Critical Thinking

Where are we heading?

I recently watched the first webisode of #sipwJerLarKar on youtube.  During this webisode, FTPT contributor, Karen Litzy, sat down with Jerry Durham and Larry Benz (with many appearances by Barrett Dorko) to discuss if we are Winning or Losing.   While the topic itself leaves much room for interpretation, I suspect the overall agreement with the participants (other than maybe Barrett), is that we are #Winning.  While I am not sure I would use this term, due to the annoying meme created around Charlie Sheen , I get their point—we are gaining ground in an ever-so-changing and competitive healthcare marketplace.   Let’s attempt to analyze where we are heading…

Education:

Obviously, most of the readers know the entry level education of a Physical Therapist in the United States is now a doctoral degree.  While this may eventually help us gain ground on our competition, the additional years of education have not resulted in any substantial market gains in reimbursement.  While this is quite disconcerting (#Losing), I suspect we need to consider the indirect revenue gains such as a large market pool of care-seekers (as stated in the discussion, more people will seek out physical therapy next month, than they did this month), and the potential impact we may have in influencing those individuals to individuals to seek us first (direct) next time.  The simple term Doctor, may help impact this change.   But is the cost of a doctoral degree, substantiated by the continue low numbers of reimbursement?

We are seeing a small shift in the education dynamics with Evidence in Motions partnership with South College.  This partnership will graduate a DPT in 2 years, followed by a one-year paid residency (hence reducing the cost of the degree).   I suspect many who hold stakes in the educational sector, such as myself, will be paying close attention to their process.  Simply, the increased popularity of post-doctoral residency and fellowship   appears to be part of a cultural shift in the perception of specialization within our education.  It appears the current #DPTStudents are driving this, and I agree with Jerry that they appear to be asking great questions, and it appears they are aspiring to become great clinicians. The future of the profession appears to be quite strong.

Direct Access:

Currently, 50 states and the District of Columbia (DC) allow physical therapists to evaluate patients without a prior physician’s referral and 48 states and DC improve accessibility further by allowing physical therapists to evaluate and treat, under certain conditions, patients without a referral from a physician. – http://www.APTA.org

With consumers carrying health plans requiring more cost sharing than ever before (high deductibles, etc), we have to promote the cost effectiveness of seeking our care first.  I have interacted with some clinicians who see as high as 70-80% of their clientele via Direct Access (check out Sports Medicine of Atlanta and Revolution PT), but this is still not the norm.   In the video, Larry mentions his sentiment for unrestricted Direct Access, and I fully agree.  We need to continue to fight for these benefits, while educating the public that we are effective; we are safe;  we are science-based; and we are cheaper— than other routes of care.  There is a bit of uncertainty on how Direct Access will pan out, but for our profession to thrive, we need  to promote and live this!   We should all take the #DirectAccessChallenge and attempt to seek out 1 new patient next week, whom will access our services, without a referral.

Practice Patterns:

While I only have experience in Outpatient and Home Health sectors, I do have to say I am very optimistic about our evolving practice patterns.  Research is indicating that we are effective in medical screening (very important for the argument that we can be stand-alone) and we appear to be dropping useless modalities, and reverting to more interactive and active programs.  We are educating in right terms, and we are utilizing more science-based, plausible interventions in the care of our patients.

I recently received a text message from Eric Lehman, a recent graduate of the University of Pittsburgh, who just began using the “Recognise” app for the treatment of a patient of his who has CRPS.  Eric was ecstatic to see the effectiveness of this simple app,within a comprehensive graded motor imagery program.   While I am a little concerned that new modalities, such as dry needling, may be replacing the ultrasound heads, I am optimistic that more clinicians appear to be thinking about why something may work vs. it works.  This is evident as you make your way around social media and observe all the discussion and debate.

Overall, I suspect we are heading in the right direct and gaining ground as a profession.   We need to continue to challenge ourselves and to continue to speak and write in right terms.

– Joe B

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Categories: Critical Thinking

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  1. Joe,
    There are two recent examples of sorely missed opportunities by leading organizations in our profession that, along with the issues you mentioned in your piece here, that have me less optimistic about the PT profession’s current trajectory.

    First, is the APTA’s response to the American Heart and Stroke Associations updated position against cervical manipulation following the publication of another study linking this intervention to stroke (http://www.apta.org/Media/Releases/Consumer/2014/8/7/). When a professional association has to resort to a “tu quoque” argument in its defense of an intervention that is capable of causing catastrophic harm to patients, then I have to wonder who up there in Alexandria is capable of making a sound and reasoned argument. I’m specifically referring to APTA citing the higher incidence of adverse events from NSAIDs and epidural steroid injections. In an apparent effort to “circle the wagons” and guard PT “turf”, the American Academy of Orthopedic Physical Therapists and IFOMT came out with their versions of essentially the same irrational cherry-picked version of the same response. I don’t know about you (although I’m pretty confident based on our previous interactions), but I didn’t go through the arduous process of becoming a professional PT so that the care I provide to my patients could be touted as the lesser of evils. My goodness, can’t we do better than that?

    My second example gives me shivers up the back of my neck. The brilliant and earnest minds over at BodyInMind.org recently submitted a critique (http://www.bodyinmind.org/dry-needling-myofascial-pain/) of an oft-cited systematic review of dry needling by Kietrys et al (http://www.jospt.org/doi/abs/10.2519/jospt.2013.4668#.U_dVMOhX-uY) that was rejected by JOSPT, according to BiM, because it was “too long”. Neil O’Connell, one of the BiM authors is an expert in meta-analysis and he’s a PT. He has an extensive publication record in high impact journals. The lead author is a PhD candidate and the third author, Lorimer Moseley, is arguably the leading PT clinical pain researcher in the world today. “Too long”? Are you kidding me?! This is scandalous and JOSPT needs to be held accountable for this editorial decision. Why was this letter rejected? When you go to the JOSPT website, it is not unusual to see a banner across the top of the homepage advertising for some TDN continuing education provider. Is JOSPT corrupt? I realize that the editor-in-chief is stepping down at the end of his term, but I think he should resign immediately. This decision by the editorial board at JOSPT is the definition of scandalous.

    A profession that lacks assertive and courageous leadership cannot be considered one that is on an upward trajectory. I applaud the efforts by EIM to radically change PT entry level education. The current DPT model is tragically flawed. However, at the same time they continue to provide continuing ed courses on TDN and cervical manipulation. Therefore, I can’t support their overall contribution to the profession at this time. On balance, I think their influence is negative, and they are also considered a leading organization in our profession.

    As a profession, we desperately need to take a reckoning of where we are right now, and in particular, look at the actions of our leaders. Right now, they are failing us, and the profession is suffering.

    • Hey John,
      We hold very similar concerns in the two points you made. But are these two concerns predictive of professional direction and future?

      I can understand and appreciate APTA/AAOMPT/IFOMPTs attempt at supporting an intervention to maintain scope of practice. That said, I do suspect the organizations need to truly consider: is this intervention valid, necessary and safe?
      We must also remember these organizations are funded and influenced by individuals who have a stake in manipulation.
      Lobbying will never end—in any political arena or organization. I suspect we have fairly good means of changing the culture though, through social media outlets and blogs. And I do see a slow culture shift and I agree with Jerry D. that the DPT Student’s are asking excellent questions. I am not sure of APTA’s numbers, but this site is getting around 20,000+ viewers a month. Add in the numbers at SS, BIM, NOI, etc. and I suspect we are influencing someone…

      JOSPT is looking for a new Editor-in-Chief, btw. There is obviously inexcusable publication bias with the denial of the Letter by O’Connell and Moseley. They had a pretty slam dunk response. If JOSPT hasn’t heard their voice yet, I suspect we could make ourselves heard through an online petition? Any interest?

  2. These two concerns, which have significant moral implications, speak directly to the issue of leadership in our profession. I submit that the lack of moral courage on the part of our leading organizations drives much of the aimlessness that we see among rank and file PTs, which is what Barrett was referring to in his comments about the hundreds of PTs he’s worked among in SNFs over the last several years. He is not exaggerating. Sure students come out asking good questions- my goodness these are kids who have scored very high on standardized tests and graduated college with the highest grade point averages. I’m not questioning the intelligence of incoming PTs. However, too many of them stop reading, stop questioning, and stop seeking answers because the have no support starting from the management of the clinics and facilities where the work to the highest echelons of our professional association.

    If APTA cannot take a moral stance on cervical manipulation, then someone please tell me what it will take for that organization to rise above the noise and irrationality that drives practice reimbursement to finally stand up and say, “This is enough. We as a profession are not going to recommend performing an intervention that has the potential to cause catastrophic harm to patients when the evidence shows that less risky interventions are just as effective.” I actually would have settled for a more circumspect response to the AHA, like, “We are going to take the AHA’s position under consideration, convene a panel of experts in clinical practice and research and develop a policy statement on the provision of cervical manipulation by PTs. In the meantime, we are going to urge PTs to exercise extreme caution and consider using non-thrust mobilization techniques first before thrust techniques.” Instead, all we got was APTA pissing around the perimeter of what is supposedly considered standard PT practice and making tu quoque arguments against our medical colleagues.

    That’s not leadership, that’s capitulation to a broken and arguably corrupt reimbursement system.

    I’m definitely interested in the online petition to JOSPT regarding the refusal to publish the BiM letter. Let me know how I can help.

  3. Joe,
    I think the statement is crystal clear. APTA wants to protect PTs “right” to perform cervical manipulation. I’d be happy to listen to what Ms. Rondon has to say about that, but at this point any alteration in the correct direction would mean that APTA would have to admit that this statement was morally weak and placed the financial well-being of PTs above the our moral obligation to protect our patients from harm. If they do that, the next time I’m in the Pittsburgh area, I’ll buy you dinner.

  4. Completely agree that we should be direct access providers. I was told in PT school of the statistic that PTs are second only to orthopedic surgeons (due to their ability to order imaging and open people up) in terms of accuracy of diagnosis in orthopedic care. Furthermore I learned that my family physician colleagues really only get about 1 month of orthopedics in med school unless they specialize outside of that. This means that all those orthopedic patients that see their PCP before us are potentially getting a diagnosis that it is inaccurate and this is causing a cost to healthcare in General when that person was likely to show up in our office as PTs anyway. With financial concerns in healthcare today, we aren’t PT’s used more efficiently?!?! We have the medical screening education now at the Doctoral level to screen out sinister pathology that warrants medical attention, not to mention we have detailed formal education on orthopedic management, so why aren’t we moving in that direction. I suppose we are challenging and old medical system model that is simple just tough to shake the proverbial bushes of, but since our profession counts on it, let’s keep on shaking. Good post

      • If the general public is used to “doctor knows best,” how do we change their minds otherwise unless to compare us to what they feel is the gold standard. The same rules apply when a new special test is developed – it is compared to the test deemed to be most valid so that direct statistical comparisons can be made. I don’t disagree that there are definite differences in our profession including scope of practice, but it’s the same patient in either office (medical vs PT) and we are trying to get that patient’s business and build a rapport to where we are considered the new gold standard for musculoskeletal health care in their eyes. Only then will we only capture patients from this direct access direction we are heading. Same thing when you go with a certain car over another, how are you won over? Comparisons have to be made, cases need to be heard and inevitably it’s up to you as the consumer. What do you think?

  5. I think we are making a mistake if we utilize a study that took our results from a 25 question examination, compared those results to existing data from a separate study which was performed years earlier, and say, “We are second to Orthopaedic Physicians in our knowledge of the musculoskeletal condition”. To me, I am hearing, “we are second…” when in actuality, we have no way of determining if those results are applicable to patient care or outcomes.

    I really like Apple. I like Apple products and I like their brand. I also believe in Apple. But what makes Apple different? They simply told the public: you need this product and essentially unveiled something that would revolutionize how music is delivered. They built a brand on emotion. None of us needed an IPod. But we thought we did. And now I can’t wait until the IPhone6 is released…

    Apple could have compared themselves to HP, Dell and other computer manufacturers at the time. They chose not to..

    Apple didn’t say, “We are only 2nd to Dell in processing speeds…”. I would have bought a Dell…

    • https://m.youtube.com/watch?v=DZSBWbnmGrE
      They compared themselves to PCs in general (their real competitor) in a series of Apple shaming PCs commercials.

      There was comparison and with comparison came people who bought in, like you, then word of mouth.

      The same can be done for us as a profession.

      We compare outcomes of meniscus surgery vs PT and use that as leverage to see us a cost effective treatment choice based on outcomes research, why would we not compare in terms of our diagnostic ability. I agree with both of you that that study was garbage, but show me a study that literally has no flaw and I will be impressed. Could that study have been done much better, no doubt about it. Perhaps another study comparing fellowship grads to ortho residency grads would be more compelling. I’m sure a comparison of a fellowship trained PT to a residency trained family physician would be hands down in favor of the PT.

      • I don’t think the study by Childs et al. is garbage by any means. I actually think it was quite clever. I am simply unsure if we can conflate the idea that we rank 2nd in the knowledge of something, by a 25-question examination (and that the exam is translatable into clinical care).

        We have to understand that while we medically screen, we do not diagnose pathology (this would be practicing medicine without a license). We treat macrobiological presentations and function. Medical screening is definitely important to argue that we are safe, front-line providers. But we do not treat pathology.

      • Good points joe. I think how it was worded when I was trained was medical diagnosis vs PT diagnosis. For instance, just the other day I had a patient who fell off her patio and dislocated her shoulder, subsequently went to ER and had it relocated, dislocated again sleeping, back to ER to have it relocated and sent to PT for preliminary medical diagnosis of shoulder strain with no orthopedist consult or imaging to look for cuff tear or bankart. My exam revealed definite signs of contractile pathology, I thought a probably 2 tendon External rotator tear. I told the patient “look I feel like your rotator cuff may be torn, there is evidence of people doing well with PT with small tears but with a large tear, there is likely surgical intervention. I realize that you have a high co-pay and potentially limited authorized visits, I feel we should get this imaged and likely have a ortho consult to determine conservative vs surgery before we starting using co-pays and visits.” The patient was very receptive. I called the ARNP who referred her and told her reasoning and she immediately was receptive and thankful and ordered an MRI. MRI came back positive for cuff tear and now we are waiting for the ortho consult before we resume. I feel like I approached this is a way that was not diagnostic (I never used the words ‘you have’) but was direct about my concern. If this end up a surgical case, which I feel it will I may have saved her money now to get it done early while also improving the surgical outcome because the tendon is easier to repair when tissue quality is superior (no fatty infiltrates or retraction as in chronic tears). I also feel like taking a stand for my patient and telling the referring provider was a thought was not overstepping any practice scope at all; it might even lead to a better referral relationship in the future.

        Question I have Joe since you and John seem pretty well versed in this is what do you do when you have a direct access patient? I don’t see this much in Washington because most carriers won’t pay for service rendered unless there is a physician referral.. Do you use an ICD-9 code when documenting? If you do, do you use pain codes in an effort to avoid diagnosing pathology or do you use pathology based ICD-9 codes like the physician might use. Interested to see what will happen for PTs in this arena as we move forward.

        Also, do you feel that cash pay direct access programs are pretty much squashed now that everyone has to have insurance under obamacare. I mean if people have an insurance carrier that they are mandated to use, don’t you think they won’t want to use cash since they are forced to have a plan? Seems like what Obama did killed the cash pay programs for private practices..

        Good discussion guys!

      • I didn’t say I felt offended- it takes a lot more than what you said to offend me. However, your characterization of how I communicate with patients was insulting. You assumed that I tell my patients that they “move funny” and that I would “plug in some data and shut off my brain.” That’s an insulting comment. And your “forgive me if you feel offended” remark doesn’t help matters. That’s like stomping on someone’s toe and then saying “forgive me that you placed your foot directly under mine as I stomped down.” It’s a non-apology.

        You’re conflating skilled medical screening for pathology, which is a critically important skill that PTs must master, with treatment of medical pathology. I see this a lot among PTs, and I think a significant contributor to that is a knowledge void of the pain experience. PTs approach something as common as a sprained ankle from this pathoanatomical perspective, and it commonly results in over-utilization of care. I shudder how often I hear about patients going to a PT for 2-3x/week for 4-6 weeks after an ankle sprain. That happens routinely around the country, especially in physician-owned clinics.

        What PTs should be doing is a better job of screening for risk factors that might predict delayed recovery, which are psychosocial in nature. You mentioned fear-avoidance- I think everybody knows about that one. But some others that don’t seem to get as much consideration are self-efficacy and, for those who are returning to work, relational issues with their co-workers and supervisors. A therapist who increases a patient’s anxiety by repeatedly referring to deficits in strength or “stability” or who run their clinics like strength and conditioning gym, give patients the impression that they are weak, unstable and out of shape, and that these factors directly relate to their pain. Well, the research shows that they don’t. Adding to a patient’s anxiety or diminishing their sense of autonomy while they are already worried about what what their co-workers and family members are thinking about their injury, just adds fuel to the fire. If we understood better how pain works, then we could avoid medicalizing, iatrogenizing and increasing delayed recovery from musculoskeletal injuries and pain problems.

      • Alright John, your right and I’m sorry. Just know that it comes from a place if passion and wanting us to succeed as a profession, and I did get carried away there and I am sorry. I do want to say that ankle sprains are not as easy as a few visits I feel. Mulligan talks about an anteriorly malpositioned femur which takes manual intervention, not to mention the other impairments not the least of which is a proprioceptive impairment that doesn’t go away over night and needs skilled intervention. Furthermore, the return to sports progression including agility, plyometrics, etc all needs to be done and can help them gain confidence in their injured limb and not alter movement patterns because they are scared (similar to post op ACLs). So my question is maybe your just better than me at treating ankles, but how visits is average for you in treating a basic ankle sprain. I typically see patients 2 times per week, some even 1. Rarely do I ever see people 3 times unless we are really trying to make up ground on something. And (not trying to be offensive) if your contention is most sprains do well if you allow for biological healing, how are you staying busy as a private practice owner? I am also an owner and I am definitely not trying to be unethical and keep people longer than what they need, but I feel we can help is many arenas of their life related to an injury and this is our place to shine. What do you think?

      • When a patient seeks my care via DA, I may suspect they have a RTC tear, but I code the ICD9 as “shoulder pain”. Again, we do not diagnose pathology and while it is an initial hit to our ego, we must be careful of not practicing medicine without a license. In our assessment, we can discuss the probable etiology, which would be “potential” damage to the rotator cuff.

        I know of several cash-based providers who are thriving. Despite everyone now carrying coverage, most plans carry a high deductible and patients appear to be more cautious before spending money. If anything good comes about from healthcare reform, its a more conservative and responsible healthcare consumer. Btw, most cash-based providers outline how to submit receipts for out-of-network reimbursement.

      • Good to know, thanks Joe. Hey by the way, I just started blogging a bit too, would love I get your feedback on stuff. It’s great to exchange communication with you guys

  6. I don’t think it is the same patient that goes to see the physician as who sees the PT. Doctors diagnose and treat pathology. PTs screen for medical pathology and treat movement dysfunction, usually due to pain. Pain is not a pathology per se, unless you’re dealing with the rare case of CRPS, and then PTs and MDs should be working closely as a team.

    So, I agree with Joe. Comparisons with physicians are misleading and unfruitful. I think we should be doing more to differentiate our skills and scope of practice from physicians instead of trying to compare ourselves to them all the time.

    • John, I disagree. A patient with dizziness for example would go to both professions. A family physician may rule out the big bad stuff (CVA, brain tumor, etc) and give them meclizine and send them to you with a script of assumed BPPV, or better yet “eval and treat.” Now it’s on you to determine is this vascular (VBI), cervicogenic, hypotension/syncope, central mediated vestibular problem, peripheral vestibular problem, or medication induced from cyclic antibiotics that are known to wreak havoc in the labyrinth as a common side effect. Furthermore, the meclizine that the physician just gave them is otosuppressant so if you did deem they had a unilateral vestibular loss that was PT amenable, the meclizine just suppressed their ability to accommodate. The same rules apply for a knee, we understand more than the lay family physician and we must give ourselves credit and be able to step out and prove we are more valuable, otherwise we will stand by and watch others like massage therapists, chiropractors, and personal trainers take our spot in health care.

      If you’re just chasing pain induced movement pattern dysfunction, I feel you may be going in circles. The patho-anatomical model is not dead, just read bogduk, grieve’s, panjabi, etc. How many low back referrals have you seen that say “sciatica” or “low back pain – eval and treat” and your telling me that physicians are treating pathology?? C’mon john, give yourself credit, your a better clinician than that.

      Joe already alluded to the fact that we work in a healthcare MARKETPLACE, therefore we must be able to show that we deserve a spot in the market. I feel that step one is training which we have, second is comparing ourselves to others in the market to have some legitimacy to our argument to come see us, third is to get out there and tell people. Why is that so frowned upon? As PTs we have not done well about telling the general public what we can do, and now we have the unfortunate repercussions of them feeling that all we do is ultrasound, massage and theraband exercises. We’re better than that and we need to change the general public and medical communities opinion of us, that’s all I’m saying

  7. BPPV is a relatively rare exception of a distinct pathological condition that PTs are qualified to treat: however, PTs are not uniquely qualified to diagnose and treat this condition. Many physicians are just as competent and effective in the maneuvers to treat this condition. In contrast, PTs are uniquely qualified to provide care for patients with persistent musculoskeletal pain problems, and this is by far what most PTs are assessing and treating on a daily basis in various clinical settings.

    The pathoanatomical model is not only dead, its rotting carcass continues to pollute our knowledge source and has prevented physical therapy from advancing to the level of professional distinction that we seem to strive for in vain. We our squandering our chance to be *the* providers of care for patients who suffer with persistent pain problems that impair their mobility and performance. We have to rid ourselves of erroneous and misguided pathoantomical/biomechanical explanations. We have to integrate the biopsychosocial model into our practice- not just add it on for those “difficult” patients. Otherwise, we will continue to see our services marginalized by payers and the public in general.

    • Couldn’t disagree more john, patients WANT to know what’s wrong with them and if all you can do is say “well you move kinda funny based on my evaluation and you fit this clinical prediction rule here that I just plugged a few pieces of data into and shut off my brain but I guess the statistics seem to show that we should have a good result if I don’t this or that so… What the heck lets give it a try..”

      Another example: PTs diagnosing a cuff tear.. Simple tests can delineate which tendon is likely the torn one without an expensive imaging study, that’s use diagnosing a pathology. Or how about an ACLU tear, there’s another one. We don’t say to the patient.. Well your knee is moving funny.. NO we do a battery of tests and use clinical reasoning to say look I feel that your ACL MAY be torn, in whichever case there is evidence for both PT without surgery or PT following surgery but that is inevitably the decision of the patient and physician whether to try it, but my point is, we can and do pick those up early on using sound reasoning and the physical exam. Anyone can plug and chug into a CPR

      • Another example, ankle sprain.. What do you tell your patient when you pick this up John. Do you use movement classification then, or tell them it which ligament you feel like it was based on your eval. You treat a deltoid ligament tear much different than an ATFL tear. What say you?

      • I have no idea where you got the idea that I communicate with my patients in such an ignorant way. Actually, your characterization is insulting. I haven’t insulted you, so I don’t know why you feel the need to descend to that level. Unless of course your argument is lacking, then throwing insults around makes perfect sense.

        You don’t see the difference between medical screening for pathology and medical diagnosis and treatment? Of course I can screen for a torn RC and ACL. Of course, I can differentiate a deltoid ligament from an ATF ligament tear. But, I also know that no two lateral ankle sprains will necessarily require the same treatment. Can you explain that? In fact, most of the time, all these injuries require is adequate time to heal (and by that I mean that the disruption in the connective tissue is restored to continuity), reassurance, and graded return to activity. Usually, a skilled PT is not needed for more than a couple of visits, if at all. The important skill that a PT brings to the table is identifying which patients might not return to activity in the expected time frame. This is achieved by assessing psychosocial factors, and in the case of distal extremity sprains/strains, level of pain within the first couple of weeks (see Moseley et al, The Journal of Pain, Vol 15, No 1 (January), 2014: pp 16-23)

        Have you reviewed all the literature demonstrating the high prevalence of false positive findings on imaging? There have been several studies showing for instance the high prevalence of labral tears in overhead athletes, particularly pitchers. One imaging study showed that 1/3 of men over 55 y/o had asymptomatic RC tears. You might want to consider that all of your confidence in identifying pathology may be creating more iatrogenesis than it is leading to effective therapy.

        Your conflation of treatment for medical pathology with therapy is likely contributing to the medicalization that has been a large factor in escalating health care costs. You might want to reconsider.

      • John I am by no means trying to insult you. I looked you up, I see that or fellowship trained, your a smart guy, that’s why I said at the end of the post comparing PTs to PCP in terms of diagnostics to give yourself credit, your better at knowing what is going on than a lot of the average PCPs, that’s what I am saying. And yes I am aware of how many people walk around with a degenerative cuff tear or an asymptomatic disc bulge on imaging. That’s why I don’t condone using them unless the person fails conservative rehab or there is really sinister signs that warrant it. It’s sad to me that a lot of ortho surgeons don’t even do a physical examination anymore (and there is research to support this) but rather go in and operate on what they can see on imaging (for example someone having a discectomy when their MRI could have ID’d an asymptomatic disc like we’re talking about, or a person have an RC repair of a degenerative cuff when the neck didn’t get screened appropriately for somatic referred dysfunction that may mimic a shoulder injury). I don’t like it even more when the MRI is owned by the physician and everyone they see gets one it seems like. I would argue that PTs trying to use movement assessment, biomechanics, and the pathoanatomical model and trying to make sense of symptoms is actually cost savings if they don’t have to order an MRI but rather you work on a sound clinical reasoning based approach (which most certainly may include both a movement classification approach or CPRs as well).

        To answer your question about how I would explain no two ankle sprains being the same, that’s just it, their not. No two ATFL tears act the same (we’ve all seen the patient who hobbles into the clinic and is a biker with a “high pain tolerance” yet a 15 y/o girl with what appears to be the same extent of a sprain is walking normally and really not limited). Of course their is more to a patient than just the tissue diagnosis, their emotions, fear avoidance, etc that makes treatment completely differenent. And yes I think a cognitive behavioral approach or a biopsychosocial approach is most definitely warranted to help with this. What I guess I am getting it is that we/you/PTs in general don’t give ourselves credit and we think we can’t figure stuff out when really I think we are a lot closer than we think. I think it’s about being eclectic because the pathoanatomical approach isn’t going to work every time, just like we can’t place everyone into a classification and have the same success every time. I use both and that’s what I am a proponent of. Forgive me if you feel offended john, I guess I am just passionate about PT getting the respect in the medical community that we deserve. We are a lot smarter as a profession now than we ever have been and I feel that we should be confident (not arrogant) as we lobby to position ourselves well in the changing healthcare market

  8. Hi omtpt talk/Steve (Sorry if that’s not your name, I think I saw that on your blog). With respect, I think you are mistaken when you say PT’s don’t give ourselves enough credit. Sometimes I think we give ourselves too much credit in the way that our profession tries to do things that we’re not set to do (i.e. medically diagnose patients). PT’s should be giving PT movement based diagnoses, considering we treat movement disorders (most often due to pain) then movement based diagnoses serve a much better purpose. I can pick up an eval from a therapist and a diagnosis of “lumbar flexion hypomobility movement impairment syndrome” tells me a lot more than a PT who diagnoses someone as “Lumbar HNP.” We are movement specialists, not physicians, so we need to stick to movement based diagnoses. Why try to be something we’re not? Let’s embrace what we are and what we do!

    • Good points mark and thanks for checking out my blog and joining this thread. I am by no means condoning practicing without a medical license by diagnosing pathology as was eluded to by Joe. What I am eluding to is taking advantage if our superior knowledge in biomechanics and functional anatomy (something I feel that we alone are experts in and should right stand by) to make more accurate PT diagnoses involving accurate pain generators. The problem I see with a generic label such as “lumbar HNP” or “lumbar flexion hypo mobility movement impairment syndrome” is it’s lack of specificity. As John so eloquently worded, patients are a whole lot more complex than we can see at the surface not only with fear avoidance as he discussed but also with their objective exam findings . Let me give you an example: you have someone with a HNP and flexion movement restriction, sure I agree with you that you want to work into extension in general to help reduce the mechanical discogenic pattern and scar down the annulus in order to commence safe flexion activities at a later date. However, how do you know what level he discogenic problem is at, and how do you know that they don’t have a functional hypermobility (some people call it instability) above or below the disc that will get all hot and bothered with straight extension as classification or movement based approaches would suggest? I find that you would find this out with end feel testing, PIVM and stress tests – all where the art and feel comes into play along with clinical reasoning. This is where I feel PTs are the stand alone providers and can figure this stuff out to give the patient the best care possible. Using this example, rather than treating in general flexion as a classification system would suggest, one might figure out the level of the disc, rule out any segmental risk factors above and below and if present use alternating techniques such as a sidelying combined posterior quadrant mobilization into the quadrant of the HNP to reduce it but with locking above and below to protect the hypermobility. That comes from finding as precise of a pain generator as possible (which admittedly is not always possible but I feel is more possible that it is given credit) using a pathoanatomical approach. Not saying I never use classification systems or CPRs, I do, but it’s not my first move. My first most is to figure out the pain generator and if I can delineate it, fall back on impairments and movement based approaches. I think it’s about being eclectic as we all know: nothing works ever time but everything works some of the

      • I think this is a good time to quote Dave Walton, a PT pain researcher and clinician in Canada. This is from a thread at Evidence in Motion earlier this year on the topic of dry needling. It addresses the seductiveness of seeking a discrete “pain generator”, whcih omtpttalk refers to in his comment above, and treating it with a highly specific intervention (in this case TDN) or set of interventions.

        “I’ll offer one insight that perhaps not many have thought about, and that’s fear of being challenged on treatment decisions. As an educator of 12 years, I’ve observed that many of our bright young minds have made it this far because they’re very good at finding the ‘right’ answer. And I’ve also realized that many struggle mightily when learning to deal with humans, for whom there is very rarely an absolute ‘right’ or ‘wrong’. The psychological construct of tolerance for ambiguity or intolerance of uncertainty seems particularly relevant here. My perception, sometimes arm’s length, sometimes personal experience, is that on average many PTs are fairly intolerant of uncertainty or ambiguity – they need someone or something (book) to tell them what to do, and then many are very capable in application of the skills technically. Truth is thought that in reality there are very few techniques we have access to in PT for which we can open a book or listen to an ‘expert’ and know ‘OK, for low back pain, I stick this here’. And then, if anyone challenges our decisions, we point to the book and say ‘see, this is what I did’. We don’t even enjoy that level of pseudo-direction with how long to put a patient on a stationary bike. So, no wonder especially young or new grads gravitate in these directions – it’s a technical skill with a bit of reasoning sprinkled in, rather than a reasoning skill with a bit of technical know-how sprinkled in. I think it’s just more comforting.”

        Personally, I think it’s folly to seek out a pain generator. Once you’ve ruled out tissue damage/pathology and you’ve determined that the patient has a pain problem and not a tissue problem (https://forwardthinkingpt.com/2014/08/28/pain-problem-or-tissue-problem/), then it’s time to adjust your thinking to allow for the complexity and ambiguity of treating an emergent phenomenon- pain.

        I don’t know how long you’ve been practicing, omtpttalk, but it took me over 10 years of practice and likely thousands of patients before I started to alter my approach, which started with educating myself about the neurophysiology of pain (stuff not taught in PT school, unfortunately), and then progressed from there. You might want to at least consider taking a fresh look at the paradigm you’re using to treat patients with a primary complaint of pain. A cursory review of the literature will reveal that the “pain generator” model has been an abject failure (references available upon request).

      • I would love to learn more about the pain neuro matrix and psychological interplay thereof, that is an area I am not trained in and would love to grow deeper – references are great thanks. However, we do see acute people, for instance the fresh lateral ankle sprain, or the acute annular tear in which there is tissue damage and we must figure out what tissue it is, in order to give appropriate advice on rest positions/activity modification/etc to allow for this biological healing, but we also must know enough about the basic sciences and patho mechanics of the tissue injury, to be able to deal with the sequelae of the tissue damage that has scarred down or “healed” and may be impairing movement in that body region. It’s a down stream effect and we need to figure out. John I highly respect you, I want you to know that, and I am open to learning from you, especially on the emerging pain concepts. Please show me where I can read. On my list was to watch a lot of the video by lorimer Mosley on YouTube. Good place to start?

      • Is your name Steve? I think I’m developing carpal tunnel syndrome from typing ompttpalktpt- or whatever it is…

        Youtube videos are good introductory material. But, I’d also pick up a copy of Butler and Moseley’s book “Explain Pain” and a good texbook on pain. Some good ones are Patrick Wall’s “Pain: The Science of Suffering”, Melzack and Wall’s “Textbook of Pain” (expensive), Strong’s “Pain: A Textbook for Therapists”. If you don’t already have Butler’s “The Sensitive Nervous System” I’d get that too. If you do, then read again closely the first 7 chapters before he gets into practical neurodynamics assessment.

        You should read as much of Lorimer Moseley’s clinical research as possible. Adriaan Louw, who’s featured in the video I linked to in this thread (which is one Joe’s recent blog articles) has written an excellent book called “Therapeutic Neuroscience Education”, which is a detailed how-to manual on educating patients about their pain. Moselely has said that the educational component is critical to a successful outcome for patients with persistent pain problems. He calls in “preparing the soil”.

        Unfortunately, PT educators didn’t do a much of a job preparing our soil while we were paying their salaries in school. Oh well, we owe it to our patients to educate ourselves.

      • Good points about it being our job to learn ourselves.. We’re in a learning profession right..? Thanks for the resources, I’ll start with mosley’s videos and research and go from there.

      • What concerns me most about that post is the quest to find a “pain generator.” We know the only “pain generator” in the human body is the brain. Joints, ligaments, tendons etc are nociceptive generators. This may seem nit picky but I think it’s important when we’re talking about pain. When you say we need to find a “precise pain generator as possible,” this is troublesome in the way that it equates tissue pathology to pain blaming faulty biomechanics and stuck in the biomechanical model of pain which is exactly what research is showing we need to work away from.

        For example, regarding reliability of palpation, we really don’t have the skills to identify a specific “instability” at a specific vertebral level like many PT’s think we do. If someone asked use to identify a specific level, I may say L4, Joe L3, and John L2. The reliability just isn’t there. I wouldn’t automatically jump to extension either to “fix” a derangement. If they liked flexion more than extension, then i would roll with flexion first.

        I think searching for specific “pain generators” and blaming a persons pain on these generators is what’s gotten us in trouble before, and the exact model we need to work away from. When you say this:

        “Using this example, rather than treating in general flexion as a classification system would suggest, one might figure out the level of the disc, rule out any segmental risk factors above and below and if present use alternating techniques such as a sidelying combined posterior quadrant mobilization into the quadrant of the HNP to reduce it but with locking above and below to protect the hypermobility. That comes from finding as precise of a pain generator as possible.” How is it you know you are actually doing this?

      • You guys are quotes that research says all this stuff, but my viewpoint is that evidence based medicine is a three tier approach with research, the clinical skill of the therapist, and patient values all taken into effect. In the spirit of “nit picky,” I think we can nit pick a lot of research out there and say there were not certain confounding variables that were controlled for which may have led to invalid result, inflated statistics and type 1 error in finding significance. What I am saying, is we can’t research the art of the therapist (I.e. The second wing if EBP) which consists of end feels, detailed bio mechanical analysis, etc but you can’t tell me that I can’t feel. I feel that certain camps of PT have gotten so caught up in the research and what does this study and that study say that we have abandoned the art of PT when that is as much of a piece of evidence as a journal article. Don’t get me wrong, I find the new pain science compelling, but I’m not putting all my eggs in that basket so to speak.

      • How I feel that I can do that is by reproducing the patients pain, or finding the concordant sign. Joe would agree with me as he got his COMT through the Maitland concept. Maitland was huge on finding the concordant sign. Even if the brain is causing the pain, there is a nociceptive bombardment from the periphery that is bombarding the thalmus and then the brain has to figure out what to do with that message. If we can figure out which tissue/joint/structure is causing the afferent noriceptive messages, then we can “close the gate” as Melzach and Wall described with our manual work, exercise, needling, etc to stimulate mechanoreceptors

  9. I’m going to call you “Steve”,

    Gate theory pretty much stopped at the spinal cord. It’s a very dated concept, but I sympathize with the fact that this is probably all you learned about in PT school. Me, too.

    Before nociception even reaches the thalamus, there’s all kinds of descending pathways that are going to modulate any incoming “danger messages”, and this happens after the incoming barrage of nociception is modulated in the dorsal horn of the spinal cord. The context of the “danger message” plays a huge part in the ultimate pain PERCEPTION- if there even IS one. When looking for the Moseley videos be sure to watch the one where he tells the story about being bitten by a snake in the woods. It’s a funny story, and very illustrative of the importance of context.

    “Nociception is neither sufficient nor necessary for the experience of pain.” There are myriad examples of this. Also, this is the reason that many of the provocative orthopedic tests that we were taught in school provide such little useful information much of the time. Have you noticed how poor the psychometric properties are for most provocation tests?

    I hear this argument that you’re making about the EBP model fairly regularly. I don’t think your description is accurate. The three components of EBP do not always, or even typically, have equivalent contributions to the process of clinical decision-making. And furthermore, within the research component there’s an evidence hierarchy that we are expected to analyze and then form professional judgements regarding the quality of that evidence based on the type of research (e.g. systematic review, RCT, case report, etc) and rigor of the methodology (effective blinding, appropriate statistical tests, large enough sample, etc). After we’ve done that, then we take into account our professional experience/clinical judgment (what you appear to be referring to as the “art” of PT) and the patient’s values. There’s a lot of high quality evidence that PTs are simply ignoring when it comes to persistent musculoskeletal pain problems. It’s called “confirmation bias”- we seek out (and perform) research studies that confirm what we think we already know to be true.

    This is not a characteristic of a profession that claims to value the scientific method and process of discovery.

    • Good points john. I did watch that video today while working out at lunch. Really interesting and good speaker. Matter of fact, I emailed it to a patient in the afternoon who has “chronic pain” secondary to a T2 fracture a decade ago and now has “disc bulges” that her doctor thinks is related. I gave her this as homework while my homework is to take the Adrian Louw “teaching people about pain” course on medbridge over the weekend. Here’s a question for you though, how to do explain the rapid improvement with spinal manipulation as well as increased pain pressure thresholds (this is well documented by cleland and others) if not via a spinal gating mechanism? Maybe we don’t quite understand the neurophysiological mechanism yet?
      John what would be really great for me is if you email me a bibliography of some of this high quality evidence that you feel we are missing. I would be happy to put it on my list of things to read and appraise it myself. Cheers to life long learning…

  10. Steve, I would start with the references mentioned in this thread. “Explain Pain” is copiously referenced with basic and descriptive research articles on pain neurophysiology as well as many RCTs and systematic reviews, which few PTs are ever exposed to during their formal education. I’ll send you an annotated bibliography by Haneline et al, which includes much of the reliability research that’s been performed on motion palpation, particularly for lumbar and SI region problems. The results have never been impressive in this area, but OMPT residency programs, in particular, continue to teach this stuff. Trust me on that because I taught a lot if myself, and it’s still included in the AAOMPT and IFOMPT “Description of Advanced Specialty Practice”.

    I’ll also send you Eyal Lederman’s “The Myth of Core Stability” and Wand and O’Connell’s article on the efficacy of conservative treatments for chronic LBP. These are both narrative reviews that are again extensively referenced; although, most PTs have no familiarity with either these articles or the references included in them. The Keller et al systematic review cited in the Wand and O’Connell article is particularly instructive because it used such rigorous methodology in pooling data to produce effect sizes from conservative treatments for LBP. The effect sizes were found to be small to moderate at best for spinal manipulative therapy with or without exercise for these patients. The authors suggested that sub-grouping may be needed because sample heterogeneity may have caused meaningful effects form treatment to be washed out. I’ve been hearing this argument for over 10 years; however, when you look at the sub-grouping research, as Stanton et al recently demonstrated for the treatment-based classification system, it’s kind of a mess. Few patients fall into just one category and categories are not mutually exclusive. Sub-grouping doesn’t work. The Movement System Impairments or MSI approach has not borne out in the research, either.

    I haven’t even scratched the surface here. There is so much research out there that disconfirms much of what we were taught in PT school, residencies, and continuing education courses, but most PTs just don’t avail themselves of this information. It’s kind of sad the money that PTs continue to shell out to learn stuff that’s simply unsupported in the evidence base.

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