Too Many Variables…

I was recently reading through an online thread regarding the best management of complex regional pain syndrome.  In this thread, a bunch of students and clinicians gave their recommendations for the treatment of this disorder.  While some of these recommendations had some evidence to support, many did not (note: a great full text on evidence behind the management of this disorder here).  One similarity I saw in many of the responses, which is common in many of these threads, was the number of variables the participants wanted the poster to consider.  Modalities, exercises, manual techniques, sensory treatments, etc.   “You should try X, Y, and Z and if Y doesn’t work try N.”
So what has lead us to recommend so much and is it all necessary?  
I suspect our current modes of thinking, in regards to treatment, is likely influenced to some degree on the current reimbursement structure.  It is well-known that in the Outpatient setting, the more treatments you deliver, and the more units the bill, the more you can be paid (its quite ridiculous when you think about it).   I know some payers have limited the max units to be billed, but does this structure of payment influence what that patient really needs (or are we influenced to add fluff to reach our productivity standards)?   Do these practices influence the future clinical decision making processes of our student physical therapists (they learn that the patient needs X,Y and Z and maybe N for the treatment of a disorder)?  Heres a secret: Things are changing (like very soon—).  As the payment model drastically shifts, I suspect panic will occur, and then a shift in practice patterns.
Clinical Certainty with Protocols(maybe Uncertainty is Better?)
I was recently talking to an academician regarding his knee pain.  He stated his physical therapist has “the” recipe for treating knee pain — ice, ultrasound and closed-chain activity.   Now put aside your beliefs of those activities and let’s consider this statement: “the” recipe for treating knee pain.   This “certainty” regarding a treatment protocol for a condition concerns me a bit.  Its not patient centered…at all.  It has nothing to do with altering behavior…or introducing context…or graded exposure…or _______.  Its patho-anatomically driven which is actually more of a physicians domain than ours (and they can have it).    When we approach a patient with knee pain, we should approach them with a hint of uncertainty of what to do.  When we provide too many “inputs”, we make the equation of treatment much more complex.   I would recommend trying something—reassessing the patients response—decide if we should try something else (ie.  Input –> Reassess the Output –> Input (Maybe same or new).   We don’t know how a patient’s nervous system will respond.  It’s ok that what we do is a bit of trial and error.  We work with humans.
Practice Culture
I once worked for a corporation that awarded and bonused clinicians.  These awards ranged vacations, to Kindles, etc.  These awards weren’t based upon clinical outcomes (ie. The winner wasn’t receiving an award based upon having the lowest visits per new patient ratio with supported outcome scores).   The clinicians were awarded and bonused based upon revenue growth (with a stipulation that your average units per patient could not drop > 5%).  Enough said.
Clinical Education
As I stated above, clinical education may influence this concept.  Students expect to learn about true clinical practice from their instructors.  Unfortunately, there is not a lot of internal control over what that clinician does clinically (I find it odd that the instructor is the only one completing a CPI—who mentors, or grades, the mentor? This concept has been noted and is tightly controlled by ABPTRFE in post-graduate education).   So with all of the variance in not only practice patterns, but reimbursement, culture and certainty, we must understand that students may suspect they truly need to deliver X, Y and Z, when coming back from clinical education.
How do we change?
Short answer: We begin to manipulate the potential variables that led us to provide a lot of variables.   As I linked above, we will soon be paid different.  As this payment model shifts, practice culture will shift.  As practice culture shifts, clinical certainty will shift to uncertainty.  As this happens, I suspect we will revert to a better understanding clinical decision making processes.
– Joe B
PS:  At the Nxt Gen Institute, we have developed a clinical decision making algorithm which we call “M.I.P”.  I recently presented this out at the San Diego Pain Summit wearing a “GoPro”.   While the video may make you a bit queasy, give it a go for better understanding what we think needs to be in place for helping patients to move.

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  • This post is fantastic and points out many issues. As a student performing clinicals, these differences in payment, management and culture are quickly noticed from placement to placement. These external constraints lead to a “this is always how we’ve done it” philosophy in many practices. We need to reintroduce thinking at all levels! We can ‘slowly’ influence the payment variable. We can (a little faster) influence clinic/practice culture.
    I wrote about the 4th Pillar of EBP (3rd party payers) when thinking about some of these very things.
    Why do we do some of the things we do in the face of contrary research (if that is known to the clinician) and against patient interests (again, if those are known to the clinician) ? Thanks for pointing out why in this post, because as a student on rotation, it is sometimes hard to understand the underlying variables in how treatment decisions are being made.

    Matt Dancigers March 4, 2015 6:12 am Reply
  • Joe,
    How can you “Reassess the Output” if the effect of some physical therapy interventions are only “visible” in the mid-term? For example, most cortical-based treatments (like two-point discrimination, GMI, etc).
    Thank you, and you’re doing a great job with the blog!

    Nicolas Sepulveda March 4, 2015 8:15 am Reply
    • Great question, Nicolas. In many cases, we can simply look at provocation and the patients comparable sign (ie. does it still feel the same when I _______). I personally have utilized an algometer, which measures pain sensitivity, to give me some idea of the sensitivity of the nervous system (I do understand this is not currently used in most practices). Unfortunately, there are some cases, such as individuals with CRPS, where this may not be feasible or applicable.

      josephbrence March 4, 2015 8:23 am
  • This is an excellent post and one that reflects many of my thoughts and observations over my career. Whether we like to admit it or not, all of us have thought, “I need to stretch this out 5 more minutes to get that 4th unit”.
    With the last 3-4 students I have had, two things I have tried to teach them are:
    1) never assume you are 100% right and never assume you are 100% wrong. Uncertainty and doubt need to be a part of your everyday clinical life.
    2) Go into each visit with a plan. But be ready to completely abandon that plan based on what the patient tells you. Do whatever you can to insure that the patient feels heard.

    Mike Terrell March 4, 2015 8:42 am Reply
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  • Joe,
    I appreciate your insights. These are tough questions, and naturally, complicated issues. I think much can be attributed to our undergraduate, pre-professional education, clinical, and even post-professional education (to say nothing of incentives from payment models and other sources).
    There is a lack of foundational training in basic science, reasoning, and critical thinking in undergraduate curriculums. Secondarily, to quote from a talk at CSM, our pre-professional DPT education is “a mile wide and an inch deep.” Add in the variable nature and quality of clinical education and you have a recipe for conceptual variance (
    My sense is that the profession lacks a philosophical, theoretical (, and (oddly) basic science foundation to build it’s interventions upon. Movement and function, broadly, are just that, broad. Now, to be fair, I’m in no way saying our DPT students are not capable or well equipped. Yet, there are obvious deficiencies. Our students are empowered with impressive knowledge, and unique skill set, that appears to lack a certain cohesion. There is no foundational glue, critical thinking models, or philosophical paradigms to hold it all together. Add to that a continued trend (obsession) of being interventionalists, and students and clinicians alike continue to pose questions of “what works?” “what techniques?” “what tools?” These are important questions, but without the context of how “things” (may) work and why we do them, it’s no wonder we are aiming a preverbal treatment shot gun and hoping something hits.
    I don’t have many great answers. Much pondering and questioning remains.

    Kyle Ridgeway (@Dr_Ridge_DPT) March 5, 2015 10:00 pm Reply

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