The EBP Purity Test: Are you or aren’t you?

Remember when online "Purity Tests" were popular?
The point, of course, is to see whether you were "pure" or not, and share the verdict (and your percentage) with your friends. While largely irrelevant to real life, not to mention the ease of giving false answers to change your percentage, it arguably got a lot of people to think about the larger issues involved in considering the questions posed.

I think EBP is in many ways similar to the purity test. Stay with me, I’ll get there.
I realize that very few of our colleagues read information about their profession on the internet, and even fewer write regularly, and possible fewer still think hard about the way they practice and try to line it up with evidence and the latest scientific advancements. However, many of the admittedly few people talking about and writing about it online are thought leaders at least, if not also some of the leading figures in our profession. That being the case, the reputation EBP gets from our thought leaders might affect to a great degree the way in which it is taught to our students and residents and the way it is promulgated through our profession.

So why am I comparing it to the purity test?

Many internet discussions of physical therapy practice have recently begun to turn towards competitions about who is more "evidence-based". I have even seen people list their percentage (the equation leading to such a number must be interesting) in their posts, presumably to convince others of their evidence-based-ness. Evidently, not only can individuals be "evidence-based" but techniques, CEU courses, and even books can be, too! Worse yet, many consider this issue not a question of percentages, but a simple question of yes or no. I mean, you’re either evidence-based or you’re not, right?

If you’re having difficulty seeing how this plays out, I’ll include a brief transcript of a discussion I’ve read recently to help you see what I’m talking about.

In the meantime, I’d like you to consider that boiling down such a complex and important movement to a simple "yes / no" or percentage does nothing to advance understanding of EBP, and it completely ignores Sackett’s originial complex blending of the aspects and considerations inherent to medical practice. In short, it’s becoming a bastardization of an important scientific concept, and I believe it has the potential to permanently mar the reputation and use of the term "EBP". I’m afraid it’s going the way of "pay for performance" – sounds great in theory, but handled so poorly in practice that the term is widely discredited. (I am not in any way expressing support for "P4P" by the use of the example) If we really want to better embrace science and make EBP a part of our therapy culture, we need to be careful how we integrate it, explain it, and use it in practice and in our discussions with colleagues.

Here’s the discussion I’m talking about. I don’t have permission (nor have I asked) to reproduce either the real names or the pseudonyms of those involved.

Therapist One: "Yes, there are times that I have referrals for unusual diagnoses or
multiple co-morbidities OR multiple body parts to be treated (there is
no easy way to convey treatment rationale with supporting literature
with those situations).  46.15% of the time I don’t have solid ground
using direct evidence that is easily related to the patient in front of
me."

Therapist Two: "By the way, I did the same thing you did and found that about 60% of what I do can be directly supported by the evidence."

While the quotes are lifted and clearly out of context, I think you can see how the use of percentages ignores the totality of the issues regarding the balance of the various forms of evidence in practice. It would be difficult or impossible to place the percentages in ANY context that would make them seem useful or relevant. We could say the numbers might reflect the number of patients that we see for whom we can apply a high-quality RCT on outcomes. However, real EBP, it must be said again, involves more than outcomes evidence. The basic science underlying physical therapy that includes physiology, biomechanics, motor control, psychology, and neuroscience (to name a few) can support a broad range of interventions and offers fertile ground for creating rational, defensible treatment plans. I doubt the two therapists above had no evidence at all underlying their treatment for such a significant portion of their caseload – but it’s worth asking why they might phrase it the way they did. I have seen the critically-important clinical research on patient outcomes and therapy treatments become a proxy for the concept of "evidence" in its entirety. Meaning the only evidence worth talking about is an RCT reflecting patient outcomes. This trend may be limited to a few thought leaders or not, but in any case it is a concern for all of us. Such "black and white" thinking is easy and convenient for those who want simple answers for simple questions. Unfortunately, integrating science and evidence in practice requires a level of reflection and understanding that is far more complex. I know that those producing these outcome studies are fully aware of this, but many people slinging those references back and forth in discussions about their EBP purity clearly do not.

It is reflective and complex decision-making that integrates all sources of evidence that we should be having serious conversations about, and its that thoughtfulness [PDF] that is required of a doctoring profession – not the myopic and obtuse yes or no to the question: "Are you evidence based?"

Jason Silvernail DPT

P.S. –  I have previously written about other issues inherent to EBP such as a deep models, the scientific method and intelligent theory here. Another mention of some of these same issues in the International Journal of Osteopathic Medicine here. International Journal of Osteopathic Medicine frontpage here. Thread on SomaSimple that started this latest discussion of evidence in practice here. Evidence In Motion’s own discussion forum, MyPhysicalTherapySpace, here.

73 responses to “The EBP Purity Test: Are you or aren’t you?

  1. jlsmith says:

    Jason, it is obvious from following your comments on several blog that you practice “thoughtfulness” in your clinic, and more importantly, in your efforts to bring people together on these blogs. We need more bridge builders.

  2. Ben Hando says:

    Jason-great post-
    While I largely agree with the spirit of your comments, I would say the bigger problem I’ve observed with PT’s interpretation of EBP is giving TOO much weight/credence to basic science research.
    More specifically, it’s choosing to ignore high quality outcomes research and citing “thoughtful” biomechanical or physiological explanations for doing so. Worse yet is when clinician’s commit this sin and then still believe they’re practicing EBP. I would contend they’re not. You have to look no further than the continued low (but improving) utilization rate of spinal manipulation among PT’s treating LBP to observe this phenomenon.
    Yes, sometimes all we have to fall back on is the “physiology, biomechanics, motor control, psychology, and neuroscience” research that you cite above. But let’s be clear; the hierarchy of evidence guides us on how much we let different kinds of research (basic science vs. outcomes research) influence our clinical decision making. Would you agree?
    Ben

  3. John Ware says:

    Ben,
    Approximately one third of my caseload are LBP patients. Less than 10% of them either meet the 2/3 +likelihood ratio CPR criteria for successful outcome with manipulation or have an exclusionary criterion for manipulation (suspicion or documented risk of osteoporosis).
    Sometimes I think the prevalence rates of patients who benefit based on the lumbar manip. CPR may be inflated.
    As far as the over-emphasis on basic science goes: I would agree that there’s an over-reliance on what someone ELSE told most PTs what the basic science is, rather than reading about it, thinking about it and developing a deeper understanding of the underlying constructs on their own.
    For instance, at the University of Miami, DPT students are being fed a bunch of bull about energy medicine by a professor who wrote and edited the textbook. I hope after that experience they’re still able to think.

  4. Jason your posts on EBM are dead on. Now if we can just pursue the balance that Rothstein advocates in the editorial you cited:
    “Theory-based arguments will never win battles over the effectiveness of
    treatments, and that is how it should be. Even snake-oil salesmen proffered theories, and theory is often the refuge of rascals who not only lack data but run from data. We need well-developed theories that can be critically examined
    in the public arena-theories that can then give rise in a timely fashion to tests of hypotheses about the application of concepts.”

  5. Jason Silvernail says:

    Ben-
    I would definitely agree that in choosing treatments we should be showing a bias toward treatments supported by outcomes research. However, that’s the “easy” part. I can teach a PT student in half a day to apply the LBP CPR. It’s when the patient presentation is not so simple that things get interesting. And I couldn’t agree more that we need to increase the utilization of proven-useful treatments such as manipulation – it’s definitely one of my most used interventions personally. More later.

  6. John Ware says:

    Rod,
    Thanks for that reminder from Dr. Rothstein.
    I’d like to get your take on how a reputable PT program at an elite private university could allow a PhD level professor to teach entry level doctoral students the “snake oil” theory that comprises
    “energy medicine” when there are more plausible, evidence-informed (based on Ramachandran, Moseley, Butler, Melzack) that support an alternative, nervous system-based explanatory model.
    I would argue that this kind of misinformation is widespread in PT education, though, hopefully, not this egregious. We are exposed to a lot of myth, beliefs based on tradition and outright pseudoscience in PT education (formal and continuing).
    Contrary to what the “evidence purists” keep hollering, until the mythology and lies are overcome and abolished, there is no chance that any balance between theory and outcomes data will be reached.

  7. Hi John. I can’t speak to a universities motivation on maintaining a professor. My guess is it rhymes with the word “funding”. sCAM treatments may be bogus, but they are trendy and do attract funding. A deeper question might be more appropriately directed at the NIH for funding research by the “snake oil” salesmen.
    I think one of the more emergent issues in this profession is the willingness to adhere exclusively either to theory OR evidence. It’d be much easier if we could only focus on one or the other without acknowledging the need for balance as Rothstein clearly advocates.
    John, what would be your solution to the crackpot professor? You may be bighting off more than you can chew. Have you been to an undergraduate history or philosophy course lately? Crackpot teaching is epidemic throught academia.
    The only way to effectively deal with the oddballs is to gradually discredit them by working within the balance of sound theory and the rigors of the scientific method. It won’t happen over night, but I feel that the state of our education will gradually evolve only as much as the profession allows it.

  8. SelenaHorner says:

    Jason, for the spirit of a better discussion, I believe that taking quotes out of context is misleading. Let’s put the context with the quote:
    “Last year I implemented a change in processes at my clinic. After every initial evaluation, I wanted a letter mailed WITH the evaluation and plan of care. I decided that the one page “letter” would provide insight into my clinical decision-making by providing just a few research articles to support the anticipated interventions/clinical thoughts. I just analyzed how that process is going. 53.85% of the time I actually have a letter going to the referring physician. That means that 46.15% of the time, I can’t easily, readily or succinctly communicate the basis for my clinical decisions. Yes, there are times that I have referrals for unusual diagnoses or multiple co-morbidities OR multiple body parts to be treated (there is no easy way to convey treatment rationale with supporting literature with those situations). 46.15% of the time I don’t have solid ground using direct evidence that is easily related to the patient in front of me. I don’t know about you, but that means that you could basically flip a coin to determine if there is evidence existing for the patient coming to you. This also means that there is a reasonable percentage of patients that won’t be treated with evidence because evidence may not exist.”
    The sad aspect of this whole discussion is that when there IS evidence for certain interventions, it is ultimately the patient that loses. Take for example the work by Kathleen Mangione and colleagues, I wonder what the heck is going on in home health and physical therapist interventions post hip fracture. Mangione has had literature out there since 2005…. it’s now 2008 and it doesn’t appear as though the evidence is being applied. What about Lynne Snyder-Mackler and the work she and her colleagues have done with regard to quadricep strength and osteoarthritis and total knee arthroplasties?
    In my opinion, it’s almost as if there happens to be fear that EBM reduces the ability for therapists to be creative and limits their control to make clinical decisions. The stance of some therapists focusing on theory allows them to feel creative. Hanging onto untested theory and putting that theory into practice during a situation with clear cut evidence isn’t what EBM is about.
    I beg to differ that implementing the evidence is the “easy” part because it isn’t really happening. Why isn’t it happening?

  9. Luke Rickards says:

    Rod,
    I know you have pointed out the same statement from Rothstein previously, and I understand why it appeals to you. Your submission that the statement reflects a call for “balance” between theory and outcomes evidence deserves closer attention.
    Theory and outcomes evidence are not in competition for the same objective. We can not aim to find a “balance” between the degree of utility of theory and outcomes evidence within clinical practice. A ‘middle-ground’ does not exist, and choosing to “battle” the two within such a context is essentially a waste of time. Each must be employed entirely, but in its proper place.
    Intelligent theory should form the basis for developing intelligent questions, both in clinical practice and in research. Since we are quoting Rothstein; “When we try to do studies in the absence of well-developed concepts, we court disaster and fight isolated battles that can never lead to meaningful victories.”

  10. Exactly, but it was never my intention to “battle” the two against each other as they are certainly complimentary to each other. Interestingly however, Rothstein uses a war metaphor (theory as a weapon) to make the a very salient point that we must utilize thoughtfulness and the evidence that results to justify our interventions.
    In this sense, maybe balance isn’t an appropriate term. How about theory as a strategic concept with evidence being the tactics that emerge from a good strategy? All the best strategy in the world is nothing without the hardware to back it up. Additionally the best tanks and technology are likely to falter without a plan. I’m sure there are holes in that metaphor as well, but you get the point. I don’t see them as diametrically opposed but complimentary.
    Interestingly, there are some folks better suited to strategy than tactics. It doesn’t make either group any less relevant. Maybe the tacticians and strategists could stand to step away from themselves on occaision to listen to what the other has to say.
    It might be a better way to win the war…

  11. Jason Silvernail says:

    Good start to the discussion.
    I think Luke makes a very important point that the question is not now, nor has it ever been, “outcomes vs theory”.
    When I talk about these concepts to students and other therapists, I like to make two basic points:
    1. We need to show preference for interventions that have solid outcomes associated with them when it’s appropriate to use them.
    2. We need to update with basic science the outdated and unhelpful theories that drive much of practice – associations and conflations between things like posture, muscle strength, muscular length, and and joint mobility, for example.
    In the absence of clear outcomes evidence pointing the way (this situation is actually quite common), we often lean on traditional memes embedded in our therapy culture that are outdated and inaccurate. When the concept of “evidence” becomes only RCT outcome evidence, we miss the chance to change more fundamental (and arguably more difficult to change) aspects of our practice.
    For me to make a good case for lumbar manipulation, I need two outcome RCTs and about 4 powerpoint slides. I give the talk frequently, and I’m quite good at it by now. That’s easy. When explaining to a colleague my problems with myofascial release, I have to rely on more complex explanations and more fundamental arguments about the scientific method and what is true about human physiology as we know it. Many people seem uninterested in such thinking, or frankly, seem unable to engage in a discussion at that level – of course it’s far easier to sling a few outcome studies around – its sure easier on the brain.
    To use Rod’s example, both strategy and tactics are important in a battle and I’m concerned that some of our thought leaders are focusing so much on tactics that our upcoming students and some our colleagues begin to think that there is no place for strategy at the table.

  12. John Ware says:

    Rod,
    The “crackpot professor” is supposed to be a clinical scientist training students to become professional care providers, not some social “scientist” waxing on with a political agenda or revising history to fit their ideological template. While I don’t condone the latter, I would hope that the demarcations of the clinical, neurobiologically-based sciences that undergird physical therapy are more distinct than the geopolitical ramifications of the Mideast peace process or the metaphysical properties of fruit flies.
    The existence of professors like the one at UM is emblematic of the bass-ackwardness of physical therapy education, theory and research. It’s a shining example of how ill-formed our theories are that this woman can fill the skulls of these student with this tripe year after year. And we have the audacity to ask for balance between theory and outcomes evidence?
    I think that’s ridiculously myopic. A few RCTs have come out on spinal manipulation, which are based partly on tradition, partly on intuition and motivated by competition with other providers of the intervention. Where’s the theory? I think it’s ok that these studies were done, but let’s not get cocky, lest we end up like we are now: “fighting meaningless battles.”
    For the record, if I were king of the world, that professor would be run out on a rail. I’m outraged that there’s not more outrage.

  13. Carina Lowry says:

    Hi Jas,
    Would you please explain and expound upon this point: 2. We need to update with basic science the outdated and unhelpful theories that drive much of practice – associations and conflations between things like posture, muscle strength, muscular length, and and joint mobility, for example.
    Are you saying a stiff/hypomobile joint should not weight the clinical decision making of the therapist to apply a manual intervention? Or that a weak low trap with concomitant poor scapular rotation shouldn’t be addressed in an impingement patient? Or that a person with low back pain shouldn’t be taught how to reactivate their transverse abdominus? Or that a person’s posture in front of the computer 8 hours per day could not be a contributing factor for neck pain?
    I am not sure what exactly you mean by your second point.
    Thanks…
    Carina

  14. John. Crap is crap regardless of the course rubric. The fact that is is physical therapy, history, or philosophy shouldn’t make it any less outrageous.
    While I agree with what you are saying and feel your outrage at what is being taught at this particular university, I’m not sure this example generalizes to the state of PT education. It also arrogantly assumes you (not universities who undergo rigorous oversight into the structure and design of curricula) are in possession of what this profession really needs to know. If you do have this depth of understanding, I know many university programs who could use you.
    We are not alone. these problems occur in many science-based professions including education, physics and engineering, and even medical school programs. You seem to think we are the vanguards of this problem, while we are actually just another example of the state of educational theory.
    Fortunately, students become professionals and are ultimately responsible for processing the tripe you are so outraged with. It is OUR responsibility to marginalize professors like the one you cited. I think focusing outrage at a single professor teaching ridiculous theory (again – happening everywhere) is equally “ridiculously myopic”. There has to be a better use of your passion and outrage.
    Unless I misunderstood the wording of your post – how audacious is it to consider the role of theory and evidence in clinical decision making? Help me out as your message may have gotten lost in all the outrage.

  15. John Ware says:

    Rod,
    You have a crafty way of making relativistic arguments that border on non-sequitur. “Crap is crap regardless of the course rubric”, what the hell does that mean?
    I’m telling you that the science that supports health care interventions should be held to a higher, more rigorous standard than some self-indulgent, former hippy yapping on about relatively inconsequential metaphysics, or the Ward Churchills of academia committing the odious act of historical revisionism. Sure, it’s crap, but it’s not about life or death, walking or wheelchair bound or short term pain or long-term suffering.
    And if you think this is the case of a single professor, your whistling in the dark. Raise your hand if you graduated from PT school in the last 5 years, and learned that ultrasound “promotes blood flow and tissue healing.” Raise your hand again if it was impressed upon you during PT school the unmistakable and indubitable link between posture and pain a la Kendall. Raise ’em up again if you learned muscle energy techniques and ERS/FRS during a clinical rotation, or even worse in the classroom.
    You are grossly underestimating the influence of role modeling in the formation of a clinician, particularly in PT where quality outcomes evidence is so scarce. We desperately need deep, clear, serious thinkers (like Jules Rothstein) educating our future colleagues. To accept anything less than honest, committed erudition from our faculty is a sell-out position. And to argue, “Well the same thing goes on in other fields, so it’s not so bad” is as defeatist and relativistic as it comes.
    I would expect more from a down home Texan. I’d also expect less snarky remarks asking me to “help you out.”

  16. Sebastian Asselbergs says:

    Carina, lets put the onus on you: can you point at studies that refute Jason’s points? Since you list a number of what you seem to consider interrelated issues, can you shed some light on these with studies to support that?

  17. Sebastian Asselbergs says:

    Carina, lets put the onus on you: can you point at studies that refute Jason’s points? Since you list a number of what you seem to consider interrelated issues, can you shed some light on these with studies to support that?

  18. Sorry to disappoint John, but you are the half of the argument using terms like myopic, defeatist, relativistic, and snarky. You’ll understand if I don’t allow this to degrade into an argument over who occupies the high ground.
    Sorry for seeming to be patronizing or snarky on my last post, but you seem to have strong enough feelings on the issue, that I really did loose your message.
    I think you (and I) are bright and insightful enough to rise above mischaracterizations of each other. Let’s step back from the emotion of the discussion. I also don’t believe you derive satisfaction from such a discourse. I did not pick this fight with you nor will I be a party to continuing it.
    Lost in the argument between us was the fact we agree that the professor should not be pushing false theories. However, If you feel strongly about an issue like this, you should take action by trying to get this professor fired from the university. Despite the fact I would support such a referendum, I think you would quickly discover just how futile your efforts will be in seeing this through. You may even discover there are better uses of your time and energy in the name of advancing our profession.
    I’d love to fight each battle on every front as well, but realize there is only so much within my circle of influence. I treat, learn, teach, write. Getting upset or devoting my ire to something over which I have no control get’s me nowhere but further from salient action. Others may find issues like this well within their circle of influence and I encourage them to act accordingly. I assumed it to be a waste of your time so I do apologize for being so presumptive.
    I will attempt to bow out of this conversation by saying simply that I respect your opinion. You’ve likely been practicing longer than I have and put more hours in the clinic and in thinking about these issues. All I can say is I’m getting there.
    There is no reason for us to go at it when there are better things we can be doing with our time.

  19. Sebastian Asselbergs says:

    Rod, it does not work to point at other “bad apples” in the world of academia: this is about PT and its weaknesses at this time. Just because we are a part of a larger problem, does not absolve us from the responsibility to protest and condemn bad practices in our house. It sounds too much like chiros : “You think we are bad!? Look at all the deaths by MDs!!” Tu quoque….
    John’s point is well made: SWD, US, “ideal posture”, manual muscle testing, spinal motion palpation, etc etc – none have exactly a solid scientific foundation….Yet are taught at most unis – at least, in North America.

  20. Sebastian Asselbergs says:

    Rod, it does not work to point at other “bad apples” in the world of academia: this is about PT and its weaknesses at this time. Just because we are a part of a larger problem, does not absolve us from the responsibility to protest and condemn bad practices in our house. It sounds too much like chiros : “You think we are bad!? Look at all the deaths by MDs!!” Tu quoque….
    John’s point is well made: SWD, US, “ideal posture”, manual muscle testing, spinal motion palpation, etc etc – none have exactly a solid scientific foundation….Yet are taught at most unis – at least, in North America.

  21. It actually wasn’t meant to be a tu quoque argument. The central meaning of that post was that getting frustrated over what one professor is teaching at one private university is wasted energy. Not that it’s ok because everyone else is doing it. If you want to fight city hall go for it. I will not stop you.

  22. Jason Silvernail says:

    Hi Carina-
    I think John Ware made my point pretty well for me – I could have made a whole post on Kendall’s “Posture and Pain” alone. Maybe I will in the future. I turned in my “posture police” badge years ago.
    The so-called “neurobiological revolution” has happened all around us, giving us reason to dump much of what was taught as traditional PT theory in favor of more useful avenues of thought and research. However, we have ignored that information with all the speed and success that many PTs have ignored the high-quality outcomes research. This is distressing in both ways.
    Selena-
    Your addition of context to your quote did, as I predicted, no further work towards making your percentage meaningful. Additionally I have no idea what research you are referencing about home health care or its relevance here.

  23. Christie Downing says:

    Jason,
    It’s always a good dicussion from you that gets me out of lurker mode. Just when I was ready to “hang up” on this blog, you’ve sucked me back in!!!
    Regarding outcomes and outcome studies, I agree that we limit ourselves when we focus on RCTs (I think that’s a point you were trying to make). Rather, we need to take a step back further and get a better understanding of: A. To whom are we applying certain interventions?
    B. Are the groups we are applying them to really homogeneous?
    C. In otherwords, do we need to get a better grasp on our assessment procedures and diagnostic triage? We’ve done a fairly good job of identifying what physical tests correlate with said findings that appear on imaging studies, but as the link between pathoanatomics and disability/pain becomes more and more blurred, our diagnostic triage is becoming useless. Clearly, we need more work here and focusing on RCTs is putting the proverbial cart before the horse.
    Furthermore, I believe someone questioned about getting rid of useless theories. I couldn’t agree with you more. Let’s go back to my original arguement, that our assessment process really needs work…so how we decide who is “weak” and who is “hypomobile” clearly needs work. MMT test remains a cornerstone in a PT assessment but we’ve yet to prove what, if any validity it has. To borrow John’s phrase “Raise your hand” if you’ve done an assessment where someone had 5/5 quad strength, yet cannot get out of a chair without using their hands. Therefore, these impairments for which we first look for first has the issue of lack of evidence for their use. Secondly, that these impairments (when we believe they exist)cannot yet be relaibly applied to lead us in the direction of appropriate treatment. The concept of “It’s weak therefore we must strengthen it” or “It’s hypomobile therefore we must mobilize it” ignores the notion that perhaps it’s not the cause of the underlying problem, but rather the result.
    I think the notion behind evdience based practice goes way beyond outcomes because we still need so much work on our assessment process. I believe that we can only start applying apporpriate outcome studies once we’ve identified more appropriate/homogeneous groups and we stop performing “impariment based” interventions. It’s going to take a whole shift in how we look at problems. Yet, when we look back to our basic sciences…anatomy, neurobiology, histology and how those things are affected by movement, loading, sensory retraining, etc, we have a good basis, we just need to start putting it in more useful contexts.
    Thanks for a good discussion.
    Christie

  24. Jason Silvernail says:

    Christie-
    Thanks for your contribution, excellent post. You and John Ware answered Carina’s question better than I did.
    If the “stretch the tight muscle and mobilize the hypomobile joint” approach feels as unsatisfying to you as it does to me, then you might enjoy something I wrote a while ago called “The Problem with OMPT”. You can find it on Soma Simple here:
    http://www.somasimple.com/forums/showthread.php?t=3886

  25. Gregory Redmond says:

    As a graduate of UM, I have to say that it took me several years to shake the hold of unbelievable-unsupported theory that was offered by this professor as food for a growing mind and developing skill set. Now several years later, I can see what a diversion it was to true learning and development as a EB-practitioner. I am only happy that I was able to write it off as a lesson in how to examine literature and look elsewhere than that part of my formal education for guidance.

  26. Jason Silvernail says:

    Greg-
    Please feel free to contribute to the MFR blog post series:
    http://blog.myphysicaltherapyspace.com/2008/03/myofascial-re-2.html
    Especially the first post in the series.

  27. Christie Downing says:

    Jason,
    Thanks for the link…My sentiments exactly…what are we feeling anyway?
    As a side note regarding your comments about Mosley. He was a very welcome and well-received lecturer at the “McKenzie” conference of the Americas. His theories and work will supplement what has otherwise been labeled as a “mechanistic approach” to treatment by those outside this arena. The concepts of nerual inhbition, perceived threat and “central sensitization” are still very real components of this assessment process.
    …and Mosley is a STITCH…very dynamic speaker.

  28. John Ware says:

    Did you hear that Rod? It took Greg SEVERAL YEARS to decontaminate energy medicine B.S. from his clinical decision-making process. Talk about a mind being a terrible thing to waste…
    The propagation of myth in PT schools is not at all rare. The example I cite here merely shows to what degree it is allowed at a prestigious (and expensive) private university, no less.
    If this doesn’t get your Texas ire up, well then, I’m not sure what would.
    I waste some things but passion is not one of them. It’s why I keep arguing in the face of seemingly intractable resistance.
    By the way, is it better to be subtley sarcastic and indirect in one’s comments rather than state precisely and accurately with which positions one disagrees?
    “Defeatest,” “myopic” and “relativistic” characterize your positions, NOT your character. But if you’d like me to be sardonic and snarky, I can do that, too.

  29. Again…NOT disagreeing with you John. It does draw my ire, but not my energy. Like I said if you want to take this on, you’ve got my support.
    Why not set up an affiliation agreement with UM and start teaching their students in a clinical setting? It would give you an opportunity to erode this professors credibility in a productive manner.
    Arguing in the face of intractable resistance is fine. Action works too.

  30. SelenaHorner says:

    Jason, I had 2 points.
    #1 In an outpatient orthopaedic setting, there really isn’t enough strong, concise evidence to guide clinical decisions for all the various types of diagnoses treated. In those cases in which there is little definitive evidence, I’m sure some literature can be a part of assisting the clinical decisions, but the literature would need to be extrapolated somewhat. This also means that physical therapists will fall back on habit, common sense and previous experience.
    #2: As you all discuss EBM, reality is that even when there is good, quality evidence to guide clinical decisions, in general, across our whole physical therapist population, I highly doubt that evidence is being implemented. Mangione’s work is just one example. It seems as though many here are focused on manipulation and the clinical prediction rule for manipulation… but look at Mangione’s work with physical therapy post hip fracture. (Hip fracture is quite common with elderly individuals.) It is very easy to implement her work into practice and it isn’t happening. I’m not really sure what happens when physical therapists read reasonable research that is easy to implement. Are therapists hung up on their “experience” and that what they do “works?” I don’t know, but if I were in the researchers’ shoes, I’d be disheartened and confused as to why clinically relevant research isn’t being implemented.
    I tend to think that those that regularly comment here are not representative of the physical therapist population. All of you: your critical thinking ability, passion, and continual daily education in your specialty area are not typical of most physical therapists.
    In my opinion, there are quite a few barriers for EBM:
    1) as a whole, physical therapists (and even physicians) refuse to believe that mathematics and statistics can assist with making clinical decisions
    2) the example of education with a continual perpetuation of crap
    3) the lack of accountability of physical therapists for their performance
    4) a poor individualized process or lack of process that individual physical therapists use to determine their own performance in knowing their clinical experience/expertise
    The real question, Jason, shouldn’t be one that pits theory vs outcomes against each other, but instead, how can we motivate and mentor other therapists so there is a measurable reduction in variation of practice?

  31. Jason Silvernail says:

    Selena-
    I think in almost every case, evidence “must be extrapolated somewhat”. I’m not sure about you, but I often have patients with low back pain who do not neatly fit the manip CPR or who might fit it but also might benefit from directional preference exercise. So in order for me to treat this patient, some degree of judgment and weighing of options must take place. This is what I’m referring to as the more difficult component of evidence in practice and it can’t be answered by a simple yes / no.
    Of course I agree that people aren’t implementing good evidence in practice, though that isn’t really the thrust of this post.
    Also I agree with your last paragraph noting that it isn’t about outcomes vs theory and that is just repeating Luke’s point above.
    What do you think about the issue brought up by the post – that outcomes evidence has become a proxy for all evidence and that people are already battling about who’s purer than whom in their “evidence-based-ness”? And how to tell who’s “evidence-based” enough or more “evidence-based” than another?

  32. John Ware says:

    “It does draw my ire, but not my energy.”
    Hmmm…then who’s the one that needs to start taking action lest the ire turns to angst?
    I’ve learned to act on my passion, and don’t presume that an action plan for my specific example is not underway as we electronically speak.
    Gregory,
    Do you have access to a message board at the UM PT program? You can PM me from the MyPTSpace section if you’d prefer.

  33. SelenaHorner says:

    Critically thinking and reflecting about one’s own clinical practice with others and sharing those thoughts doesn’t equate to some childish comparison of numbers.
    Evidence based practice can’t be a yes/no kind of thing because evidence based practice could describe how one makes decisions while at the same time can be measured by behaviors. A physician either prescribes an anti-coagulant or doesn’t. When a patient meets the criteria for lumbar manipulation, the therapist either manipulates or doesn’t manipulate. When a patient is receiving home health physical therapy services for a fractured hip, the physical therapist either provides moderate to high intensity strengthening exercises or doesn’t.
    Outcome evidence does trump all other evidence. It is good for therapists to be discussing potential treatment strategies based on published literature. It probably is a bit intimidating for some therapists to share their thoughts because there inherently will be questions with regard to rationale and supporting evidence. The days of “because it works” are gone, unless there really isn’t much evidence out there for the situation. In those cases, therapists are either going to use theory, habit, common sense, or experience. Evidence based medicine also considers the patient’s perspective. If aquatic therapy would be the intervention of choice, but the patient is deathly afraid of water and pools, that option isn’t going to work.
    If you really want to know who is more evidence based when comparing physical therapists, you’d need to actually collect data and measure behaviors. Behavior determines if one is evidence based or not.

  34. Jon Newman says:

    Hello Selena,
    If this is true
    “If you really want to know who is more evidence based when comparing physical therapists, you’d need to actually collect data and measure behaviors. Behavior determines if one is evidence based or not.”
    Then pay for performance schemes ought to pay for what a therapist did rather than their outcomes.
    Tracking could be made more easy by assinging CPT codes to specific treatments rather than groups of treatments.
    Someone in CPT land could fiddle with pricing and raise or lower the reimbursement rate for each code depending where the evidence is pointing. (I imagine this would be a full time job.)
    An electronic message could be sent our daily or weekly as to reimbursement rates will be each day.
    What do you think?

  35. Jon Newman says:

    This is a restatement of the above. Sorry for doing my editing online rather than off-line.
    Hello Selena,
    If this is true–
    “If you really want to know who is more evidence based when comparing physical therapists, you’d need to actually collect data and measure behaviors. Behavior determines if one is evidence based or not.”
    –then pay for performance schemes ought to pay for what a therapist did rather than their outcomes. I’m assuming here that evidence based practice is something worth promoting and that outcomes will necessarily follow.
    Tracking what a therapist did could be easy if CPT codes were assigned to specific treatments rather than groups of treatments. Of course the codes would have to come with evaluative contigencies.
    Someone in CPT land could fiddle with pricing and raise or lower the reimbursement rate for each code/evaluative contingency depending where the evidence is pointing. (I imagine this would be a full time job.)
    An electronic message could be sent our daily or weekly indicating what reimbursement rates will be each day.
    What do you think?

  36. John Ware says:

    So, based on Jon’s hypothetical P4P scheme,if you apply the lumbar CPR to a patient who meets at least the 68% +likelihood ratio for successful outcome with manipulation, AND then you utilize an “acceptable” evaluative tool to measure this outcome, THEN you’ll get paid? What if the patient meets the 95% level? Do you get paid more? Or, is the cut-off just set at a certain arbitrary level (developed by some pinheads at CMS). What if they go from 60% to 40% on the Oswestry, do you get paid more than if they went from 40% to 30%? What if they go water skiing after getting down to a 30% and then shoot up to a 60%. Do you have to pay CMS back?
    Sounds complicated- perfectly consistent with the current system. And would coincided with the end of my career treating Medicare beneficiaries.

  37. Selena Horner says:

    Jon, this discussion isn’t about reimbursement and alternative payment schemes.
    Internally, physical therapists themselves OR administration could implement a process to monitor clinical decision-making. This is actually occurring at Intermountain (Julie Fritz comes to mind) and with work being done by Anthony Delitto. They have designed data collection sheets that capture relevant data about the patient and the clinical decision-making process of the clinicians. The patient population is very narrow and seemed to be those with low back pain. The process I have heard them describe definitely increases clinician accountability.

  38. Jon Newman says:

    If we have good reason to promote EBP then why not tie reimbursement to the behavior of the therapist? What could be more motivating?
    I don’t understand why people would decry a lack of evidence incorporation into daily practice but not endorse a system that demands it or at least rewards it.
    Shouldn’t the one best therapist behavior (that day’week) make good outcomes inevitable?

  39. John Ware says:

    Selena,
    I thinks it’s pie in the sky to assume that there would be widespread implemenation of EBM based soley on “accountability.” There needs to me a profit motive as well. Since health care is a business, the practice of EBM would have to be tied to reimbursement for it to gain widespread acceptance. Isn’t this at least the idea behind P4P?
    Jon’s scenario exquisitely highlights where we are with EBM in PT at the current time. To attempt any pragmatic implementation system-wide would place too much discrectionary power in the hands of beauracrats, and would be a disaster for our already teetering health care system.
    You would see a mass exodus of professionals who are already fed up with byzantine compliance and reimbursement regulations.

  40. Luke Rickards says:

    One might conclude from a number of comments here that:
    – one or two studies of high internal validity supporting a particular approach ensures applicability of the data to all patient and practitioner populations.
    – practitioners can be satisfied with such data in the absence of a reasonable explanation for it.
    – EBP dictates that the appearance of a few such studies in the literature is some kind of mandate that the approach must be incorportated into clinical practice immediately.
    All three of these positions are erronous.
    A satisfactory outcomes evidence-base in support of a given approach will not come from a few studies. It must come from a cohesive body of evidence of varying types, using varying populations and in varying settings, that consistently demonstates a clinically meaningful effect.
    What is the most appropriate way to justify what we do with patients in the meantime?

  41. John Ware says:

    Based on the points Luke just so lucidly made, is it possible, based on the lack of a theoretical underpinning, that lumbar manipulation may NOT be the best, safest, most efficacious method to treat someone with an acute episode of LBP who happens to meet the CPR criteria?
    I’d argue without a sound theory to back it up, it’s my right as a thinking, reasoning and intelligent person, to choose something else with any given patient. Furthermore, I shouldn’t be told by anyone based on current evidence that I’d better use this technique, or I’m not going to get paid OR that I’m going to be held “accountable.”
    That attitude is scientific hubris, and, as I said, will run a lot of smart, excellent practitioners out of the field.

  42. Diane says:

    John Ware, “I’d argue without a sound theory to back it up, it’s my right as a thinking, reasoning and intelligent person, to choose something else with any given patient.”
    I couldn’t agree with you more. Thank you for putting it so succinctly.
    “Furthermore, I shouldn’t be told by anyone based on current evidence that I’d better use this technique.”
    I distinctly remember a certain discussion a number of years ago, post CPR on lumbar manipulation, in which it was declared that anyone who did not, use it would be considered to be practicing “suboptimally.”

  43. Sorry to break into the middle of the “exquisitely”, “lucidly”, and “succinctly” made points to ask a question here…
    Is it your contention this profession is headed in the wrong direction with respect to how we view clinical problems, OR are we just not as developed as you would like?
    If it is headed in the wrong direction, what do you propose to reverse the slope? Put yourself in charge of the profession and tell us what you would do.

  44. Jason Silvernail says:

    Rod-
    I don’t think your question was directed to me, but I’ll answer it in terms of what I’m writing about in this post. I think our profession is headed in the right direction, but its foundational concepts, that should have changed years ago, hang on despite the neurobiologic revolution. In my opinion, this is a larger threat to our true embrace of EBP than the unwillingness of some therapists to weight properly the existing high-quality outcomes RCTs.
    I propose that we have open discussions about aspects of our foundational science that have changed and exert professional pressure on our peers (and especially our academics) that reflects that change.
    Also we absolutely should be encouraging the use of well-supported interventions as first-line treatment such as manipulation, directional preference exercise, active therapy in general, high intensity strengthening exercises when appropriate, and education. But as I said I believe this is less important in the long run to our health as a profession and in terms of the quality of care we provide.

  45. SelenaHorner says:

    Maybe it is time for some theories to be put to the test?
    Here in MI there existed a theoretical plan for a particular bridge – the Zilwaukee Bridge – which many of us in MI shake our heads over. Not calculating appropriate heights, not calculating appropriate loads and not recognizing the impact Mother Nature can have on the expansion and contraction of cement led to problems in the initial theory/design.
    How can implementing known beneficial interventions be less important than an unknown?

  46. Jason Silvernail says:

    Maybe it is time for theories (eg posture and pain) that have been put to the test and failed, to be eliminated from our therapy culture?
    I am talking about the fact that changing some of our foundational science to reflect what is known, and abandoning outdated processes and ideas that have been falsified by data is also Evidence Based Practice. What “unknown” are you talking about?
    I could provide examples if you’re having trouble seeing what I mean. I recommend the MFR blog series as a starter, though manual palpatory diagnosis and the posture/pain link provides fertile ground to consider these issues as well.
    Isn’t the act of incorporating this information into practice and abandoning inaccurate ideas about manual diagnosis and postural correction for pain relief (just two examples) also Evidence-Based Practice? Or is it all about whether or not I use a few interventions that have some RCTs behind them?
    Because if that’s the case, then EBP is easy. Just use a handful of interventions without thinking about other sources of evidence (or other reasons to change your practice or reasons to be reflective in why you do what you do). That and a few patient-centered outcomes and you get your gold “EBP Star”, right?
    If so, then send me a Tshirt already. I’ve been using subgroup classification for back and neck pain, manipulation/ stabilization /directional preference for low back pain for years, including administering outcome measures. I contend that what makes me a true “EBP” practitioner is my willingness to change my practice and my ideas with ALL sources of evidence. But like I said, if it’s just a few interventions and using the Oswestry scale, then I guess I’ve done all the EBP I need to do.
    This issue is the genesis of this post – what exactly does it mean to be EBP and how can we decide such things based on the use of a few interventions alone, as many would have us believe? How can we assign percentages and relative EBP purity when such concepts blatantly ignore the complexity and depth necessary to be a true clinician and scientist? Don’t our patients and our profession deserve a more serious conversation about how we train therapists, provide care, and define ourselves?

  47. John Ware says:

    Rod,
    I think the tide is just starting to turn in terms of improvement in understanding of the need for deeper, theoretical explanations for what we do. The internet forums like this, I think, are starting to make a difference in educating clinicians and educators (although I wish I heard from more academics at these sites).
    However, I’m very concerned, as a private practitioner, about the entrenched reimbursement/3rd party pay system that fails to recognize or accept that the provision of health care desperately needs more, not less, competition and real accountability based on financial, not regulatory, incentives. I cringe when I hear political candidates suggest nationalizing our system based on a Canadian or British model. I don’t see that as a viable solution-not in our diverse, historically individualistic American culture. In a word, such a change would be “Un-American.”
    We need to see the reimbursement practices as a strong, if not primary, underlying force behind the inertia that supports the outdated, biomedical reductionist approach to treating pain. We currently get paid more for what we do, rather than the results we achieve. It’s really that simple, and has reached Dickensian levels of lunacy with regards to the Medicare regulations.
    We now have leadership at APTA that seems to “get it” that PT is a business as well as a caring profession. Perhaps we should update the tagline to: “The science of healing, the art of caring, the business of getting you better.”

  48. SelenaHorner says:

    Yep, APTA leadership definitely gets it… all the recent “news” on “tummy time” is gonna help my business! Don’t even start on the “business” aspect of it. It seems as though the APTA supports the current regulations that reduce profitability.
    Jason, I already gave you my “data” that just a little over 1/2 the time I can concisely, easily and directly supply evidence in literature that will heavily factor in on the treatment to be provided for the patient. The other patients have me thinking, “hmmm, what might accomplish the desired outcome?”

  49. John Ware says:

    Come on Selena, give credit where it’s due. I don’t want to get too far afield of the topic, but APTA is definitely getting more aggressive about protecting practice scope, and they are soliciting input from membership for more effective marketing strategies.
    The leaders can set an example, but they won’t change the system. Only mass efforts by lots of clinician, educators and even consumers/patients will ultimately produce real change (notwithstanding the Obama campaign mantra).
    The same goes for PTs getting off their butts and educating themselves about the neurobiological revolution that’s currently underway. If we continue to treat pain the way we are now, waiting around for RCTs and meta-analyses, then we will miss out on a critical opportunity to grow the profession.

  50. “The other patients have me thinking, “hmmm, what might accomplish the desired outcome?””
    And what eventually guides your decisions in these cases?

  51. There isn’t a quote/paste function so I’ll need to address each post individually.
    Jason. Your points are well taken and I agree. However, as one of my professors puts it, the process is an “evolution and not a revolution”. I know I’m a semantics-honk think this distinction is important. The proliferation of neuroscience has grown from the inadequacies of a strict biomedical model. It represents an evolution of thought – it’s not some counterculture. It’s the commen sense use of evidence (at all levels as you mentioned).
    I think it would be interesting to review this conversation in ten years. My suspicion is that we would share a laugh at how we were trying to force a process that is naturally occuring. Neuroscience and orthopedic science are being recognized as integrated fields instead of “specialties”.
    For me, I am already seeing students emerging from their studies at schools like UTMB and TWU with this understanding; needing the occaissional nudge from a clinical instructor for that ‘aha’ moment. Ultimately, it is up to the individual practitioner to choose a deeper understanding of what’s going on. The evidence-based practice will be a natural consequence of this choice.
    It may not be happening quickly, but nothing worth having happens quickly. The evolution will proceed with theory and the evidence to support it. Just look at the orthopedic literature over the last 5 years – riddled with neuroscience.
    It will be up to us as clinicians to run with the ball we are being thrown.
    John…you and I are lock-step on the political front. Third party (anyone other than us) regulation is not the way to allow this evolution to occur at its natural pace. In fact, it will be a great way to stifle it. I feel the life blood being sucked out of me when I think about CMS guidelines or fill out ACN paperwork.

  52. John Ware says:

    Rod,
    I think “revolution” is an accurate term. Evolution implies that current practice is headed in the right direction and the underlying paradigm is accurate, but just lacking in information.
    The neurobiological revolution that Jason refers to will cause a necessary paradigm-shift, which would be revolutionary as it would profoundly alter current PT education and practice- at least with respect to treating pain. The neuro folks understand this much better than we ortho types.

  53. Jess Brown says:

    Some of the recent comments here highlight what I believe to be Jason’s original point – that to say one is practicing in an evidence-based manner is not as cut and dried as some of us would like to believe.
    For instance, Jason states :”…
    we absolutely should be encouraging the use of well-supported interventions as first-line treatment such as manipulation, directional preference exercise, active therapy in general, high intensity strengthening exercises when appropriate, and education…”
    Whereas John had previously pointed out: “
    Based on the points Luke just so lucidly made, is it possible, based on the lack of a theoretical underpinning, that lumbar manipulation may NOT be the best, safest, most efficacious method to treat someone with an acute episode of LBP who happens to meet the CPR criteria?
    Now, having been lurking about this site for a while now, I’d argue that both of these clinicians are people who practice physical therapy in an evidence-based fashion. But, as highlighted above, they are, at least hypothetically, choosing different interventions to treat the same sub-group of LBP patients.
    So, throwing this out there for the group: Is it possible, that it’s not necessarily the intervention chosen (particularly given the relative dearth of great data out there to guide us in our decision making), but the thought process one uses to arrive at that intervention that helps to define an evidence-based practitioner? This seems to me to be the “thoughtfulness” that Jason was speaking of earlier.

  54. John. I’m not sure when or where you went to school, but I assure you the principles of neuroscience are alive and well in some PT school curriula. They are being taught. You think we aren’t getting there and I think we are. That’s probably the foundation of our disagreement.
    I’m taking a course at TTU’s ScD program this Fall titled “Neuroscience in Orthopedics”. That will follow with a course called “Motor Control in Orthopedics”. Those courses have been around since the programs inception. I’d love to think this program is incredibly unique in offering this material, but I doubt it. Evidence is slowly mounting in support of an integrated approach and we are headed in the right direction…and have been for a while.

  55. John Ware says:

    I don’t know about you, Rod, but I’m treating patients with pain, not motor control problems.
    I’d be interested to get a summary of the topics covered in that neuroscience in orthopedics course.
    I graduated from PT school in 1994 and completed a full-time AAOMPT residency program in 1998. I didn’t read or hear about Clifford Woolf’s studies on central sensitization published in 1983in the journal “Nature” until last year. Why do you suppose such critical information about the nature of chronic pain took so long (and is still waiting to be) disseminated to clinicians treating pain?
    Can you say “biomedical reductionism” three times real fast?

  56. Jess,
    “So, throwing this out there for the group: Is it possible, that it’s not necessarily the intervention chosen (particularly given the relative dearth of great data out there to guide us in our decision making), but the thought process one uses to arrive at that intervention that helps to define an evidence-based practitioner? This seems to me to be the “thoughtfulness” that Jason was speaking of earlier.”
    Nicely stated. Clinical reasoning implies a thought process. Evidence sould inform our reasoning. When we simply plug patients into data fields without regard for the question we are attempting to answer, then I feel we are replacing reasoning.

  57. Christie Downing says:

    Cory and Jess…
    In agreement with both. As I had stated earlier, we need to go back and review who we are treating with what interventions before we can decide whether they are effective or not.
    Cory, you and I have argued with others in other blogs about the ADTO model…I think we agree that the A-D (assessment-diagnosis)link needs to be established before the T-O link.
    Having graduated in the not-TOO-distant past (8 years)and being actively involved in an educational institution, the pathoanatomic and impairment based models are still alive and well. Subclassification is still a relatively new concept. Although many paradigms have been developed: Petersen, Fritz, Sahrman, O’Sullivan, etc that each have their own unique focus on biomechanics, psychosocial factors, pathoanatomical, and neurobiology. Even those that aren’t new (McKenzie) continue to evolve. It’s becoming evident that focus in either one area is not as effecient as taking multiple bases into consideration. Take, for example, some of our internal data collection with our affilate facility. While those who used McKenzie’s classification system have somewhat better outcomes than those who used Butlers (I think it was a Butler system), both (separately) are more effective those who are NOT trained, educated and implementing EITHER of these systems. YET, those who use BOTH (providing both an MDT and pain classification) have better outcomes than anyone else. Clearly, these systems either need to continue to develop further internally (I already mentioned how Mosely has been incorperated into the MDT system and how neurodynamics are being introduced at the diplomate level of MDT training) or further systems need to be developed. In the end, the pathoanatomic model that most of us had at our entry level education is clearly inadequate. Therefore, our educational instituations really need to revamp how they are teaching assessment rather than focusing on what is an effective “treatment” or not. It makes no sense to me that instituations are implementing manual therapy residencies at the entry level without being able to show them a reliable and valid way to assess and classify their patients. Time to get back to the beginning.

  58. “I didn’t read or hear about Clifford Woolf’s studies on central sensitization published in 1983 in the journal “Nature” until last year. Why do you suppose such critical information about the nature of chronic pain took so long (and is still waiting to be) disseminated to clinicians treating pain?”
    Is this a serious question? Did you want Woolf do waltz into your office and guide you through his article? The fact you didn’t discover it until 25 years after it’s publication doesn’t mean the evidence isn’t there. It means the evidence was there and you didn’t find it. Not really a legitimate reason to indict the profession. A close look in the mirror might reveal part of the problem. (for all of us)
    You are treating patients with pain and not motor control problems? Good for you hoss. You don’t see the two as related? Let’s kick this around via email…I’ll pm you.
    I have the reading list for my neuroscience class. I think you might be pleasantly surprised at the content of the course. If not, that’s ok too but I thought I’d offer some evidence that we are emerging from the caves.
    I have TONS of clinical literature dating back to 1995 on the issue of pain and neuroscience as it relates to clinic. Granted I haven’t always made the best use of it, but that’s MY fault. Not my profession’s! I am finding better ways of incorporating it into my practice. I just don’t believe I am one of the elite few who see things this way.

  59. John Ware says:

    In other words, Christie, what I hear you saying is that we need to revolutionize physical therapy education to fit into the emerging neurobiological paradigm, which more accurately explains what we know about the role of the nervous system in the perception of pain. (I added on that last part.)
    A little history to add perspective:
    The current reimbursement system is a product of the biomedical model of reasoning, which is as old as the “Age of Reason”- that’s about 300 years.
    Our orthopedic orthodoxy is merely a branch of this biomedical reductionism. Up to now, physicians have been successful in carving out (no pun intended) this special, rationalistic place where they’re in sole control of diagnosing “disease.” However, their efforts at treating chronic pain where’s there’s no distinct etiological source are marginal at best, and destructive at worst.
    Bowing to doctors’ superior education and mastery over their definition of disease, PTs have marched on within the field of rehabilitation carrying the orthopedic torch to search in vain for the pathoanatomic “holy grail”- or what my good friend Dave Z. in Texas refers to as “the angle of the dangle.”
    Yet, the truly honest, hard-working clinicians who work in the trenches with pain patients everyday and who don’t have a stake in the current continuing education/orthopedic residency market are beginning to get restless and frustrated. I don’t know him, but I suspect Lorimer Moseley may have been one of them at one time.
    I remember reading a novel by Chiam Potok in a freshman theology course (the Jesuits made me do it) called “In the Beginning.” I remember the first line of the book: “All beginnings are hard.” Christie’s right about this being a beginning, but I don’t know about going back. I do know that it won’t be easy.
    I also remember something I read more recently from Strong’s Textbook on Pain. World-renowned pain researcher, Patrick Wall wrote the forward. In the first sentence or two he said this: “I believe physiotherapy and occupational therapy are sleeping giants.” He was talking, of course, about treating chronic pain.

  60. John Ware says:

    Rod,
    If you’d save your down-home Texas vernacular for the boys down at the ho-down I’d appreciate it.
    (Only my wife can call me “hoss.”);)
    I think I made my over-arching point about the failure of modern orthopedic medicine in the post above. Of course, motor control theory is an element of all movement therapy, but pain theory supersedes in a patient with a persistent pain problem. Those are who I’m treating at least 2/3 of the time. And I really don’t know who your patient population is. (I wasn’t being snide there.) If your caseload is 2/3 post-op extremities, then we live on different planets, so that might be the source of the disconnect here.
    Regarding Clifford Woolf’s “Nature” article being broached in PT school or my residency goes, well I guess I’m guilty as charged. I had absolutely no say over the curriculum in either case, but you’re right, I should’ve found that sucker. I should have told ’em to hell with your FRS/ERS, to hell with you grade I-V, to hell with your myofascial this craniosacral that, to hell with your slumped shoulders=pain, to hell with your ultrasound for tight, sore back muscles, to hell with it all….
    I should’ve been a rock star!

  61. Jon Newman says:

    I’ve made this argument in the past. Please feel free to shoot it down so I can discard or modify it if I need to.
    While there are different kinds of CPRs the interventional (prescriptive) CPR doesn’t tell someone which intervention a particular sub-group of people needs, it tells a practitioner that plans on using a specific intervention which sub-group of people it works best for. It also gives data about that group of people so that if an alternative is chosen for that group (and the same goals pursued) but similar results are not being obtained, then one should really change their intervention.
    Fire away.
    Also, the following has been posted here before (in the comments section of another thread) but I’m reminded of it as I read through the discussion.
    This paragraph from the link sticks with me
    ” Having said all that trenchant stuff, which I sincerely believe, I have a confession to make. I practice many unscientific therapies myself. In particular, I manipulate. I constantly invent new and sometimes better ways of doing things, and I use them before they have had anything approaching the dignity of a randomised controlled trial. I can’t list them all now, in fact it would take longer than I have just to tell you my techniques for removing peas from children’s noses, let alone my technique for stopping pin-hole leaks from oedematous legs, which almost never fails. Or my original idea (as it was at the time) of using tiny doses of beta-blockers for driving-test nerves, it was a long time before I had a failure with that as well.”
    Here’s the link.
    http://www.friendsinlowplaces.co.uk/sea_monster_and_the_whirlpool.htm

  62. Christie Downing says:

    John:
    “In other words, Christie, what I hear you saying is that we need to revolutionize physical therapy education to fit into the emerging neurobiological paradigm, which more accurately explains what we know about the role of the nervous system in the perception of pain.”
    I would certainly agree that a purely biomechanical concept of pain is certainly inadequate. Wheather it’s “neurodyanmic” or “neurobiolgical” Butler, Shacklack, or Mosely I certainly don’t have the answer…but I agree that the science behind pain needs some element of both the biomechanical and the neurological. I think you would agree that although nocioception can be painful, pain does not require nocioception. I think it was Mosely who said that the nociocpetive fibers being labeled as the “pain fibers” is one of the greatest tragedies of our understaning in pain.
    “Bowing to doctors’ superior education and mastery over their definition of disease, PTs have marched on within the field of rehabilitation carrying the orthopedic torch to search in vain for the pathoanatomic “holy grail”-
    …precisely.
    It frustrates me to no end when I can make a patient’s pain go away, but they still want a pathoanatomical reason or that they think they need an MRI to confirm it. In the end, that MRI will not change how I approach their treatment (of course except in cases of suspected red flag pathology).

  63. John Ware says:

    “I think you would agree that although nocioception can be painful, pain does not require nocioception.”
    Close, but not quite. Nociception in and of itself is NEVER painful, but it often is a contributor to the pain experience. You have only to note those wacky S&M types to realize that nociception is actually pleasurable to some.
    Pain is built in the brain.

  64. Christie Downing says:

    “You have only to note those wacky S&M types to realize that nociception is actually pleasurable to some.”
    …um, thanks for the visual…
    (that’s why I said “can” and not “always”…you can insert “contibute” I will conceed)

  65. John my Texas vernacular get’s me in Texas-sized trouble at times. Hoss, boss, and chief always seem to get worked into my posts. It sounds much better face-to-face and is not meant to be disrespectful.
    I called bullsh** on more than one occaision in PT school. At the time I’d already been through a graduate program in exercise science, and much of what was being taught didn’t quite jibe with what I’d learned previously. On the whole, I think I was very fortunate in school. My professors at UTMB were/are very active, enthusiastic, and receptive to criticism. Some of what they taught me was not accurate, and some was just plain wrong.
    However, they did what good teachers do…opened doors.
    PT students are not nose-picking teenagers. They are adult learners and should be questioning every single word being taught them. This simple act of questioning (continually) leads to answers you never would find by relying on the so-called experts of the profession. As Carl Sagan put it “There are no authorities in science”. As such, the individual practitioner, is ultimately responsible for understanding what EBM is and is not.
    These individual practitioners (including myself) are the ones who will hopefully go on to add strength to the evolution of our field.
    Nerdy statement follows: I am very excited and optimistic about the direction this profession is heading. We are in the middle of an unprecidented explosion of theoretical understanding and evidence to back it up. We’ve come a long way baby and I see nothing but good things in our future as long as we stay vigilant.

  66. John Ware says:

    Just to encapsulate the points I’ve been trying to make about EBP purity and and its origins:
    1)Orthopedic medicine is a biomedically reductionist approach to treating pain, and does not account for the multi-dimensional aspects of the pain experience.
    2)Physical therapy’s origins,particularly in the U.S., are in orthopedic medicine, and our profession remains inextricably linked to reductionistic methods of identifying MSK impairments.
    3) The reimbursement system was created by physicians with insurance companies showing them how to codify it to fit the biomedical model of disease.
    4) PTs are forced, if they want to survive financially,to participate in a payment system that doesn’t jive with the vast majority of conditions we treat. This is a source of either frustration or passive acceptance, depending on your personality or motivations (obviously, I fall in the frustration camp).
    5) Most “diseases” in modern times (in Western cultures) are chronic, and do not fit the biomedical model, and therefore aren’t treated effectively or efficiently. Pain is largely the common feature of chronic conditions.
    6)EBP purity is our misguided (and vain) rational attempt to try to make pain patients fit into a biomedical model. Worse than trying to fit a square peg into a round hole, it’s more like trying to stuff an elephant through a keyhole.
    7) We not only need a new keyhole, we need a whole new door, and the neurobiological revolution provides the key.

  67. A similar issue was raised on the neurologica blog of Dr. Steven Novella recently in the thread “How Much Modern Medicine is Evidence Based.” Definitely worth a read.
    http://www.theness.com/neurologicablog/?p=51
    I particularly liked this:
    “My personal experience is that nearly 100% of the clinical decisions I make are based upon the best available evidence combined with plausible and rational extension of what is known. I can’t think of any time when I use treatments that are based upon nothing, or even nothing but anecdote. At the very least there is a biologically plausible mechanism of action and adequate evidence for lack of harm. The only exception to this, of course, is experimental treatments – but they are highly regulated and follow their own stringent ethical guidelines.”

  68. John…seriously? Are you performing manipulations as well? If you aren’t, keep doing what you do. You’ll likely help this woman and get her away fromt he chiropractic paradigm.
    If you aren’t performing manips on her, what kind of legal issues could you possibly be concerned with? In the battle for hearts and minds we often fight against the chiros, I think you could do more by not giving her such an ultimatum. Just my 2 pesos.

  69. John,
    I don’t think there is evidence of lack of harm. Not at all. I also don’t think there is evidence of tolerable risk.
    I’ve heard that risk be compared in the past to that of being struck by lightening and therefore within tolerable risk. That analogy is not correct though. If the patient were suffering a condition in which the options were treatment A, which carried a risk similar to being stuck by lightening, and treatment B which carried a risk similar to being in a car accident, and no treatment which carried a risk similar to being struck by a car while standing in the middle of the interstate, then I’d take my chances with the lightening. That is not the case with manipulation as a treatment for neck pain.
    Other plausible treatments carry much less risk. For me, one lightening strike in a career would be too many.
    Cory

  70. John Ware says:

    Rod,
    No, I am not using cervical manipulation in this 60-something y/o female with advanced DJD in her chronically painful neck. Why on earth would I?
    Regarding legal issues, I’ll refer you to this website:
    http://www.neck911.com/
    There’s a list from reputable medical journals of documented neurological events, including stroke and death, directly attributable to cervical HVT at this site. I encourage you and anyone else reading this to take a look.
    One of the more sinister consequences of cervical manipulation is the possibility of causing a small tear of the intima, the inner lining of the vertebral artery, resulting in thrombosis and potentially an embolic stroke weeks or even months following the injury.
    I don’t want to see any little old ladies eyes roll back in her head while she’s lying on my plinth after coming from her chiropractic appointment.
    In short, I agree with Cory.

  71. Jason Silvernail says:

    The excellent blog “Science Based Medicine” has a good entry on issues concerning EBM/EBP, and it can be found here:
    http://www.sciencebasedmedicine.org/?p=42
    It highlights many of the issues we are discussing here.
    Hat tip to Cory Blickenstaff.

  72. No sh** John. I didn’t imply you should or would manipulate the patient. In the words of Sgt. Hulka: “Lighten up Francis…” What basically literate person hasn’t seen or read about adverse events of manipulation?
    The point (the one you didn’t pick up on obviously) was the odds of this woman stroking out on your table AND said stroke being traced back to your nonmanipulative approach is really remote. You may as well tell her you won’t treat her until her hypertension is under control or stops smoking.
    I just think the “it’s him or me” attitude you expressed is over the top. Go for what you know though.

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