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An Essay for Physical Therapists: Lets Move Forward…

This essay is a result of a recent prescription I received  from a Podiatrist which read:  Physical Therapy for Achilles Tendonitis.  Eval and Treat with Ultrasound and Electrical Stimulation.  I am frustrated that despite our gained autonomy and direct access rights, we are still recognized as interventionalists who simply perform modalities.  This essay is to identify how we became a profession, what we know as a profession and how we can move forward.  This essay is important

Part 1:  Historical Review of Physical and Manual Therapy Practice

Hippocrates: the Father of Medicine

Early roots of Physical Therapy and Rehabilitation date back as far as 460 B.C.  Physicians, such as Hippocrates and Galenus, documented the medical use of manual therapy, massage and hydrotherapy in treating various ailments.   In the  17th and 18th centuries, the practice of “bone setting” was all the rage, and practitioners believed that bones would dislocate and you would need to set them back in (this fad died out—kind of…).  American Indian tribes were also documented around this time in using primitive forms of joint manipulation by walking on each others backs.  In 1895, a magnetic healer named Daniel David Palmer, founded the manual profession known as chiropractic and believed illnesses could be treated through the repositioning of dislocated vertebrae.1

Early reminants of modern Physical Therapy entered existance in the United States in the late 19th century.  In 1881, the Sargant School, in Boston, MA, opened up their doors to welcome the first Physical Training class.2  Dr. Dudley Sargant, who founded the school, built a reputation as an innovator in promoting health through physical conditioning and wellbeing and recognized that physical rehabilitation was a necessary part of the healing process of musculoskeletal disorders.3

Over the next several decades, other programs began to be offer similar training.  In 1918, women were recruited to assist orthopedic surgeons in restoring function to those injured in World War 1.  This lead to the development of the Reconstruction Aide.  These individuals served in military hospitals in the US and overseas as assistants in the rehabilitation of injured soldiers.  Around this time. the first, official, Physical Therapy school was developed at Walter Reed Army Hospital in Washington DC.  Other schools also began offering Physical Therapy training.4  In 1921, the first recognized Physical Therapy Association came into existence in the United States, and was called the American Women’s Physical Therapeutic Association which eventually became the American Physiotherapy Association by the end of the 1930s.

From its start, Physical Therapy was developed as an occupation which acted in a supportive role to physicians.  Practitioners were considered “educated trained assistants to the members of the established medical profession”.4  Manual therapy was an integral part of early physical therapy, and in a paper written in 1923 titled, “Physiotherapy in Stiff & Painful Shoulders”, the author stated that “on forceful manipulation it is found that the scapula moves coincidentally with the arm”.  Other treatments recommended for a stiff shoulder included: heat, chlorine ionization, massage, stretching, monipolar high frequency vacuum tube and exercise.5

The profession came into much greater demand in the 1940s and 1950s following the second World War as well as during the height of the polio epidemic. At this time, over 8,000 individuals became members of the professional organization, which changed its name to the American Physical Therapy Assocation.2  Physical Therapists played a crucial role in field testing the polio vaccine, prior to its mass distribution, and continued to treat those inflicted with the disease.

Currently, there are close to 200,000 licensed physical therapists employed in the United States.6  In forty-seven states and the District of Columbia, Physical Therapists can practice as Direct Access providers (without a physicians referral).    This has been a huge step forward, in the recognition of Physical Therapists as highly trained, autonomous practitioners.

But despite this move forward, we must understand that we are still evolving.  The general public is still largely unaware that they can seek our care without a medical referral, and many would seek another professional before us in the care of musculoskeletal issues.   As so-called “musculoskeletal and movement” experts, we still hold onto some “questionable” beliefs and interventions, and I suspect a stronger sense of coherence and agreement is needed, before we will be recognized at this caliber.

Part 2: Evidence-Based Interventions: What do we know?

So when I say “questionable”, what do I mean.  Well, one thing that we do very well as Physical Therapists is perform research about our diagnostic skills, interventions and outcomes.  One thing, I do not believe we do well is incorporate some of that research into practice.  Now don’t get me wrong, experience is important. Very important. Especially for deductive reasoning.  But to truly be an evidence-based practitioner, you must also be performing scientifically sound interventions. Here are some things to consider:

  1. Modalities:Ultrasound:  We all learned about the magical qualities of ultrasound in Physical Therapy school.  We learned about it bringing nutrients and cells via bloodflow to damaged and inflamed tissues. We learned about those cool little cavitation bubbles.  Well here’s how those theories stood up in the literature…A systematic review performed in 1999 by van der Windt found that there is little evidence to support the use of therapeutic ultrasound in the treatment of musculoskeletal conditions. 76 studies were found by the researchers, 38 of which were included in this review (after inclusion/exclusion were met).   The majority did not find a statistically significant difference between therapeutic ultrasound as compared to a sham interventions.8 Another review performed in 2001 by Robertson et al had the same, exact conclusions.9 A systematic review which assessed the use of ultrasound for the treatment of knee/hip OA found no beneficial effect as compared to placebo.10

    This TENs unit is reminiscent of an ipod. How cool!

    TENs:  A systematic review performed in 1996 determined that TENs had no statically significant difference as compared to placebo in controlling pain or disability.11

    Thermotherapy/Cryotherapy: A 2009 systematic review and meta-analysis on cryotherapy, after total knee arthroplasties, determined that despite theoretical applications in the reduction of pain and swelling following surgery, the evidence does not support the routine use of cryotherapy (there were only very small benefits when used immediately after surgery).12

  2. Exercise:Unlike modalities, exercise has been demonstrated to be highly effective in the treatment of many disorders in the literature.  Unfortunately, the  type of approach to exercise does not appear to matter, as much as simply movement.  A recent study prospectively assessed the outcomes of 172 individuals with chronic, nonspecific LBP who were randomized to receive either motor control exercises or graded activities.   The results indicated that both approaches were effective in decreasing pain and disability in individuals with chronic LBP but one approach wasn’t superior to the other.13   Another study, compared traditional core stabilization exercises with trunk balance activities in the treatment of LBP, and found that the trunk balance group had more significant improvements in disability and quality of life.14 A preventative study performed by George et al. found that education, not core stabilization, was more important in preventing care seeking for incidences of low back pain.15  Maybe all that stuff about the tA and multifidis really isn’t that important.  Or at least as important as we thought…please don’t hate the messenger.  
  3. Manual Therapy:Manual therapy, like exercise, has been demonstrated by countless articles to be an effective treatment, often when combined with other therapeutic interventions.  A systematic review on the treatment of mechanical neck pain found that multimodal manual therapy care including exercise was superior to controls in improving pain and patient perceived outcomes.16  Similar studies and outcomes have been demonstrated in the treatment of low back pain.17 The evidence is inconclusive whether manual therapy is effective in treating hip and knee OA.18

Part 3: What barriers have we created for ourselves?

Barrier # 1: Continued Use of Non-Evidence/Scientifically Supported Interventions. As you can see from part 2, we have built a profession that utilizes some great, evidence-supported interventions but also one that routinely performs and bills for unnecessary modalities.  There continues to be a large reliance on holding onto what we believe(d) to be true, and a resilience in letting go of our comfort tools (definition of toola handheld device that aids in accomplishing a task. What task are we accomplishing if we are using modalities?).

Barrier #2: Too  Much Emphasis on “Suspected” Tissues. We have also become too focused on “tissue-specific theoretical interventions” and less on scientific plausibility.  As Physical Therapists, one of the most common symptoms our patients tell us about is Pain.  And despite this, we have over-simplified pain by thinking of it as a bottom-up response, in which the tissues are injured and and therefore hurt. The true scientific explanation of the pain involves the neuromatrix, which is a brain-involved, top-down response, in which the brain and nervous system defend an injured tissue through sending a perceived signal, pain Ignoring that the brain is the ultimate player in ALL pain is a costly mistake.  The brain’s defense of a tissue may not only be related to the damage of the tissue, but also to the environment in which the tissue was injured, the psychological well-being of the individual, the history or memories of past injuries, etc.  Below is a diagram of the neuromatrix which demonstrates all of the associated inputs into the brain which may cause it to respond by sending a pain output.

Neuromatrix model borrowed from Diane Jacob’s blog, http://humanantigravitysuit.blogspot.com/

Barrier #3: Too much emphasis on board examinations for new graduates.  I doubt many will have an argument with this.  Much of what is taught in Physical Therapy schools in the United States is driven by the state licenser examinations and accrediting bodies. Emphasis of education should be built on teaching the most current, scientific methods of treatment.  Instead we are spending time teaching students about theories which have been ultimately outdated (convex/concave rules, veretebral and sacral rotations—palpating the ILA, etc.) so that they can pass an outdated examination.

Barrier #4: Unscientific Continuing Education Courses.  I get daily brochures promoting continuing education courses which will teach me the skills to eliminate anyones pain or dysfunction! Unfortunately, many of these courses are teaching outdated treatment models or pure garbage (don’t get me wrong—there are some fantastic courses out there).  Sciencebasedmedicine.org wrote a blog a few months back about visceral manipulation being embraced by the APTA.  For those of you who aren’t familiar with this magical hands-on approach, it is built around a theory that through hands-on evaluation, you can determine structural imbalances throughout the body (involving different organs and tissues), and you improve balance through manipulation of organs. Ummmm yea….

Part 4: How do we overcome our barriers?

Barrier # 1: Continued Use of Non-Evidence/Scientifically Supported Interventions.  We must agree as a profession to gently let go of interventions which have been demonstrated to be of little therapeutic value.  Plain and simple.  It will be hard at first, I’m sure.  But in the end it is the right thing to do.

We should also re-educate ourselves in the scientific method and become aquatinted to new understandings of pain, fatigue, etc. Things evolve.  So should we.  I recommend we move forward through open discussion in the work place, online (websites such as somasimple), etc.  Everyone, in some point of their career (for me, daily) has had the thought in the back of their mind, “I wonder if this is really doing, what I think it’s doing”.   Discuss these thoughts.  Try to make sense of them.  If you haven’t ever been able to palpate the ILA, determine which leg is longer, vertebral rotation, etc,  join the club.

Barrier #2: Too  Much Emphasis on “Suspected” Tissues.  As I stated above, we must question what we think we are doing and what we think we are affecting.  When we place are hands on a patient, how do you know you are touching anything but the skin?  Our reliability in palpatory skills is inherently low.  And this is because of human anatomy variability. But who cares.  By adopting a neuromatrix explanatory model of pain, we understand that the human pain experience is much more than a tissue and determining the tissue at fault is not necessary (after ruling out systemic involvement through symptomatic screening).  By moving past the “this-tissue-is-the-cause-of-your-pain-model”, will result in lower nocebo responses and ultimately better long-term outcomes.  For more about this topic, read here.

Barrier #3: Too much emphasis on board examinations for new graduates. This is one barrier I do not see changing.  I’m just being honest.  But, if I had any influence on accrediting bodies, my idea would be:

  • Drop the current board examination and require a 6-month to 1 year residency for specialization in a desired field of therapy
  • Residency would involve clinical mentorship by fellowship-trained mentor
  • Have a comprehensive board examination, written and practical, following completion of residency

Barrier #4: Unscientific Continuing Education Courses.  I recommend “taking out the garbage” here.  I believe a peer-review process should take place for all CEU course applications.  All information included in the course should be well-cited and have scientific basis and plausibility.

Part 5: Let’s move forward

Alright, so this essay has been quite exhaustive but in my opinion, quite necessary.  We need to be forward thinking if we want to move past prescriptions which state Physical Therapy for Achilles Tendonitis.  Eval and Treat with Ultrasound and Electrical StimulationWe must all work together in making this change.

Please comment and let’s start a discussion, not an argument, on how you will make a change to move our profession forward. Are you willing to hang up the ultrasound head?

1. Paris S. A history of manipulative therapy through the ages and up to the current controversy in the United States. JMMT 2000. 8: 66-77.

2. http://www.apta.org/History/

3.http://www.bu.edu/academics/sar/

4.http://beckerexhibits.wustl.edu/mowihsp/health/PTdevel.htm

5. Granger. Physiotherapy in stiff & painful shoulders. Physical Therapy Review. 1921.

6. http://www.bls.gov/ooh/Healthcare/Physical-therapists.htm

7. http://www.apta.org/StateIssues/DirectAccess/Overview/

8. van der Windt D, Geert JMG. Ultrasound therapy for musculoskeletal disorders: a systematic review. Pain 1999: 81: 257-271.

9. Robertson VJ, Baker KG. A review of therapeutic ultrasound: Effectiveness Studies. Physical Therapy 2001. 81: 1229-1250.

10.Welch V, Brosseau L, Peterson J, Shea B, Tugwell P, Wells GA. Therapeutic ultrasound for osteoarthritis of the knee. Cochrane Database of Systematic Reviews 2001, Issue 3. Art. No.: CD003132. DOI: 10.1002/14651858.CD003132.

11. Carroll D, Tramer M, et al. Randomization is important in studies with pain outcomes: systematic review of transcutaneous electrical nerve stimulation in acute postoperative pain. British Journal of Anaesthesia 1996. 77: 798-803.

12. Adie S, Naylor JM, et al. Cryotherapy after total knee arthroplasy: a systematic review and meta-anlysis of randomized controlled trials. The Journal of Arthroplasty 2010. 25: 709-715.

13. Macedo LG, Latimer J, et al. Effect of motor control exercises versus graded activity in patients with chronic nonspecific low back pain: a randomized controlled trial. Physical Therapy 2012: 92; 363-377.

14. Gatti R, Faccendini S, Tettamanti A, Barbero M, Balestri A, Calori G. Efficacy of Trunk Balance Exercises for Individuals with Chronic Low Back Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther 2011: 41(8); 542-552.

15. George SZ, Childs JD, et al. Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military cluster randomized trial. BMC Medicine 2011: 9; 128.

16. Gross AR, Kay T, et al. Manual therapy for mechanical neck disorders: a systematic review. Manual Therapy 2oo2: 7; 131-149.

17. Slater SL, Ford JJ, et al. The effectiveness of sub-group specific manual therapy for low back pain: a systematic review. Manual Therapy 2012: 17; 201-212.

18. French HP, Brennan A, et al. Manual therapy for osteoarthritis of the hip or knee- a systematic review. Manual Therapy 2011: 16; 109-117.

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38 replies »

  1. There have been a couple of randomized controlled trials demonstrating the efficacy of manual therapy for the treatment of knee OA. These trials resulted in large effect sizes, decreased use of meds, and decreased surgical rates.

    Deyle GD, Allison SC, Matekel RL, et al. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther 2005;85:1301-17.

    Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med 2000;132:173-81.

    You have made some good points in my opinion. However you have made very broad statements which require further investigation. The use of core stabilization may not be as important in the prevention of back pain, but does that hold true for individuals with back pain? I think that as a profession we must bring along the things we have found to be beneficial to our patients and leave behind the tools that we have found to be ineffective. However, there are a plethora of things that we still need to figure out through rigorous scientific study. Generalizations do not help us in this cause as they only swing the pendulum to extreme ends. We must not forget that not all research is of the highest quality. Physical therapists (as a profession) must learn how to digest the evidence properly and learn the difference between a well constructed study and a poorly constructed one. Once that hurdle is cleared I believe the real discussion can begin.

    • Thanks for the comment Alden.!Even though a couple of RCTs may have demonstrated some benefit of manual therapy for knee OA, the systematic review that I cited, published in Manual Therapy last year, took these into account, along with other studies on the subject. Maybe we can attribute this to regression towards the mean?

      Core stabilization is most definitely a hot topic which I expected would raise some criticism. My issue with core stabilization is this: #1. How do we reliably identify an unstable spine or individuals who would benefit from this treatment approach? #2. Do these muscle fibers fire correctly after one has injured their back (read: Macdonald D, Moseley GL, et al. Why do some patients keep hurting their back? Evidence of ongoing back muscle dysfunction during remission from recurrent back pain. Pain 2009. 142: 183-188.) #3. How can we justify that core stabilization is more beneficial vs. other movement approaches?

      I agree that PTs need the access, as well as knowledge, to sift through quality research (I like the QUADAS). The articles that I cited, are all well-done, quality systematic reviews (excluding the 2 RCTs in the exercise sections), and I think we at least know enough about modalities that we can leave them somewhat behind.

      Have a good one! Good discussion and points!

  2. “Well, one thing that we do very well as Physical Therapists is perform research about our diagnostic skills, interventions and outcomes. One thing, I do not believe we do well is incorporate some of that research into practice. Now don’t get me wrong, experience is important. Very important. Especially for deductive reasoning. But to truly be an evidence-based practitioner, you must also be performing scientifically sound interventions. Here are some things to consider”

    Clinicians have some work to do, no doubt. But, I think researchers and the academic PT community are just as much to blame. Researchers continue to perform trials investigating interventions with little to no regard of a deeper theory of mechanisms, pain, or treatment effect. Researchers continue to perform trials guided mis-founded theories, or with a potentially short sighted view of other data on impairments certain populations exhibit (i.e. poor motor control, muscle recruitment patterns, firing of certain muscles in low back pain).

    We continue to focus and frame our interventions and affects too narrowly, mistakenly assuming that are interventions are “specific” with regards to target and mechanisms.

    As Jules Rothstein said “Our research needs more practice and our practice needs more research.”

    We need more clinicians who live in the middle zone of the scientist/researcher——–clinician spectrum. And yes, we need clinicians to be more scientifically and research minded.

    Excellent piece Joe, I hope this creates further discussion.

  3. First off let me tell you this article was very refreshing. I most certainly agree with you. The old saying about “follow the money” certainly applies here. in order to survive we must generate money and the way that is done is by billing for units and unfortunately unproven modalities generate units which generate bucks and bucks are needed to turn the lights and pay the staff. I hate ultrasound – what a waste of time – still it brings in about $10 and $10 x 50 patients per week = 500/week which is $5000 per year – and the guy down the street is going to bill it and get the $5000 so should I not do the same? it is a real conundrum. yet if we continue to do more of the same we are doomed to die as a profession cause we are basing our practice on BS. What am I going to do – I will think on that and save it for another post

  4. since we can all agree that Ultrasound is ineffective then how come the PT schools continue to teach it? As I mentioned above about following the money we get paid based on procedures – too bad it can’t be like the old times when we got paid per visit no matter what was done.

    • Thanks for the comments Tim!

      We need to drop modalities—at least for the majority of our patients. They likely add little therapeutic value and who cares if the guy down the street is using them—he’s stuck in the stone age (btw, Tim and I work for the same company). I agree that there are financial incentives to using junk, but morally and ethically speaking, that puts us in the same classification as physicians who prescribe medications for kick-backs. There are other ways to generate revenue. Providing unnecessary treatments is not one of them.

      In terms of PT schools teaching ultrasound…there is alot of catching up to be done in PT educational institutions. But it’s not their fault. I blame the accrediting bodies and federal/state licensing boards.

      I also suspect that alot of “out-dated” things are being taught because practicing clinicians are still using these “out-dated” things. Ultrasound/E-stim, convex/concave rules, Freyettes laws, SI joint palpatory tests, the gate-control theory of pain (still valid but much more complex than originally thought w/ the concept of the neuromatrix), static stretching, the term “malingerer” and Waddell signs, etc.

      The change needs to come within the practice of PT. Educational systems will then follow…

  5. Thank you for putting forth a thought provoking blog post. I would like to comment on a few points.

    You have said both “Maybe all that stuff about the tA and multifidis really isn’t that important. Or at least as important as we thought…”, and “How do we reliably identify an unstable spine or individuals who would benefit from this treatment approach?”

    In studies of PT for LBP, there are a variety of designs. There seems to be a trend in that more successful outcomes are found in studies that target a specific intervention to a specific patient population. For example, with motor control training positive outcomes have been found in subgroups including those with spondylolysis or spondylolisthesis (O’Sullivan), post-partum pelvic girdle pain (Stuge), and first time, acute, unilateral low back pain (Hides). With directional preference exercises positive outcomes have been found by identifying those with a directional preference and placing them into the appropriate treatment category (Long). Studies that tend to lump people with LBP into one treatment program without making an effort to predict who will respond best to which treatment appear less successful…if not doomed to fail.

    You also stated that we place “Too Much Emphasis on “Suspected” Tissues. We have also become too focused on “tissue-specific theoretical interventions” and less on scientific plausibility.” There are only a handful of studies out there that have shown a reliable, valid evaluation scheme that predicts the anatomical source of low back pain when compared to a gold standard (Laslett). In my experience, very few people are using this sort of examination in the clinic, and there have yet to be sufficient studies done to determine which (PT) treatments these groups of patients would respond best to.

    I do agree with you in that physical therapists need to have a better understanding of the pain neuromatrix. IMHO, it is best used for cases that do not fall into a treatment category that can reasonably be expected to bring about a positive outcome.

    Again, thank you for posting, and thank you for offering the opportunity to respond.

  6. I’m thinking about translating this (awesome) post to spanish, so other PT’s in Spain and central/south america can read this. Just need some time and your permission, Joseph.

    This reflects the state of PT around the world, at so many levels, that seemed you were talking about Europe. Nice job.

    /clap

  7. Outstanding post and website. This reflects exactly the intention of many of us to truly “move forward”…but as you point out, there are barriers, and not only that, we also have people who simply are rowing/running sideways and backwards in this effort. You bring an excellent point about the “board examination”….being a board certified clinical specialist, I can tell you that an exam does not reflect your ability to practice, even for a “seasoned” therapist; a residency should be a must for all new grads, so they not only “practice” but they also develop a specialty

  8. Excelente articulo, felicitaciones. Parece que la misma situación se repite en todas las partes del mundo con respecto a la fisioterapia. Aquí en Colombia tengo que lidiar con la desinformación de mis colegas que constantemente atacan mi manera de trabajar. Yo he podido tener cierta independencia y libertad para decidir mis tratamientos; al trabajar en consulta privada uso procedimientos basados en la evidencia científica, sobre todo ejercicio terapéutico y algunas dosis de terapia manual cuando el caso lo merece. Espero que pronto esta informacion se masifique y todos podamos disfrutar del conocimiento adecuado para tratar a nuestros pacientes. Un abrazo desde Colombia.

  9. Joe,

    I used to have the same knee-jerk reactions to ultrasound and modalities – but don’t throw them away! Let’s change payment so that an extra ultrasound procedure isn’t separately billable. Leave it to the physical therapist’s and the patients discretion whether or not that procedure has value.

    If you throw it out you’ll just be handing ultrasound to the massage therapists and athletic trainers – who may then try to say they’re doing “physical therapy”.

    Tim
    http://www.PhysicalTherapyDiagnosis.com

  10. Tim said: If you throw it out you’ll just be handing ultrasound to the massage therapists and athletic trainers – who may then try to say they’re doing “physical therapy”.

    Or, maybe, over time, it would no longer be associated with PT (at all). And, I have no problem with that. Let ATC’s and massage therapists use ultrasound all they want. It’s not giving them any treatment or market advantage IMO.

    Let’s fully divorce this awful modality.

  11. Paul Weiss stated “I do agree with you in that physical therapists need to have a better understanding of the pain neuromatrix. IMHO, it is best used for cases that do not fall into a treatment category that can reasonably be expected to bring about a positive outcome.”

    An understanding of the pain neuromatrix and neuroscience should fundamentally change how we approach and conceptualize both patients and treatment interventions. The pain neuromatrix is not a tool to be “used” as much as it is a theoretical framework for understanding what pain IS. This has the potentially to profoundly change how we practice.

  12. Great article Joe!

    I can definitely attest to barrier #3 (board examination) since I recently went through it and it was really frustrating the amount of information I had to learn in order to pass it, even knowing that I would never use them in my career (ie. most modalities). And as far as modalities, PT programs will continue to teach them while they are on the board exam because in the end that is their main goal, get the students to pass it (preferably on their first attempt). PT school trained me to be a “generalist”, and now as a clinician I can start to shape my practice and specialize on what I want.

    @Tim: is $10 of ultrasound really worth 8 minutes of you time? Wouldn’t it maybe be more beneficial to spend that extra time educating, exercising or doing a manual intervention and more than likely going over an extra unit billable for those units? Just my 2 cents, since that would be a win-win.

    Finally, do you know what is the research behind H-waves? I already covered a couple of different clinics that use it with most of their patients.

    • Hey Francisco,
      It is my professional opinion that e-stim is e-stim. The H-wave sales-women in my/your region is a bit pushy but does attempt to push the unit with providing a piece of literature that show’s that it can be effective in reducing edema. I’m still quite skeptical and chose not to place the unit in my facility. In terms of it reducing pain—no e-stim device will be therapeutically effective in reducing all pain. The reason is that pain is much more than nociception. A multitude of variables are contributory and you must effect the central output, not simply the peripheral input. The H-wave clinical unit is quite large and hollow. So one mechanism of short-term effectiveness is that if the size of the unit is correlated with the expectation that it will work (ie. “look at all those knobs and its size–this must work!”). It likely can elicit short-term placebo but I would be very, very, very surprised if it demonstrated any long-term statistically significant effectivenss as an isolated intervetion or in conjunction with other interventions.

      • Interesting that you mention the size of the unit, because I also wondered why is it so big considering their home unit is a lot smaller and does the same thing.

  13. “An understanding of the pain neuromatrix and neuroscience should fundamentally change how we approach and conceptualize both patients and treatment interventions. The pain neuromatrix is not a tool to be “used” as much as it is a theoretical framework for understanding what pain IS. This has the potentially to profoundly change how we practice.”

    I think we agree more than disagree. When dealing with someone who has chronic pain that does not respond rapidly to a PT intervention I spend a good deal of time going over the material in Explain Pain. I don’t bring out that book if someone’s pain responds quickly to a few simple exercises, posture modifications and manual treatments.

    These are people who are in different places in the pain neuromatrix. One is likely dealing with somatic, referred, or radicular pain whilst the other is experiencing a chronic pain state.

  14. Nice post.
    One of the largest barriers (IMHO) to science is this notion of experience. When talking with clinicians who continue to perform treatments which have been disproven or have very questionable plausibility the most common defense is anecdotally driven. For example “The research may not show it works but I have seen tons of patients respond positively to craniosacral therapy so I will continue to use it” Despite being a large barrier to science informed practice we often glance over this topic with statements like “Now don’t get me wrong, experience is important. Very important.” I rarely see a deep conversation about the importance of experience. Based on my limited knowledge of how our brains work, it seems that our experience is often flawed, biased and self serving. We are much more likely to observe and remember events and relationships which support our beliefs and understanding of the world. We also commonly make assumptions about causation without critically appraising our judgments for errors.
    Unfortunately our own brains are masterful at deceiving us. We are often blind to this deception and have a strong sense of confidence even when we are wrong.
    I think understanding the limitations of experience is the key to moving past anecdotes and into the realm of science. I wish every PT would read books like “The Invisible Gorilla and other ways are intuition decisive us” and “The Believing Brain”

    Here are some questions I think we should all spend some considering.
    How does experience help us as clinicians?
    How does experience hinder us as clinicians?
    What can we learn from experience?
    What can’t we learn from experience?
    Thanks for the great blog post!

    Adam

    • Adam,
      That is a great comment. I believe we have overemphasized the role that experience should play in clinical decision making and woefully underemphasized the value of experience in creating positive patient encounters. In a large number of patients the novice and expert should make the same clinical decision however, the type of interaction in terms of caring, empathy, motivating, etc. is likely very different. It is inevitable that the longer we live life the more likely we will suffer loss, heartache, etc. this frequently creates a better understanding of the pain and suffering of others and great clinicians use this to heal not harm. Another book to add to you list on self deception is Kahnemann’s “Thinking, Fast and Slow, my top recommendation for all grad students.
      Tim

      • Agreed. I have posted the abstract of the 2011 article by White and Bishop, “Practice, practitioner or placebo? A multifactorial, mixed-methods randomized controlled trial of acupture” from Pain, below. Patients beliefs and expectations as well as your confidence, beliefs and clinical interaction are all influential over outcomes. As stated below, outcomes from acupuncture are likely not directly due to the acupuncture…
        a b s t r a c t
        The nonspecific effects of acupuncture are well documented; we wished to quantify these factors in
        osteoarthritic (OA) pain, examining needling, the consultation, and the practitioner. In a prospective randomised,
        single-blind, placebo-controlled, multifactorial, mixed-methods trial, 221 patients with OA
        awaiting joint replacement surgery were recruited. Interventions were acupuncture, Streitberger placebo
        acupuncture, and mock electrical stimulation, each with empathic or nonempathic consultations. Interventions
        involved eight 30-minute treatments over 4 weeks. The primary outcome was pain (VAS) at
        1 week posttreatment. Face-to-face qualitative interviews were conducted (purposive sample, 27 participants).
        Improvements occurred from baseline for all interventions with no significant differences
        between real and placebo acupuncture (mean difference -2.7 mm, 95% confidence intervals -9.0 to
        3.6; P = .40) or mock stimulation (-3.9, -10.4 to 2.7; P = .25). Empathic consultations did not affect pain
        (3.0 mm, 2.2 to 8.2; P = .26) but practitioner 3 achieved greater analgesia than practitioner 2 (10.9, 3.9
        to 18.0; P = .002). Qualitative analysis indicated that patients’ beliefs about treatment veracity and confidence
        in outcomes were reciprocally linked. The supportive nature of the trial attenuated differences
        between the different consultation styles. Improvements occurred from baseline, but acupuncture has
        no specific efficacy over either placebo. The individual practitioner and the patient’s belief had a significant
        effect on outcome. The 2 placebos were equally as effective and credible as acupuncture. Needle and
        nonneedle placebos are equivalent. An unknown characteristic of the treating practitioner predicts outcome,
        as does the patient’s belief (independently). Beliefs about treatment veracity shape how patients
        self-report outcome, complicating and confounding study interpretation.

  15. Tim I agree with your assessment of the value of experience. Far too often PTs who think they are practicing EBP use experience as an excuse for providing unproven, disproven or implausible treatments. However, we need to understand that it is impossible to determine if a treatment is effective based on experience alone. There are far too many variables and we are unable to rule out non-specific effects. That is why we need science.
    Experience does help us with the “art” of PT which is the skill of interacting with patients in a way that enhances outcomes and improves satisfaction.

    Thanks for book suggestion I look forward to reading it!

  16. I would encourage the research community in rehabilitation to give greater consideration to conducting large, population-based cohort studies. Understandably these studies take longer to produce results and require greater numbers, but the construct is so much more appropriate to enable us to answer the questions most important to PT. RCT’s frequently control for the very variables that may be contributory to better or worse outcomes. RCT’s are excellent to compare interventions in a strictly controlled environment but large cohort trials can give us much richer information extrapolable to a greater number of our patients!
    Further, in this age of EMR, when we have so much data captured in electronic format, we should be looking to novel statistical analyses such as Bayesian belief networks and Machine learning to identify predictive patterns and profiles.

    • Conducting large RCTs. Is much easier said than done. To conduct one with a large enough sample size usually takes a lot of time (years) and costs money (LOTS of it). There are grants out there, but they can be hard to obtain.

    • Ms. Stout isn’t suggesting large RCT’, she’s suggesting population based research. We all know RCT’s are the gold standard but narrow inclusion criteria and time spent make me wonder if the “juice is worth the squeeze (Delitto)”. I’d take Ms. Stout’s statement one step further and suggest that large population based studies better represent the true practice and current clinical environment of physical therapy. Nice work Joe. Great discussion.

  17. As a new grad I could not agree more…..this is a frustration I face on a daily basis. I realize this is a problem but have few PTs I can seek out for the appropriate answers.

  18. Hello! APTA’s vision for physical therapy is transforming society by optimizing movement to improve the human experience. How will you embody this vision as a future physical therapist? By the way the best paper writing service that I saw: http://speedypaper.net/

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