What’s the Cost of Quality? New ABPTRFE standards mean an uncertain future for Fellowships.

Back in February at the Combined Sections Meeting, the American Board of Physical Therapy Residency and Fellowship Education (ABPTRFE) announced their new quality standards for post-graduate education. The release of the new standards marked ABPTRFE’s first step towards its initiative of revamping old policies and procedures. According to Tamara (Tammy) Burlis, Chair of ABPTRFE, the intent is to“ultimately enhance patient care and support overall goals of the physical therapy profession”. An external consultant company specializing in accreditation and compliance solutions for higher education helped with the development of the new standards. After a 6-month call for comments, the standards were finalized and are now slated to take effect on January 1, 2018. Residency and fellowship programs have until January 1, 2019 to comply. Physical therapy news outlet Talus Media News featured this story in their August 14th episode.

Behind the buzz of the shiny new standards, however, is the discontent expressed by some fellowship directors. The biggest concern regards the change in admission criteria into fellowship programs. Historically, there were three ways to be considered for admission into fellowship: (1) complete an accredited residency, (2) earn board certification in a related field, or (3) have adequate prior experience as judged by the program directors. The new standards have removed the third option, leaving residency training or board certification a mandatory requirement prior to applying for fellowship.

Pieter Kroon, program director and co-owner of The Manual Therapy Institute (MTI), a fellowship program started in 1994 for advanced manual therapy training, spoke up in an interview on Talus Media, “I understand where [ABPTRFE] wants to go with it but…there are some nasty consequences that come with that which threaten the viability of the physical therapy manual therapy fellowship programs…We have given input, but we always have the feeling it doesn’t get listened to a whole lot at the ABPTRFE level.” According to Pieter, fellowship directors don’t seem to have much of a voice in the decision-making process at ABPTRFE. The way in which program directors currently share their concerns is akin to a bad game of telephone. The manual therapy fellowship program directors share their thoughts in their Special Interest Group (SIG) meetings. SIG representatives then report to the Board of Directors at the American Academy of Orthopedic Manual Physical Therapy (AAOMPT). After that, it is AAOMPT’s responsibility to talk to ABPTRFE and pass the messages along. It’s not hard to imagine why Pieter describes the communication between program directors and ABPTRFE “tenuous at best”. Of note, AAOMPT declined to comment on the potential impact of the new standards.

The consequences Pieter referred to are a few in number, but of primary concern to fellowship programs is sustainability. Or, as Pieter more bluntly puts it: “we would be out of business”. To illustrate his point, 95% of the fellows that graduated from MTI in the past five years were admitted via review of prior experience, the route now deemed obsolete. Without such a large section of the cohort, his program would not have had enough overhead to be self-sustaining. Pieter shared off record that he runs his program because he loves teaching and helping clinicians become their best; the revenue the program generates is marginal. The new standards pose a big bottleneck to fellowship admissions, limits student accessibility, and places programs like his on a pathway to an uncertain future.

But what makes fellowship programs think they won’t get enough applicants?

Though there has been a paradigm shift in recent years where clinicians are looking towards residency training soon after entering the work force, there has yet to be an identifiable fiscal incentive for clinicians to become experts in the field given their low ceiling of professional compensation. Furthermore, time is of the essence. The American Board of Physical Therapy Specialties currently only offers certification exams once a year. So, not only are the additional certification exams expensive, it also requires foresight and planning to fit it into one’s professional and personal timelines. There is additionally a current lack of evidence that suggests being a resident-trained therapist and/or having board certification contributes to being a more prepared fellow. Though that’s not to say there won’t be evidence of this in the future, it does call into question how this new admission standard was arrived at. Did it consider any of the current evidence in post-graduate education? Or, was it developed with more philosophical underpinnings? To that end, it remains to be seen…

PT Think Tank community: the point of this piece isn’t to say that the new admission standards are “bad”. Rather, I hope it makes us consider how its proposal potentially overlooks the current reality of the residency/fellowship climate. What parameters are in place, if at all, to help address the worries of Pieter and other program directors? What will be in place to aid them during this period of transition?

I’ll end it here, but do think on this last part of ABPTRFE’s position on the new admissions criteria: “Our goal is to support residency and fellowship programs, while addressing and planning for the future…As a part of our own continuous improvement process, we will continue to monitor the data that occurs as a result of this revised change. We will go back to this concept if we find that it has been detrimental to fellowship programs.”

Pieter and Tammy’s full interviews are available on Talus Media Talks.

What are the Issues with Therapeutic or Trigger Point Dry Needling? 9 Considerations to Ponder

Dry needling continues to garner increasing popularity within physical therapy. And, the focus is not just clinical, a pubmed search for “physical therapy” and “dry needling” illustrates an 8 fold increase of manuscripts from 2010 to 2015 (66) compared to 2000 to 2005 (8).1,2

The number of continuing education courses, certifications, and companies offering dry needling continues to rapidly expand. Further, there appears to be no shortage of anecdotal reports of the remarkable “power” of this intervention and clinical experiences suggesting it’s “the next big thing.” But, I have some questions, and justified concerns regarding the outpatient orthopaedic physical therapist’s most invasive intervention. Larry Benz has commented “trigger point dry needling is not #physicaltherapy.”3

Yes, while there is a paucity of evidence, TDN probably works in some instances-likely more to “meaning effect” and placebo than anything else (which of course is fine but in states with informed consent forms it probably works as a  nocebo).  My concern is the nocebo effect of TDN on our profession.

The irrational exuberance around TDN within the #physicaltherapy profession is ironic if not downright damaging.  We fight and defend for direct access, expanded scopes of practice, evidence as the core basis of our interventions, and being recognized in the healthcare chain as force multipliers within the musculoskeletal world yet state legislators in many states are hearing PT’s fight for the right to stick needles into patients. TDN is hardly a transformative intervention and regardless it does not define #physicaltherapy.

Like Larry, I am concerned and request that we as a profession take a moment to appraise this intervention, in terms of applicable clinical evidence and appropriate critical reasoning, before enthusiastically implementing dry needling, let alone recommending it to patients in professional publications.4 Further, the issues and assessments are not limited to dry needling specifically, as the approach can be applied to other interventions and concepts such as cupping.

Clinicians utilizing dry needling will exclaim “dry needling is not acupuncture!”, but the paradox is proponents continue to use acupuncture“evidence” (of both traditional Chinese medicine and biomedical flavors) to supposedly support their practice. Obviously, dry needling is not actually acupuncture. I’m not sure it even bears repeating that rarely is dry needling the sole intervention provided by a physical therapist. But, given the invasive nature and significant learning cost, in terms of both time and money, the addition of dry needling to a treatment plan as either an additive intervention or in replacement of other interventions, seems suspect without research supporting significant improvement in outcomes.5 And, this improvement should be specific to needling itself, not the byproduct of other non-specific mechanisms. Or, alternatively, needling must illustrate some measurable, or even highly plausible, physiologic effect known to improve a patient’s condition, main complaint, or medical diagnosis.

What issues with dry needling should be considered?

1) Acupuncture Literature Applies
2) Dry Needling Research is Underwhelming and Misrepresented
3) Poor Terminology Surrounding Needling, Trigger Points, and Myofascial Pain
4) Lessons from the Evolution of Manual Therapy: Manipulation
5) Treatment Targets and Proposed Mechanisms
6) Insights from the Study of Pain
7) Risk vs. Benefit and Invasiveness
8) Cost and Time
9) Bias in Research Interpretation and Conflicts of Interest

The Acupuncture Literature Applies

I contend that the acupuncture literature can provide us with some insights on the specific effects of inserting a needle into human flesh, be they physiologic, psychologic, perceptual, or otherwise.6 Of course, this is dependent on the assumption that any specific meaningful effects exist beyond transient, clinically irrelevant short term improvements in symptoms and subjective reports likely mediated by meaning response, expectation, context, non-specific effects, and placebo.7

In short, it is unambiguously clear from high quality investigations, systematic reviews, and meta analyses that acupuncture is nothing more than a “theatrical placebo.8 The research illustrates:

  • Poorly designed smaller studies with high risk for bias showing promising results
  • Larger, well controlled studies show no meaningful clinical benefit
  • Needling location doesn’t matter
  • Needle depth doesn’t matter
  • Skin penetration doesn’t matter18
  • The needle doesn’t even matter, toothpicks work just as well

Interestingly, similar to potential mechanisms in manual therapy what does appear to modulate, or predict, small observed outcomes in select patients is expectation, patient beliefs, and individual practitioner factors among others.7,9-14 Specifically,

The individual practitioner and the patient’s belief had a significant effect on outcome. The 2 placebos were equally as effective and credible as acupuncture. Needle and non-needle placebos are equivalent. An unknown characteristic of the treating practitioner predicts outcome, as does the patient’s belief (independently). Beliefs about treatment veracity shape how patients self-report outcome, complicating and confounding study interpretation.

Whether studied as a means to move qi along meridians or under a more western and biomedical informed lens, acupuncture has consistently failed to show that is an effective treatment.15 Such results should not only give us pause regarding the recommendation of acupuncture to patients for the treatment of various painful problems, but should also raise serious questions regarding the enthusiastic implementation of dry needling into physical therapist practice, clinical research agendas, and post professional education.

If needle insertion, needle location, needle depth, or even using a toothpick do not seem to affect outcomes in acupuncture, I’m perplexed by those who propose dry needling is somehow, in some way profoundly physiologically different.16-18 And furthermore, how anyone can subsequently claim dry needling location, depth of penetration, and other specific factors relating to application technique can robustly impart some important physiologic effect or meaningfully impact on clinical outcomes. Physical therapists should likely temper claims of mechanistic specificity, or effect, and be cautious in citing acupuncture literature to support the practice of dry needling. For those seeking additional certifications in related healthcare fields, visit https://cprcertificationnow.com/products/bloodborne-pathogens-certification to explore valuable courses and enhance your knowledge in critical areas of healthcare.

Dry Needling Research is Underwhelming and Misrepresented

Many will claim the research around dry needling is growing, and promising results suggest broad applicability. Oddly, some will state that dry needling is not acupuncture and in the next breath cite flawed, or misinterpreted, acupuncture literature as a seemingly evidence base plea for the usefulness of dry needling. While the volume of manuscripts relating to dry needling continues to rise, the actual trial data is underwhelming at best, if not outright negative. Yet, articles in professional magazines, clinical perspectives, and (flawed) systematic reviews positively frame the intervention as effective.19-21 These assertions may mislead casual readers to conclude the data supporting dry needling is quite strong. This is not the case. Harvie, O’Connell, and Moseley at Body in Mind conclude:22

We contend that a far more parsimonious interpretation…is that dry needling is not convincingly superior to sham/control conditions and possibly worse than comparative interventions. At best, the effectiveness of dry needling remains uncertain but, perhaps more likely, dry needling may be ineffective. To base a clinical recommendation for dry needling on such fragile evidence seems rash and risks exposing patients to an unnecessary invasive procedure.

A more recent systematic review effectiveness of trigger point dry needling for multiple body regions concluded “The majority of high-quality studies included in this review show measured benefit from trigger point dry needling for MTrPs in multiple body areas, suggesting broad applicability of trigger point dry needling treatment for multiple muscle groups.”23 Unfortunately, that is not what the trials included indicated as only:

  • 47% showed a statistically significant decrease in pain when compared to sham or alternative treatments
  • 26% displayed a statistically significant decrease in disability
  • 42% did not include a sham or control intervention group
  • 32% investigated only the immediate effects (ranging from immediately post-intervention to 72 hours) of TDN which is a research design with remarkable limitations24
  • 3 assessed the quality of the blinding in the sham group
  • 1 was retracted at request of the journal editor

Specifically, one randomized trial effectiveness of trigger point dry needling for plantar heel pain found a number needed to harm (NNH) of 3 and a number needed to treat (NNT) of 4. So, for every 3 patients treated with needling 1 is likely to develop an adverse event while for every 4 patients treated only 1 is likely achieve a beneficial outcome. Or, in other words, patients in the treatment arm were more likely to experience an adverse event than a beneficial outcome. One of the most commonly reported adverse events, in addition to bruising, was an exacerbation of symptoms, which I will argue is only acceptable if intermediate and long term outcomes of dry needling are somehow superior. An invasive intervention that results in more adverse events, lacks long term benefit, or fails to measurably change an underlying physiologic derangement should likely not be employed. Subsequently, available interventions that are effective, less invasive, and less likely to result in symptom exacerbation such as graded exercise/activity/exposure, cardiopulmonary exercise, pain education/therapeutic neuroscience education, and non-invasive manual therapy should be preferentially implemented.

These are significant and specific concerns that require careful consideration.

Poor Terminology: Trigger Points, Myofascial Pain, and Needles

Unfortunately, dry needling is riddled with poor terminology and vague language. Admittedly, such an issue is not unique to dry needling, and thus this entire post is applicable to many interventions and trends within physical therapy: cupping, scraping the skin with instruments (instrumented assisted soft tissue mobilization), and trendy tools in the proverbial tool box.25,26 But, never the less language is a significant issue as researchers attempt to investigate and understand the intervention in greater depth and clinicians continue to broadly implement it into practice. It’s not just semantics, precision in language is an absolute necessity.28

What are the actual differences between trigger point dry needling, dry needling, therapeutic dry needling, intramuscular manual therapy, functional dry needling, systemic dry needling, integrative dry needling, or any other form of physical therapists poking patients with needles?

Regardless of the clinical trial data (which is actually weak), those utilizing a myofascial trigger point approach to dry needling need to acknowledge the current issues with regards to a lack of consistent criteria defining a trigger point, the questionable clinical importance (if any) of the proposed trigger point construct, and the poor reliability in trigger point identification. There are many foundational issues at the core of the trigger point theory including an absolute lack of established validity. John Quintner upon evaluating trigger points:29,30

The existence of such bands had never been demonstrated and it was therefore highly speculative and erroneous to attribute nerve entrapment to such a mechanism. Other weaknesses in their theory included the somewhat metaphysical concepts of “latent trigger points,” “secondary trigger points,” “satellite trigger points” and even “metastasising trigger points”. To further confuse matters, it was later shown that “experts” in MPS diagnosis could not agree as to the location of or even the presence of individual MTrPs in a given patient. The mind-boggling list of possible causative and perpetuating factors for MTrPs was completely devoid of scientific evidence and therefore lacked credibility…Finally, those who became “dry needlers” appeared to be unaware that when justifying their assault on MTrPs they were following the “like cures like” tenet of homeopathy. In their parlance, physical therapists (including physicians) were obliged to create a lesion in muscle tissue in order to cure (“desensitise”) a lesion (for which there was no pathological evidence)…

…subsequent literature was also notable for its failure to acknowledge that the underlying hypothesis was flawed – no one has ever succeeded in demonstrating nociceptive input from putative myofascial trigger points. All subsequent “research” simply assumed the truth of what started out – and remains – as conjecture.

Also, worth mentioning are the significant issues such as tautological reasoning inherent in not just trigger point theories and hypotheses, but also myofascial pain syndromes and fibromyalgia.30-33 I do agree with the term “Therapeutic Dry Needling.” I contend this language and nomenclature separates the technique from theoretical and mechanistic principles, thereby allowing continued growth and open discussion as the science evolves. In addition, the current terms, and many of the accompanying theories, are not fully encompassing of the state of the literature in regards to trigger points, myofascial pain, pain treatment, and possible treatment mechanisms. Lastly, some further perpetuate specific targets and theories of intervention that are quite frankly unreliable, and worse, invalid. Not to mention, understanding will inevitably change over time. Specifically, precise operational definitions are required for scientific inquiry. Vague language leads to vague reasoning and muddies research results. Geoffrey Maitland is credited with the insight “to speak or write in wrong terms means to think in wrong terms.”

In aggregate there is sufficient reason to not only doubt, but discard, the foundational premises  of trigger points, myofasical pain, and potential “needleable lesions” as clinically meaningful entities and necessary treatment targets.34-35

The Evolution of Manual Therapy: Manipulation

History, some may say, is our greatest teacher. A rearward glance into the evolution of manual therapy practice and mechanisms, specifically manipulation, appears eerily applicable to the current discussion. Specific derangements such as sacral nutations, ESRL, FSRL, sacral flares, leg length discrepancies, static posture position, and subtle biomechanical “faults” supposedly necessitated specifically matched techniques for proper symptom resolution. The minute differences between techniques such as angle, spinal level, specific joint mechanics, and other application factors such as speed were presented as highly important to garnering the proper effect. The tissues were hypothesized to be the primary dysfunction and treatment target. Concepts such as the “manipulatable lesion” were developed.

The paradigm of assessment and treatment attempted to mirror diagnostics in other segments of medicine, a laudable effort to be sure. Clusters of information, in the case of manual therapy the patient’s symptoms, palpable dysfunctions, and malalignments, were supposed to be aggregated into a specific diagnosis. Specific diagnoses warranted specific treatment at a specific dosage or speed or spinal level. Unfortunately, the fatal flaw with this diagnostic approach in manual and physical therapy is the overall lack of essential diagnoses, commonplace in medicine, and the high prevalence of nominal diagnoses.36 Outpatient orthopaedics is primarily characterized by pain complaints, often times absent of significant trauma, tissue injury, or diagnosable physiologic derangements. In a failed attempt to solve such a conundrum, nominal diagnosis or clinical syndromes such as patellafemoral pain syndrome or “pain on the front of the knee mostly when squatting or bending the knee with the foot on the ground” and shoulder impingement syndrome or “pain on the front of the shoulder mostly when raising the arm overhead that sometimes feels like a pinch” were created with the goal of improving the specificity of treatment and our ability to match interventions to patient presentation.

Proposed mechanisms included changing tissue length, loosening joint capsule, breaking adhesions, unsticking stuck joints, and improving tissue related joint mobility. Minute, subtle, questionably detectable, but in actuality irrelevant, biomechanical faults were pitched as the cause of patient symptoms. But, years of research now state otherwise.37

Matching a specific manual therapy technique to a specific, theoretical, but quite frankly imaginary, fault proved not only to be futile, but unnecessary.38 The amount of force provided through the hands lacks the speed, acceleration, and load to meaningful change tissue length and other material properties. Manual therapy techniques were shown to result in movement at many levels of the spine. And, the specific technique utilized didn’t seem to matter much. Overall, technique type, long lever vs. short lever, speed, and exact level of the spine didn’t seem to matter much either. Predictors of response to treatment did not include classical palpation and hands on motion testing. Fear avoidance beliefs and length of symptoms did however. The neurophysiologic mechanisms of manual therapy appeared similar to placebo mechanisms.9 Patient expectation of success was important as was therapeutic alliance.11,39,40 Clinician expectation was correlated with outcome. Framing of the intervention’s potential effects seemed to affect degree of analgesia.41

Manual therapy can now be conceptualized as a neurological input and patient interaction whose overall effect, in both direction and magnitude, appear to be related to host of a complicated interacting factors, most of which have little to do with the specific technique.10

Yet, those teaching and researching dry needling appear to be clearing an old trail. Peripheral derangements, specific techniques, and minute, likely minimally important dysfunctions as a root cause of a patient’s symptoms. Assumptions, in my opinion incorrect ones, are leading us down a long road, which if manual therapy and manipulation research is any indication, will require an even longer journey to reverse.

Treatment Targets & Proposed Mechanisms

In addition to vague language, the currently proposed treatment targets and purported mechanisms of dry needling fail to integrate understanding from the acupuncture literature and compose an incomplete consideration of potential mechanistic factors.

Trigger points, latent trigger points, twitch response, trigger point referral patterns, facilitated segments, neuro-trigger points, micro-tissue trauma, chronic local inflammation healed by needle induced inflammation, and the list goes on. The fact that a dense array of sensory receptors of various types, including nociceptors, exist in nearly every layer of tissue including the cutis and subcutis, suggests it is not only possible, but quite likely that stimulation of these receptors is sufficient to produce the proposed therapeutic benefits. This is anatomically and neurologically true regardless of needle depth. The clinical studies of acupuncture support such a claim as neither needle location nor depth nor skin penetration nor the needle itself appear to specifically contribute to outcomes. The skin contains dense array of free nerve endings, and other receptors. Those who present possible dry needling constructs should acknowledge the current, multi-factorial mechanisms of manual therapy and the various factors contributing to overall treatment responses.

  • Can we ascertain specifically which structures are needled?
  • Is it not likely we are needling a host of structures?
  • Can we ascertain the receptors that are stimulated during needling?
  • Is it not likely we are needling various receptors?
  • Can we actually target specific tissues or receptors?
  • Is targeting specific tissue necessary, or even sufficient, for symptom resolution or a positive clinical outcome?
  • Does specificity in anyway affect outcome?

There are many inherent issues with assuming, let alone presenting, specificity of a treatment target and subsequently proposed mechanism based on test/re-test assessments and clinical observations of benefit. Such an explanatory model assumes the underlying theoretical construct is accurate but also that:

1) The test is specific to that tissue, structure, or defined dysfunction (validity)
2) A positive, or negative, test (or test cluster) is accurately identifying the tissue, structure, or defined dysfunction (reliability, sensitivity and specificity)
3) The subsequent treatment intervention is specific to the identified dysfunctional structure and thus
4) The mechanism of effect specifically relies on treatment target, application, and location
5) Resolution of the symptom and clinical outcome is dependent on the preceding

A test/re-test approach, while clinically appropriate for assessing response to treatment, is inappropriate reasoning as a mechanistic explanatory model. So, we must further explore:

  • What is the premise of this intervention?
  • Is it more efficacious, effective, or efficient than other interventions?
  • Are the models of assessment and treatment plausible? Valid? Reliable?
  • Are there other explanations that may explain the observed effects, and thereby question the necessity of needling?
  • Is this intervention as specific to certain tissues or explanatory models as it is presented?
  • Is needling necessary, or even sufficient, for symptom resolution? Or, a positive outcome?

All approaches to and explanations of dry needling need to incorporate current, multi-factorial mechanisms of manual therapy and various factors contributing to overall treatment responses in pain. Such research would suggest that targets and mechanisms of many of our interventions for pain are not nearly as specific as previously assumed and currently presented. With this this in mind, one should be cautious in making claims of specificity. How can all the other potentially stimulated neuro-vascular structures, contextual factors, patient-practitioner interactions, and various other treatment effects be ruled out, or at least addressed as not only potential contributors to outcomes, but confounders to study results?

Pain Science and Complexity

Pain is now understood as a multifactorial, individualized, lived sensory and emotional experience much more profound than mere peripheral nociceptive signaling. The neurophysiologic, psychologic, environmental, contextual, as well as social factors present in the concept of pain are exceedingly complex. And, that is not inclusive of the profound philosophical and linguistic challenges of defining, studying, understanding, educating, and ultimately interacting with someone in pain. Attempting to accurately reconceptualize pain illustrates:42

 …the biology of pain is never really straightforward, even when it appears to be. It is proposed that understanding what is currently known about the biology of pain requires a reconceptualisation of what pain actually is, and how it serves our livelihood. There are four key points:

(i) that pain does not provide a measure of the state of the tissues;
(ii) that pain is modulated by many factors from across somatic, psychological and social domains;
(iii) that the relationship between pain and the state of the tissues becomes less predictable as pain persists; and
(iv) that pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger.

These issues raise conceptual and clinical implications

And thus, it is worth mentioning not only a few of the myriad of factors that contribute to symptom severity, symptom report, and seeking medical treatment, but also the the swarm of interacting constructs that contribute to effect.43

Treatment Mechanisms in Pain
>Non-specific effects
>Placebo
>Nocebo
>Patient Expectation
>Provider Expectation
>Context
>Previous Experience
>Believability of the Intervention
>Psychologic State
>Framing and Language Surrounding the Intervention
>Regression to the Mean
>Naturally History
>and others

Obviously, such factors are not unique to dry needling. They are present in all treatments, especially those for pain. But, given the current understanding of pain stemming from a multitude of varied scientific disciplines, how can we assume, let alone propose, that sticking a human in pain with a fine needle contains sufficient and significant effect to be a primary contributor to relief and positive outcomes in both the short and long term? And, more importantly, why should we? It appears we’ve learned little from decades of research into the nature of pain, the mechanisms of treatment, passive vs. active approaches to care, acupuncture, “wet needling,” and manual therapy. Physical therapists, will rightly so I might add, critique the overuse of “wet needling” (and other interventions) by physicians, yet barely raise but a whimper of protest at the proliferation of dry needling. It may be time to refine our internal, smaller picture to facilitate crossing the chasm.44,45

Risk vs. Benefit and Invasiveness

The invasiveness of dry needling within the scope of physical therapist practice presents a unique and complicated challenge when attempting to assess risk vs. benefit in isolation, risk vs. benefit in comparison to other medical procedures, as well as risk vs. benefit in comparison to other physical therapist delivered interventions. It seems we over simplify, and potentially misunderstand risk versus benefit analysis as it applies specifically to physical therapy interventions. Sure, comparing dry needling adverse event types and rates to other medical interventions is tempting. It is an interesting health services inquiry. And, such an approach does hold some value for comparing intervention risks, benefits, and efficacy within the spectrum of the many possible health care interventions. Arguably, and quite plausibly, dry needling within the confines of a physical therapy treatment plan is safer than early imaging, prolonged NSAID use, delayed physical therapy referral, opiates, and of course spinal surgery. But, it seems to me this particular argument, even if compelling, even if true, is a weak and incomplete justification for needling. Although, please note even acupuncture may not be as safe as assumed.46-48

Comparisons regarding the risk, invasiveness, efficacy, and effectiveness of specific physical therapist delivered interventions are necessary.49 These comparisons are required in general, but also specifically within various conditions, complaints, diagnoses, and patient populations. Given the invasiveness, regardless of risk profile, to justify widespread utilization dry needling must illustrate robust effectiveness (or even significantly more efficacy) in relation to other physical therapist delivered interventions. And, any potential effectiveness must be assessed in the context of possible negative effects such as an exacerbation of symptoms and other more significant adverse events.

On the grounds of efficacy, effectiveness, risk, invasiveness, and potential benefit when compared to our other interventions for pain, I can’t understand an argument that currently justifies dry needling. Physical therapists must not merely claim superiority, or justify interventions, on the tenuous foundation that we are less invasive and less risky than other medical interventions. It’s not quite that simple. Physical therapists must provide the same internal scrutiny to comparing our own interventions in addition to comparing physical therapy interventions to physician practice patterns.44 Further, when taking into account the training cost and time it does not make sense to advocate for this intervention.

Training Cost & Time

An often undiscussed problem with dry needling is both the cost and time required to learn the technique. Currently, all states that allow physical therapists to practice dry needling require further training or even certification. So now, unfortunately, physical therapists are burdened not only with assessing the potential applicability, safety, risk and benefit of the intervention, but also the cost (time and money) required to even be granted permission to practice dry needling. Such a situation is quite acceptable for an intervention with robust effectiveness and broad applicability. But, for a single, questionably effective, invasive intervention this seems unnecessary if not wrong. For clinicians, what knowledge could be gained or other skills developed? For professional organizations, what other legislative challenges could be addressed? Who stands to benefit from such a scenario? Well, most obviously those who sell dry needling courses.

Bias in Research Interpretation and Conflicts of Interest

Similar to manual therapy, an alarming number of studies investigate immediate effects only which regardless of results is likely “much ado about nothing.”24 Many of the manuscripts pertaining to dry needling also contain overstated conclusions or even a misrepresentation of results.

In this regard, it is worth noting that many of those publishing positive systematic reviews, providing anecdotes and patient stories of success, and presenting on the potential favorable impact of dry needling teach or directly financially benefit from the teaching of dry needling.19, 20 For example, Kenny Venere and I observed that the authors of a highly positive viewpoint on acupuncture for knee osteoarthritis that was published in PT in Motion not only teach dry needling continuing education courses, but also offer a certification in dry needling.15,50 Oddly, this section and the subsequent statements were edited out of the final printed version of our letter. In any case, one of the authors is the “President of the Spinal Manipulation Institute and Dry Needling Institute of the American Academy of Manipulative Therapy” which offers a postgraduate diploma (which I’ve been openly critical regarding the name).51 The diploma is described as such:

an evidence-based post-graduate training program in the use of high-velocity low-amplitude thrust manipulation and dry needling for the diagnosis and treatment of neuromusculoskeletal conditions of the spine and extremities.

Now, other individuals and companies in the dry needling post-professional education business are all also at risk of being significantly influenced by financial incentives. For example, a program director for another dry needling continuing education company, continues to publish manuscripts defending the construct of myofascial trigger points which are, unsurprisingly, the foundation of their approach to dry needling.51 I’m sure many will contend I’ve unfairly singled out these individuals. But, I am by no means insinuating those financially vested in the dry needling continuing education business are insincere or intentionally misrepresenting trial data.

I do however wish to highlight the potential for interpretation bias of research evidence when significant (or even potential) conflicts of interest and financial incentives are present. Chad Cook, PT, PhD referring to manual therapy research poignantly states don’t always believe what you read:53

…there have been a number of manual therapy studies that were designed by clinicians who have a personal interest in the success of one intervention over another. These clinicians have either a vested interest in the applications that are part of the interventional model because they provide instruction of these techniques in continuing education courses in which they profit from (although it may seem minimal, it is not); or because the tools are part of a philosophical approach or a decision tool that was designed from their efforts or efforts from those they were affiliated with. In nearly all cases, the bias is not intentional and certainly not malicious…

I am concerned that new clinicians, passionate followers of selected manual therapy approaches, and in some occasions, seasoned clinicians, will be mislead because they lack expansive/formal research training with respect to study methodology. Certainly, once information is advocated within the clinical population, it takes years to diffuse its use, even after acknowledgement of its erroneous findings.

Dr. Cook’s concerns, which I urge you to consider, relate intimately to the surge in dry needling literature and clinical application. In physical therapy research the impact of potential conflict of interest and resulting bias of researchers also highly involved in continuing education companies is in a word: unknown. But, it is quite obvious that there is a potential conflict of interest and subconscious bias present for individuals who directly financially benefit from teaching a specific technique, or approach. And, this issue transcends dry needling. Regardless of intent, there is an incentive for positive conclusions surrounding that particular technique or school of thought. What and where are the incentives? I understand, and openly support, those who identify and ask difficult questions surrounding the possible unidentified conflicts of interest which have historically been neither discussed nor disclosed. It absolutely requires consideration. More disclosure within academia and the research literature regarding business relationships and continuing education ties is warranted.

In designing, or interpreting research conscientious checks and balances, for example blinding and proper study methods, must be executed. My sense is that it would be profoundly difficult to conclude an intervention is minimally effective, or even unnecessary, after designing, teaching, and selling courses founded upon the apparent diagnostic power and treatment effectiveness of a single intervention or specific treatment paradigm.

Summary & Conclusion

Unfortunately, I sense that dry needling is the new manipulation, which to be clear is not a compliment nor an endorsement. The intervention is not going away, and precious research dollars, cognitive space, and professional resources will undoubtedly be devoted in attempts to “prove it works” (or even “how does it work?”) which is in direct contrast to the true scientific method which is founded upon falsifiability, or “prove yourself wrong” (or even “does it even work?).

But, in getting to the point, the terminology is poor, the constructs questionable, and the current research underwhelming. Acupuncture literature suggests effects are small and non-specific to needling, and the current dry needling data demonstrates the same pitfalls in both design and interpretation. Note this is our most invasive intervention for pain, and it is technically quite passive. Additionally, many of the theoretical constructs and clinical explanations are myopic, vague, and appear invalid. Assessing risk vs. benefit of the intervention in isolation, and in comparison to other physical therapist delivered interventions, is an important, under discussed complexity of implementing needling into practice. Significant potential conflicts of interest and bias are present in the literature. As if that wasn’t enough, the time and cost to learn this intervention are astounding.

Yet, positive clinician experiences, professional publications, and overly optimistic reviews continue to escalate. Jason Silvernail, DPT, DSc, FAAOMPT asserts:

We should all – every one of us – be nothing but disturbed by our colleagues’ use of emotional anecdotes. I look forward to the day when mentioning an anecdote automatically makes our students shake their heads and turn away…Highly recommend people look into MJ Simmonds’ work on intolerance of uncertainty in our profession and how that anchors practitioners beliefs into concrete and wrong explanatory models loaded with nocebo and external loci of control.

Given the discussed issues, and likely others, the current unbridled enthusiasm and growing popularity of dry needling seems unwarranted, if not a mistake. I urge physical therapists, educators, clinicians, researchers, students, and professional leaders to re-consider.

History, it appears, has taught us little in this regard.

References & Resources

1. Pub Med Search. "Physical Therapy AND "Dry Needling" 2010-2015. Performed August 3, 2015

2. Pub Med Search. "Physical Therapy" AND "Dry Needling" 2000-2005. Performed August 3, 2015

3. Benz L. Trigger Point Dry Needling is Not #PhysicalTherapy. Evidence in Motion Blog. March 2014

 4. JOSPT perspectives for patients. Painful and Tender Muscles: Dry Needling Can Reduce Myofascial Pain Related to Trigger Points. J Orthop Sports Phys Ther. 2013;43(9):635

 5. Ridgeway K. Measuring Outcomes, Outcome Measures, and Treatment Effects. Physical Therapy Think Tank. December 13, 2014

 6. O'Connell N, Moseley GL. Acupuncture research – the path least scientific? The Conversation. October 30, 2012

 7. White P, Bishop FL, Prescott P, Scott C, Little P, Lewith G. Practice, practitioner, or placebo? A multifactorial, mixed-methods randomized controlled trial of acupuncture. Pain. 2012 Feb;153(2):455-62

 8. Novella S. Acupuncture Doesn't Work. Science Based Medicine. June 19, 2013

 8. Colquhoun D, Novella SP. Acupuncture is theatrical placeboAnesth Analg. 2013 Jun;116(6):1360-3

 9. Bialosky JE, Bishop MD, George SZ, Robinson ME. Placebo response to manual therapy: something out of nothing? J Man Manip Ther. 2011 Feb;19(1):11-9

 10. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive modelMan Ther. 2009 Oct;14(5):531-8

 11. Bialosky JE, Bishop MD, Cleland JA. Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal painPhys Ther. 2010 Sep;90(9):1345-55

 12. Linde K, Witt CM, Streng A, et al. The impact of patient expectations on outcomes in four randomized controlled trials of acupuncture in patients with chronic painPain. 2007 Apr;128(3):264-71

 13. Kong J1, Kaptchuk TJ, Polich G, et al. An fMRI study on the interaction and dissociation between expectation of pain relief and acupuncture treatmentNeuroimage. 2009 Sep;47(3):1066-76

 14. Bishop FL, Lewith GT. A Review of Psychosocial Predictors of Treatment Outcomes: What Factors Might Determine the Clinical Success of Acupuncture for Pain? J Acupunct Meridian Stud. 2008 Sep;1(1):1-12

 15. Venere K, Ridgeway KJ. Acupuncture Effect Not Clinically Meaningful. PT in Motion. 2015 Aug;7(7):6-7

 16. Chae Y, Lee IS, Jung WM et al. Psychophysical and neurophysiological responses to acupuncture stimulation to incorporated rubber handNeurosci Lett. 2015 Mar 30;591:48-52

 17. Bulley A, Thacker M, Moseley L. Against all reason- effects of acupuncture and TENS delivered to an artificial handPhysiotherapy . 97 Supplement S1

 18. Cherkin DC, Sherman KJ, Avins AL et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back painArch Intern Med. 2009 May 11;169(9):858-66

 19. Ries E. Dry Needling: Getting to the Point. PT in Motion. 2015;5

 20. Dunning J, Butts R, Mourad F et al. Dry needling: a literature review with implications for clinical practice guidelinesPhys Ther Rev. 2014 Aug; 19(4): 252–265

 21. Kietrys DM, Palombaro KM, Azzaretto E et al. Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysisJ Orthop Sports Phys Ther. 2013 Sep;43(9):620-34

 22. Harvie DS, O'Connell N, Moseley L. Dry needling for myofascial pain. Does the evidence make the grade? Body in Mind. July 4, 2014

 23. Boyles R, Fowler R, Ramsey D, Burrows E. Effectiveness of trigger point dry needling for multiple body regions: a systematic review. J Man Manip Ther. 2015. DOI: http://dx.doi.org/10.1179/2042618615Y.0000000014

 24. Cook C. Immediate effects from manual therapy: much ado about nothing? J Man Manip Ther. 2011 Feb; 19(1): 3–4

 25. Cotchett MP, Munteanu SE, Landorf KB. Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trialPhys Ther. 2014 Aug;94(8):1083-94

 26. Brence J. The Tools We Use. Forward Thinking PT. July 29, 2013
 27. Silvernail J. Why I don't like the 'toolbox' concept. SomaSimple. Discussion Lists. February 8, 2015

 28. Ridgeway KJ. Precision in Language. Physical Therapy Think Tank. May 7, 2014

 29. PubMed Search for Author "Quintner JL[Author]."

 30. Quintner J. The trigger point strikes … out!. Body in Mind. January 20, 2015

 31. Quintner JL, Cohen ML. Fibromyalgia falls foul of a fallacy. Lancet. 1999 Mar 27;353(9158):1092-4

 32. Cohen M, Quintner J. The horse is dead: let myofascial pain syndrome rest in peace. Pain Med. 2008 May-Jun;9(4):464-5

 33. Cohen ML, Quintner JL. Fibromyalgia syndrome, a problem of tautology. Lancet. 1993 Oct 9;342(8876):906-9

 34. Quintner JL, Bove GM, Cohen ML. Response to Dommerholt and Gerwin: Did we miss the point? J Bodywork & Move Ther. July 2015;19(3):394–95

 35. Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenonRheumatology (Oxford). 2015 Mar;54(3):392-9

 36. Dorko B. Incantation. The Clinicians Manual.

 37. Rupiper M. Over at LinkedIn: Reply to The Drama of Manipulation; is it necessary? SomaSimple. Discussion List. April 7, 2013

 38. Ridgeway KJ, Silvernail J. SI Joint Mechanics in Manual Therapy: Relevance, Please? Physical Therapy Think Tank. March 18, 2012

 39. Ferreira PH, Ferreira ML, Maher CG et al. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back painPhys Ther. 2013 Apr;93(4):470-8

 40. Fuentes J, Armijo-Olivo S, Funabashi M et al. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled studyPhys Ther. 2014 Apr;94(4):477-89

 41. Bialosky JE, Bishop MD, Robinson ME, Barabas JA, George SZ. The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjectsBMC Musculoskelet Disord. 2008 Feb 11;9-19

 42. Moseley GL. Reconceptualising Pain According to Modern Pain Science. Physical Therapy Reviews. 2007; 12: 169–178. Accessed via Body in Mind

 43. Taylor AG, Goehler LE, Galper DI et al. Top-Down and Bottom-Up Mechanisms in Mind-Body Medicine: Development of an Integrative Framework for Psychophysiological Research. Explore (NY). 2010 Jan; 6(1): 29

 44. Venere K. The Bigger Picture. Physiological. May 30, 2015

 45. Silvernail J. Crossing the Chasm - Meso to Ecto. SomaSimple. Discussion List. January 19, 2009

 46. Hall H. Acupuncturist’s Unconvincing Attempt at Damage Control. Science Based Medicine. June 21, 2011

 47. Ernst E. New evidence on the risks of acupuncture. Edzard Ernst. October 13, 2014

 48. Ernst E, Lee MS, Choi TY. Acupuncture: does it alleviate pain and are there serious risks? A review of reviews. Pain. 2011 Apr;152(4):755-64

 49. Venere K. Let’s Talk About Efficacy and Effectiveness. Physiological. September 9, 2014

 50. Dunning J, Butts R, Perreault T. The Evidence of Acupuncture. Viewpoints. PT in Motion. April 20105(4)

 51. Ridgeway KJ. Osteopractor™ Not now, not ever. Physical Therapy Think Tank. May 17, 2012

 52. Fernández-de-las-Peñas C, Dommerholt J. Myofascial trigger points: peripheral or central phenomenon? Curr Rheumatol Rep. 2014 Jan;16(1):395

 53. Cook C. Don't always believe what you read. Forward Thinking PT. February 27, 2012

 54. Silvernail J. Enough is Enough. SomaSimple. Discussion List. December 11, 2010

#DPTStudent Chat for July 15, 2015 at 9PM EST: Your First Clinical Rotation

As the summer semester draws to a close, many students are preparing to begin their first rotations. Others have just finished theirs, and every #DPTstudent is going to experience it at some point. What do you wish you would have done differently? What are must-know facts for each setting and what should you brush up on? What surprised you about your first rotation? And, most importantly, what did you excel at?

Join us at 9PM EST on July 15, 2015 to discuss! Use the #DPTstudent hashtag on Twitter to keep up with the conversation!

#DPTstudent Chat Moderators

@Jocelyn_SPT, @MarkyKev, @TylerTracy10

Doctor is Just a Title: How to really experience your #DPTstudent education

The collective here at PTTT appreciate the insights, contributions, and struggles of the #DPTstudent. And thus, we present a new guest post by a current 3rd year #DPTstudent @GabeStreisfeld. Gabe is an eager, motivated student who connected with both Kyle and Eric at #APTAcsm. His insights are both thoughtful and valuable. We also owe him for attending our talks. So, enjoy the read…
——

Don’t worry, I am not about to argue why or why not the doctor of physical therapy is important, or whether or not we should market it. You can find that argument plenty of other places on the internet. Instead, I’d like to discuss the DPT education process from my perspective as a 3rd year doctor physical therapy student, and why I believe some students miss out on a huge aspect of it.

First let’s pave the way with google’s top answer to “definition of education”:

1) The process of receiving or giving systematic instruction, especially at school or university
2) an enlightening experience

Furthermore, when googling “definition of formal education”:

Formal education is classroom-based, provided by trained teachers. Informal education happens outside the classroom, in after-school programs, community-based organizations, museums, libraries, or at home.

I would argue that formal education is closely related to Google’s first definition. It is the hours spent in class. It is the hours spent memorizing the origin, insertion, and innervation of every muscle of the body. It’s the practicals, competencies, OSCEs (objective structured clinical examinations), and paper tests. The logistics that pave the path between students and those 3 powerful letters: DPT. Formal education can absolutely harbor definition two; enlightening experiences. Although, I sense the busywork and exam-related stress can sometimes interfere with the more contemplative, reflective, and self-directed experiences that many would consider enlightening. Formal education is only one side of the coin, and although I cannot dispute its importance, my observation is most students focus too heavily on the formal only to neglect the potential power of the informal.

Informal education is where definition two takes the forefront. It is seeking those enlightening experiences outside of class. Getting involved with PT organizations at the school, community, and national level; pro bono and volunteer experiences; the conferences; lively social media debates, and self-driven PubMed searches. It is even the critical blogs and podcasts that continuously question and reframe. Informal education is not merely the knowledge gained, but the actual process of seeking that information. It is a unique, learned skill. Informal education allows the student to add her personal interests, inquiries, and discoveries to the DPT. It is where the student can evolve herself , nearly without restraint, to a higher level of critical thinking. You know the saying “it’s not the destination, it’s the journey.” However, why is some of the knowledge, skill, and insight gained outside the classroom unable, or unlikely, to occur in the formal education environment?

Obviously, informal education differs from formal education. There is no set end product. No exams for which to study, or degree to be obtained. This allows the student to focus on the process, present experience, and self paced exploration which can ultimately lead to that sense of enlightenment and profound self- discovery. I have observed formal education struggle to extract such concepts, because the end products of grades, degrees, and expectations often cloud the student’s view of the present experience. And, the narrow focus can also hinder a sense of the bigger picture.

However, investing in informal education pays dividends. It provides motivating power, allows intrinsic self-guidance, and hopefully facilitates the evaluation skills necessary to add perspective to a seemingly endless list of assignments and tests. This facilitates the ability to fully appreciate the intended processes and outcomes of formal education. It is imperative that students and professors alike recognize this connectedness between the informal and formal, because if nurtured properly, it will contribute to the experience and meaning of achieving a doctor of physical therapy degree.

The opportunities that lie within the realm of informal education are equally as important to the DPT program as the concrete curriculum. The doctorate is 3 years of classes, assignments, and exams; but it is also 3 years of potential time. Time to explore the profession we will all be entering; to view the profession, beautiful and ugly, from the inside before actually practicing. Time to map out and dip our feet into the numerous career pathways before embarking on our own professional journeys. 3 full YEARS of time to hone not only our professional skill set and knowledge base, but lay the foundation upon which we build our future careers.

Personally, I feel that informal education has contributed significantly to my personal and professional development during the pursuit of my DPT. It is where my professionalism thrives, and my critical thinking is tested and molded; where my thought processes and assumptions have been challenged. Informal education has only one rule: that you are motivated enough to direct yourself toward improvement. None of your professors can fully guide you in this experience, although they may attempt to initiate a spark through various structured experiences like reflection assignments, discussion boards, research assignments, and compiled portfolios. But, these are still well within the construct of the formalized education process. Potential barriers to informal education include time, resources, and support.

However, the vastness of this informal domain allows for a variety of successful approaches; you just have to be willing to explore the possibilities. It does not need to happen every day, or even every month. It requires no schedule. As long as you remain pro-active, inquisitive, and open minded, informal education will find its way to you, even if you don’t recognize it. This self-directed discovery, the auto-didacticism, prepares us to remain ever a student even after formal education has commenced. This is where I truly believe the title doctorate gains substance, otherwise what is it besides grades on a transcript?

Due to the self-directed nature of informal education, I cannot tell you where to explore. I personally find my informal education at national and state level conferences; by reading blogs, both scholarly and opinionated; following and entering twitter debates; listening to PT related podcasts; collecting, organizing, and disseminating research on topics that I find interesting; engaging classmates in philosophical PT discussions. Even writing a blog post. It does not matter how you conduct your informal curriculum because it is that: informal. The only advice I can give on making the most out of your 3 year doctorate education is the following:

Do not limit yourself to formal education.
Do not think everything you have to learn about being a physical therapist will be taught in school. It won’t.
Learn how to question what is being taught to you, and how to seek your own answers to those questions.
Learn how to ask the right questions.

The profession has much to offer students who demonstrate interest, so take advantage. Informal education is what will make the difference in your education. It will help solidify the foundation of your career. It will give you the bigger picture of our profession, the one we, as DPT students, will soon be entering.

Finally, if you have been, or are planning on, spending your 3 years of PT school just getting through classes “B’s get degrees” style, by all means, you will obtain a DPT. But, then again, doctor is just a title. Remember, the piece of paper you receive on graduation day signifies merely the beginning of your journey, not the end.
——-
Gabe Streisfeld is a 3rd year DPT student attending Thomas Jefferson University in Philadelphia, PA. He is a life-long student of human movement both professionally through his physical therapy education and personally via a variety of physical pursuits including (but not limited to) powerlifting, hiking, parkour, and bouldering.

He’s always been intrigued by human movement and its capabilities. He believes in not overcomplicating the elegant and evolutionary simplicity of the human movement system. We are beings with the ability to adapt and grow in the presence of a stimulus. He yearns to use his knowledge and views on the human movement system to help others understand their capabilities and improve their physical function.

Follow him on twitter @GabeStreisfeld

Assessing and Integrating the Evidence

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 statistically 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.

Plenty of systems and check lists exists for systematically evaluating the quality of an individual study including it’s design and methodology. The PEDro scale  (PEDro Website), The Consort Statement25 Item ChecklistChecklist for Qualitative AnalysisPRISMA for Systematic Reviews and Meta-analyses, and other Critical Appraisal Checklists all guide and contribute to appropriate analysis. But, a critical review should not only critique the rigor of the inquiry and accuracy of the conclusions, but also, and maybe more importantly, assess the study’s plausibility in context of the whole of current scientific understanding.

What does this tell us? What can it tell us given the design? What doesn’t it tell us? Too often scientific research, clinical and otherwise, is interpreted too broadly and thus inaccurately. It’s one of the major flaws of popular “pop” science journalism: over reaching conclusions. The sensational headlines touting miracle cures and “bad” foods that cause cancer. But, even a narrow lens of assessment focused only the specific study may lead to improper understanding. Outside of a purely methodological critique, an article analysis can not, must not, be done in isolation.  The current state of the literature on the topic specifically, in conjunction with basic science generally, must be taken into account.

Is this plausible?

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

The complications continue. Concepts such as placebo, non-specific effects, nocebo, incentives, behavioral psychology, decision making, logical fallacies, cognitive biases, and epidemiology all play vital roles in not only which treatments we (should) utilize, but how they (may) work. In addition to clinical and scientific research, the understanding of the how’s and why’s of decisions in clinical practice rest upon these concepts (by jennifer). Given where trials of physical therapy interventions are published it’s imperative to read outside the physical therapy specific literature. Research in psychology and behavior assists in a deeper understanding of the importance of the entire treatment encounter in addition to how clinicians make decisions within a treatment encounter.

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

So, stop volleying RCTs back and forth in an evidence ping pong match, and begin integrating knowledge. The information from seemingly unrelated fields contain insights that can result in true evolution in our understanding of clinical practice. Surprisingly, even many of the randomized control trials of physical therapy interventions are not published in physical therapy specific journals. Ponder how  the “evidence base” should be selected.

We rarely believe we are ignorant, but could we be wrong?

Should we all do the same thing? Perceivable vs. Conceptual Practice Variation

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.

Words matter. The stories we tell patients, and those we tell ourselves. It appears that in medicine generally, and orthopedics specifically, the language utilized by clinicians affect not only patient’s understanding, but perceptions including pain, disability, function, and quality of life. Beliefs are powerful. So, why do we keep beating around the bush? There is a remarkable range in treatment paradigms, potential mechanisms, and explanations on why things (appear to) “work.”

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?

Regardless of setting, physical therapists should strive for the most accurate deep models of practice, validated and efficient processes in conjunction with an individualized, assessment based, response dependent approach. The best clinical research evidence should be incorporated. This will lead to less practice variation, you just might not be able to see it. Observational variation in interventions may not actually represent difference in concepts. Conversely, two clinicians may perform exactly the same “interventions” with marked disagreements in conceptual framework, reasoning, patient interaction, and patient education. Maybe the method is not the trick? Maybe the process is as important as the product? It’s high time for the accountable practitioner. That means metacognition, critical thinking, and science based practice. Simple…now only if it were easy.

Do you need to care to be caring? Sympathy, Empathy, Compassion, and Caring in Healthcare

What I couldn’t say – but wanted to – was the truth: I don’t care.

Seriously. I don’t. I can’t.

Keith P states “I don’t care.” And, I think he’s right. A certain type of detachment from the potential suffering and emotional struggles of patients is vital for a clinician. The ability to assess, analyze, and make proper decisions may be clouded if those treating are overly emotionally involved in the circumstances of those they treat. Further, shouldering the burden of the many unfortunate clinical, emotional, and social situations encountered within healthcare can easily leave one with a sense of hopelessness. It’s quite easy to succumb to pessimism and apathy when the grand scale of suffering, inequality, and just plain bad luck occupy the beds and treatment tables daily. But, is this ideal for patient interaction? What do patients prefer? Establishing and enhancing alliance, rapport, and an environment of care is necessary. An explicit connection with the patient is a precursor to, or maybe even the foundation of, the therapeutic process. Too far to one extreme and the risk is burnout. Too far to the other and the risk is a cold, distant clinician (and still burnout). As in anything, explicitly defining terms and concepts is helpful.

Definitions and Terms

Sympathy, empathy, compassion, and caring are connected concepts, but have differing definitions. And, specifically within healthcare these concepts require more specific exploration. While various, and vague, characterizations of sympathy exist within and outside of healthcare, for the sake of clarity sympathy generally centers around an emotional state of feeling. It can manifest as pity or sorrow for another, a common feeling, or a relationship in which that which affects one mutually affects the other. The simplest definition is entering into or sharing the feelings of another. Empathy, by contrast, is characterized by identification and understanding. But, empathy has been sub-characterized into two, or even three, separate conceptualizations: emotional (or affective), cognitive, and compassionate empathy. To complicate matters, compassion itself is an awareness of suffering of another and a desire to act in order to relieve it. Therefore, compassion is best understood as an action, or potential action. This desire and subsequent action may stem from both rationale and emotional sources.

Healthcare & Empathy: Emotional vs. Cognitive vs. Compassionate

Daneil Goleman briefly outlines and discusses the three (potentially) separate kinds of empathy. Empathy is founded upon understanding and identification which may include projecting ourselves (hypothetically) into another’s situations. And, it can happen emotionally and/or cognitively. Emotional empathy is the ability of a person to feel a similar emotion as another (which confusingly can be accomplished cognitively). Although this appears to mirror sympathy, sympathy is a sharing of emotion, or emotional state, feeling along with another. In contrast, cognitive empathy relates to recognizing, understanding, or even appreciating a person’s feelings. To be fair, the definitions of sympathy and empathy as well as cognitive verses emotional empathy appear to overlap. It seems they are, at times, used interchangeably. Specifically to healthcare, empathy is “a cognitive attribute that involves the ability to understand the patient’s inner experiences and perspective and a capability to communicate this understanding,” Many in healthcare education recognize IQ and didactic skill are only a portion of the ideal clinician equation. The ability to understand and perform within the above constructs relates to emotional intelligence. And, “empathy, as defined here, must be included in the curriculum. It is a powerful communication tool that enables a clinician to clearly express his or her understanding of another’s suffering while protecting his or her own psychological integrity.”

Do you have to care to be caring in your practice?

A major issue in health care professions generally, but therapy specifically, is mistaking the necessity of cognitive empathy for a requirement to sympathize and feel with patients. Front line clinician burn out is in part due to an understandable inability to sympathize with every patient, and the resulting cold, concrete distance that can result in situations when sympathy is not feasible. Whether clinician fatigue, a need for emotional distance, or carryover from the patient before feeling the emotions, sympathizing, and providing pity to every patient is likely not possible. And, probably not effective. The issue is likely further clouded by a lack of understanding regarding the differences of sympathy and empathy. I don’t ever remember learning about this stuff. But, it’s vital. The concept of objective empathy grossly changed how I approach patient interactions. Patients and practitioners report “compassionate care” is important to successful medical treatment. So, what’s to be done?

The role of the clinical instructor is paramount in helping students to become aware of behaviors that can block empathy. We can no longer simply hope that our students will become mature professionals with compassion and empathy for patients. We must create experiences to develop these attributes, and we must take responsibility for modeling these behaviors and reflecting on them with students, to raise their consciousness about the nature of a mature healing presence.” The art of healing is, in part, made up of a therapeutic use of oneself or a therapeutic presence for patients. This presence is more than knowledge and skill alone; it is also composed of a compassionate understanding of the patient and a communication that the therapist is worthy of the trust that the patient has bestowed. Empathy enhances the therapist’s therapeutic presence and deepens the patient practitioner interactions without fear of losing one’s self in the process. This shared meaning seems to enhance the patient’s process of healing.  Carol Davis, Can Empathy be taugh? PTJ, 1990

To the observer I’m sure it appears I do care, and care deeply. But, in the end Keith, you’re right. I don’t care. And, I don’t need to. Does that mean I never engage with patients on an emotional level? That patient’s circumstances never affect me? That I never feel a connection, or shared emotional states with a patient? Or, a powerful emotional response during the course of treatment? Of course not. It happens. And, that’s OK. But, we don’t need to strive for it. Someone inquired to Keith “I wonder if being detached from our patient makes for a better clinician… Any thoughts?” He responded:

A therapist needs an appropriate amount of attachment for success, but that attachment, I reason, needs to be to a high professional standard of care, not the patient’s outcomes themselves.

You don’t need to sympathize to provide appropriate empathy. You don’t need to care to be caring. You don’t need to feel the emotions of your patients to address the emotions they feel.

When I freed myself from the responsibility for the “outcome” of the clinical encounter, something interesting happened. I freed my patients from blame, also. –Jason Silvernail

It’s important to care, but maybe not in the assumed emotional involved ways. And, I think we should not apologize for claiming not to care. I’m still, I think, a caring clinician. I just don’t make a point of feeling pity for the suffering I encounter. I am passionate, empathetic, and hopefully a thoughtful interactor.

 an older relative of mine who has cancer is going back and forth to hospitals and rehabilitation centers. I’ve watched him interact with doctors and learned what he thinks of them. He values doctors who take the time to listen to him and develop an understanding of his situation; he benefits from this sort of cognitive empathy. But emotional empathy is more complicated. He gets the most from doctors who don’t feel as he does, who are calm when he is anxious, confident when he is uncertain. And he particularly appreciates certain virtues that have little directly to do with empathy, virtues such as competence, honesty, professionalism, and respect. –Paul Bloom, Against Empathy

We need to be able to treat our patients, all of them, and still function in our own lives. If not, we risk riding the roller coaster of sympathy and pity in clinic at the potential expense of engaging emotionally in our personal lives. It’s a bad outcome all around. Our patients need us to understand, interact, and guide them along the best possible course of recovery. So, whatever we call it, put your pity aside. I’m not sure our patients want it anyway. Be resilient. You don’t need to care to provide compassionate care. Our patients need us to listen, but also to initiate difficult, honest conversations.

Data Quality: Garbage In = Garbage Out

Measuring and objectifying observations and phenomena. Numbers. Data. These are the cornerstones of analytics. The presentation and appearance of (apparent) objectivity. Whether in research, health care policy, economics, business, or clinical practice, data is important.

The data doesn’t lie.

But, sometimes the people that interpret it do. Not that they mean to. It’s not done on purpose (except when it is). So, yeah, unfortunately, the numbers can lie. And, they will lie to you if you are not conscientious about assessing them more deeply.

“What gets measured, gets managed.” Peter Drucker

Data Quality

Questions of why this works, or, maybe, more importantly, “does this work as proposed? Does the explanatory model make sense?” are not inherently built into the evidence based approach. Yet, these questions are vital to integrating and understanding outcomes research, while evolving our theoretical models. Such a task mandates metacognition and critical thinking. Failure to critical assess the quality, and potential meaning, of data, will result in improper conclusions.

The evidence hierarchy is sorted by rigor not necessarily relevance –EBP and Deep Models

But, the questions and issues surrounding data quality and interpretation transcend assessing the literature within the context of the evidence based hierarchy. Much like the research literature, the data collected, analyzed, and utilized everyday warrants critical appraisal. It all requires assessment; data encountered inside and outside the clinic, data utilized for decision making and understanding. The concepts of scientific inquiry should be wielded routinely, including assessment of quality, source, and limitations of the numbers. Only then, can proper interpretation and subsequent decision making occur.

Is it accurate?
Is it representative?
Where did the numbers originate?
What do the numbers actually represent?
What conclusions can or can not be concluded from a data set?

The evidence based practice hierarchy is concerned mainly with questions of “what works?” and “what is effective and efficacious?” These are necessary, important, big questions. But, the term “evidence” as utilized by most clinicians and researchers is focused mainly on randomized clinical trials, systematic reviews, and meta analyses of randomized control trials. Outcomes based research. This is a necessary and obvious step forward from purely observational, experienced driven clinical practice and education. Despite the obvious importance of experience (or more accurately deliberate practice) in clinical decision making, analysis based on experience or clinical observation only is prone to errors such as confirmation bias and convenience. Clinical observation alone is limited in it’s ability to ascertain phenomena such as a natural history and regression to the mean. And thus, this issue is related not only to data quality, but proper data interpretation. Understanding data quality assists in assessing “what works”, but also in tackling the complex question of “why does it appear to work?” Both questions are inherent to, and reliant upon, the quality of data.

Numbers, Data, and Objectivity

In attempting to objectively measure the world, has the potential accuracy and quality of data been forgotten? Overlooked even? A number seductively presents the appearance of objectivity and accuracy, but does not guarantee it. Big Data provides an excellent example of data quantity with relatively overlooked quality. Astounding data-sets through avenues such as social media and search engines afford researchers and large companies the opportunity to analyze data-sets that would literally explode your lab top. For example, in 2008-2009, based on web search data Google Flu Trends more accurately and quickly predicted and modeled flu outbreaks than the Centers for Disease Control (CDC). Well, until 2012-2013 when it wasn’t so accurate, over estimating peak trends. In big data are we making a mistake? Tim Harford explores the scientific and statistical problems still present (even when the size of a data set requires it to be stored in a warehouse): 

But a theory-free analysis of mere correlations is inevitably fragile. If you have no idea what is behind a correlation, you have no idea what might cause that correlation to break down. One explanation of the Flu Trends failure is that the news was full of scary stories about flu in December 2012 and that these stories provoked internet searches by people who were healthy. Another possible explanation is that Google’s own search algorithm moved the goalposts when it began automatically suggesting diagnoses when people entered medical symptoms…

Statisticians have spent the past 200 years figuring out what traps lie in wait when we try to understand the world through data. The data are bigger, faster and cheaper these days – but we must not pretend that the traps have all been made safe. They have not…

But big data do not solve the problem that has obsessed statisticians and scientists for centuries: the problem of insight, of inferring what is going on, and figuring out how we might intervene to change a system for the better.

Measurement Matters

Now, just because it can be measured, does not mean it should be measured. Measurement alters behavior. And, the change is not always as envisioned or desired. As soon as a goal is set to alter a metric, incentives apply. This concept transcends clinical care. It applies to business, management, and clinician behavior. Enter the cobra effect.

The cobra effect occurs when an attempted solution to a problem actually makes the problem worse. This is an instance of unintended consequence(s).

So, is the goal to change that specific metric only?  Or, is the actual goal to encourage specific behaviors that appear to directly affect, or are correlated with, that metric. Regardless of the goal, care must be taken in defining success. This requires a clear definition of what is measured and why. Again, deep analysis of data quality and interpretation are necessary to properly interpret results of process changes. Due to the appearance of objectivity in the presentation of numbers, it is easy to make inaccurate or far reaching conclusions. This is especially true when care is not taken to assess all the components of the data:

What does the data actually represent?
Who or what measured it? Who or what entered it?
How was it initially assessed and subsequently interpreted?
What other data needs to be considered or measured?

Now, even with reliable and accurate data input, inaccuracy can occur. The wrong conclusions can be “output” because of the misinterpretation regarding what the data is representing or signifying. Wrong numbers = wrong analysis = wrong conclusion = wrong interpretation = misguided application.

Steer away from subjectivity

The complexity of even the simplest data sets is astounding. Ever present are questions such as: Is the data valid? Does the data represent the assumed construct or principle? What potential bias is involved? Is it reliable between people; between subsequent measurements? Is it actually measuring what we think it’s measuring? Can it answer the questions we are posing? Measured and presented data is rarely as simple as a concrete number.

The attempted objectification and simplification of subjective, individualized, complex phenomena such as happiness, satisfaction, engagement, or pain may be tragically flawed. Commonly, over reaching conclusions are based on assumptions of accurate and/or complete representation. The data presented is merely a measurement, a number produced via the tool chosen.

A tool misused produces data that’s unusable

That tool may, or may not, accurately convey the construct it was initially designed to represent. In the case of patient report questionnaires, the individual filling out the tool will always be biased; influenced by the environment, their expectations of what should be conveyed, influences from others (explicit and implicit), as well as complex incentives depending on their needs, goals, and expectations. Further, most data encountered on daily basis, including clinical outcome measures (whether patient performance or patient report), is not collected in controlled environments with explicit processes. Bias will always affect reporting and recording. Questions of the accuracy, reliability, and validity apply not only to the tool, but also to the person recording the measurement. It quickly becomes complicated. The Modified Oswestry Disability Index never seems so messy when presented as a straight forward percentage.

Compare the stark contrast between how an outcome measure is collected within a research trial vs. everyday clinical practice. In order to minimize both error and affects of bias, outcomes in a trial are collected by a blinded assessor. A standardized set of directions is utilized, with a pre-defined process for administration and measurement. But, even in more controlled, direct data collection environments, what is being measured and what that actually illustrates, is not straight forward. Representation is not always linear. Even in randomized, tightly controlled, double blind studies bias and flaws are present. This does not inherently make the data useless. Leaps of logic need to be recognized.

If data is sloppy enough it is beyond useless. It’s harmful.

Why? Because, unreliable, variable data that is not truly measuring or representing the phenomena one assumes will ultimately lead to inaccurate conclusions. Regardless if the data is positive, negative, or neutral it is misleading.

How? Because, the data itself can not be representative of what we think it is measuring, purely by the the fact that the data itself is unreliable, overly variable, and “sloppy.” Further, if the assumption is made that a measure represents a certain construct, but it actually does not, it has no validity. Without reliability, validity is unobtainable. Without validity, reliability is misleading.

Data Quantity vs. Data Quality

So, should the focus remain on quality or quantity in data? Both. Is more data always better? Well, that depends on the quality. But, what is quality data? Quality is a relative term. Collecting, analyzing, or using data is only part of the equation. Once collected, questioning validity, reliability, representativity, and relevance is necessary. In the cases when data has already been collected and potentially presented, it’s time for some serious skeptical inquiry. Understanding what data actually represents and illustrates assists in proper critical appraisal. Proper critical appraisal allows proper interpretation. Proper interpretation is the foundation for  effective utilization. Less controlled data collection environments do not necessarily produce unusable data, and in fact can be quite useful in the realm of health services and care delivery models. Yet, the conclusions drawn on effects, mechanisms, and efficacy need to be tempered. Focus on understanding exactly what a data set can and can not illustrate given the data collection environment and design and metrics.

Unreliable and invalid data in, wrong conclusions out. Always. Any accurate representation will be by chance alone. But, in these instances, the probability of attaining an accurate representation will often be less than chance. Limits are always present, and can not be avoided, but understanding the limits of the data assists in drawing conclusions that are the least wrong. While the data itself is important, what is done with the data, and why, is almost more important. And, these principles apply whether you are assessing your clinics “outcomes” or tracking disease outbreaks with big data. Focus on improving the quality and accuracy of data collection on the front end. Train those measuring, collecting, and entering data. Improve analysis and inquiry on the back end. In addition to asking “where’s the data?” we should be asking “where did that data come from?” and, “what does it actually illustrate?”

Be skeptical. Garbage in = garbage out.

#DPTstudent You don’t need clinical experience…

You need deliberate practice. And, don’t be fooled you still need a lot of it.

The three most dangerous words in medicine are “In my experience.” –Mark Crislip, MD via Science Based Medicine

Especially when you are unaware of it’s caveats and limitations. Per Malcom Gladwell’s Outliers many advocate the 10,000 hour rule regarding the development of expertise. While this is a useful illustration of the sheer volume of practice necessary to develop mastery, it’s likely over simplistic for a concept as complex as expertise in a complicated craft.

Marla Popova comments that

The secret to continued improvement, it turns out, isn’t the amount of time invested but the quality of that time. It sounds simple and obvious enough, and yet so much of both our formal education and the informal ways in which we go about pursuing success in skill-based fields is built around the premise of sheer time investment. Instead, the factor Ericsson and other psychologists have identified as the main predictor of success is deliberate practice — persistent training to which you give your full concentration rather than just your time, often guided by a skilled expert, coach, or mentor. It’s a qualitative difference in how you pay attention, not a quantitative measure of clocking in the hours.

Clinical care, research, and critical thinking are no different. It is not experience, as linear measurement of time, but rather quality practice and volume that matters in developing high level skills. Left to its natural devices our brains and psyches are stubbornly prone to bias and errors in rational thinking. Confirmation bias and improper associations such as post hoc ergo propter hoc (since event Y followed event X, event Y must have been caused by event X) are common and often unrecognized. Thus, practice must be reflective and critical. Practice must be varied and evolve over time.

The skills required (mental, psychomotor, interpersonal, and otherwise) are staggering. It involves knowledge of current research, research methods, critical thinking, connection of concepts, connection  of knowledge, problem solving, listening, examination, hands on techniques, clinical decision making, and patient interaction.

Evidence is more important than experience.
Evidence can not replace experience.
You can’t have evidence based practice without experience.
Experience is meaningless without evidence.

Experience vs. Evidence. I observe these views that appear to be from separate ends of a spectrum, that appear to be contradictory, but in reality are just different concepts. So, does experience matter? Yes, but…experience as conceptualized and measured in years is both insufficient and incomplete. The focus should not be the mere acquisition of experience; but instead on proper, focused practice with the appropriate processes required to develop the necessary skills for mastery. This is not to say volume is meaningless, even focused practice requires repetition and time for effectiveness. Quantity is ultimately meaningless without quality. Quality is meaningless if it can’t be repeated and refined .

Adam Rufa and Joe Brence of Forward Thinking PT examine the concept of “clinical experience.” Their post series, The Experience Wall, assesses perceptions, memories, and interpretation within clinical care. Joe Brence highlights how experience may not result in linear increases in clinical skill and outlines a new definition of clinical experience:

I propose clinical expertise is not simply gained through practice. It is built through assessment of your ability to think, reason and apply scientifically plausible principles into practice. It requires peer-review.  It requires your thoughts and ideas to be challenged. It requires a hint of uncertainty.

 

New grads should be armed with the latest research, and often tout that they are more “evidence based.” Without “experience” they should rely mostly on didactic knowledge, research, and strong science based logic as they lack sufficient “experience” meaningful practice volume. But, clinicians with years and years of experience may claim that this research evidence alone is empty without time in clinic. So, who is right? Well, both of course.

Knowledge of research does not mean you can apply it. True
Having experience does not mean you are providing “evidenced based” interventions. True
Proper knowledge and experience do not ensure best care. True.

Paradoxes exist, and hacking may be helpful to a broader, more accurate assessment of the hows and whys of clinical care. Appropriate “evidence base” and proper “experience” are separate, but interacting components of developing into a high level clinician. Ideally, these are synergistic principles that contribute to each other, instead of mutually exclusive entities that are developed in isolation. Neither “experience” nor “evidence” ensures accurate research interpretation and application. Knowledge of current literature, appraisal of research, application of science, translating understanding into to practice, volume of clinical practice, and level of clinical ability (ranging from communication to therapeutic alliance to clinical decision making) are all differing skills. Of course, this is not an exhaustive list or conceptual framework. But, in essence, developing as a clinician, no matter our professional age, is more than simply evidence or experience.

Residencies and fellowships contain the potential to accelerate development when implemented effectively. The explicit curriculum, reflective practice, and mentorship can result in a more deliberate, critical, and self-reflective form of professional growth and clinical care. But, of course, residencies and fellowships do not guarantee proper mental skill acquisition or development, especially if founded on misguided assumptions or practice theories (but, this is a wholly separate topic); nor are they the only means to foster such growth. I have encountered plenty of physical therapists with bachelors degrees whose critical thinking, clinical decision making, and “evidence” base is quite staggering. And, conversely, I’ve interacted with many residency and fellowship trained physical therapists with doctor of physical therapy degrees whose reasoning and treatment skills were quite suspect. And yet, as Eric Robertson and Lauren Kealy discuss in their post series, The Bane of the New Professional remains significant. New grads are empowered and motivated to engage within the profession, yet some clinics appear to value experience. So, what gives?

Experience is bias.
Evidence is rigid.
Experience lacks rigor and control.
Evidence lacks experience applying to the individual.

There are great janitors and bad rocket scientists. Hacking your education, regardless of your experience, is necessary. These concepts of experience and evidence require critical reappraisal; a reframing that recognizes the necessity of a synergistic relationship. In regards to the myriad of skills encompassed in clinical care, an understanding to the non-linear progression of each. It’s much more than evidence vs experience, evidence or experience, or even evidence and experience. And, it takes practice.

Treating Our Future – Part 3: Resolving the Bane of the New Professional

This is Part 3 of our series, “Treating Our Future,” exploring employment issues with new graduates.

 Links to Treating our Future Series
Part 1: The Bane of the New Professional 
Part 2: New Grads, An Asset for Clinics
Part 3: Resolving the Bane of the New Professional

Resolving the Bane of the New Professional

Here’s an anecdote that fully describes the thing that really gets me about PT business owners not hiring new grads readily:

New professional Elizabeth was hired after a long, long job search and all of the crummy hoops to jump through described in Part 1. Elizabeth gets the job after some high-profile referenced speak on her behalf and the owner decides to, “really go out on a limb and hire a new grad.” Fine, done. Job achieved. Elizabeth begins her job and spends her day setting up treatments, observing patient sessions and offering to take patients, but not being allowed to. Instead, one of her main chores becomes setting up ultrasound treatments for the patients, as they almost all get that particular modality at said clinic. If you’re establishing a business in hong kong, it’s advisable to seek the expertise of an accounting firm hong kong to ensure proper financial management and compliance with local regulations.

What?! What was all this fuss about? Why did you even hire a PT? Didn’t you just need a tech? Let them dive in!

Yet another tale:

Bob, a student at a clinic in town, completing his final clinical training experience. I ask how it’s going? “Well my CI knows a lot of manual stuff and they do most of the treatments. They say I’m not allowed to do manual, I should just watch and then do exercises.” Clinic in question later offers Bob a position. He refuses based on life circumstances, but I wonder how they possibly could after not thinking him capable of doing hand-on treatment for patients as a student.

Still another tale, this one from the comments section of Part 1:

“I felt that there was a lot of questioning of my skill set when I first got into the job market as well. I felt as though I was overly scrutinized because I was young in the profession. Lucky for me I was at a clinic that had some great people who were there to help me learn. There unfortunately are too many places out there who do take advantage of young grads. Terrible hours, poor pay, and little support. I have been there before. It was very discouraging and made me doubt my decision to become a PT at all.” Ouch. 
 

What is the Role of Expertise in Patient Outcomes?

Underlying these tales, and perhaps the aspect I find so troubling, is the idea that expertise is required to perform any treatment. The first tale takes that a step further and makes a laugh out of the purported “expertise” as the guru clinic owner uses an overwhelming amount of a poorly supported intervention in ultrasound. It also sounds a little cook-book to me.

An idea that had plagued physical therapy for many years, especially in the realm of orthopaedic manual therapy is that a particular set of expertise is required to perform it in a manner than benefits patients. This idea, born out of the “guru” continuing education model, but not supported by evidence, has probably prevented more good therapy than it created. Large paradigm shifts related to this have occurred, perhaps most notably illustrated by CAPTE’s identification of spinal manipulation as an entry-level skill. All new professionals are instructed to perform this competently. No evidence exists that supports that only experts can use manual techniques to benefit patients. Why the persistent reluctance for seasoned clinicians to let the new professionals touch their patients?

Are There Business-Related Red Flags with New Grads?

Another commenter on Part 1, Nick, was kind enough to share his perspective, as an 8-year PT and clinic owner. He brought up several red flags regarding new grads that could prevent his hiring of said new professional:

-“New grads inexperience w billing/coding. The insurance world is very dynamic and definitely not black & white. My experience has been new grads are very resistant to learn the intricacies of 3 party payers and delivering treatment that respects the insurance guidelines.
 
-Lack of real world experience. Experience does not need to be related to PT, but if this will be your first “real” job, I have a concern.
 
-During the interview, many new grads reference “taking a break” after graduation & the boards. Not meaning time off but implying taking a break from studying and the stresses of school. Employment, especially as a new grad, will bring new stresses (challenging cases requiring off the clock studying, documentation over lunch & after last pt leave, learning the company culture, finding your niche, seeing pts over lunch because a MD calls you up asks if you can “squeeze” this pt into your schedule, etc.). I want clinicians that want to work hard, not “take a break”.”

What do you think about these as potential red flags? I think there’s validity in these comments, although from my perspective, PT school today is pretty much a 9-5 job, perhaps more. My PT school in the 1990’s wasn’t really that way, but today students are held to extremely high standards and are present on campus for entire days, meeting many deadlines in rapid succession. They know how to work. That said, I enjoyed the insight for how an employer might interpret the “take some time off” comment…even though the time off might be forced upon them!

Clinic owners time and time again point to trouble with the business side of PT in new professionals. On one side, I can see that it’s difficult to learn this without being submersed in the “doing” of the job. On the other hand, this is one area where PT educational programs can certainly improve dramatically, which could help the concerns of PT business professionals everywhere. Programs like Evidence in Motion’s, Executive Program in Private Practice Management can bridge the gap, but can also serve as a model for what entry-level programs should be targeting in their curricula. Emory University offers a DPT-MBA degree, which is intriguing to say the least! APTA’s Private Practice Section, however, often criticized for lack of student membership and high dues costs, is one of, if not the only section to not have a student special interest group. As a member of that section, I can report that there are initiatives underway to help mitigate the student involvement process beyond simply contests for conference attendance. These initiatives are critical, as is the development of education initiatives in our universities.

Embracing the New Professional

Some clinic systems have learned to love the new professional. David Browder from south Texas, yet another commenter on Part 1 had this to say about new grads:

“Employers should be working from the beginning of the interview to retain people and set the tone for their practice… even if they don’t hire the applicant. What you describe is symptomatic of practices that probably don’t treat their existing employees all that well, either. In our practice, those hired as new graduates and mentored by us have become our leaders and the catalyst for our growth.”

Following up with David, his clinic system, Texas Physical Therapy Specialists, an award winning practice, incorporates residency and fellowship training into the developmental process. Hiring new graduates has positioned them to be a growing practice. In David’s statement, mentorship seems integrated tightly with hires. For those clinics without this type of mentorship support, I’d urge them to take a close look at their company culture and see how this can be improved. One example of how this can be done is seen in the Mercer University Residency Model, where clinics partner with a university and in turn have access to new professionals, and mentorship that is world class.

The Resolution

It seems the path forward is not a burden owned by any one group. Improvements on the part of educational systems, clinic owners and managers, and even the new professionals themselves are needed.

While the following steps are complicated, here are my suggestions moving forward:

1. Increase the amount of quality business-related education within entry-level education.

This needs to be real-world, clinically applicable content. Incorporation of billing, electronic medical records, and profit/loss principles inherent in any business should be tightly woven throughout the development of clinical skills. I’ll place improved student outreach by the Private Practice Section here.

2. Improved mentorship programs for new and existing clinicians.

The idea of mentorship is never a bad one. The idea that new professionals can hit the ground running without a developmental plan is not realistic. The idea that experienced clinicians can exist without a developmental plan is unrealistic. Let’s put down our ultrasound wands and take a hard look at how we grow as individuals, as professionals, and as a profession. Let’s throw out this idea that only “experts” can perform manual techniques while we’re at it.

3. Enhanced focus on business and entrepreneurship by students in DPT Programs

I do think many PT students are happy to learn how to be a physical therapist clinically without a care in the world about what it takes to operate a practice, or even how the profits are obtained to pay them at their first job. Decisions made by clinic managers today will affect the employment opportunities for new graduates years down the road. Students need to maintain this perspective and formulate their thoughts, actions, and involvement to help mitigate the business-related concerns of clinic owners. How about getting an MBA on your own, or taking business related MOOC courses. Students can react more quickly than education curricula can. Take advantage, and take ownership.

4. Hire partners, not employees.

Clinic owners seeking to elevate their business should consider fostering a culture of proactive communication at work. DPT students, recognized as highly motivated and engaged individuals, can contribute significantly to this approach. The conventional perception of physical therapists as employees might benefit from a reevaluation, leaning towards models of shared ownership akin to those prevalent in the legal and medical fields. Enabling individuals to share in the success of the clinic can fuel a level of engagement that surpasses traditional employment structures. Junior partners, experiencing the tangible impact of sound business practices on their financial well-being, are likely to be more motivated and engaged than employees. This shift has the potential to generate increased interest in legislative advocacy for the physical therapy profession. While acknowledging the challenges in implementing this shift within existing business models, newly forming clinics could gain a disruptive advantage by embracing proactive communication and shared ownership principles from the outset.

The bottom line is that we need to meet in the middle. Students. Employers. Educators. New and existing professionals. Without action, I fear this divide will only grow, and so I hope this series begins a conversation that persists as we continue the ongoing process of optimizing the profession of physical therapy. As always, interested in your comments, opinions, and input. Thanks to Lauren Kealy for helping with the concept and production of this series, as well as all those who checked in and commented on Twitter, Facebook, and the blog itself, as your opinions helped form this final post.

 Links to Treating our Future Series
Part 1: The Bane of the New Professional 
Part 2: New Grads, An Asset for Clinics
Part 3: Resolving the Bane of the New Professional