On Providing Discerning Opinions: A Vlog

how-about-no

Following the Olympics this past summer, the utilization of interventions (see cupping) that possess paltry or inconclusive scientific support became rather prevalent. This discussion highlights a larger issue within rehabilitation and medicine over all; which is offering a discerning opinion to our patients and subsequently the tacit approval of interventions lacking sufficient scientific support from not offering said discernment. This is certainly a complicated issue but I feel that as a profession this issue needs to be discussed amongst our profession, if we are to continue to move forward as a profession. I discuss this issue in my first Video Blog (Vlog) embedded below, Please feel free to comment and share.

Let’s start talking!

 

 

The Role of the Clinician in the community; selling meat to vegans.

Following the most recent media craze around cupping and other alternative medicine in MSK rehab, many in our profession have provided commentary on this issue. I feel that this most recent event highlights a bigger issue within our profession, which is the role of the clinician. My opinion on this matter was requested by a colleague of mine on a thread, which realizing how long it became, I felt might be good for blog post. Please, enjoy and let me know what you think!

Though I am more in the lab and lecture hall now as an academic, I still see a few patients and serve as a clinical educator to both students and practicing clinicians. This is my general view of the role of the clinician in communication with patients and the community:

A clinician should be confident in their understanding of the human body, based on the current accepted body of knowledge, while humbly accepting their personal limits of understanding and the current gaps in knowledge. They should also avoid filling those gaps with ideas that escape the realm of scientific plausibility, especially when interacting with patients and their community. The reasoning behind a given treatment is almost as important as the physical act. Our thoughts and words matter, a lot. This is a particularly important concept to bear in mind. Remember when interacting with a patient or the community it is from a position of authority (a clinician is viewed as an expert), in that power dynamic people tend to believe what is told to them. Therefore it is imperative that we strive to ensure that the information which is communicated to patients and the community is as truthful as possible. More on the consequences of failing to do so by my colleague Kenny Venere PT, DPT (FYI he’s a bit blunt).

Clinicians should remain committed to becoming excellent in their field and learning more throughout their career and most importantly doing right by their patients. Sometimes that means being a discerning yet respectful voice of reason to the patient and in community to the nonsense that is perpetually disseminated by others, for whatever reason. A clinician at the core is a motivator and an educator. As an educator sometimes what’s right isn’t popular and it’s not easy to tell or convince someone that they’re wrong. However if someone is wrong it’s important that they are told so but it should be done in a respectful manner. Changing someone’s opinion on anything is incredibly difficult and it doesn’t become any easier by being boorish and discourteous. Always remember to be tactful and be mindful that some people just won’t change, despite how well informed a counter argument might be or the degree of cognitive dissonance present. Clinicians should also learn to effectively communicate, empathize and relate with the different types of people entering into a clinic. Communication and use of language is probably a clinician’s most important tool after what’s between the ears.

Lastly, the majority of patients arriving at a clinic already are confident enough in a providers abilities, as they likely wouldn’t be there otherwise. Even if a given clinic is the only one covered by a patient’s insurance, most have the option of not showing up (trust me I’ve practiced in systems like this and people still don’t show up). Therefore they don’t need to be sold on some esoteric and novel for the sake of being novel treatment, they just want to get better. They are seeking the help and guidance of a clinician to do so and they also want to be listened to by someone who cares. Listening to a patient is not synonymous with doing whatever they want so that they feel better. Listening is using the information they’ve provided to develop the best choices for them to make, we’re providing them guidance and options that they have to choose. It’s a give and take but the role of the clinician is the adviser, that’s why a profession requires so much schooling, training and licensure. Also factor in that most MSK injuries are self limiting, we don’t really need to make rehab too complex or creative. It just needs to be intense enough so the patient progresses to meet their goals in the most effective and efficient manner and creative enough to keep them interested.

In short, keep it simple and use the body of knowledge to inform and guide decision making (not replace it), stay current, be an adviser for patients and community, be careful with use of language and have the courage to offer a discerning opinion and humility to accept one. This is not always easy to do in the clinic while working with individuals with health related problems (who we all want to help get better) who may have been exposed to all sorts of information/misinformation and may take some convincing. However, if a patient doesn’t want to listen to a clinician’s advice they can always go somewhere else. We aren’t short on people needing help and if a patient doesn’t buy in they probably aren’t going to have too much success with that clinician anyway. This is basic marketing/argumentation/social theory, as an example people who are vegans aren’t interested in people trying to sell them meat but there are plenty of meat eaters and they are sure to find those selling meat.

Image: Courtesy of Deborah Dunham 2012; cavementimes.com

 

On Bridging “The Gap”

the gap

amymarquez.com

In my PhD studies the concept of the “knowledge gap” is often discussed which essentially means that there are limitations in our understanding of the human body and that what is known is often ineffectively translated into clinical practice (let alone the public). I feel that the latter problem is the more pressing issue and rather complex. Many clinicians don’t consume research often or effective enough, this could be due to a lot of reasons including: interest, access and time cost. Additionally, this may be due to the rather insular method of dissemination of research findings and manuscript publication. Scientific journals are written for other scientists in their given field, which is likely due to the fact that manuscripts are reviewed for publication by fellow researchers who also consume journal articles most often. This is playing to the audience in a certain sense. As a clinician, an emerging academic/researcher, I wonder what needs to be done to address this issue. What are some issues that you all have encountered as clinicians or researchers or students and how do we address this issue? Please feel free to comment and share!

On The Cause of Diversions

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Each time I encounter a post or comment by a clinician regarding an approach to rehab or an explanation for treatment effect or diagnosis, I wonder what experiences led them to their decision and perspective. I analyze this for all posts irrespective of accuracy and my own biases. Overall, the majority of thoughts appear to subscribe to contemporary scientific explanations. However, there is a significant faction within our field that does not. (Bear in mind this analysis acknowledges that there will be slight differences in approaches which can be substantiated by evidence.  This is both expected and good for the profession.) Given that for the most part our education/training are similar from primary school through graduate school, access to scientific literature is fairly available to all and clinicians must stay current with CEUs, what are these deviations attributed to? What is the cause for the pseudoscience and in some cases anti-science pervasive within our profession?

However does this matter? Is there actually an ethical dilemma?

Clinical outcomes are important, as are experience and findings of research report typically represent the significant averages. There will always be individual variation and guidelines are meant to be just that, they are not intended to replace clinical decision making. In a sense summary findings of a meta-analysis or clinical practice guidelines should not be viewed as dogma and unalterably infallible. However, ascribing a treatment effect or diagnosis to something factually inaccurate and contrary to the contemporary understanding of physiology is not ideal. Especially considering that an explanation of observed responses to treatment should be disseminated to the patient throughout the course of care. If we are not providing patients and the community accurate explanations for what is occurring with treatment yet they still improve is that ethical is that justifiable?

Case example of many…..

A patient is referred to a clinic for chronic headaches and the clinician provides cranial sacral therapy which results in a positive outcome for the patient. The clinician attributes this beneficial effect from the cranial bones being misaligned and then subsequently being reduced with this treatment. Though the patient’s status improved, the explanation has no substantive evidence to support what was disseminated by the clinician. Is that ethical despite the good outcome? What would the best way to explain the response to this treatment?

 

Let’s hear your thoughts!

On Truth (Quick Post)

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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”

On “Breathing Dysfunction”

diaphragm

The term “breathing dysfunction”  is referred to quite often in physical therapy discussion groups/threads as having an influence on musculoskeletal disorders. However it’s often described in a rather nebulous and vague manner with questionable explanations for what is being observed clinically. Similarly, the mechanisms for addressing “breathing dysfunction” are also vague with questionable veracity. As someone with a particular interest in this area, I would appreciate thoughts and opinions on this topic.

Deep slow breathing (DSB) and mindfulness has been shown to improve symptoms of pain, both chronic and acute. Though autonomic responses such as increased heart rate variability and reduced skin conductance (markers of increased parasympathetic tone) have been observed following DSB, their influence on pain rating has been questionable. More recent evidence suggests that the effects of DSB are likely more due to achieving a relaxed state or distraction from the noxious stimuli. Therefore these changes in autonomic activity in following DSB are more likely a reflection of supraspinal activity due to achieving a relaxed or non-threatened state than the cause.

It has also been demonstrated that patients with LBP have demonstrated altered diaphragm position and function, increased diaphragmatic fatigue, impaired maximal inspiratory pressure (MIP or PiMax) and reductions in spinal proprioception. Acute fatigue directed at the inspiratory muscles (primarily the diaphragm) have been shown to alter postural control. Similarly, inspiratory muscle training (IMT), which primarily loads the diaphragm, has been shown to improve postural control and pain ratings in patients with LBP. IMT also has been shown to improve exercise performance; especially in patients with cardiopulmonary disease(s) or disorders. Therefore “breathing and inspiratory muscle function” ARE important and clinically relevant changes can be observed by addressing it appropriately. However, it is important that the mechanisms attributed to clinical observations and treatment effects are based on scientific evidence that accurately reflects what is most likely occurring. It is also critical that these mechanisms are fully understood by clinicians and disseminated accurately to patients.

In summary, clinicians should continue to utilize these techniques as there is decent support for their implementation clinically. However, ascribing these observed effects to inaccurate and unsubstantiated mechanisms is not recommended and neither is disseminating them to patients. A clinician’s accurate understanding of the physiological responses to a treatment is critical to providing accurate and effective education to patients. With patient education being one of the most important components of clinical practice.

On Logical Fallacies

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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.

On Preventative Physical Therapy

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.

CSCS for the DPT Student: You’ve got questions, we’ve got answers.

MK strength & conditioning

Well, I hope we have answers to your questions about the CSCS.  I just want to thank everyone who answered the survey I posted out on social media to help with material for this blog post.  A number of my colleagues and I have noticed a trend in the interest for the CSCS credential from the NCSA.  I wrote a blog post a while back and you can read that here. There you can learn basic background information on what the CSCS is (unfortunately, some of the links are outdated because the NSCA updated their study materials).  With the recent spike in interest, I’ve decided to update my blog post with a group of fellow PT students who are also CSCS Certified to try and help answer your questions about the CSCS.

An amazing 65+ of you answered the survey so unfortunately I can’t answer everyone’s specific questions.  I had…

View original post 5,291 more words

Updates

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.