As many of you know, our beloved PT Think Tank was hacked two weeks ago. The hack consisted of copious amounts of comments being posted, and some code inserted into the database that returned pharmaceutical ads when any page on our blog was queried on Google. It was annoying, expensive, and a real bummer that we would be victims of random trolling.
We never thought spammers could cost real cash on a free blog site! Boy did we learn!!
We are all fixed, thanks in no small part to the very excellent skills of one Aaron Brazell. However, talent like that does not come inexpensively, and so we quickly realized help was in order. And to that notion, you, our readers, came through wonderfully!
The purpose of this post is to publicly thank all who donated to our GoFundMe campaign and express our deep gratitude. To date we have raised over $1200 to repair our site and recover from the hack. THANK YOU!
Without further ado, we present to you the “Benefactors of PT Think Tank,” after all, without you we would not exist. In no particular order:
Several who wish to remain anonymous, but who still rock!
This was touching, and inspiring. The authors of this site are indebted to you.
Please don’t hesitate to say hi and introduce yourself one day if you happen to be some of the folks we don’t know. We’ll be glad to shake your hand in person.
We’re going to leave the campaign open for another week and then close it and move on. With your collective help, we certainly made lemonade from these lemons!
At the 2014 APTA Combined Sections Meeting in Las Vegas, during the Orthopaedic Section membership meeting, Dr. Catherine Patla stood up and expressed a notion to the Section’s Board of Directors. She was concerned physical therapists were giving away their hands (she also expressed a similar concern to the AAOMPT Executive at AAOMPT 2014). After over a year of consideration and contemplation, I have to agree. We are in the midst of a silent crisis of physical therapy scope of practice!
Motivated by Dr. Patla’s observations and concerns, I began keeping unofficial (and admittedly unscientific score) of students in my musculoskeletal programs and how their clinicals handled, well, the hand. Conservatively, about 50% of the students reports that they were expressly forbidden by clinic policy to treat hands, elbows, and to a lesser degree, shoulders. Concernedly, the distal upper extremity appears to be the land of the OT.
This is a complicated situation.
A Handsomely Negative Impact
From a profession-wide perspective, there’s not much that can easily be done to counteract clinic-level policies. Certainly, both Occupational Therapy and Physical Therapy are qualified to perform rehabilitation to distal upper extremity injuries. Furthermore, I think the ultimate care pathway, for many injuries common to the area, involves both professions. I’ve not actually met a member of either profession who thinks differently (or at least admitted as such), yet the policies exist.
This trend has potential long-term, and wide implications. From my perspective as Director of the Kaiser Hayward Physical Therapy Fellowship in Advanced Manual Therapy, this increases the challenge to train fellows, who by decree, must have experience treating and managing patients with distal upper extremity diagnoses. Outside of residency/fellowship training, new professionals may exist without ever getting to see a hand patient in some clinics/regions! Over time, the collective knowledge of physical therapists will be diluted and will atrophy. Soon no one will be left to TEACH the hand. At my previous University, it was common practice for the senior orthopaedic PT faculty to contract an OT to come in and teach the hand to DPT students. This was a constant and disappointing source of stress for me. What message does this send! We could literally be voluntarily cleaving off an important scope of our practice! The irony is, it’s the body region most important to how we treat! It’s decidedly more difficult to be a PT if you don’t have hands.
The Hand Rehabilitation Section
I don’t know any more than a couple people in the Hand Rehab Section of the APTA. Perhaps that’s my issue. Perhaps it’s because the Section itself is a bit of an anomaly. Of the 18 Sections within the APTA, it’s the only one designated by an anatomical focus. The other sections are delineated by practice areas like Orthopaedic or Neurologic, settings like Home Health, Acute Care, or Aquatics, or related professional activities like Research, Education, and Federal Advocacy. Arguably, the Women’s Health section is anatomically focused, but in fact it’s not, since Women’s Health is more broad than a pelvic floor and I think “The Vagina Section” would offer some terribly difficult search engine optimization challenges! I do not know the history of how the Hand was excised from the rest of the Orthopaedic Section and would love to learn.
All that criticism on name/organization aspects aside, you have to also argue that the Hand Section is doing the best it can with the membership audience it has (~472 members and 36 Facebook likes). It offered an outstanding selection of programming at this years CSM Meeting in Indianapolis. Everything from a high-profile lecture including ESPN’s Stephania Bell, to a comprehensive clinical reasoning model for TFCC management by Brenda Boucher and Pieter Kroon was offered. Notably, the Hand Rehab Section also offered two pre-conference courses and presented the results for projects for 3 different clinical practice guidelines: carpal tunnel, distal radius fractures, and lateral epicondyalgia. Yet, while all this is taking place, other PT’s seem more than happy to give up the hand and let someone else manage it. Let some other PROFESSION manage it.
Hands are for Holding
To me, this boils down to a grassroots effort, and is an issue of personal responsibility as a professional. You cannot in good conscious, let your clinic enforce and carry out a policy that prohibits, or through practice, eliminates the opportunity to treat any body region, especially the hand. We all know the outcry when outside professions claim a technique is only their purview, and attempts are made to remove that from our practice. Physical therapists rise up in a collaborative rage and claim it back. Yet, I see malaise and laziness, and an acceptance of insufficient knowledge as a behavior pattern among physical therapists in these clinics. That may seem harsh, but I can’t see it any other way.
My one caveat, and an important one at that, is that some hand injuries do require a very experienced hand specialist. Hand tendon surgical repairs quickly surpass entry-level practice. There is an insufficient numbers of physical therapists trained Certified Hand Therapists. In fact, I have only encountered one PT who holds the dual acclaim of Fellow of the Academy of Orthopaedic Manual Physical Therapists AND is a Certified Hand Therapist: the aforementioned, Dr. Boucher, who hails from Texas State University and teaches as part of the Manual Therapy Institute’s manual therapy fellowship program.
There are pathways, and opportunities that can happen, and I’ll outline my suggestions in just a moment, but this boils down to each and every physical therapy professional deciding to hold onto hands. It’s up to YOU!
Getting a Grip on this Problem
By all means, this is just a suggestion, but we need to start somewhere and why not now? Please comment, edit, innovate, or ACT on this:
Hand Rehab education should be led by physical therapists as often as possible in DPT programs.
Individual PT’s in clinics with hand-prohibitive policies should challenge these, and reach out to professional advocates like those in the Hand Rehab Section for assistance if needed.
Consideration of upper extremity policies in DPT Clinical Education should occur.
Joint clinical practice guidelines should be developed by OT’s and PT’s collaborating as authors.
Increased visibility and ultimately membership in the Hand Rehab Section. 36 Facebook likes is not going to cut it. 472 members is difficult to defend.
Development of post-professional pathways for Hand/Wrist/Elbow instruction including residencies, fellowships, and some stake in the Certified Hand Therapist credential.
Consideration of how the Hand Section can further collaborate with the Orthopaedic Section (absorbed by the Ortho Section?) and AAOMPT to further their collective mission.
Wide APTA support for these endeavors, including resources for training training, pathways for expertise, research, and advocacy.
Thanks for listening. Thanks for thinking. Thanks in advance for taking the challenge to not let this problem get any worse!
Utilizing the ICF framework, I ponder where to best fit the importance of psychological constructs? Psychology, within the ICF, could be classified as a body function. Yet, psychological understanding is usually applied at the level of the whole person spanning thoughts, emotions, behavior, and perceptions. Potentially a personal factor? But, my sense is such factors are not merely peripheral in rehabilitation. How about social issues? Social factors are inherently a part of the environment, but are also deeply personal.
What’s beyond weakness and beyond function?
Conceptualizing the environment of critical care and a critical illness course requires, at the very least, considering the perspectives of patients, families, and caregivers. I think it’s helpful to reflect back on your first experience in a hospital, your first time stepping into an intensive care unit. Whether as a student or young professional or even for personal reasons, was this a welcoming environment? I’m not so sure many of us, or the patients we treat would describe it as such. Sure, we, as clinicians, may be comfortable now. That comfort results in part from exposure and understanding. Exposure to the environment, logistics, and processes. Understanding of the lines, treatments, and procedures.
Patients and their families may report quite different experiences and understanding (or lack thereof). The ICU environment provides inputs. Ponder the 5 senses and the inputs (or lack of inputs) likely to occur. The environment of the ICU is not exactly routine and definitely not calming. It is quite foreign and unsettling…
What is touching the patient? Lines on the skin, an uncomfortable bed, not the softest sheets, maybe a tube in the throat, invasive lines in veins and arteries, cold monitoring wires. Are they moving? What is that? Perhaps even restraints or mitts. A catheter, maybe even a tube in the rectum. Visual input is varied and vision even obstructed. Bed rails to the right and left. Or is it a cell? Crawling ceiling patterns and equipment all around. Is it day or night? What’s that shape? Did that thing move? Artificial light and dark fluctuate seemingly at random. Perhaps the TV flickers. Beeps and buzzes abound. Are those voices outside? “Mrs. Smith, open your eyes and look at me.” Who the hell is that? Maybe a familiar voice. Poking, prodding. “I’m just going to draw some blood here.” A blood pressure cuff inflates, maybe a bit too tight. There’s no drinking, definitely no eating. A dried mouth. “Mrs. Smith what month is it?” “Beep, beep…beep beep.” “Ding….ding….ding.” Oh, the dryness. Just want some water, water, moisture. Pressure, a slide up. Is the skin tearing? An achey backside, pain in the buttocks. Hot, cold. Light, dark. Quiet, chaos. Confusion. Agitation. Pain.
How could one not be delirious? The environment, from a neurologic lens, is quite profound. Inputs via a range of various modalities encoded by different receptors resulting in action potentials travel along neural pathways and arrive at the brain as potential sensations. Subsequently, these neural inputs are assessed and result in possible perceptions and affects. Conversely, there may be a relative lack of input or sensation (mitts, restraints, social interaction, medication effects). Movement, or lack of movement, is also an input. As humans, a certain amount of movement and position change is normal (although, admittedly individually dependent and varied). Cardiopulmonary, neurologic, vestibular, psychologic, and neuro-musculo-skeletal systems, all systems really, are accustomed to it. These systems respond and adapt to movement at a macro and micro scale. Fortunately, much is known regarding the multi-system, micro, macro, global, and specific effects of decreased activity and input.
Sensory Deprivation and Perceptual Isolation?
…extended or forced sensory deprivation can result in extreme anxiety, hallucinations, bizarre thoughts, and depression. A related phenomenon is perceptual deprivation, also called the ganzfeld effect. In this case a constant uniform stimulus is used instead of attempting to remove the stimuli, this leads to effects which has similarities to sensory deprivation. -Wikipedia
Unfortunately, the environment and process of medically treating critical illness and stabilizing organ systems likely predisposes patients to physical, functional, neurocognitive, and psychological impairments.
Cognition and Psychology
Short term psychological and neurocognitve problems during critical illness may include stress, decreased memory, decreased attention, fluctuating wakefulness, confusion, delirium, anxiety, agitation, delusional memories, and depressed mood. Socially, there is an obvious breakdown of normal roles and support. Social interaction is decreased and varied. Roles and responsibilities become blurred at the individual and social level. Overall control is lost, and for some likely decreases in locus of control and self efficacy. Family roles may shift, or completely reverse.
“I was never told by anyone what to expect.” –ICU Survivor
What happens after ICU and hospital discharge? Anxiety. Depressive Symptoms. Depression. Post Traumatic Stress. Post Traumatic Stress Disorder. Decreased quality of life. Care giver burden and stress. Complicated grief. Inability to return to work. Who? Medical ICU patients, those with acute respiratory distress syndrome (ARDS), severe sepsis, sepsis, surgical ICU patients, and those requiring mechanical ventilation. Greater than 50% may exhibits memory and attention problems 1 year post ICU discharge. Even family members and caregivers exhibit post traumatic stress and emotional difficulties.
Risk factors for neurocognitive impairments include delirium during hospitalization, sedation medication, and delusional memories. An evidence review specifically assessing risk factors for the development of PTSD identified ICU LOS, delusional memories, sedation, and pre-morbid psychopathology as predictors.
Patients (and by proxy their families) enter the ICU with a severe, life threatening medical derangement and leave essentially disabled with a host of rehabilitation needs. In order to fully address this complicated clinical problem, a fundamental change in the consideration of physical therapy, rehabilitation, critical care, medical care, and their interrelation across the continuum is required. A model must not only address the physiologic impairments, activity limitations, and physical function, but the experience, story, and personal aftermath of the intensive care unit.
People do not ‘have’ diseases, which are really descriptive mechanisms created by contemporary medicine.
People have stories, and the stories are narratives of their lives, their relationships, and the way they experience an illness. -Arthur Kleinman, MD
An individual’s physiology is pathologic, or diseased. An individual, the person, has an experience. The necessity, and power, of expanding the bio-medical model to include psychological and social domains stems from the recognition that complex individuals, people, are the ones that must suffer and cope with their diagnoses. Further, observations and research illustrate the important influence of such domains in both illness and health. Research across diagnoses and disciplines, as well as the philosophical considerations of treating an individual, support the premise of a model that considers more than abnormal anatomy and physiology.
But, the BIO matters. The physiology matters. And, we need to know it really well. Biology, physiology, diagnoses, medical treatment, medications, treatment mechanisms, pathophysiology, body systems. The bio-psycho-social model does not discount nor disregard the biomedical. It’s not biomedical vs. psycho-social. It’s the integration of psycho-social into the biomedical.
Even the ICF model is focused primarily on a disease or health condition and how that biology interacts with function. Environmental and personal factors are peripherally connected in the model. There is no robust way to account for psychological and social constructs and contributions.
The bio-psycho-social model attempts to address patients individually, psychologically, and within the influence of their social lattice while integrating the available biomedical knowledge and population based research.
As layers are added to the conceptual model general research relating to each domain is applied. Included is applicable literature of how these individual constructs interact and potentially affect one another. But, this knowledge must be applied to the individual patient within the specifics of the current situation and the present moment of each domain. For example, general knowledge of biology, psychology, social, environmental, and cultural factors is fused with applicable clinical research ranging from epidemiology to prognostic studies to clinical interventions which is in turn applied to the individual within the specific contexts (personal, social, environmental) relevant to the patient. It’s complicated, but conceptual buckets build cognitive representations to guide thinking, assessment, and decision making.
I’m no psychologist! And, nor should we strive to be. But, physical therapists should aim to develop knowledge and skills in the multitude of systems, domains, and potential constructs that affect movement, function, and disability. Principles of psychology are thus paramount. As therapists, expertise in the domain of rehabilitation and therapeutic processes including behavior change, basic counseling skills, and motivation are needed.
Psychologically informed practice…
recognizes the necessity of understanding and applying psychological constructs into our practice. It also recognizes that function, symptoms, and disability are inherently personal and psychological.
Most physical therapists probably acknowledge the importance of psychosocial factors, and many would assert that they recognize them as part of their clinical practice. However, as Bishop and Foster have documented, simple identification or knowledge of such factors does not lead to a change in focus or style of patient management. Yet, there is persuasive evidence for the influence of a patient’s beliefs, emotional responses, and pain behavior on response to pain, treatment participation, and outcome. – Chris Main & Steven George
Research now illustrates that treatment interventions affect psychological domains, and conversely, that psychologically targeted interventions can affect function, symptoms, and disability. For example:
How does therapy fit into this hierarchy? How can we? Can physical therapists interface with the entirety of this spectrum? All interventions exhibit affects across body systems and patient domains. This includes psychology and this hierarchy. Even though our “target” may be at the physiologic, activity, or functional level, interventions result in unintended consequences (positive and/or negative) with regard to belonging, esteem and self actualization. Recognizing these constructs can assist in assessing their impact on function, participation, and coping. Meaningful interventions or care processes constructed based on these models, and the resulting understanding, may prove worthwhile and effective. Summarizing research from a multitude of practice areas and diagnoses suggests:
1. Effects of specific interventions cross body systems and patient domains
2. Exercise and activity interventions may result in positive unintended affects
3. All interventions are “non-specific” as effects cross many systems & domains
4. Exercise affects cognition & psychology
5. Psychology affects function & participation
Can physical therapists target interventions to psychological and social domains and issues? Can psychologically informed physical therapist driven interventions affect psychological and social domains and issues? It’s time to find out.
Direct Access is a hot topic for outpatient physical therapists. Many may feel pursuing the ability to practice to their full potential within a direct access environment is fundamentally a private practice outpatient issue. But, do we need to take a broader view of what the term direct access represents? Physical therapists in all settings need to have a stake in pursuing direct access for our profession. And, not just the legislative logistics of direct access, but also the mindset. Direct access is more than legislative semantics and private practice marketing. The education, knowledge, training, mindset, and approach to direct access patient care is not specific to private practice nor the outpatient setting.
It is time for physical therapists to simply say NO to accepting anything less than true direct access. We should not just accept the scraps as they fall from the table. In accepting anything less, we do a disservice to our profession by viewing ourselves as deserving of and accepting of a subservient role in the health care arena. Worse yet, we do a disservice to our patients who look to us as advocates for cost-effective and quality conservative care.
Direct access is something a patient either has – or doesn’t. There is no in-between. Physical therapists should not play in-between either.
In absence of profound legislative change from state to state what actions can each individual therapist, educator, and student perform tomorrow to advocate for and illustrate the value of direct access? Can we adopt a direct access mindset. Join Karen Litzy, PT, DPT, Kyle Ridgeway, PT, DPT, and Ann Wendel, PT, ATC, CMTPT at #APTAcsm to discuss not the logistics, but the professional mindset of #PTDirectAccess through the continuum of care from acute care to home health to outpatient orthopedics.Follow and utilize the #PTDirectAccess hashtag during #APTAcsm to ask questions, tweet about the session, and share resources on direct access.
Learn how to be an effective part of the medical team to address the needs of today’s patient, healthcare consumer, and other professionals. A direct access mindset contains the potential to add much value to all settings of care.
Recognize benefits of adopting a Direct Access Mindset across all physical therapy settings
Identify the key benefits of experience in the acute care setting as preparation for spotting red flag incidents, differential diagnosis, understanding medical treatment, and the team based approach in all other practice settings.
Describe ways that physical therapists can form partnerships with other medical professionals who see the value, and necessity of direct access to physical therapy.
To conceptualize and discuss these ideas
Define role of PT as part of the medical team & global health care system: acute care to home health to outpatient clinics
Outline key points of a direct access mindset
Examples of other providers who already value consulting and referring to physical therapists across the continuum
Discuss and illustrate the potential value of physical therapists
Across a variety of diagnoses as well as in risk reduction in both pathologic and healthy populations
Via ideal acute care practice
By connecting acute care to a direct access mindset
In potential direct access in various settings
How does acute care facilitate, reinforce, and contribute to direct access?
What is the future of sports medicine? How do we get there? Whether considering APTA’s original Vision 2020, discussing the current state of affairs during a break at work, or participating in discussions on Twitter, the future direction of our profession is constantly debated. The past 20 years have contained tremendous growth and the profession of physical therapy continues to mature, however, the question for the future is: how do we continue to evolve in meaningful ways? Who do we need to discuss our clinical challenges with to improve collaboration within research, education, and clinical practice?
A panel discussion at Combined Sections Meeting on Saturday February 7th at 8am will discuss these topics and propose one path for the future of sports medicine. STEM is an acronym for Science, Technology, Engineering, and Mathematics and experts from each of these disciplines will present on how a greater understanding and application of concepts contained within these fields hold the potential to evolve physical therapist education, research, and clinical practice. Future collaboration amongst these disciplines can assist clinicians in hopefully making better clinical decisions and improving patient outcomes. What is the new vision and role for physical therapists in athlete management? Join us at CSM to discuss…
It’s about that time when acceptances are coming in for DPT-to-be’s across the country! If you’re lucky enough to have garnered multiple acceptances, you’re probably working hard to figure out what school is right for you. How much should location matter? Is a higher cost ever justified and in what situations? How do different programs set up their clinical affiliations? Do different programs focus more heavily on different settings?
We’ll discuss these questions and more on Wednesday, January 28, 2015 at 9PM EST! If you’re a current #DPTstudent please join us & add input about why you chose your program! Follow & use the #DPTStudent hashtag to participate.
In other news, we are sad to announce that Laura Webb (@lauralwebb) has finished her time as a moderator of the #DPTstudent chat. She is onto bigger & better things as she nears graduation and we are grateful for her enormous contributions to our team! The good news is we are happy to announce that Mark Kev (@MarkyKev) has agreed to join the team. He is an integral part of the #DPTstudent community and we are excited to have him on board.
More about Mark:
“Greetings everyone, my name is Mark; almost everyone calls me Mark Kev. I’m a second year physical therapy student at The Richard Stockton College of New Jersey (which will soon become a university sometime soon I believe), a Certified Strength and Conditioning Specialist (CSCS) through the National Strength and Conditioning Association (NSCA) and also a Level 1 Sports Performance Coach through USA Weightlifting (USAW-1). I’m a baseball lover, bourbon aficionado #BourbonPT and a lifter of all things heavy. My endeavor into the #DPTstudent world on Twitter just so happened by chance. At the time, I was applying to schools and connected with prospective/current students which lead me to stumble upon the chat. I’ve been hooked ever since participating in my first chat. I’ve been fortunate enough network with some amazing people, both students and professionals alike and even had the opportunity to meet some of them in person – one of my goals is to meet and hang out with all you cool people! I’m excited to be part of the #DPTstudent moderator team and I look forward to all great adventures to come. “
As a reminder, you can request that we cover certain topics by emailed DPTchat@gmail.com!
As the spring semester begins, we’re addressing practice-relevant topics you will need to know once your start your clinical rotations and begin interviewing for PT jobs!
To get things started, we’ll be talking with Mark Dwyer (@MarkDwyer87), for some quick tips on administrative aspects of PT practice.
This discussion will teach you how to:
–Spot fraud and abuse
–Appropriately bill for Medicare patients
–Clarify an organization’s labor practices in job interviews (productivity, use of techs, etc.)
–Choose the best CPT codes for your interventions
…and much more!
Do you have questions related to PT billing, administration, etc? This is your chance to ask an expert! Tweet us your questions using #DPTstudent, then tune in at 8pm CST on Wednesday January 14 to hear your answers LIVE during our YouTube broadcast.
See you then!
@LauraLWebb, @Jocelyn_SPT, @TylerTracy10
Atul Gawande, MD, MPH is a surgeon, writer, and researcher who provides genuine insights into the challenging complexities of medicine. But, he also creates novel solutions like check lists in operating rooms. Dr. Gawande connects reflection on personal experience, processes from other fields, and scientific research into insightful narratives that outline the rationale and concrete action needed for improvement. He contends problems in healthcare are not necessarily conceptual, but rather stem from poor processes. There is a lack of knowledge translation and application. In his book Better: A surgeon’s notes on performance, he explores the science of performance and specific high performing individuals. At the end, he outlines general advice for improvement. Atul Gawande’s suggestions for becoming a positive deviant:
1. Ask an unscripted question
Ours is a job of talking to strangers. Why not learn something about them? On the surface, this seems easy enough. Then your new patient arrives. You still have three others to see…But consider, at an appropriate point, taking a moment with your patient. Make yourself ask an unscripted question. So ask a random question of the medical assistant…a nurse you into on rounds…you start to remember the people you see, instead of letting them all blur together. And sometimes you discover the unexpected. If you ask a question, the machine begins to feel less like a machine.
2. Don’t complain
We all know what it feels like to be tired and beaten down. Yet nothing in medicine is more dispiriting than hearing doctors complain. Medicine is a trying profession, but less because of the difficulties of disease than because of the difficulties of having to work with other human beings under circumstances only partly in one’s control…You don’t have to be sunny about everything. Just be prepared with something else to discuss: an idea you read about, an interesting problem…
3. Count something
Regardless of what one ultimately does in medicine–or outside medicine, for that matter–one should be a scientist in this world. In the simplest terms, this means on should count something.
4. Write something
It makes no difference whether you write five paragraphs for a blog, a paper for a professional journal, or a poem for a reading group. Just write. What you write need not achieve perfection. It need only add some small observation about your world. You should not underestimate the effect of your contribution, however modest.
Look for the opportunity to change. I am not saying you should embrace every new trend that comes along. But be willing to recognize the inadequacies in what you do and to seek out solutions. As successful as medicine is, it remains replete with uncertainties and failure
Simple, applicable, and needed suggestions.
To be sure, we need innovations to expand our knowledge and therapies, whether for CF [Cystic Fibrosis] or childhood lymphoma or heart disease or any of the other countless way sin which the human body fails. but we have not effectively used the abilities science has already given us. And we have not made remotely adequate efforts to change that. When we’ve made a science of performance, however–as we’ve seen with hand washing, wounded soldiers, child delivery–thousands of lives have been saved. Indeed, the scientific effort to improve performance in medicine–an effort that at present gets only a miniscule portion of scientific budgets–can arguably save more lives in the next decade than bench science, more lives than research on the genome, stem cell therapy, cancer vaccines, and all the other laboratory work we hear about in the news. The stakes could not be higher.
More specifically to physical therapy within the realm of healthcare, two of the most profound, if not obvious, examples are the “treatment” of musculoskeletal conditions (pain) and the mobilization of hospitalized adults. The knowledge is present to dramatically improve both. Societally, there is dire need for more movement, whether activity or exercise, in healthy individuals as well as older adults, those with chronic medical conditions, and cardiac & pulmonary disease. Again, the knowledge is there. But, are the processes and incentives for performance available? How can physical therapy as a profession and each of us as individuals move forward to enact meaningful change? Atul comments:
True success in medicine is not easy. It requires will, attention to detail, and creativity. But the lesson I took from India was that it is possible anywhere and by anyone. I can imagine few places with more difficult conditions. Yet astonishing successes could be found. And each one began, I noticed, remarkably simply: with a readiness to recognize problems and a determination to remedy them.
Arriving at meaningful solutions is an inevitably slow and difficult process. Nonetheless, what I saw was: better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.
Ask questions. Sideline complaints without solutions. Count things. Write. Change.
Are we teaching it backwards? Without understanding premise or argument validity in relation to research, an individual article analyses may be useless. A study may be flawed on premise alone even with strong methodology and statically significant results. A valid argument is false. And, inappropriate conclusions will be drawn. Likely, this will lead to misguided justifications and explanations. Such errors can affect clinical practice, education, and future research.
Plausibility must not only take into account previous clinical research and outcomes studies (efficacy and effectiveness), but also basic science and current mechanistic research. Such an approach prevents reinforcing an unlikely or inaccurate explanatory model despite positive outcomes. Unfortunately, physical therapy is likely plagued by positive outcome studies misinterpreted, and thus explicitly or implicitly, supporting a theoretical construct that is (may be) invalid. One example, more specifically, is the variance in explanatory models of manual therapy effect.
What are my beliefs? Biases? Preferred treatment constructs and approaches?
An overlooked area of assessment is ourselves. The person doing the analyzing. It’s imperative that the critical lens of analysis be pointed back upon its user. Rarely will an orthopedic manual physical therapist postulate that manual therapy does not work. The very best may ponder if the mechanisms are completely outside the current understanding. A physical therapist practicing in an ICU rarely questions the effectiveness of movement and mobility. But, clinicians and researchers should strive to rigorously falsify via the scientific method in order to focus accuracy and understanding over time. Physical therapists are inherently, and understandably, focused on the specifics of treatment that appear most important. What exercise? What technique? What works? Yet, the scientific rigor, and uncomfortable thought, of attempting to prove physical therapy does not work will lead to more specific knowledge on why it does work and the potential attainable outcomes. Seems contradictory, but falsifiability is the basic tenant of hypothesis testing in science. So, ask yourself: what would it take to change my mind? It’s time for some serious critical thinking.
Points to Ponder
Hypothesis & Null Hypothesis
Plausibility of Hypothesis based on previous research and overall knowledge
Methods Critique (utilize checklists)
Efficacy vs. Effectiveness Design
What is the comparison or control group?
Are these groups similar in abstract variables such as frequency, duration, and one on one time?
Believability of the comparison or placebo by patient?
What the results can tell us given study design
What the results can NOT tell us given the study design
Plausibility of results from author’s interpretation
Plausibility of theoretical model presented or utilized
Plausibility of the discussion & conclusion in relation to understanding on the topic specifically
Plausibility based on basic science, physics, mechanics, including tissue mechanics, physiology, psychology
How else could the results be explained? Placebo? Regression to the mean? Different mechanisms?
Did the authors make the appropriate conclusion?
What’s YOUR conclusion and understanding?
Overall summary and critique
How and why to integrate?
What is the take away?
“That’s valid,” you say, but what do you mean by that? A single statement can be valid by itself if it is a previously proven “truth”, but what about an argument? You remember arguments, right? Premise, premise, therefore conclusion? Funny thing about valid arguments, they have nothing to do directly with truth. Arguments can be valid and false at the same time, just as they can be invalid and true at the same time. What?
Since deductive arguments are the basis of all research, you need to understand this concept. I have quoted before on a podcast, “A flawed study is still a flawed study regardless of p-value or level of evidence. – Erik Meira, When a valid argument can be false
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, DSc
Conceptual variation is more damaging, and a bigger issue, than perceivable, apparent practice variation. Because of the multi-faceted nature of the mechanisms of effect in physical therapy treatments, especially for pain, striving for observable decreases in “practice variation” may not actually solve many of the issues within the profession. The real problem is conceptual differences. The stark contrast between explanatory models, and stories told, results in significant variance in explanation and education received by patients. Patients are still routinely told they have “bad” posture, an SI joint that is “out” and weakness causing their painful problems. Such unhelpful and debunked ideas are the unnecessary imaging of our profession.
Now, to be fair, striving for a decrease in practice variation within physical therapy is a worthwhile endeavor. However, I am not convinced current conceptualizations are the appropriate approach. Assessing variation in medical treatments and practice is likely easier than in physical therapy practice. Why? It’s more concrete. Medical treatment relies heavily on the appropriate diagnosis of essential, or substantial diagnoses. Treatment follows, and is mostly dependent on proper diagnosis. Thus, analysis of timely proper diagnosis, matching of treatment and diagnosis, and actual treatment content is more concrete to study. For physical therapy, a different construct is required. The complexities of the clinical encounter and individual nature of the therapeutic process in conjunction with the many potential and identified mechanisms of treatment effect complicate the study of variance. Striving for utilization of the exact same interventions is likely to be a surface level success. It appears like progress. Therapists are dealing with many nominal diagnoses and messy concepts such as unexplained symptoms, function, and behavior change. (note: medical diagnosis is still very complex and full of challenges)
Specificity should be sought after, but not assumed. As more is understood about the effects of interventions it is becoming apparent that techniques, exercises, and interventions themselves are not as specific as originally assumed. If observably clinicians appear to have no practice variation, but utilize different conceptual frameworks and tell the patient in front of them different stories, gross variation is actually still present. Utilization of similar constructs may result in similar “outcomes,” but with significantly different “interventions.” So, what are the common factors?