Covington, NY to spend Easter with family. While the kids watched Despicable Me (again) I listened to one of my favorite podcasts, This American Life. I highly recommend you take a listen to this episode which was dedicated to the disability system in the US. If you are not into podcasts then you can read about the topic here.
This episode focused on Hale County Alabama where 1 in 4 adults are on disability. However, this problem is not isolated to one county in one state. States like West Virginia, Arkansas, Alabama and Kentucky all have over an 8% disability rate for 16-64 year olds.
The US pays disability benefits to over 14 million people each month and these numbers continue to grow. Not surprising the fastest growing sector of disability is from musculoskeletal disorders (33.8%, up from 8.3% in 1961). I am sure like me, many other physical therapists have seen firsthand how messed up the system is.
What was most interesting to me about the episode was the impact that politics, social ideals and economics had on the disability system. For instance, the unemployment rate makes headlines all the time, but you never hear about the disability rate. So it is a political advantage to move unemployed workers to disability (poof, the unemployment rate goes down). Also, states have to pick up the bill for welfare but the federal government pays for disability. As a result, states will hire consultants to contact people on welfare and attempt to get them qualified for disability.
The episode further expands on this misalignment of incentives. Once on disability you are “punished” (disability benefits taken away) if you get better and/or get a job. As a result, very few people ever get off disability once approved. This got me thinking about the neuromatrix and pain. Imagine a patient with low back pain whose only source of income is a disability check and they have no job prospects. Getting better poses a huge threat and staying disabled and in pain may be the safer option. Maybe we need a questionnaire which measures the fear of getting better?
If you get a chance check out the podcast or article and let me know what you think.
Red Flags
The last thing any physical therapist (or any health care practitioner) wants to do is diagnose a patient with a musculoskeletal problem when they actually have something nasty like a tumor. To avoid this potentially costly error we take a thorough history and detailed exam, keeping a close eye out for red flags. For patients with spinal pain there are 4 red flags (used to rule out spinal tumors) which are commonly cited and endorsed by the American Pain Society .
1) Unexplained weight loss
2)Being older than 50
3)Failure to improve after 1 month
4) A history of cancer
If a patient has one or more these red flags (there are others as well) they are considered to be at higher risk for having cancer and further testing should be considered. If red flags are not present, imaging such as x-rays and MRIs are often not indicated. But how useful are these red flags? A recent Cochrane review on the subject helps us answer that question.
Before we look at the details of the study it is important to remember what makes a good screening tool. First the tool needs to increase the probability that a condition is present. Second there needs to be few false negatives (high sensitivity).
In this review, the authors identified 8 studies which examined 15 red flags from the history. The sensitivity of the individual tests ranged from .5-.77. One study combined several red flags (age >50, history of cancer, weight loss and failure to improve with conservative treatment) and found the combination to have a sensitivity of 100%. The majority of the historical components examined did not significantly increase the post test probability of having cancer. The only exceptions were unexplained weight loss (increased from .3% to 1.2%) and previous history of cancer (increased from .3% to 4.6%).
5 physical exam tests were also identified and they had very low sensitivity and did not increase the post test probability.
The authors conclude that:
“Commonly suggested “red flags” for malignancy in clinical practice guidelines are: age > 50 years, no improvement in symptoms after one month, insidious onset, a previous history of cancer, no relief with bed rest, unexplained weight loss, fever, thoracic pain, or being systemically unwell ( Koes 2010 ). These “red flags” are usually elicited through the initial assessment (history taking and physical examination), to decide which patients should be referred for imaging or specialist consultation. The limited evidence available suggests that only one “red flag” when used in isolation, a previous history of cancer, meaningfully increases the likelihood of cancer. “Red flags” such as insidious onset, age > 50, and failure to improve after one month have high false positive rates suggesting that uncritical use of these “red flags” as a trigger to order further investigations will lead to unnecessary investigations that are themselves harmful, through unnecessary radiation and the consequences of these investigations themselves producing false-positive results. While the lack of evidence to support or refute the use of “red flags” is recognized, a more pragmatic solution is to consider the possibility of spinal malignan
cy (in light of its low prevalence in primary care) when a combination of recommended “red flags” are found to be positive.”
So it looks like other than a history of cancer, red flags are not all that helpful for determining when someone with spinal pain has an elevated risk of cancer. Hopefully, future studies will identify better screening tools.
Clinical Case 1: Kevin Ware
So I want to present a new type of post called “Clinical Cases”. This type of post will show a video and then ask the viewers of this site to not only give their impressions on the anatomy and physiology involved in the injury but also the societal impact of the video, psychological variables that may impact or hinder recovery, personal and clinical “feelings” when viewing the video, potential rehabilitation, etc. Let’s learn how to utilize a “biopsychosocial” model in understanding injury and recovery.
So here is video #1 showing an injury sustained by Kevin Ware from this weekend’s Louisville/Duke game . Please note, this is not an easy video to watch. Let’s begin a discussion below:
Arthroscopic Treatment of Knee OA
Not all that long ago, arthroscopic surgery was routinely used to treat patients with knee OA. This practice was first called into question by a study published i
n 2002. In this study subjects received arthroscopic debridement, arthroscopic lavage or a placebo surgery in which the scope was inserted but nothing was done. There were no differences in pain or function between the three groups. Another trial compared the effectiveness of arthroscopic debridement to non-operative care. Again, there was no advantage to having the surgery. A study of 90 patients by Herrlin et al looked at partial meniscectomy in patients with OA and found no advantage over physical therapy at 6 months and 5 years.
A recent RCT performed by Katz et al (METEOR trial) looked to confirm these results with a larger multi-centered study. 351 subjects from 7 institutions were randomized into a surgical group or a physical therapy group. The surgical group had a partial meniscectomy and the physical therapy group “was designed to address inflammation, range of motion, concentric and eccentric muscle strength, muscle-length restrictions, aerobic conditioning (e.g., with the use of a bicycle, elliptical machine, or treadmill), functional mobility, and proprioception and balance” and was administered in three stages. Overall the physical therapy protocol seemed reasonable and did include manual therapy. The description of the protocol (which can be found here) did not give specifics on the manual therapy (which joints and which techniques) and did not give detailed information on the intensity of the exercise. Outcomes were measured (6 and 12 months) using the physical function scale of the WOMAC, KOOS and the SF-36.
The authors found no significant difference between the groups at 6 and 12 months. There was a 30%(6 months) and 35% (12 months) cross over from conservative to the surgical group. The authors did an intent-to-treat analysis to try and deal with this cross over.
Overall this is a good study and it confirms that physical therapy is a viable option for symptomatic patients with OA and meniscus tears. Hopefully this data will help to reduce the over 465,000 partial meniscectomies performed in the US each year.
Deconstruction of Reconstruction
Picture this scenario. Skippy, a 41 year old male software engineer comes into your clinic after tearing his right ACL when he slipped on a floppy disk at work. He lifts weights at the gym 3 days a week and runs 2 miles on the treadmill 2 days a week. On his first visit Skippy asks “should I get my ACL reconstructed?”
What would you recommend?
In the recent past this would not have even been a question. Still today, most patients who tear their ACL are encouraged to have it reconstructed. Without a reconstruction patients have been expected to have reduced function, knee instability, meniscus tears, osteoarthritis etc….
More recently studies have started to call into question the practice of automatically reconstructing ACLs on every patient. Some patients are being classified as copers and are expected to function well with an ACL deficient knee.
A recent study by Frobell et al in BMJ adds to the mounting evidence which calls into question early and blanket ACL reconstruction. The authors followed a group (121) of patients (average age of 26 and “active”) who either had early ACL reconstruction or delayed optional surgery. 49% of the patients in the delayed group decided not to have an ACL reconstruction.
At the 5 year follow-up, outcomes for the two groups were similar. Early ACL reconstruction did not lead to improved outcomes or reduced incidence of subsequent meniscus injury.
” CONCLUSION: In this first high quality randomised controlled trial with minimal loss to follow-up, a strategy of rehabilitation plus early ACL reconstruction did not provide better results at five years than a strategy of initial rehabilitation with the option of having a later ACL reconstruction. Results did not differ between knees surgically reconstructed early or late and those treated with rehabilitation alone. These results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear.”
Do the results of this study change the recommendation you would give to Skippy?
Dr. Oz is being sued…
It appears that the all-in-powerful Oz is being sued after a New Jersey man suffered third degree burns after following a recommendation he saw on the show. The man claims to have slept with “heated rice-filled socks” which were recommended by Oz in a show filmed in 2012. Unfortunately, the man is diabetic and suffers from neuropathy and could not feel his feet burning. Ouch.
As Physical Therapist’s, we must always educate our consumers on the safe use of modalities, and to always consult a medical professional before trying something they heard on this (or any other) show…
Regional Interdependence
I am very excited that Dr. Brence invited me to join him here at forwardthinkingpt.com. He has a great blog with lots of wonderful content. My first few posts are going to be recycled from my bog, which I am shutting down.
I recently read an article by Muth et al which looked at the effects of thoracic spine thrust manipulation on patients with signs of rotator cuff pathology. This study utilizes the concept of regional interdependence which has gained popularity over the last several years. This theory suggests that pain and dysfunction in one area of the body can be treated with interventions to adjacent regions. This concept is not new, however more recent studies have fueled its increased popularity by providing support for it. For example, treatment of the hip is thought to have an impact on knee and low back pain, and treatment aimed at the thoracic spine as been shown to have effects on shoulder and neck pain. These effects are often explained based on biomechanics however, the exact mechanism is still unclear. It is possible that some of these effects can be explained by changes in biomechanics, although there are a few reasons why I remain skeptical about this explanation . First, many of these studies use manual therapy and 
exercise as an intervention. It is assumed that these interventions have an impact on the biomechanics of a joint however this hypothesis remains unproven. The often immediate effects of manual therapy may suggest that its actions go further than just local changes to a joint. Although possible, I would not expect small changes in biomechanics at one joint to immediately result in reduced pain and improved function at a distant joint. It seems more plausible that a change in the nervous system (increased pain threshold etc.) would be more likely to result in this immediate effect. If we consider exercises to either strengthen or stretch a muscle it may theoretically change biomechanics, however there are few examples of this in the literature. The other major reason I am skeptical of the biomechanical explanation for regional interdependence is the consistent failure of studies to find a strong connection between biomechanical factors and patient symptoms. Even in cases where a correlation between mechanics and symptoms has been documented (for example shoulder pain and scapular dyskinesia) it is often unclear if the changes in biomechanics are the cause or a result of the problem.
The study by Muth et al built off other studies (here and here) which found a reduction in shoulder pain after thoracic spine manipulation (TSM). The goal of this study was to try and determine a mechanism for the reduction in shoulder pain after TSM. The authors took 30 subjects with shoulder pain and put them through a battery of tests including: scapular kinematic testing (using electromagnetic tracking), EMG (infraspinatus, upper/middle/lower trap, serratus), pain rating (during empty can test, Hawkins-Kennedy test, Neer test and loaded elevation), peak shoulder elevation force and a few shoulder function questionnaires.
As with previous studies they found a reduction in pain and an improvement in function after the TSM. This reduction in pain was not associated with changes in biomechanics. The only statistical significant change in scapular motion was a reduction in upward rotation after the TSM. Based on current thinking we would expect a reduction in upward rotation to decrease the subacromial space, result in more pressure on the cuff and cause increased pain. At this point you are probably thinking “but what about thoracic motion”. Good thought but no, that did not change either.
The results of this study calls into question the biomechanical explanation for the improvements found after TSM. I would not suggest that regional interdependence is never a result of biomechanical changes, however we should be careful not to assume the mechanism is biomechanical. It is important for us to consider the mechanism behind regional interdependence because often our understanding of mechanism dictates how we use the intervention. For example, TSM may not be used in a patient with shoulder pain who is found to have a normal or hypermobile thoracic spine. We assume that TSM is only effective in patients with a stiff thoracic spine because we believe the mechanism of action is increased thoracic extension (or motion in general). If the patient has good extension with no stiffness there would be no reason to perform a TSM. If we understand that the mechanism behind TSM may not be mechanical, we would avoid using only mechanical findings to dictate whether we performed a TSM or not. At this point, all we know is that the presence of shoulder pain is an indication that TSM may be helpful.
Another important issue to address about the Muth et al study (and many other studies looking at manual therapy) is that there was no sham treatment group. The absence of a sham treatment group makes it impossible to determine whether the benefits from TSM were due to a specific effect or a result of non-specific effects such as placebo or patient expectation.
To sum things up, TSM seems to provide short term improvements in pain and function for patients with shoulder pain. The mechanism behind these improvements does not appear to be biomechanical. We need more studies looking into the mechanism behind this, and other examples of regional interdependence, so we can more accurately match interventions to patients.
Who is ForwardThinkingPT?
As we tirelessly write posts to challenge and improve the critical thinking amongst Physical Therapists, we thought it might be a good opportunity to introduce some of those who contribute to the site…
Joseph Brence
Joseph Brence, PT, DPT is a Physical Therapist and clinical researcher from Pittsburgh, Pa. He is also a fellowship candidate with Sports Medicine of Atlanta. Joseph’s primary clinical interests involve a better understanding of the neuromatrix and determining how it applies to Physical Therapy practice. He is currently involved in a wide range of clinical research projects investigating topics such as the effects of verbalizing of pain, the effects of mobilizing vs. manipulating the spine on body image perception and validation of a instrument which will assess medical practitioners understanding of pain. Clinically, Joseph treats a wide range of painful conditions in an outpatient setting including Complex Regional Pain Syndrome, Fibromyalgia, Chronic Fatigue Syndrome, etc. He is married to his wife, Kristen, and enjoys spending Sunday’s watching the Steelers.
Adam Rufa
Adam Rufa, PT, DPT is a Physical Therapist and educator from Syracuse, NY. He is a specialist in orthopedics with a particular interest in chronic pain conditions. Currently Adam teaches entry level physical therapy students in biomechanics, spine, orthopedics, clinical decision making and practice management. He continues to treat patients with a variety of musculoskeletal and pain conditions. His research interests include simulation tools in education, manual therapy and clinical reasoning. Outside of work he spends his time with his wife and three young children.
Sigurd Mikkelsen
Sigurd Mikkelsen, PT, MSc is a Physical Therapist and educator from Fredrikstad, Norway. His primary interests are the effects of manual therapy on the neuromusculoskeletal system and its consequences for clinical reasoning in acute and chronic pain conditions. He is also concerned with the value of epistemology and ontology in the application of research into clinical practice. Sigurd is a strong advocate of patient empowerment and promotes manual therapy as an active learning process. Besides being a practice owner, he teaches personal trainers in biomechanics, anatomy, pain physiology and sensorimotor principles of exercise-based rehabilitation. His spare time is spent with his girlfriend, with his guitar and his fly fishing rod.
We are always looking for additional ForwardThinkingPTs to join our team and mission. If you believe you have what it takes, leave us a comment and tell us why.
Let’s Talk…Californian Chiropractic Bill 381 appears “subluxed” and needs an “adjustment”
I recently came across a bill (SB 381) that was proposed on February 20th, in California, by Senator Yee (twitter @LelandYee —I am sure he would love to hear from his constituents). The bill (seen below) proposes that any healthcare practitioner, excluding Chiropractors/MDs/DOs, can perform an adjustment or joint manipulation. I was quite taken back by this proposal but believe it’s something we now need to openly discuss (according to my comment sections of previous posts and web analytics, this blog has garnered the attention of prominent members of the American Physical Therapy Association and American Chiropractic Association and believe it’s time we openly “talk”). Before progressing, I suspect there are several great forward thinking Chiropractors out there such as Dr. Shawn Thistle, Dr. Gregory Lehman, etc. This post is not to degrade them. The intention is to open up some much needed scientific (not pseudoscientific) dialogue. So let me begin…and get real…
1. Why is this bill necessary? I would suspect that a bill like this would be necessary if it were determined that healthcare practitioners were providing unsafe or unnecessary joint manipulations. I am quite in-tune with the emergence of manual therapy literature and I am unfamiliar with any research that indicates that Physical Therapist’s are unsafe with joint manipulation or provide joint manipulation which is unnecessary. On the contrary, as a profession we have identified those who have benefited from joint manipulation (clinical prediction rules)[1], determined prognostic indicators of who has the best outcome when they have an initial within/between session change to joint manipulation [2] and lead the scientific community in research that attempts to identify what is happening with joint manipulation. If anyone can provide support to the contrary, please leave me a citation in the comment box below.
2. The terms adjustment and manipulation are not synonymous. Sorry, but they aren’t. “Reference to subluxations in medical literature is often presented as support for the practice of chiropractic as a method of adjusting vertebral subluxations to “restore and maintain health.” [3] The issue with this concept is that while it may be accepted by many chiropractors, it is not well- supported in qualitative or quantitative literature. I recommend those who are unfamiliar with this concept to read by this well-done review by Harriet Hall, MD.
3. I would say the chiropractic lobbyists who proposed this bill, can HAVE the terms “Joint Manipulation and Adjustment”. The APTA needs to grow a pair and own the terms “Neurophysiological Manipulation” and “Neurophysiological Mobilization”. Trademark these. And trademark them now!!!!!!!!! It appears that the benefits from manipulation have very little effect on the joint and likely have more effects with neurophysiological tissues. You can push on bones all day long, but we must have an effect on the body-self neuromatrix to get a result…In other words, we do these techniques to 1. reduce pain or 2. get something to move, correct? So let’s reason…can joints feel? Well, without nerves, no. And without nerves, can tissues move in a functional way? Well, without nerves, no. So, the results on improved movement are most plausibly due to alterations made in the somatosensory and motor homunculus (provide me a more plausible scientific argument and I’ll consider). So if we “own” NEUROPHYSIOLOGICAL MANIPULATIONS AND MOBILIZATIONs”, then chiropractors can do “JOINT MANIPULATIONS or ADJUSTMENTS” all day long, but cannot perform them for pain relief or altered movement patterns. If you disagree, I refer you to an article in published in Physical Therapy ahead of print entitled: “ Immediate Effects of Region-Specific and Non‒Region-Specific SpinalManipulative Therapy in Patients With Chronic Low Back Pain: A Randomized Clinical Trial.”[4]. Thoughts?
So all of this stated, let’s begin a discussion. A scientific discussion. This is a completely unnecessary bill and the chiropractors are continuing to fight an unnecessary turf-war. If you comment in my box and make a “wild” claim without a “reference”, it is open to be deleted. Leave cognitive dissonance at the door and tell me why this bill is or is not necessary.
1. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 2002: 27; 2835-2843.
2. Cook CE, Showalter C, et al. Can a within/between-session change in pain during reassessment predict outcome using a manual therapy intervention in patients with mechanical low back pain?Manual Therapy (2012), doi:10.1016/j.math.2012.02.020
3. http://www.sciencebasedmedicine.org/index.php/chiropractic-vertebral-subluxations-science-vs-pseudoscience/
4. Oliveira RF, Liebano RE, Costa L. Immediate effects of region-specific and non-region-specific manipulative therapy in patients with chronic low back pain: A randomized controlled trial. Physical Therapy Published online February 21, 2013; doi: 10.2522/ptj.20120256.
BILL NUMBER: SB 381 INTRODUCED
BILL TEXT
INTRODUCED BY Senator Yee
FEBRUARY 20, 2013
An act to add Section 734 to the Business and Professions Code,
relating to chiropractic practice.
LEGISLATIVE COUNSEL'S DIGEST
SB 381, as introduced, Yee. Healing arts: chiropractic practice.
Existing law, the Chiropractic Act, enacted by an initiative
measure, provides for the licensure and regulation of chiropractors
by the State Board of Chiropractic Examiners. Under the act, a
license authorizes its holder to practice chiropractic as taught in
chiropractic schools or colleges but does not authorize its holder to
practice medicine, surgery, osteopathy, dentistry, or optometry.
Existing law provides for the licensure and regulation of
physicians and surgeons and osteopathic physicians and surgeons by
the Medical Board of California and the Osteopathic Medical Board of
California, respectively.
This bill would prohibit a health care practitioner from
performing a joint manipulation or joint adjustment, as defined,
unless he or she is a licensed chiropractor, physician and surgeon,
or osteopathic physician and surgeon. The bill would provide that a
health care practitioner who performs a joint manipulation or joint
adjustment in violation of these provisions engages in the unlawful
practice of chiropractic, which shall constitute, among other things,
good cause for the revocation or suspension of the health care
practitioner's license, as specified.
Vote: majority. Appropriation: no. Fiscal committee: no.
State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 734 is added to the Business and Professions
Code, to read:
734. (a) Notwithstanding any other law, a health care
practitioner subject to regulation pursuant to this division shall
not be authorized to perform a joint manipulation or joint adjustment
except for the following individuals:
(1) A chiropractor licensed by the State Board of Chiropractic
Examiners.
(2) A physician and surgeon licensed by the Medical Board of
California.
(3) An osteopathic physician and surgeon licensed by the
Osteopathic Medical Board of California.
(b) A health care practitioner who performs a joint manipulation
or joint adjustment in violation of this section engages in the
unlawful practice of chiropractic, which shall constitute good cause
for the revocation or suspension of the health care practitioner's
license, or any other disciplinary action deemed appropriate by the
health care practitioner's licensing board.
(c) For purposes of this section, "joint manipulation" and "joint
adjustment" are synonymous terms that describe a method of skillful
and beneficial treatment where a person uses a direct thrust to move
the joint of a patient beyond its normal range of motion, but without
exceeding the limits of anatomical integrity, as taught in
chiropractic schools or colleges.
