Greetings, my name is Eric and I am excited to join the Forward Thinking PT blog. As a contributor I want to ask questions about where our profession is going and how we are getting there. Rather than waste anytime I want to dive right into what I have been thinking about lately.
Firstly, if one wants to start with the question, “What is best practice?” Typically, one might look towards scientific support to answer this question. Our field, that of physical therapy, is borne out of the bio-medical model and therefore enjoys a strong relationship to science (or at least it should). Science based reasoning has a lot of advantages. Of these, the most important is that ideas, theories, and concepts can be put to the test of observation.
What is not widely discussed is the drawbacks of science. Science after all can only tell us what has occurred and what is likely to occur given a specific set of determinants. What it cannot say is what should be or what could be. These are much more difficult questions to answer. In fact these are not scientific questions but belong to the province of humanism: the ethics, values, and knowledge surrounding acts of human creation. A particularly apocalyptic example is that of nuclear physics: a branch of science that has given us the atomic bomb. While science for its part has created the technology and power, it is us, as humans, that must determine its use.
Asking conditional statements about the future invokes creativity and imagination. However, before we imagine and create something, we must determine what values will be our guide. What we create is a reflection of us and this is carried out through the values that we hold. We often take for granted the legacy of values that have been passed down to us. Many of us accept these values as right, just and valid in as much our teachers accepted them as well. For example, common medical values include:
- Respect for autonomy
One such value that is tacitly implied in the four values above is that a provider treats a patient to alleviate, cure or palliate. We have seen this value reflected in our own practice in the innumerable treatments that have come, gone and stuck-around: ultrasound, infrared, manipulation, iontophoresis, phonophoresis…etc. Suffice to say we have applied every (safe) aspect of the electromagnetic spectrum to the body with the hopes of changing the patient’s subjective experience (i.e. the patient’s pain). I would summarize this value is the patient is to be treated value. Inherent to this value is that we must do something to the patient, what that something is I will get to later.
Many of these treatments listed above have been applied–for years if not thousands of years–in advance of any scientific evidence. As the science has caught up, the evidence has not shown to match with the anecdotal experiences of clinicians and patients (see some systematic reviews listed below). A therapist might say, “I performed X technique and the patient got better.” Post hoc ergo propter hoc is the fallacy that I did X, and because Y changed it is therefore because of X. This fallacy has created a paradox between the clinician’s experience and what science tells us is occurring. Fortunately, science is catching up and describing the clinical encounter with greater fidelity. Much of this research is being carried out in labs that emphasize psychology, neuroscience, social-contextual effects and placebo. For some excellent reviews see the links section below.
Based on this new research, the something (i.e. treatment techniques) that I mentioned above, that are the cornerstones of our practice are turning out to be different than we originally conceptualized. Leaders in our field are aware of some of this evidence. Unfortunately, for many this new science only helps justify things we have already been doing for years. From this perspective the application of new science adds little value to our profession. If we instead flip our perspective by including humanistic questions like: “In light of this new evidence, what should we be doing as a profession?” and “What could we be doing instead of what we have been?” we, I believe, can facilitate a discussion that provides immense value to our profession and our patients.
I look forward to getting deeper into this discussion with your input. Future posts will expand upon the following:
- Post hoc ergo propter hoc — Otherwise known as the misattribution bias in the physical therapy treatment of pain.
- How can we use emerging research to re-conceptualize our practice?
- Should we be taking responsibility for changes in the patient’s pain?
Discussion of these topics and more will involve the evidence i.e. science, but it will also critically examine the values we attach to the things that we do. My hope is that if have a nuanced discussion not only about the evidence but also including our values we will be able to move forward.
Eric Kruger @Kintegrate
P.S. An interesting and somewhat related tangent, for an example of a prescient view of the future read, Isaac Asimov’s Visit to the World’s Fair of 2014 from the New York Times in 1964.
Articles highlighting social/contextual factors and placebo:
Benedetti, F. (2013). Placebo and the new physiology of the doctor-patient relationship. Physiological reviews, 93(3), 1207-1246.
Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual therapy, 14(5), 531-538.
Craig, K. D. (2009). The social communication model of pain. Canadian Psychology/Psychologie canadienne, 50(1), 22.
Krahé, C., Springer, A., Weinman, J. A., & Fotopoulou, A. (2013). The social modulation of pain: others as predictive signals of salience–a systematic review.Frontiers in human neuroscience, 7.
Some links to systemic reviews of the evidence:
de las Peñas, C. F., Sohrbeck Campo, M., Fernández Carnero, J., & Miangolarra Page, J. C. (2005). Manual therapies in myofascial trigger point treatment: a systematic review. Journal of bodywork and movement therapies,9(1), 27-34.
Miller, J., Gross, A., D’Sylva, J., Burnie, S. J., Goldsmith, C. H., Graham, N., … & Hoving, J. L. (2010). Manual therapy and exercise for neck pain: a systematic review. Manual therapy, 15(4), 334-354.
White, A. R., & Ernst, E. (1999). A systematic review of randomized controlled trials of acupuncture for neck pain. Rheumatology, 38(2), 143-147.
van der Windt, D. A., van der Heijden, G. J., van den Berg, S. G., ter Riet, G., de Winter, A. F., & Bouter, L. M. (1999). Ultrasound therapy for musculoskeletal disorders: a systematic review. Pain, 81(3), 257-271.