The tools we use…

In my last article, I discussed the concept of the clinical toolbox and questioned if the number of tools we add, truly matter.  Below I have posted several videos of tools that are often marketed and employed by Physical Therapists.  I would love to hear your thoughts on each video and if you believe “they makes sense”.   I have also added a few informal polls, to learn a bit about the readers of this site (I only ask they are completed by licensed Physical Therapists).
The Graston Technique
[youtube=] [polldaddy poll=7284659] Trigger Point Dry Needling
[youtube=] [polldaddy poll=7284674] Cervical Spine Thrust Manipulation
[youtube=] [polldaddy poll=7284679] Joint Mobilization
[youtube=] [polldaddy poll=7284693] Neural Mobilization
[youtube=] [polldaddy poll=7284698]

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  • By concept do you mean how they work or how they are said to work by people who sell them to clinicians? They all could work based on the idea of neurophysiology and perceived expectations but likely do not break down scar tissue, stretch nerves etc.

    Steve July 29, 2013 6:13 pm Reply
  • Either Steve. As a clinician, in your most honest opinion, do they “make sense”? In other words, does each intervention make sense enough, to you, to employ on YOUR patients?

    josephbrence July 29, 2013 6:17 pm Reply
  • Geez! I’m amazed so many still consider Cx thrust as a sensical treatment in physical therapy… But then again, maybe I’m not that surprised, perhaps more disapointed.

    Frédéric Wellens, pht July 29, 2013 9:02 pm Reply
  • I chose to comment on Graston as this one makes the least sense to me. I have never performed graston technique or have had it done to me, however due to how the patient’s skin response I assume that’s it’s not comfortable. I try really hard to not cause any discomfort/pain while treating, and don’t understand why so many PT’s think it’s ok to cause pain. To me this is “harming” the patient and will result in pain response, increased sensitization, especially to someone already in pain. I think it’s more important to focus on decreasing pain, instead of increasing it no matter the benefit.

    Mark Powers, PT, DPT, OCS July 29, 2013 10:01 pm Reply
  • Great poll! A bit like the Oxford Debates without the noisemakers! I appreciated the order you presented the polls – I assume you ordered them after looking at the results. The ‘favorable’ rating increased with the order of the polls. I wonder if a random order or a different order would produce different results?

    Tim Richardson, PT July 29, 2013 10:16 pm Reply
  • Graston = DNIC, surely?

    Bozo July 30, 2013 5:15 am Reply
  • con·cept
    An abstract idea; a general notion.
    A plan or intention; a conception.
    With these definitions (especially the second one): none of these make sense in my mind. All interventions listed are addressing confirmation biases’, perceptual fantasies and peripheral structures/tissues without creating structural changes. That said, using these with the ‘plan or intention’ of structural alteration, they don’t make sense.
    All involve skin contact, clinical equipoise, patient expectation, placebo (possibly nocebo) and a therapeutic alliance.
    The interventions that enhanc patient self-efficacy and reduce negative thoughts/perceptions make the most sense. I would argue this occurs with any treatment under the appropriate context with proper education.

    Matthew Rupiper July 30, 2013 6:13 am Reply
  • Interesting to see the difference in the way people have voted between cervical spine thrust manipulation VS mobilisation.
    I wonder if there would be a difference if it was cervical spine thrust manipulative vs cervical spine mobilisation (non thrust).

    jonathan price July 30, 2013 8:42 am Reply
    • I agree Jonathan. This is a great observation.

      josephbrence July 30, 2013 3:16 pm
  • In principle, I agree with Matt. But in practice I think that Graston is so vacant of a deep explanatory model and cervical manipulation is so obviously capable of causing catastrophic harm that both of them should be avoided no matter how well they are explained to the patient.

    John Ware, PT July 30, 2013 3:12 pm Reply
  • I agree with John, although I do manipulate I have cut down significantly on how often I manipulate, and focus more on mobilizations. Just explaining the process of manipulation to the patient I think gets the pain process initiated and can be more detrimental to care, even if it is fun! Definitely important to make sure that the patient will have a beneficial response.

    Mark July 30, 2013 3:56 pm Reply
  • Great concept here with the polls Joe! Interesting results so far with 50/50 on cervical mob/manip and dry needling, generally more dangerous interventions. ; compared to general agreement on understanding neural gliding and joint mob.
    Based on your results, I’ll like to see what a poll of patients with same questions would be too. And, if treating them with the highest agreement vs lowest agreement on understanding will make a difference in outcomes.

    Harrison Vaughan July 30, 2013 6:38 pm Reply
  • Above, “Bozo” wonders if skin scraping is equivalent to DNIC. I don’t doubt that as a specific effect that DNIC is in play, but I think there are many non-specific effects of the “treatment” based on patient expectation (“no pain, no gain”) and the placebo response associated with using a shiny, curvilinear piece of steel that are likely more impactful than DNIC. The brilliant minds at Science-Based Medicine have recently addressed the evidence behind this intervention, and, needless to say, it’s not very impressive. When you look at the evidence in toto, you wonder how PTs ever embraced it as an evidence-based intervention. This is a stupid thing to do to a patient.

    John Ware, PT July 31, 2013 8:11 am Reply
    • Hi John
      I wouldn’t say stupid. Based on what I’ve read, I’m happy to admit that it likely “doesn’t do what it says on the tin” (“connective tissue remodelling”). OTOH, can we discount those factors you identified (patient expectation + DNIC)?
      There are several questions to ask wrt to graston, not least of which are is risk vs reward.
      Truthfully, I don’t know very much about it (apart from that fact that it originates from Tuina and that the official branded course is quite expensive – but that’s not news).
      To me, It actually seems like …quite a cunning method in some ways, for a select ‘no pain, no gain’ population.

      Bozo August 4, 2013 10:41 am
    • Bozo,
      My problem lies in encouraging and promoting a set of cognitive errors in my patient that will continue to fester in the broader community of patients who hold the same distorted views of why they hurt. Our duty as professionals who proclaim to be part of a science-based profession is to educate our patients about what the science tells us. If we fail in that regard, then we should work to become better at it, not capitulate to the culture that demands a quick fix for their ache or pain.
      We have to do and be better than that.

      John Ware (@JohnWarePT) August 4, 2013 1:06 pm
  • John Ware, PT July 31, 2013 8:13 am Reply
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  • As a PT, I am curious as to why you posted chiropractic videos to demontrate Graston and cervical thrust. Surely there are videos of PTs demonstrating cervical manipulation and Graston techniques. I am a manual PT and I utilize a lot of the tools you mentioned, but I no longer manipulate the C-spine with thrust techniques.

    Heidi August 2, 2013 6:08 am Reply
    • Heidi,
      If you use Graston or some other tool-assisted STM, I’m curious what evidence you’re using to arrive at the clinical decision to use this intervention. I’ll grant you that the Graston video above is particularly disturbing, but I’ve seen patients in my clinic with bruising after receiving this intervention from PTs. Do you think it’s ever ok to create bruising from a supposedly therapeutic intervention?

      John Ware PT August 2, 2013 6:58 am
    • John,
      I do not use Graston technique and do not intend to with my patients. I feel that we should not create a painful state or bruising in our treatment. I do use joint and spinal mobilizations (mostly non-thrust), neural glides and dry needling as just a part of my manual therapy and have not left my patients bruised or in pain. I don’t usually comment, but if we are talking about the PT “toolbox” though, I would like to see PT’s not Chiro’s in the video whether we agree with the technique or not.

      Heidi Chichester August 2, 2013 2:22 pm
  • Fair enough, I see your point. Joe may have sensationalized these interventions a bit by using chiro videos, but I think the point is that many PTs are utilizing these interventions without giving much thought to the current state of the science.
    Dry-needling is an interesting example. The target for this intervention is the myofascial trigger point (MTP). Putting aside the formal studies that have questioned the reliability and validity of this diagnosis, let’s step back and look at what we are fairly certain is going on neurophysiologically in patients with persistent musculoskeletal (non-pathological) pain. The signaling tissue, i.e. nociceptors, has either detected a threat in the periphery OR the brain has constructed a threat based on non-nociceptive input from the periphery (or within the CNS), which is sufficient enough to reach consciousness as a pain output. We DO NOT KNOW based on our current methods of clinical examination how much, if any, of the input from the periphery is nociceptive in nature. The issue becomes even more complicated when pain that is mechanical in origin exists- as it often does- along with an inflammatory condition in the tissues, such as an arthritic flare. We can be fairly certain, in this case, that nociceptors are firing, but we have no idea how much is due to chemically-mediated or mechanically-mediated depolarization of nociceptive neurons. And, even if we did, we would need to account for non-nociceptive input that the potentially centrally-sensitized areas of the brain might interpret as threatening and produce a pain output.
    What do we know about our patient- the person living with this unyielding pain experience? We know that depression and fear of movement often accompany a persistent pain problem. These patients may catastrophize. They commonly lack confidence that they will be able to overcome their malady (low self-efficacy). In fact, having been patients for so long, they may have acquired certain ideas about their condition that contribute to all this fear and catastrophizing behavior. They believe that they are “damaged goods”- and none of these learned people in white coats can figure out what’s wrong with them.
    So, getting back to our MTP and the needle that is purportedly going to “de-activate” it… just because you prod someone’s body and find a tender spot in an area that has been painful for several weeks or months or years, doesn’t mean that you’ve identified a “pain generator”. I think it’s pure hubris to assume that you have. What’s more, to stick a needle into that sore spot and risk adding even more nociception (not to mention the low risk of infection and puncturing a lung) seems to me to be utterly contrary to what the role of a therapist is supposed to be. The only reason I can see that a patient would benefit from such an intervention is because they, themselves, believe in it and skill of the person delivering it- for whatever reasons.
    What they also come to believe is that some skilled professional with a needle was able to fix their problem. Where’s the edification of the patient’s self-confidence in that?
    If I wanted to fix people, I would have become a surgeon. I want to help people without fixing them. That’s therapy.

    John Ware (@JohnWarePT) August 2, 2013 5:41 pm Reply
  • Heidi,
    Thanks a million for following the site and making those observations. Do you suspect there would be a difference in the application of these interventions if performed by a PT vs. a chiro? Obviously our practice philosophies differ, but does a graston intervetion look different when applied by a PT? Does a cervical manipulation look different? I am trying to make an observation of the “tool”…

    josephbrence August 2, 2013 6:08 pm Reply
  • Having practiced in Indiana for over 5 years, near the epicenter of the development and popularization of instrument-assisted STM, I attended an inservice by a PT who had been Graston certified. She demonstrated the technique with a variety of tools over various body surfaces. She demonstrated extremely light contact and surprisingly rapid brush strokes. My question was, “Why not just do this with your hands? Why do you need an expensive, engineered piece of steel alloy to do this?” She tried to explain that the contour of the tool allowed these kinds of strokes across boney prominences, and I just wasn’t buying it.
    It’s almost as if the tool was thought to possess some magical properties, some implied piezoelectric effect to alter the connective tissue below the skin. In a word, it was weird.
    I suspect therapists like this guy above also think that light stroking- as perhaps is officially taught- is weird. So, they take the technique a step further by inducing visual changes that imply in the uneducated and thoughtless recesses of their belief-system that they are “breaking up scar tissue” or “releasing adhesions”. I mean look at all that redness and/or bruising!
    This is what happens when an irrational intervention is embraced as mainstream and “evidence-based” despite the lack of plausibility and the thinness of the evidence. Charismatic therapists take it and run with it– and then they post this stupidity on YouTube.

    John Ware (@JohnWarePT) August 4, 2013 12:52 pm Reply
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