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What Problem Does The Human Movement System Solve?

Apparently evolving from the new vision statement, the APTA and the board of directors introduced the “human movement system” as the potential professional identity and rallying cry for physical therapists. The definition of the human movement system is:

The human movement system comprises the anatomic structures and physiologic functions that interact to move the body or its component parts.

Chris Powers, PT, PhD, FAPTA recently discussed the concept of the human movement system on Karen Litzy’s podcast Healthy, Wealthy, and Smart. He stressed it’s conciseness, applicability to educating consumers, and it’s ability to be a unifying theme across practice settings. Dr. Power’s asserts the profession of physical therapy needs an identity, a central theme, and something that applies across patient populations and settings. He describes the human movement system as a system comprised of many systems. “We treat the entire movement system, and in order to do that you have to be an expert in all of the subsystems.”

Matt Sremba, PT, DPT, OCS Paul Mitalski, MS, and myself are interviewed by Adam Van Cleave on the Conatus Athletics’ Podcast regarding the Human Movement System and Role of the Physical Therapist. We think there are issues in regards to the definition and it’s implications. All of us agree with Dr Powers that there are problems within the field of physical therapy spanning education, research, and clinical practice. But, we do not see the creation of a “human movement system” nor the definition as assisting in either solving nor identifying any significant problems.

It’s over ambitious and under precise…this definition allows for a misinterpretation of the physical therapy profession…The first example I’ll give is the word components and how it’s used. In this instance the word is too broad….The word movement is too narrow…do they really mean ALL components of all anatomical systems involved in movement? Because that is what they say. In fact, what system wouldn’t be involved? What system or component of human anatomy doesn’t directly or indirectly contribute to movement? This is too broad. Didn’t narrow the scope…

When you propose a definition that has no bounds you end up not defining anything. And definitions have to be precise. So, this is a lack of precision. On the other hand, the word movement also has a lack of precision, but it’s opposite. The word movement, to me, is too constraining. It’s inconsistent with what the physical therapist does and it limits what the physical therapists does. PTs should have a medical role…for the human whether or not the human is moving. The therapist should be involved in non-movement aspects of the human. -Paul Mitalski, CEO of Conatus Athletics

Sure, this may appear like nit picking, minutia, and nothing but semantics. Is the human movement system really a system? Is this our professional identity? Do we want to create something else that no one knows about? If the physical therapy profession senses there are issues communicating our knowledge and roles to various stakeholders any proposed solution must be clear. Precision in language is needed.

The problems have not been specifically identified or labeled meaningfully. Is the definition for marketing and branding only? One liners and advocacy for physical therapy are not bad. In fact, rallying generally around PTs helping people move is a likely a meaningful cause. And of course, PTs deal in human movement quite frequently. But, we remain skeptical that attempts to create a human movement system will contribute meaningfully to education, research, clinical practice, or advocacy efforts. Further, this definition will not contribute meaningfully to communication. We think creating new systems with broad definitions that demand assumptions may only complicate an already cloudy communication problem.

Are the problems properly identified? And, does the creation of the human movement system and it’s definition address them? Some of the issues we identify (and will discuss further in future podcasts) are leadership, collaboration, and education modifications.

Listen to The Human Movement System with Dr. Chris Powers on Healthy, Wealthy, and Smart as well as our reply The Human Movement System and the Role of the Physical Therapist on The Conatus Athletics’ Podcast. Our goal is to open a dialogue on this topic.

So, what do you think?

Resources
The Human Movement System with Dr. Chris Powers on Healthy, Wealthy, and Smart
The Human Movement System and the Role of the Physical Therapist on The Conatus Athletics’ Podcast
Human Movement System information on APTA website
Rothstein Roundtable Debates Implementation of Human Movement System
Rothstein Debate: Putting All our Eggs in One Basket: Human Movement System on PTJ Podcast
Discussion: The Human Movement System on PTJ Podcast
Shirley Sahrmann explains why PT’s are THE Movement System Specialists on PTPintCast
‘Movement System’ Is Our Professional Identity
The human movement system: our professional identity by Shirley Sarhmann
On “The human movement system: our professional identity…”

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Debate and Dissent. Do We Need Contrarians?

Debate and dissent are useful in their own right. In the realm of professionals, argument should not be a pejorative. Agreeing to disagree is the start, forming the foundation of the discussion, not the end. Yielding of discourse and the parting of ways is but to avoid the required conflict of progress. Contrary to popular belief, dissent for dissent’s sake and debating just to debate are necessary to sharpen and sculpt the knowledge base and thinking in any realm. We need contrarians.

Time spent arguing is, oddly enough, almost never wasted. -Christopher Hitchens

Hang out with individuals who ask tough probing questions, not those that give you high fives and excessive praise. As Jerry Durham routinely proclaims “if you are the smartest person in the room, you are in the wrong room!” Pursue disagreement.

On the charge that debate, “nit picking,” and argument tarnish the public image of physical therapy, I must protest. Generally, Science and debate are already misunderstood in the public sphere. This problem is not unique to physical therapy that the process of progress appears contradictory and self defeating . Yet, all scientific disciplines evolve through argument. Critique, alternative explanations, and disagreement force the community at large and the individuals therein to analyze current assumptions. Theories, processes, and understanding all require frequent sharpening. Critical analysis and differing viewpoints are the wetstones of inquiry. We can simultaneously argue fiercely within our profession while advocating passionately for it. These two necessities are not mutually exclusive. Further, we must actively seek to address and engage critiques from outside our profession. Physical therapy writ large should engage other health professions and scientific disciplines.

Picture all experts as if they were mammals. Never be a spectator of unfairness or stupidity. Seek out argument and disputation for their own sake; the grave will supply plenty of time for silence. Suspect your own motives, and all excuses. -Christopher Hitchens, Letters to a Young Contrarian

The proposition of challenging and questioning our current understanding is an uncomfortable one. Cognitive dissonance involves feelings of discomfort that we usually seek to avoid. However, consistently aiming to prove ourselves and our professional assumptions wrong is not only beneficial, but necessary. Questioning is not an attack, it’s the process of refinement. The difficult task of reasoning through and critically thinking about our conclusions is a component of strong clinical reasoning. Reflection, as it is proposed, is a hallmark of clinical expertise.

Often, skepticism and critical inquiry are mistaken for antagonism, if not outright cynicism. Although, to some extent professional antagonists are likely to improve our thinking and development. The contradiction is such: disagreement is necessary and debate is fruitful in it’s own right, but constant contrarianism appears to yield little concrete action. Those who dissent by asking the tough, uncomfortable, uncommon questions should improve their counterparts as well as their own thinking. Hopefully all involved in a discussion are at least subtly affected by the exchange. But, there is more at play. The dissenting may positively affect the spectators. Seemingly fruitless and circular discussions in which neither side appears to change are of benefit to those who bear witness. Considerations to ponder, questions to investigate, and new ways of thinking become available.

There’s a small paradox here; the job of supposed intellectuals is to combat oversimplification or reductionism and to say– “well, actually, it’s more complicated than that.” At least, that’s part of the job. However, you must have noticed how often certain “complexities” are introduced as a means of obfuscation. Here it becomes necessary to ply with glee the celebrated razor of old Occam, dispose of unnecessary assumptions, and proclaim that, actually, things are less complicated than they appear. -Christopher Hitchens, Letters to a Young Contrarian

Don’t avoid dissent. Answer the question. Attempt to prove yourself wrong. Disagree and debate. Reflect. Be fierce, but respectful. Admit mistakes. Concede where indicated. Anything less, I contend, is unacceptable. Perhaps you disagree?

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A Personal Endorsement for Eric Robertson #AAOMPT Secretary

Naturally, I’m biased on this matter. So, please consider that as you read this endorsement. But, I also plead that you digest my narrative and what it illustrates about Eric Robertson.

As a #DPTstudent, I was fortunate to be involved in the AAOMPT student special interest group. At the risk of sounding cliche, the experience was transformative. I was exposed to the inner workings of a professional organization, afforded the opportunity to organize events, involved in advocacy, and even saw my beginnings as a blogger. Our student SIG was full of energy and set lofty goals.

Students, often, are eager and idealistic expressing grandiose visions and unconstrained thought processes. This, of course, is positive. A motivated and engaged student does not know impossibility. And, thus can be quite an agent of change, or a least reflection. I’d like to share a story with you about how Eric, without even being formally involved in the student SIG, brought focus and professional growth to the student members one evening.

It was 2009 at the AAOMPT National Conference in Washington DC. The AAOMPT sSIG leadership sat around a table in those classically ill lit and muggy conference rooms, frantically discussing ideas and topics almost at random. Bob Boyles, the AAOMPT sSIG advisor at the time listened to us. It was great times! Eric, who at the time, I had only just met, was also present. Eric also listened to our grandiose plans to save the world, cure hunger, and eliminate back pain. After listening intently, as Eric does, he spoke. With pointed questions and strategic steering he efficiently nudged us towards more meaningful conversation without stifling our enthusiasm nor tempering the discussion. Oddly, I can’t remember at all what he said. I just remember his presence and effect. It was effortless, but profound and has stuck with me as an example of the kind of impact Eric can have in a room.

Eric routinely engaged the students as colleagues, but also challenged in a productive manner. After attempting to write meaningfully for the AAOMPT sSIG he extended an invitation, and opportunity to blog at PT Think Tank, an experience for me that has been a professional highlight.

Over the years, I’ve known Eric to possess a cool demeanor, strong thinking skills, and excellent strategic planning. He’s not afraid to tackle a problem from multiple angles and balances a host of commitments with ease. I know a long time goal of his has been to serve in a leadership capacity within AAOMPT, so his decision was not at all rash. He’s a constant advocate for physical therapy with a knack for concise and clear communication.

I’m indebted to Eric for his guidance along my own career path and the informal, but always beneficial discussions. His unique experiences and point of view could facilitate amazing progress. I recommend him highly and without reservation. His vision, his commitment, and his skills would serve the AAOMPT well. But, don’t take my word for it.

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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 placebo. Anesth 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 model. Man 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 pain. Phys 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 pain. Pain. 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 treatment. Neuroimage. 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 hand. Neurosci 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 hand. Physiotherapy . 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 pain. Arch 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 guidelines. Phys 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-analysis. J 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 trial. Phys 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 phenomenon. Rheumatology (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 pain. Phys 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 study. Phys 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 subjects. BMC 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
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A Year and a Day Later

A year later, a patient returned with an unlikely outcome and positive feedback. But, let us not be so naive to think the impact of clinician is always positive. Sampling bias is not always bad I guess, I’m lucky she walked into the medical ICU that day. Hopefully, the impact of her visit will last past tomorrow. Clinicians, after all, are human as well.

I wondered to myself about how easy it was to treat, interact, and generally be pleasant to this patient and her husband. Not that her case was simple, or her progress quick, but the interactions with family, the social aspect was nearly effortless. And, she was full of gratitude and positive energy. Every clinician, at some point, experiences cultivating a strong therapeutic alliance and connection with a patient. Why? It’s likely a complex interplay between personalities, the situation, the patient’s psychological state, and the clinicians current demeanor. The perfect storm. Naturally, variance occurs in our own attitudes, performance, and interactions. Despite her struggles, her long journey, her complications, a surprising lack of complaints, in fact none, were aired. It was the patient room you never dreaded entering. Is it possible I benefited more from the therapeutic interaction than the patient and family?

I also wonder about the patients, the people who are challenging to engage. Those without social support and coping mechanisms. High symptom burden and remarkable distress. Pain. Lack of understanding. Unmet desires or requests. No resources. Learned helplessness. The patient room everyone dreads entering. Difficult, non-compliant, lost causes…or so some would say. How does the previous story end if they return for a hospital visit? I shudder at the potential. Post traumatic stress. Resentment. Acquisations. Confusion. Anger. Sadness. Loss. Depressive symptoms. What happens to those patients? Likely we see them again. By we, I mean the healthcare system. I’d postulate those are patients with a higher degree of medically unexplained symptoms, poor functional status, readmissions, poorly managed chronic conditions, and other complications. I’m sure they never volitionally come back to “visit” and tell their story, unless it’s during another hospitalization. Although, I wish they would, because it’s a narrative all healthcare professions should attend to. It’s easy, and I sense commonplace, to blame the patient in those exceedingly difficult circumstances. We’ve seen other patients do better. We’ve seen other patients understand. We’re trying our best with the knowledge and skills we possess. Why isn’t this person improving? Unfortunately, in such situations, neither the patient nor the providers are likely well equipped to deal with, rectify, or even improve the situation.  What can be done to modify our education and approach to such difficult patient scenarios?

Despite the satisfying and motivating effect of this specific patient visit, I’m not sure my personal day to day practice will evolve much from the experience. Hopefully, it remains a reminder on the potential, and long lasting impact of our interactions. Hopefully, it doesn’t lead to arrogance. Hopefully, I can muster the focus and resolve to remember not everyone returns with a happy ending. And, those patients, the difficult ones, need our help too…arguably even more so. I hope I don’t forget the instances, well actually the people, that the system and myself failed…not by direct fault or intent, but because of the convoluted, complicated, regulated, inexact, and at times rushed human enterprise we practice within. Healthcare. Humans trying to take care of other humans.

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A Year Later

I had been assisting another therapist with a treatment session on the other side of the medical ICU when one of our unit clerks peaked her head into the room. “Kyle, I know you’re busy, but we need you out here.” Naturally, my mind begins listing every possible worst case scenario as if I’m about to walk into a corridor of unimaginable horror. “There’s someone here to see you.”

She was dressed nice and looked younger than her age. Her hair was full and well done. She was thin, but muscular. Very healthy looking actually. Walking, standing, talking, and smiling. Her face appeared eerily familiar, as if from a dream, but I immediately recognized her husband. Their names, initially escaped me, as names usually do. Her smile though, that I had seen before.

“I’m back for a one year follow up appointment.”

I couldn’t recall the details of her case, but I remembered she was in the MICU for a long time. She offered up that she herself remembered nothing from her ICU stay. Not uncommon, of course, but still a shock to hear directly. Especially as someone who spent, well resided really, in the ICU for over 6 weeks requiring prolonged mechanical ventilation. “Did I stand up while I was here?” Her husband, recalling more details than I, “Kyle held you up honey, your arms were around his neck. He basically lifted you into a chair.” At that time, she was maybe 90 pounds. She could stand for less than 2 minutes with maximum assistance and was unable to march, take steps, or ambulate.

To the casual observer her physical function was now normal, if not better. Well placed wrinkles covered a tracheostomy scar, and she moved without obvious, or discernable deviation. She reported she had been reviewing her medical record. “I was scared at first, because I had no memories of the ICU. But, also no nightmares. My doctor said that was rare.”

“I still get tired.”

“You know sometimes I go go in the morning and I just need to rest some.” Her husband chimed in “she tries to do it all you know.” She talked about the challenge of lifting her grandson “he’s a little chunk. And, he’s over a year so I need to get stronger to keep up with him.” Every limitation augmented by a goal.

In reflection, what was most unique about the case, beside her remarkable outcome in the face of a guarded prognosis, was the attitude and perspective of both the patient and her husband. Constantly positive, but realistic. Engaged, and focusing on the tasks to be done, what was improving and what could be controlled. Her husband, I recalled, was always hopeful, yes, but not blindly optimistic. Not every patient outcome turns out like this one. In fact, most do not. Exceeding the realistic range of possible prognoses involves the interplay of complex medical, physiologic, physical, environmental, psychological, and social factors. And, I’m a vocal advocate of clinicians focusing on the right process, and not validating their approach post hoc based on observed positive outcomes.

Despite this, it still feels good to encounter a success story. It’s touching of course and it’s motivating. As I shared with her, these patient stories, even the simple ones, “keep us going.” The patient and the husband exuded appreciation and satisfaction; his memory of people, names, events was remarkable. Flattered at the perceived impact, I couldn’t help but feel some guilt percolating under my pride. We should’ve done more, we could’ve started earlier, was I attentive enough to psychological issues? Did I “push” her enough physically?

But, it appears that this woman likely was to progress, to be “better” with, or honestly, without me. Her husband’s constant, but empowering support combined with her positive, focused attitude were the foundation for an outcome a few standard deviations or so from the norm. Not that I feel what I did, my role was insignificant. All I can hope is that I was a small part of nudging the momentum in the right direction. Or, at the very least, not a hindrance, an inhibition to her journey. I’m reminded of the often referenced idea that it’s not what you do, or necessarily even the outcome, but what the person experiences, their feelings that affect how they perceive events upon reflection. People don’t care what you do per se, they care about how you make them feel.

“I tried to get out of bed on my own at rehab. They got mad at me for that because, I fell.”

“She melted to the ground before 1 step.”

“I was trying to get out of bed to the bathroom.” She felt guilty and a burden ringing the call light then waiting for assistance. Especially the times when her ability to control her body were not as she would desire. “I felt so bad, I didn’t want to wet the bed.” Despite being unfortunate, my sense is the feelings she expressed are not uncommon amongst previously independent, newly debilitated patients. Her guilt and feeling of burden could break your heart. Are there means of improving our interactions to decrease this perception? Or, is this guilt, this desire to not be dependent upon others potentially a motivating factor; a goal in it’s own right?

One should never underestimate the power of a patient story. Clinicians of all professions and settings harbor them. Stories of loss, unfortunate outcomes, horrible situations, triumphs, system failure, lack of resources, personal failure, professional limitations, outcomes that defy explanation, and unimaginable bad luck. These plots impact us, because they force us to confront the longer term, the personal narrative and the very real and human enterprise of health care. And, after all we are human too. The illustration of one individual’s unique journey and the construction of a patient’s personal story, their illness narrative, is a vital part of coping, confronting, and rectifying experiences. It’s assigning meaning. These stories likely can assist other patients. And, maybe, they can assist clinicians by highlighting the potential power of our interactions. Our words, our demeanor, our interface with each unique psyche is an intervention.

It’s easy to forget the impact of clinicians on a patient, or even a family member. Fleeting and brief, even the unforgotten moments, the words we can’t recall, may be etched in stone within our patient’s nervous system. A memory, good or bad, helpful or harmful, that persists long afterwards. But, let us not be so naive to think the impact is unidirectional. At times we may forget names, or details, but the themes stay with us. Unscripted and subconscious lessons forged through the cognitively unseen process of emotion. Our personal experiences within this professional realm can simultaneously, and paradoxically, taint our future perspectives and motivate thoughtful change.

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What Scientific Ideas are Ready for Retirement?

Every year Edge poses a question and subsequently curates responses from a variety of intellectuals. The result is a fascinating compilation of short essays on a range of ideas orbiting around a central theme. Previous questions include “what scientific concept would improve everybody’s toolkit?” and “what is your favorite deep, elegant, or beautiful explanation?”

And in 2014, “what scientific idea is ready for retirement?”

Science advances by discovering new things and developing new ideas. Few truly new ideas are developed without abandoning old ones first. As theoretical physicist Max Planck (1858-1947) noted, “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.” In other words, science advances by a series of funerals. Why wait that long?

WHAT SCIENTIFIC IDEA IS READY FOR RETIREMENT?

Ideas change, and the times we live in change. Perhaps the biggest change today is the rate of change. What established scientific idea is ready to be moved aside so that science can advance?

Knowing is Half the Battle

by Laurie R. Santos and Tamar Gendler

The lesson of much contemporary research in judgment and decision-making is that knowledge— at least in the form of our consciously accessible representation of a situation—is rarely the central factor controlling our behavior. The real power of online behavioral control comes not from knowledge, but from things like situation selection, habit formation, and emotion regulation. This is a lesson that therapy has taken to heart, but one that “pure science” continues to neglect.

So, in knowing that knowing is not nearly sufficient, what are we to do? Metacognition, reflective experience, and recognition of incentives are components of improving our decision making performance. Studying cognitive bias, behavior change, and philosophical argument also aid critically thinking. Beyond our own personal, and professional, growth these concepts are salient within clinical practice, patient care, research, and education.

Heights And Lengths And Areas Of Rectangles

by Robert Sapolsky

The problem with “a” gene-environment interaction is that there is no gene that does something. It only has a particular effect in a particular environment, and to say that a gene has a consistent effect in every environment is really only to say that it has a consistent effect in all the environments in which it has been studied to date. This has become ever more clear in studies of the genetics of behavior, as there has been increasing appreciation of environmental regulation of epigenetics, transcription factors, splicing factors, and so on. And this is most dramatically pertinent to humans, given the extraordinary range of environments—both natural and culturally constructed—in which we live.

Sapolsky’s essay illustrates complexity and interaction. While simplicity is important, caution is warranted to avoid over generalization. And, of course, do not discount the effect of dependency. Everything depends; on incentives, environment, previous experience, the current situation, and more. Some factors, and influences, likely have not even been identified. This is especially true in the realm of humans and behavior. An interesting book The Dependent Gene: The Fallacy of Nature vs. Nurture is an in depth exploration and refutation of inaccurate understandings of genetics.

Big Data

by Gary Marcus

But science still revolves, most fundamentally, around a search of the laws that describe our universe. And the one thing that Big Data isn’t particularly good at is, well, identifying laws. Big Data is brilliant at detecting correlation; the more robust your data set, the better chance you have of identifying correlations, even complex ones involving multiple variables. But correlation never was causation, and never will be. All the big data in the world by itself won’t tell you whether smoking causes lung cancer. To really understand the relation between smoking and cancer, you need to run experiments, and develop mechanistic understandings of things like carcinogens, oncogenes, and DNA replication. Merely tabulating a massive database of every smoker and nonsmoker in every city in the world, with every detail about when they smoked, where they smoked, how long they lived, and how they died would not, no matter how many terabytes it occupied, be enough to induce all the complex underlying biological machinery.

Physical therapy likely under utilizes big data and available data sets. None the less, big data inherently contains all the methodological issues of any study or data set: sampling bias, reliability, validity, blinding, confounding factors, operational definitions, and control. Remember, garbage in = garbage out. Big data must be put into context, and properly analyzed. What question is being posed? What questions can the data actually answer? And, what are the limitations? Quantity in data is never a direct substitute for quality. As Marcus asserts, “we should stop pretending big data is magic.” Data, after all, is just data, and is nothing without analysis. Analysis, if conducted improperly or with bad assumptions, breads false interpretation.

Mental Illness is Nothing But Brain Illness

by Joel Gold and Ian Gold

That a theory of mental illness should make reference to the world outside the brain is no more surprising than that the theory of cancer has to make reference to cigarette smoke. And yet what is commonplace in cancer research is radical in psychiatry. The time has come to expand the biological model of psychiatric disorder to include the context in which the brain functions. In understanding, preventing and treating mental illness, we will rightly continue to look into the neurons and DNA of the afflicted and unafflicted. To ignore the world around them would be not only bad medicine but bad science.

The direct parallels to physical therapy are striking. Psychological, contextual, and social factors are now recognized as foundational contributions to symptoms, function, intervention mechanisms, and treatment response. How will education, clinical practice, and research evolve to accommodate such insights?

Only “Scientists” Can Do Science

by Kate Mills

However, limiting the potential contributions of informally trained individuals to the roles of data-collector or data-processor discounts the abilities of citizen scientists to inform study design, as well as data analysis and interpretation. Soliciting the opinions of individuals who are participants in scientific studies (e.g., children, patients) can help traditional scientists design ecologically valid and engaging studies. Equally, these populations might have their own scientific questions, or provide new and diverse perspectives to the interpretation of results.

There is a growing need for individuals to occupy the historically ill defined black box between research science/academia and clinical practice. Further, healthcare yearns for clinicians approaching patient care, clinical data collection, and clinical care from a scientific lens. Scientific and clinical research is challenging, time consuming, and expensive. Well trained, highly skilled researchers and scientists a requirement, I won’t argue otherwise. But, interpreting and translating such knowledge into clinical practice is an often under appreciated skill set. And, formal academic or clinical roles devoted to this necessary bridge are sparse. Conversely, formal means of translating clinical practice, clinical data, or even clinical observations into research (or to academia in general) are lacking. Well designed quality improvement projects are a means of fusing clinicians and scientists, clinical care and research. Yet, many clinicians lack the time and expertise to design projects, ensure proper data collection, analyze, and write manuscripts. Despite this clinicians (and academics) must: ask questions, collect data, and collaborate. We all have a role to play in knowledge creation and translation.

Big Effects Have Big Explanations

by Fiery Cushman

There is, of course, an alternative and very plausible source of big effects: Many small explanations interacting. As it happens, this alternative is worse than the wrong tree—it’s a near-hopeless tree. The wrong tree would simply yield a disappointingly small explanation. But the hopeless tree has so many explanations tangled in knotted branches that extraordinary effort is required to obtain any fruit at all…

…the world has large problems that demand ambitious scientific solutions. Yet science can advance only at the rate of its best explanations. Often, the most elegant ones are clothed around effects of modest proportions.

Physical therapy, as a profession, appears to fall victim to the search for big explanations. The factor, the intervention, the mechanism, the tool, the explanation. But, pause and appreciate the complexity of the therapeutic process. It’s complicated, it’s dynamic, and it takes time. Therapy interventions, inherently, must be the result of a multitude of smaller factors interacting, for better and for worse, to produce effect.

Immediately, I’m reminded of the effective philosophical tool of Occam’s Razor. Now, many misquote Occam’s assertion as the simplest explanation should always be favored. But, there is an often missed subtlety to the Razor originally sharpened by William of Occam. The premise is that the hypothesis with the fewest assumptions should gain favor, not necessarily the simplest. Often, the more complicated the hypothesis the more leaps of logic, and thus, the greater the number of assumptions. But, remarkably simple explanations may rely on astounding, and even grossly inaccurate, assumptions. Or worse, may be initially founded upon a false premise upon which all subsequent assumptions are, to some extent, wrong.

The Pursuit of Parsimony

by Jonathan Haidt

Occam’s razor is a great tool when used as originally designed. Unfortunately, many scientists have turned this simple tool into a fetish object. They pursue simple explanations of complex phenomena as though parsimony were an end in itself, rather than a tool to be used in the pursuit of truth.

Don’t make unwarranted, unfounded assumptions. But, be wary also of oversimplification. Simple is nice, but accuracy is better. It’s complicated after all.

The Power of Statistics

by Emanuel Derman

But nowadays the world, and especially the world of the social sciences, is increasingly in love with statistics and data science as a source of knowledge and truth itself. Some people have even claimed that computer-aided statistical analysis of patterns will replace our traditional methods of discovering the truth, not only in the social sciences and medicine, but in the natural sciences too.

I believe we must be careful not to get too enamored of statistics and data science and thereby abandon the classical methods of discovering the great truths about nature (and man is nature too).

Statistics, despite being a field of study, are merely a tool. And, thus are prone to be misused, abused, and misunderstood.

Statistical Significance

by Charles Seife

It was designed to help researchers distinguish a real effect from a statistical fluke, but it has become a quantitative justification for dressing nonsense up in the mantle of respectability. And it’s the single biggest reason that most of the scientific and medical literature isn’t worth the paper it’s written on.

When used correctly, the concept of statistical significance is a measure to rule out the vagaries of chance, nothing more, nothing less…

Nevertheless, even though statisticians warn against the practice, it’s all too common for a one-size-fits-all finding of statistical significance to be taken as a shortcut to determine if an observation is credible—whether a finding is “publishable.” As a consequence, the peer-reviewed literature is littered with statistically significant findings that are irreproducible and implausible, absurd observations with effect sizes orders of magnitude beyond what is even marginally believable.

Beyond the misuse of significance mentioned, the concept of clinical significance is also important. Statistical significant alone can not support clinical significance, or clinically meaningful effect. And, paradoxically, apparent clinically meaningful effects are not sufficient for statistical significance. Partially, this is why research attempts to construct minimally clinical important change (MCIC) or difference (MCID) for certain measures. Although, even this concept is likely elastic. But, at the foundation of the entire issue, is the misunderstanding and misapplication of statistical significance.

Beware of arrogance! Retire nothing!

by Ian McEwan

Every last serious and systematic speculation about the world deserves to be preserved. We need to remember how we got to where we are, and we’d like the future not to retire us. Science should look to literature and maintain a vibrant living history as a monument to ingenuity and persistence.

I’d contend that more than a few ideas within physical therapy are ready, in fact likely over due, for retirement from discussion and clinical care. What are they? And, how do we guide them into the history books and out of our text books? Can we pay our respects to these ideas by identifying the potential mistakes within them? What lessons could be learned without perpetuating artificial relevance and unwarranted influence?

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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

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The Filling

Some people utterly despise going to the dentist. I get it. The face and mouth are a locus of sensory innervation, and a dentist’s tools don’t exactly exude comfort. The grinding, the drilling, the scraping. Someone else’s hands in your mouth. Bleeding gums. Mouth held open, saliva building up, and plaque flying like saw dust in a wood working shop. Me? I actually enjoy it. At least the cleanings. The feeling of having my teeth scraped clean and polished is somehow satisfying. Afterwards, my mouth feels great. I’d go to the dentist every week, if I could. Recently, my dentist told me I needed a filling replaced. The current one was worn out, discolored, and not as smooth as the dentist desired. I’ll spare you the details. She informed me it would likely take less than 30 minutes. Not a problem I thought. So, I made the appointment.

Two days later, I sat into the customary recliner chair. A partner of my usual dentist would be performing the procedure. “Simple” he said. “I just need to numb that tooth and surrounding area and then we’ll get this done and get you out of here.” I panned to my right to see the syringe and needle.

And, that’s when things got interesting…

As a child, most (see almost all) of my baby teeth required extraction. Those experiences were not pleasant. In fact, quite the opposite. With merely a local anesthetic, I would pin my eyelids shut so as not to view the medieval metallic torture tools required to unroot the stubborn (and might I add inappropriately named) “baby” teeth. Not that I needed to see. The sensory experience of pressure, pulling, and vibration combined with the sounds of the tools upheaving teeth from my gums provided more than enough information for my young nervous system to make a judgement of the situation. This sucked. Plus, as I took my position into the torture victim’s dentist’s chair I didn’t miss eying the tools purposefully arranged in an evenly spaced row of exponentially increasing painful possibilities. At least so they seemed. The imagination may be the most frightening tool. I shuddered just looking at them.

My memories of those extractions are fractured, cloudy, and likely a bit inaccurate.

The build up was always horrible. I dreaded the waiting, the anticipation. Subsequently, I continually reassured myself as I received shots of numbing medicine. Shots in the cheek, the gums, and worst of all, the roof of my mouth. Those ones always hurt, that I did remember. I feared the procedure itself. It’s hard to express what in particular was so frightening.. Likely a combination of the unknown, the possibility of pain during (and after), and just the unsettling experience itself. It’s hard to recall the exact content of my self talk and inner experiences. Although, it felt like some type of duel or argument within me. It’s as if I had multiple inner agents all vying for control of reality. A teeter totter between feelings, assessments, and projections of the possibilities. I attempted to balance “being tough” with the acceptance of the reality regarding the horrible nature of the experience. Imagine someone grabbing you by the tooth with a pair of plyers and shaking your jaw about as if to scramble the contents of your skull.

In regards to both quality and intensity, I honestly can’t remember any pain. I do recall pain with pre-procedure shots in the gums and the roof of the mouth. But, no real details, no illustrative adjectives. I also remember a soreness and difficulty eating after the procedures. My most vivid memories are the experience and associated feelings of sitting in the chair prior to and during extraction. By far, the build up was worse than the actual event. I’m unsure how much explanation I received prior, whether distraction was helpful, or how my dentist even acted. But, I  vividly remember how odd the feeling of a numb mouth and cheeks. I couldn’t spit accurately into a sink for hours afterwards. But, boy could I ever drool down my chin and onto my shirt. The sensation of no sensation always amazed me. My cheeks felt as big as balloons.

Oddly, I’m not afraid of needles. When I have blood drawn or receive a TB test I actually watch the needle being inserted. It’s interesting to me, sensorily, visually, and cognitively. Although, on this day, settling in for a routine filling repair, the dentist informed me I needed to receive a shot of local anesthetic…I felt a rush of not just memories, but palpable states, from my childhood. My body tensed, my respiratory rate elevated. I’m sure my heart raced, and my mind immediately went into a manic panic. I was actually frightened. I tried self-talk, deep breathing, and cognitive re-assurance. These were mildly helpful initially.

Instantly, all the fears, feelings, and thoughts surrounding those previous experiences engulfed me. The intensity lasted but a few minutes. But, I definitely wasn’t comfortable. And, I definitely couldn’t escape. I wanted to ask if he was going to inject my gums or the roof of my mouth (I sure hoped not!). He grabbed my lip and cheek. “I’m gonna shake this for a bit then give you a few small injections around that tooth.” Surprisingly, they didn’t hurt at all. The dentist’s demeanor was friendly, calm, and reassuring. Not too upbeat, not too distant, not too involved in my experience, but present. He instructed me to signal to him if I was having any sensation during the procedure. Even in the moment, I was struck by simple behaviors that likely could be helpful to many patients. Explaining details. Laying out expectations and potential time frames. Gently probing for concerns. Allowing for expression. Listening. Despite his gesture of support, again, a sense of dread ballooned from stomach to throat. One of my extractions as a kid began prematurely without enough anesthetic. The sensation of cold steel gripping your teeth and gums followed swiftly by a downward tug will definitely make you appreciate the necessity of blocking afferent sensory information. But, none the less, I appreciated this dentist’s presence.

The filling removal and replacement proceeded smoothly. Sporadically, but briefly, feelings of anxiety or nervousness would creep into my chest. It wasn’t acutely distressing as much as interesting. I found it a challenge to balance experiencing those feelings, attempting to control them (futile), and analyzing them. Oddly, what affected me most profoundly were not the sensations or experience itself, but rather thoughts of my previous dental disasters and the unknown of upcoming future moments. Recently, Jason Silvernail, DPT, DSc, FAAOMPT stated:

If you’re in healthcare you should periodically be afflicted with something you provide care for. Just enough to keep you humble and patient focused. It’s done wonders for how I behave in the clinic over time.

Even though I am not a dentist, I reflect on my recent experience and am inclined to agree with Jason’s assertion. My experience, my “symptoms” were not a product of the pathology (failing filling) per se nor even specifically related to the procedure (filling replacement). This specific individual experience resulted from my personal past colliding with current events. I’m not convinced any specific intervention would have altered my experience. Although, in retrospect, I’d desire a more detailed explanation of the procedure. What locations would the anesthetic be injected? (Please don’t inject the roof of my mouth!) How many times? How much of my mouth would be numb? Straight forward and detailed (but not too detailed) information may have eased my feelings of unrest. Or, maybe they wouldn’t. I don’t know.

What can we glean from these personal events? Obviously, there are limits to what our first person experiences and observations can illustrate. Despite our intimate knowledge of health care, symptoms, physiology, and hopefully psychology, we may actually be prone to under appreciate the cloud of uncertainty and confusion swirling in a typical patient’s head when faced with common healthcare encounters, symptoms, and procedures. But, what insights do they provide about the patient in pain or distress? Those suffering with chronic pain or disability? The patient facing the unknown during a hospitalization? An individual awaiting a procedure? Those recovering from a surgery? Attempting to return to sport? Dealing with the trauma of an ICU stay?

Philosophers and scientists studying human consciousness continue to debate the role of first person experience in creating a framework and understanding of consciousness.

Each patient we see has a lifetime worth of memories that are going to color their experience on your treatment table. –Kenny Venere, PT, DPT

At the very least, our personal experiences may assist in caring. But, maybe there’s more. What would you want when facing the unknown during a hospitalization? What’s helpful when you are in acute pain? An awareness to the needs of the person, not the patient, might be honed through our own personal struggles and reflection.

Patient Questions Gifford

Maybe first person inquiry, reflection, and patient narrative are integral to our practice? It may be time to sit with our patients, and ask. It may be time to rethink rehab.

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Do you have the resources to perform your job? #sportsPT

Matt Sremba, PT, DPT, OCS authored this guest post. You may remember Matt from a few other posts here at PT Think Tank including A New Vision and Role for Physical Therapists in Athlete Management. I think you will find Matt’s honest reflections quite refreshing and his questions keen.

@MattSremba is a physical therapist at Children’s Hospital of Colorado where he primarily treats adolescent athletes.  He also serves as a physical therapist with Conatus Athletics. Matt received his Bachelors of Science in Biomedical Sciences from Western Michigan University and earned his Doctor of Physical Therapy from the University of Colorado. Matt is avid thinker, question asker, and non-accepter of the status quo. He has also been known to ride two wheeled objects and hike up inclines.

Do you have the tools and resources to do your job?

Have you been asked this question? How do you answer it? I explored this question at CSM 2015 in Indianapolis as the first speaker on a panel discussing Science, Technology, Engineering, and Math (STEM) and Physical Therapy: The Future of Sports Medicine. I believe examining this question will help us determine the vision and path for the future of sports medicine and physical therapy.

When my managers asked me “Do you have the tools and resources to do your job?”, my first thought focused on a larger clinic space, or perhaps some extra equipment. However, at some point, I started to ponder this question seriously. And I concluded, in order to determine the tools and resources I needed, I first had to re-examine a more fundamental question…

As a sports medicine physical therapist: What is my job?

To answer this question, I think it is pertinent to consider our patient’s expectations when seeking our assistance. My patients all come to me asking nearly the same questions:

1. What is the diagnosis?
2. Why did this injury happen?
3. How do I prevent this injury from happening again?
4. How do I get back to playing sports or activity?

Assuming this list makes up a significant percent of my job responsibilities, the question really becomes:

Do you have the tools and resources to successfully meet your patient’s expectations and answer their questions?

What do you think? Do you? My answer is: maybe. Sometimes I’m confident I can answer these questions. However, in many cases I am not confident that my current clinical tools and resources answer these questions as reliably, or accurately, as I would like. Lets look closer at one of these questions that all sports physical therapists are asked on a daily basis:

How do I return to sport?

Return to sport is a very challenging assessment and decision. I find it difficult to answer patient questions of: When can I run again? When can I cut again? When can I play basketball again?

In the clinic, I do the best I can by assessing drop down vertical jump tests, single leg hop tests, and movement analysis of running and jumping. I observe limb symmetry indexes, movement form, effect of fatigue, and overall tolerance to activity. However, I find these decisions very challenging.

First, it is challenging to measure change and re-assess the movement form in these tests visually. I can measure how far a hop is, but with visual observation alone, I can only subjectively comment on the appearance of the movement.

Second, these tests bring up many questions for clinicians. I’m left wondering: What am I looking for when I watch someone move? More specifically, how do I accurately analyze human movement?

I know that I need to look at strength. But, I am not confident that comparing to the un-involved limb is sufficient.

I know I need to look for shock absorption. But, what is shock absorption? What makes it good or bad?

I know I need to look for knee valgus. But what is normal knee valgus? What is an acceptable knee valgus angle to return to sport?

Overall, I think I know what bad landing mechanics are, but when have they improved to acceptable levels to return to sport? What are good landing mechanics?

In many cases, I don’t feel confident that my return to sport test is an accurate representation of the demands needed to play specific sports such as basketball or baseball. I need help because I know I can only answer, ‘are they ready for sport?’ if I truly understand the requirements and demands for that activity. For example, what are the requirements on the knee during basketball? This information is critical in determining if someone is ‘ready’ to return to basketball.

Movement_APTA

Who can help us answer these questions? Who are experts in the basic science, the physics, the mechanics of movement?

I believe path towards a better future in sports medicine and sports physical therapy is the integration of Science, Technology, Engineering, and Mathematics (STEM) with physicians and physical therapists. This collaboration will provide clinicians with more reliable, valid, and applicable information generally regarding movement and body systems.

Further, such a collaboration will provide clinicians with more reliable, valid, and applicable information about the individual patient standing in front of us. This will improve our ability to measure, assess, and progress. And, ultimately meet the goals and answer the questions of our patients.

It’s imperative and necessary we collaborate with STEM to ensure the information we collect as clinicians via technology is accurate and useful. We must ensure the proper data analysis is carried out. Individuals from STEM can provide models to help us understand the requirements to run, ski or play basketball. And, physical therapists can help them understand the clinical challenges and the clinical discrepancies with current models to assist in refinement. Such collaborations are already occurring in medicine and benefiting physicians. Reference the above video of the heart. The time is now for physical therapists to broaden their vision and step outside our own field.

Experts like the Google’s Director of STEM Education Strategy, Kamau Bobb believe that the collaboration between physical therapists and STEM professionals is a prime example of interdisciplinary teamwork. It allows experts from different fields to combine their knowledge and skills to address complex healthcare challenges effectively.

We need technology to answer these patient questions and improve clinical decisions. Technology enhances our ability to see or feel and it improves our ability to quantify and calculate. Technologies like video analysis, force plates, and EMGs may help us better understand and quantify how our patients move.

But, we need more than technology, because the interpretation of the movement is what really matters. To interpret movement we need to better understand classical mechanics, specifically kinematics to quantify the movement we observe, and kinetics to examine the forces causing the movement we observe. Then we can examine questions like:

What is good or bad shock absorption?
Is the normal knee valgus we see acceptable?

Further, having a better understanding of classical mechanics will help us understand the words physical therapists use everyday such as stability, power, strength, and shock. Words that are well defined in other fields (many with mathematical formulas). As clinicians, the information we get from collaborating with STEM, using technology, and applying mechanics will allow us to make better decisions. Decisions grounded in science. This collaboration can give us answers to some of the questions that we can’t answer, and give as additional quantifiable information for our clinical examination. That is where I want to go in the future. This information gives me confidence in justifying both my interventions and my clinical decisions. To quote Dr. Chris Powers, PT, PhD from a 2003 editorial on research priorities in physical therapy:

Ultimately, the combination of basic, applied, and clinical research will provide a more comprehensive scientific foundation for practice by ensuring that the immediate and future research needs of physical therapy are met.

Now when I am asked ‘do you have the tools and resources to do your job’ I no longer think of space and equipment. Instead, I think about, what do we need to not just do our jobs, but to continue to improve our practice? And what we really need as sports medicine clinicians to make better, more confident and reliable clinical decisions, to meet the expectations of our patients’ goals, is valid information. Currently, I’m not confident we have the necessary information we need. Are you?

Matt Sremba, PT, DPT, OCS