I came across this photo earlier and after viewing some discussions regarding EBP I decided to write a brief post on it.
People often attempt to conceptualize and understand complex topics to fit their world view and biases. This is human nature; as it is difficult to deconstruct information and assess it critically while acknowledging and remaining critical of one’s own biases. This is true for both patients and providers. The attainment of truth and knowledge is a difficult task but necessary. However in this current healthcare system untruths, oversimplifications, obfuscations, conflations and care lacking a trace of plausible evidence is reimbursable. Obscure, esoteric and novel (for the sake of being novel) methods and treatments are also easier to market; as are panacea. Imagine the perspective of the patient and their expectations. This is why the guru and missing link nature is so prominent and pervasive, which is not isolated to chiropractic. Until this issue and it’s multiple components is addressed as a society this issue will continue to perpetuate.
Simply put: “The truth defies simplicity”
This came across my newsfeed, after reviewing it and disappointingly noticing (yet sadly unsurprising) that only 1 physio (Kelly Starrett) out of 100 people was listed. It begs the question, what must we do as a profession to become more influential in this domain? This list of course isn’t from a scholarly organization or a high impact media publication (TIME, NYT, The Republic etc) and it did include Dr. Oz and other such charlatans, which is an approach we should absolutely avoid. However as the “movement experts” It does highlight an area needing improvement. I think we should strive to become more influential in the domain of health and fitness, even just for the sake of drowning some of the the nonsense that is currently being disseminated.
Popular opinion ≠ truth. Stating that a source’s credibility is enhanced by its popularity is a logical fallacy (argementum ad populum). Another important fallacy to avoid is the notion that the duration of how long an idea has been accepted reflects its validity (argumentum ad antiquitatem). The notion that something is true because it can’t be observed to be false (argumentum ad ignorantiam and argumentum ex silentio) should also be avoided. A few things to think about in regards to clinical decision making and practice.
I think we fall victim to these fallacies and others more often than we should, not necessarily with malicious intentions. Humans are creatures of habit and will often reflexively attempt to simplify complex topics and concepts to fit a narrative and world view. I am guilty of this as well, we all have our biases. However realizing this and taking time to think “why do I perform or choose the things that I do” is important to prevent this from perpetuating and having too strong an influence over one’s decisions. Remember the truth defies simplicity.
Image Coureousy of Theo Lister lifehack.org
Do we often over complicate things with our approach to the rehab of MSK disorders? I, likely more than most, firmly believe in the concept “the truth defies simplicity”; however often the causative factor for a problem is rather apparent with an equally simple solution. Too often do I observe approaches based on loose scientific principles or over extensions of human physiology. These behaviors often obfuscate thinking and make treatment more complicated than it should be. The understanding or perception regarding the attributed mechanism for an intended therapeutic effect is important; for both provider and patient. In short, why is as important as what is done or chosen for treatment. Granted there will be variability in approaches based on one’s training and knowledge base; but are our thoughts often too scattered and random when they should be more focused and directed? Does this uncoordinated way of thinking impact our outcomes? Does this matter? Let’s hear your thoughts (pun intended).
I have encountered a few discussions recently regarding the implementation of an annual physical therapy exam. The original source of this thought likely traces back to the legendary Shirley Sahrmann who has talked at length about this concept. The foundation of the argument appears to stem from the belief that preventative medicine is cost effective (which it is) and that physical therapy improves outcomes at a reduced cost (which it does for a lot of reasons and disorders). While both of these aspects are fairly valid, combining them to suggest that everyone would benefit from seeing a physical therapist (or any provider) annually and that this exam would reduce healthcare costs is a bit of a stretch.
First, we also need to acknowledge that the term “preventative” medicine is a slightly inaccurate. No disease or injury can truly be “prevented”; despite optimal care and an ideal patient, there will always be some risk. For movement based disorders physical therapy services can absolutely reduce risk and improve performance in many domains. We should also continue to screen for systemic disease. However labeling what we offer as prevention may create unreasonable patient expectations and unrealistic beliefs in a providers utility. Both of which can influence outcomes. But for now, until we devise a better word we’ll go with “prevention”
For most healthy individuals, receiving an annual physical therapy examination would be meaningless and it would come at cost. If an individual moves well and is disease free there are few benefits to them receiving examinations by a PT (or any provider) annually. This is similar to the issue encountered with the overly-capricious use of diagnostic imaging. If the pre-test probability is low then the test/image isn’t going to be useful and may result in false positives (See Bayes’ Theorem of conditional probability). Which leads to more testing, clinical visits and further costs. This issue occurs with imaging and tests that actually possess strong statistical power, which many of our movement based exams lack. Thus the false positive rate for an annual physical therapy exam may potentially be even worse!
We also must consider the bio-psychosocial ramifications associated with these potential false positives. One of the issues with over-utilization of imaging is that provides a tangible “proof” to patients that they are “broken” and often remain attached to those results. It can be quite difficult to break that cycle once it starts. Another example of this are those who visit a chiropractor monthly ad infinitum for tune-ups. What is actually being improved and is manipulation necessary even if the technique results in cavitation? Most (rightfully) would consider the notion of regular chiropractic visits to be unreasonable. Seeing a physical therapist annually despite being asymptomatic would be as well.
Even the utility of annual medical exams/physicals have even been investigated recently. With the majority of the evidence suggesting that they may actually increase costs without reducing much risk. This further analysis of risk reduction is also likely why the ACSM has recently adapted their recommendations and removed ETT/medical exams for many patients even those with risk factors. The old ACSM guidelines created bottlenecks in access to care, and delayed the initiation of exercise which affected outcomes. With the provider gap that currently exists in this country, the delivery of care needs to be as efficient and effective as possible. Annual visits to a physical therapist could also potentially impair access to care for those most in need of rehab services.
When deciding on policy change it must always be asked, does the intervention reduce risk and associated healthcare costs more than the cost of providing it? While I agree that access to physical therapy services needs improvement this annual model needs to be further analyzed. I suggest that maybe a “regular” physical therapy exam combined with other providers should be implemented. The frequency of this exam could then be modified based a number of health-related factors (congenital diseases, family history) and adapted to any novel changes (weight changes, acute injury etc). From our end we also need to start tracking outcomes data more consistently to help improve the effectiveness and efficiency of our care (which I have been working on improving with my software “Outcome Manager” set to release in the coming months) and develop more accurate tests and measures.
Again, as always the truth defies simplicity.
I wish more PT/physios would realize the potential in owning a box or gym and operating a clinic contained within. Instead of commenting on the issues with training and programming that Crossfit or any other training model has, we should be looking at ways address them while incorporating them into practice models. I’m more of an academic at this point in my career (and likely going forward) but it would seem that having a more fit and motivated patient population would be ideal. Having multiple revenue streams, a greater potential for direct access and collaboration with fitness professionals to ensure a smooth transition post rehab are all decent perks; not only for clinicians but patients too. These are all items that are frequently mentioned as lacking in most clinical models and barriers to outcomes. Why more of us haven’t explored this business model is beyond me and appears to defy logic.
The primary point I am getting at is that owning a gym, box, Pilates studio, fitness centers etc should not be the exception rather the norm. As would owning your own clinic vs working for one of the large PT chains. We complain about revenues and reimbursement, yet we as a profession choose to work in situations where our earnings are limited with sometimes ridiculous work demands and paltry compensation. What other profession practices in this manner? Of course there is significant capital required to operate your own business with increased risk, especially early in one’s career. But this sort of model is ideally developed over time and possibly in partnership with a few like-minded clinicians (not necessarily PTs) to divide the risk. At the end of the day one will never earn as much as they can working for somebody else. Until we as a profession realize this, from a practice standpoint we will continue to remain significantly impaired in our ability to move forward.
Proud to announce my partnership as a contributor with New Grad Physical Therapy! Their team offers a great resource for PTs of all levels of experience (not just entry level) on a variety of topics and practice settings. Looking forward to working with them more in the future!
PTReviewer: As for this site I am still continuing to update and add more content, The official “re-launch” should take place around mid-August.
We as therapists and humans in general try to compartmentalize concepts in a manner that drastically oversimplifies physiological, biomechanical and psychosocial processes of human movement. Evidence based practice is NOT shifting from one indoctrination to another whilst abandoning the prior practice patterns and research.. Too often are we, physical therapists, guilty of subscribing to the newest trend in research and abandoning what existed prior. There are too many examples of this: McKenzie based extension exercises for patients with low back pain, everyone with back pain has a weak TrA, every runner needs to start running bare foot and shoes are suddenly the worst thing ever, all patients with tendinopathy need to do eccentrics, patients who fall within a CPR for SMT need to be manipulated and suddenly everyone has a weak diaphragm. Patients improved prior to these studies and body systems are rather complex. That’s not stating that we should not adapt our behaviors and practice patterns, as research continues to develop more effective treatments. As a clinical researcher, DPT educator and PhD student, I fully support the idea of evolving your practice with time and staying current. I do not condone jumping ship, once a new idea presents itself
Science is a constantly evolving process that builds on the work of previous studies and changes gradually; most often due to the development a novel method of visualizing and measuring phenomena. There are few absolutes in life, one that best reflects this particular problem we face is that “The Truth Defies Simplicity”. Evidence based practice is not defined as abstaining from treatments that aren’t supported by the most recent meta-analysis. It is also not giving the same treatment for every person because research supports it. For example, when a patient demonstrates signs of Achilles tendinopathy it doesn’t mean you should automatically use eccentrics 3×15 x 5 times per day per Alfredson. Some patients won’t tolerate it or be appropriate and there are other interventions that can be used to reduce pain and improve function. Blanket statements for treatment decisions such as those can’t possibly be valid and therefore interventions cannot be the same for every patient. If we are to believe that exercise is medicine, which it is, then we must conceptualize it as such and be dose specific.
Movement disorders are multimodal with varying degrees of deficits relative to each person. My mentor from my cardiopulmonary residency at the VA in Madison, WI, Jim Carlson, offered a great quote to me, which my students may be familiar with as a I use it often, “treat what you see in front of you.” This simple quote offers a lot in terms of practice patterns and decision making. Identify what limits a patient’s ability to function and interact with their environment; then address those issues. Identifying dysfunction also coincides with another great quote I remember by CI from my first clinical, Emily Kelley, “focus on function not the diagnosis”. The diagnosis often doesn’t matter as much as we give it credit for and often even correct imaging or diagnostic tests don’t reflect a patient’s ability to move and function. For example a patient may have positive findings on an MRI for a herniated disk but be asymptomatic and a patient with heart failure may have an ejection fraction of 27% but may move better than a patient with an ejection fraction of 45%. Diagnoses are useful as a starting point but can also cause clinicians to be too myopic with decision making. This segways into, another quote from a mentor of mine here at UIC, Aaron Kiel, our residency director, “have a reason for doing what you choose as an intervention”. That quote right there so succinctly defines EBM at its core. Don’t just go through the motions and solely base decision making on the regurgitation of results from a meta-analysis or clinical practice guideline. Though often the patient will improve over time, that’s not EBM, that’s being a technician. That type of practice is wasteful not only to you but to the patient. In a climate where reimbursement and coverage is increasingly becoming more based on outcomes and efficiency, one cannot afford to continue practice in this manner. Evidence is meant to enhance decision making and critical thinking, not replace it. Clinical practice is called such, as a clinician one should be constantly reflecting, refining and appraising their skills over time. It is easy to become complacent with perpetuating the same practice patterns; and within the current landscape of healthcare that is still reimbursable. Being a good clinician, scientist or any skilled worker is difficult and requires all those things mentioned prior. It is up to the individual to decide on how they choose to act and doing the right thing may be more difficult, however the fruits of that labor are much more enjoyable.
Have a Happy Sunday.
Due to many unexpected yet amazing developments this past few months I have not been as active as planned this year. However during that time, I think I have finally found my niche as a provider and researcher which is combining Cardiovascular and Pulmonary Physiology to orthopedic populations and vice versa. These areas are viewed as dichotomous to each other yet in reality they should definitely be integrated. Especially considering that heart disease and pulmonary diseases are the #1 and #3 cause for mortality in the USA. Additionally other providers frequently ask me questions regarding this and I feel that is due to the lack of a large enough voice talking about these issues. Therefore the direction of this blog will be to focus attention on those areas, as well as provide therapists and rehab professionals content related to areas I find interesting and and those which there aren’t many resources. This will include resources for lab values, medications, cardiopulmonary diagnostics, early mobility guidelines, considerations for OP ortho providers as well as other topics. There are too many good blogs that cover ortho, manual therapy and sports; here are a few of the best ones
http://snyderphysicaltherapy.com/ http://www.mikereinold.com/ http://chrisjohnsonpt.com/ http://scotmorrison.com/
But there just aren’t any good ones that cover cardiopulmonary areas and acute care. Let’s change that.
Have a good week.