TelePT: Inform Thyself

Sunset over a sheltered Bay Area

Day 65,000 of Shelter in Place (a.k.a 8),

There has been a heck of a lot of info flying around the airwaves as PT’s rapidly prepare themselves to be full on telehealth providers. I wanted to link to some resources:

 

 

It’s a Strange, New World!

View of San Francisco Bay

Well it’s been a bit. And what a bit it’s been!

I’m presently completing day one of “shelter at home” courtesy of COVID-19. As I am a regular worker from home, some parts of my day has not changed. Others, have changed greatly, and, really, who knows what is to come. I translate all this to: it’s a fine time to start writing again. Thus, new theme, new look, new images, and new thoughts for everyone!

Things on my mind:

Stay tuned. I need to go fixed m “Y” button on m three week old MacBookPro which makes me ver angr .

#dumbcoronavirus #DCV

4 Take Home Points from Ascend 2017

WebPT’s 4th annual Ascend Conference took place in Washington, D.C. the weekend of September 29th. Rehab therapists from around the world attended business discussions on increasing revenue, outcomes, payment reform, Medicare audits, healthcare, and much more. There was SO much to learn over two full days. If you didn’t get a chance to attend, you can still benefit from the great material presented! Check out my main take away points below!

Be where your feet are

Whether you’re at home, work, lunch, or meeting someone for the first time, give him or her your utmost attention. We live in a world where distractions are everywhere. It’s not uncommon today to see two people dining together while staring at their phones instead of engaging in each other. This breaks my heart.

Alan Stein Jr.

Alan Stein Jr. hit this point home during the keynote address day 1 at WebPT’s Ascend Event. He emphasized giving everyone in your life your full attention while focusing on the things and people that make you the happiest throughout your day. It’s so easy to lose sight of what we cherish most in life. I challenge you to put your phone down, worry less, listen more, and be where your feet are.

 

Outcomes, outcomes, outcomes

Healthcare, as we know it today, is changing. We’re moving from a fee-for-service system to a value-based care system. So what does that mean? Currently, clinics get paid based off of the services they provide. $100 for an eval, $10 for a modality, whatever it may be. By 2019 this could be something of the past for Medicare payment. The Merit-Based Payment System or MIPS will provide payment based on quality and performance in the clinic. How can that be measured? OUTCOMES. MIPS will account for plus or minus 9% of your Medicare payments. Losing 9% for low performance on outcomes is a BIG deal. Check out my interview on the matter with CEO of WebPT, Nancy Ham. How can you lessen the stress of the payment reform? Prepare.

Prepare for Payment Reform

Discussing Payment Reform

Start now by using data-driven outcomes. Measure not only outcomes but also patient satisfaction. One of the biggest questions during the discussion on outcomes was, “What about non-compliance?” It’s not always easy to have a patient complete their plan of care and that can lead to loss of success with outcomes. Practice owners Mike Mundry and Mike Manzo gave great advice on how to increase participation in patient-reported outcome measures. When determining patient satisfaction, consider emailing the report straight from the clinician. Patients are more likely to open and respond when they know it came straight from their provider. Why not give a paper report in the clinic? This can skew results. If a clinician hands you a satisfaction survey and stands over you smiling would you be honest with your report? I’d feel pretty pressured. Accuracy is key.

What about those patients who never show up for a formal discharge? This is tricky. Try contacting the patient through multiple routes. Give a phone call and ask them to come in for one more visit and a new HEP, email the outcome directly, consider mailing the outcome to patients who might not use the computer as often. Start practicing these measures now and determine your faults and successes before the payment reform begins. Refine your skills, try different outcome measures, find what works best for you now so you don’t have to panic later when change comes.

CPT Codes are important

As you know, new CPT codes came out this year. CMS projected that initial evaluation complexity codes would add up to 25% low complexity, 50% moderate complexity, and 25% high complexity. WebPT researched their data from the first 6 months of the year to see if those projections are in alignment with what we’re seeing in the clinic. Guess what? They’re not. After collecting over 500,000 initial evaluation CPT codes reported, WebPT determined the rehab industry is actually submitting around 45% low complexity, 45% moderate complexity, and only 10% high complexity. What does this mean? As of right now, these complexities don’t reimburse differently, BUT one day they could.

Rick Gawenda, PT emphasized the importance of choosing the correct CPT code for your evaluation. Professionals need to report accurately because in the future each code could come with a dollar amount. Let’s say you’re choosing the low complexity CPT code for every evaluation because, right now, it doesn’t affect how much you’re getting paid. Then, CMS comes out and decides to pay a certain percentage more for high complexity and less for low complexity. If you start increasing your evaluation codes to higher complexities compared to what was first projected, you could be looking at a Medicare audit. Learn the identifiers for each complexity, choose accurately, avoid the audit.

*******

Check out the Talus Media Talks interview with Nancy Ham, CEO of WebPT:

The Opioid Crisis: What Former NFL Lineman Jeff Hatch is Doing to Help

Addiction is a disease that disregards an individual’s race, socioeconomic status, and prior achievements. Since 1999, deaths from prescription opioids have more than quadrupled. From 1999-2010, the number of prescription opioids sold to pharmacies, hospitals and doctors’ offices has nearly quadrupled as well. Yet the amount of pain Americans report has not changed during this time.1 In 2012, health care providers wrote 259 million prescriptions for painkillers. That is enough for every American adult to have their own bottle of pills.2

I was lucky to get the opportunity to speak with former NFL offensive lineman Jeff Hatch. Throughout his life, Jeff did everything the “right” way. He won the Presidential Award for his work with the homeless, graduated from the University of Pennsylvania, where he became unanimous first team All-Ivy selection and Division I-AA All-American, dated Miss Maryland, and signed a multi-year $1 million contract with the New York Giants – all by the age of 22. However, Jeff was not happy. According to him, checking off all of his accomplishments was a way to disguise his contempt for himself:

I was determined to be successful as I could be… On one hand, doing everything well enough could make me happy and on the other hand doing   things well… would keep people from looking too deeply into what was going on with me… It was a way I could mascaraed and keep people at bay

This contempt, in addition to a family history of substance misuse disorder, fostered Jeff’s relationship with substances.  The first time Jeff was exposed to opioids was following his career-ending spinal fusion surgery. He recalls the opioids working great to relieve his physical pain, but it wasn’t long before he was utilizing the pills to resolve the emotional pain he was dealing with.

People say [substance abuse] is a slippery slope that you go down. For me it wasn’t a slope, it was a cliff and I jumped off

Opioids and alcohol gave Jeff something that all his past achievements did not fulfill. It allowed him to be comfortable in his own skin. He shares how drug and/or alcohol consumption is different for someone affected by substance misuse disorder: “I think there’s a difference between somebody who suffers from the disease of addiction and somebody who can participate in using drugs or alcohol recreationally and not have a problem. For those of us who suffer from the disease, the use of drugs or alcohol is a tool by which we escape our reality, not a means by which we seek a good time.”

Jeff was fortunate to receive treatment in 2006 and has now been sober for over a decade. Though he continues to experience pain from a physically taxing football career, he believes exercise and NSAIDs are powerful analgesics that are often overlooked in the management of chronic pain.

Not only has Jeff successfully battled this disease, but he also uses his personal story and experiences to inspire others to seek and remain committed to recovery. Jeff works for Granite Recovery Centers, a New Hampshire based substance misuse disorder treatment provider. This comprehensive program treats individuals throughout all phases of recovery. The program focuses on the 12 steps then offers a bridge program, The Granite House, that continues to work on life skills necessary for community re-integration. Although getting quality treatment is a staple for those in recovery, Jeff states there are additional factors that need to be addressed to successfully combat the epidemic.

We need to continue to break the stigma down, we need to continue to fight against the insurance industry and them trying to close the portals by which people use to get treatment and we need to continue lobbying the government to treat this disease the way it needs to be and to really follow through with that Parity Act that got signed in 2008

Though it is easy to get caught up in the statistics surrounding the current state of the opioid crisis, Jeff explains how we should look at the glass as half full: “We look at the 23 million people suffering from substance misuse disorder in America and we go ‘Oh my God what a terrible problem’ but on the other hand there are 24 million people who are in long term recovery from it and we don’t ever really talk about that.”

For more on Jeff Hatch and his work with those in recovery, visit Granite Recovery Centers. To learn more about the APTA’s initiative to choose Physical Therapy for safe pain management, check out Move Forward and #ChoosePT. Jeff’s interview with Talus Media News can be heard in its entirety here.

 

 

 

 

 

 

 

  1. Centers for Disease Control and Prevention. Understanding the Epidemic. https://www.cdc.gov/drugoverdose/epidemic/index.html. Updated August 30, 2017. Accessed September 2, 2017.
  2. Centers for Disease Control and Prevention. Opioid Painkiller Prescribing. https://www.cdc.gov/vitalsigns/opioid-prescribing/. Updated July 1, 2014. Accessed September 2, 2017

Whiplash: JOSPT Special Issues Highlight the Challenges Facing Clinicians, Patients

The Journal of Orthopedic and Sports Physical Therapy (JOSPT) recently released a special issue on the topic of whiplash-associated disorders (WAD). This July 2017 publication followed up on the October 2016 issue, both with guest editors Dr. James Elliot, an associate professor at Northwestern University, and Dr. Dave Walton, an associate professor at the University of Ontario. This rare opportunity to have outside editors underscores the challenge that not only clinicians are facing when treating WAD, but the imperative need that patients with WAD struggle with on a daily basis. From an overarching perspective, the special issues highlight that WAD is not simply an orthopedic condition, yet one that encapsulates the physical, social, and cognitive aspects of the patient at hand, which works to complicate the treatment approach further.

Whiplash-associated disorders are common neck injuries, most often seen in motor vehicle accidents. In Europe and North America, WAD is seen in 300 per 100,000 individuals in an emergency room setting.1 The annual cost of personal injury claims in the United States alone is estimated to be around $230 billion.1 In addition, consistent international data suggests that approximately 50% of those who sustain a whiplash injury will actually not recover and continue to report ongoing pain and associated disability one year after the injury.1 This low rate of improvement underscores the idea that whiplash has other psychosocial components. A 2014 article in the Journal of Physiotherapy discuss that of those who have sustained a whiplash injury, many concurrently are affected by mental health concerns, as well. 25% of those with WAD have post-traumatic stress disorder, 31% have a “major depressive episode,” and 20% have generalized anxiety disorder.1 This combined psychiatric involvement leads to poorer outcomes, secondary to the elevated levels of disability, chronic pain, and physical activity that these patients have.

Talus Media’s Eric Robertson had the opportunity to interview Elliot and Walton recently to discuss the special issues, as well as the current landscape of WAD in a physical therapy setting. The conversation discussed many components of WAD, including the approach that clinicians take when treating patients. Elliot stated that:

“Considering whiplash as a homogenous type condition and treating it as a homogenous condition is really at the crux of really why we haven’t seen fantastic results of management strategies.”

The two also argued that therapists should not be looking at whiplash from a biomechanical or tissue-focused perspective, “It might be more valuable to take an approach that moves away from the tissue at fault, because so far that has proven to be a fool’s game, and move more toward the question of ‘what is the likelihood the patient is going to get better.'” Elliot and Walton did, however, state that they do believe there may be the involvement of some specific tissues in the body. “We do have some fairly compelling evidence that it looks like in some discrete number of people with chronic problems that their white matter in their cord may have been damaged or certainly involved in some of these changes in muscle structure and function.”

The two JOSPT special issues are available online from both October 2016 and July 2017. In addition, the full interview with Dr. Elliot and Dr. Walton is available on Talus Media Talks. What is your experience in treating WAD? Do you feel as if there is something missing in the treatment of these patients? Let us know what you think on our Facebook page.

 

References:

  1. Sterling M. Physiotherapy management of whiplash-associated disorders (WAD). J Physiother. 2014; 60(1):5-12.

Photo by Vladlane Vadek

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

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

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

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

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

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

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

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

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

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

2017 House of Delegates Preview: Lifecycle of a Motion

PT Think Tank is proud to announce that over the coming weeks leading up to the NEXT Conference and the annual House of Delegates meeting, we will be covering all proposed motions in detail. These motions by nature are complex and have taken enormous amounts of effort and time from the authors and the Reference Committee to compile. Our goal is to provide insight and high-quality background information to these motions and begin a conversation about how these motions if accepted, could change our everyday practice of Physical Therapy. In order to effectively understand the motions that are being presented for the 2017 HOD, we must first understand how motions are developed, organized, and presented.

According to the APTA, all motions other than bylaw amendments, serve one of four major purposes. They define a course of action (policy), a stance (position), a binding statement to judge the quality of action (standards), or clearly state a goal the APTA wishes to achieve. Motions are vetted, researched, and revised over the course of a one or two year cycle, which typically revolves around the HOD meeting at APTA Next in June. Some more complex motions may take up to 2 years of research and refinement prior to being introduced to the House. The APTA has identified 3 major phases of the motion lifespan: Conception, Development, and Presentation.

Lifecycle of a Motion Infographic

So what does the Reference Committee do, and how many motions are introduced every year? According to Dr. Michael Pagliarulo, PT, MA, EdD, Member and former Chair of the RC, roughly 20-30 motions come before the HOD each year, but that number is decreasing as a result of considering issues of more significant impact on the profession and society.  The RC’s job is not to research these motions, but to assist the delegates in the motion development process. They provide advice and counsel to the delegates on form, wording, and method of motion presentation – helping the delegates clearly state motion’s intent. This is a complex process and the RC provides the guidance necessary to the authors so it can run as smoothly as possible. And running smoothly is extremely important in this process, as Dr. Pagliarulo explains what happens once the motion is moved:

“Once motions are moved, seconded, and announced by the speaker, they become the property of the voting body. That body then debates that motion and can then vote to adopt or defeat.  Amendments are also in order during the debate.  The amendment can also be amended.  Then you must go backwards to vote on the amendments.  Once they are dispensed, other amendments are in order, and they must be voted on.  Once the body has exhausted amending the main motion, then the main motion is voted on as amended, if any of them had been adopted.  To make matters even more exciting, there are other types of motions that could occur during the debate. For example, the motion could be referred to the Board of Directors for further consideration, or postponed definitely to be considered after interested parties had an opportunity to meet and reach consensus on issues, or postponed indefinitely, which essentially defeats the motion.  There are even other types of motions, but these are the main ones. This is why we always have a parliamentarian present at the House to help us get through some complex strategies.”

 

Got it? Good! Starting May 11, we will report on each of the motions that will be coming before the HOD in June. Stay tuned!

 

Resources:

PT Think Tank would like to sincerely thank Dr. Michael Pagliarulo for his assistance in this project.

2017 Packet I can be found here.

2017 Background Papers can be found here.

Helpful Webinars (Free to APTA members!):

#BadAssMary: Mary McMillan in 8 Memes

Mary McMillan is a founder and the first president of the American Physical Therapy Association. She wasn’t the first person to practice physical therapy, but as Mildred Elson stated in her 1964 McMillan lecture, “She thought in terms of the whole country and foresaw its great civilian need for physical therapy.”

She’s also a bad ass.

Here’s her story, in memes. 

Note: The majority of this re-telling of Mary McMillan’s history has been pulled from her speech in 1946, entitled “Physical Therapy from the Embryo on Three Continents,” and the 1944 annual conference proceedings at which Mary McMillan was awarded an honorary active lifetime membership in the APTA. The proceedings were published in Physiotherapy Review, now the Physical Therapy Journal. 

Mary McMillan was raised in England and completed her studies at the University of Liverpool Gymnasium, where they were offering a 2 year course in physical education. She also took a break from these studies to head to London for further courses in neuroanatomy, neurology, and psychology.

1.

At the outbreak of World War I, Mary applied for a Voluntary Aid Detachment (VAD) unit out of the University of Liverpool. Fortunately for physical therapy in the United States, she failed the medical examination and decided to travel to Boston…during the war, in a convoy, under complete blackout conditions.

After arriving in the US, she met Marguerite Sanderson, another important figure in the development of physical therapy. She was put to work at Walter Reed Hospital, and matter-of-factly states: “That was the beginning of physical therapy in the US Army.” Physical therapy was accorded as a health service in 1917 by the US Army.

Mic drop.

2. 

Dr. Everett Beach, from Reed College in Portland Oregon, wanted Mary to come teach the 200 potential reconstruction aides (the original name for physical therapists) he had signed up for an emergency course to assist with the war effort. Mary immediately applied for a leave of absence from the Army to go where she was needed. When the Army dragged its feet, she threatened to resign. Within 24 hours, she was granted a leave of absence, and left for Portland.

So that’s how that’s done.

3. 

Post WWI, a letter was sent to the reconstruction aides, asking if they wanted to see a professional association built. The answer was a resounding yes. Here are some cool facts about what they built, from Eleanor Carlin’s 1976 McMillan Lecture:

  • “Whether by design or accident…nothing was said about working only under the direction of a physician” (Carlin, p. 1113).
  • Our founders had the foresight to include policy that would allow the development of chapters, and they almost simultaneously founded the Physical Therapy Journal, ensuring that publication was valued.
  • The Association was originally called the American Women’s Therapeutic Association, but charter members realized that this would be alienating to men, and voted to change the name to the American Physiotherapy Association. The first man was elected to national office in 1942.
  • Women entering the profession were required to have a college education.
  • By 1924 the charter members had discussed the standardization of physical therapy through state registration and licensure. By 1971, practice acts had been established in all 50 states (Blair, 1971).

4. 

Mildred Elson, first McMillan Lecturer, first president of the World Confederation of Physical Therapy, and first president of the Wisconsin Physical Therapy Association, quotes Mary McMillan: “What we need is one unanimous effort in order to establish a high standard for our profession and enthusiasm that knows no bounds.”

Elson goes on to say in her 1964 lecture, “Early members at the first convention did not join & say, “What can I get out of it,” they said, “I intend to join to see what I can make out of my profession and to see what I can do to create and maintain standards.” So on that note, you know the APTA is trying to reach 100k members, right? Check it out here.

5. 

After WWI, Mary answered the call from the China Medical Board of the Rockefeller Foundation to work in the Peking Union Medical College in China. Of course, the Rockefeller Foundation knew who she was, and Mary took charge of the Department of Physical Therapy at Peiping Union Medical College in 1932. She first got rid of the “obsolete apparatus” in the gymnasium, then set about finding people who were up to her standards. In her speech, “Physical Therapy from the Embryo on Three Continents,” she states: “This necessitated that some people must be taken off the payroll—it was not an easy thing to do—it hurt me very much to do it, but it had to be done. I was able to replace these people with more modernly trained nurses and a physical education graduate.”

She also set up scholarships to encourage graduates to apply, and partnered with a physician to head the department.

6. 

November 1, 1941, all Americans were urged to evacuate Peking. Mary, along with several others, wound up in Manila (capital of the Philippines) in a roundabout way to get home, with no chance of sailing before December 20. December 7, 1941, Pearl Harbor was bombed. Mary offered her services to the Army Hospital in Manila, where she was one of the first to assist the dead and wounded upon arrival. Christmas Eve, Manila fell to the Japanese. Mary, realizing what was about to happen, “borrowed” a truck, and with 3 women drove to the hospital to recover drugs, instruments, beds, and bedding. These supplies furnished the internment camp hospital at Santa Tomas. Mary slept on a filing cabinet.

7. 

Mary, who referred to her work in the Japanese internment camps as her “swan song” recalled this episode of patient care:

Excerpt from Mary McMillan’s 1946 speech, “Physical Therapy from the Embryo on Three Continents”. © 1946 American Physical Therapy Association. Adapted with permission. All rights reserved.

8. 

Mary McMillan was repatriated in 1943. When she stepped off the boat, she was met by Dorothea Beck, previous editor of the Physical Therapy Review. She continued to be a source of strength and inspiration to the Association until her death in 1959. She assisted with efforts to found the World Confederation of Physical Therapy and was known to show up at parties. Margaret Moore, the 1978 McMillan Lecturer, recalled: “…a lively party with lots of people, loud music, much dancing, and rattling of glasses was taking place at my home. Who should appear at my front door but Molly McMillan…Within 10 minutes, Miss McMillan was in the middle of the group with her shoes off…I treasure the moments with that fun-loving, warm, and lovely lady.”

 

References

Blair, Lucy. “Past Experiences Project Future Responsibilities.” Physical Therapy 52.5 (1971): 493-99. Print.

Carlin, Eleanor J. “The Revolutionary Spirit.” Physical Therapy 56.10 (1976): 1110-116. Print.

Elson, Mildred, ed. “Twenty Third Annual Conference.” The Physiotherapy Review 24.4 (1944): 148-50. Print.

Elson, Mildred O. “The Legacy of Mary McMillan.” The Journal of the American Physical Therapy Association 44.12 (1964): 1066-072. Print.

McMillan, Mary. “Physical Therapy on Three Continents.” The Physical Therapy Review 40.2 (1960): 140-43. Print.

Physical Therapy Metrics

With the widespread use of EMR, more and more data is being collected about the way we practice. A recent post on the Four Hour Work Week by Eric Ries, has me thinking about metrics, specifically PT metrics and how they relate to the care I provide, and the experience my patients have. Eric breaks business metrics down into two types: vanity metrics and action metrics. Vanity metrics is the data that “might make you feel good, but they don’t offer clear guidance for what to do.” On the other hand, action metrics help us make decisions and give us valuable information about our practice. Traditionally metrics in the PT world can generally be broken down into 3 categories: billing, productivity, and referral metrics. More specifically, lets explore how vanity and action metrics relate back to individual (not company wide) practice.

Vanity Metrics: Private practice owners might argue that “no data is bad data” when it comes to tracking patients and therapist performance in the clinic. However, some data points simply do not provide an accurate picture of individual therapist performance, and could be better suited when applied to company performance, or ignored altogether.

  • Visits per case/referral: In my opinion, this data set is the most inconclusive of all metrics commonly tracked to individual PTs in EMR programs. The general rule-of-thumb for most private practices is that the visits per referral number should be between 10-12. This depends on several factors: skill level of therapists; number of post-operative referrals, geographic location, patient population/SES, referral source, clinic reputation, and the list goes on and on. I have found this metric has no bearing on patient outcomes, or patient/physician satisfaction. If you can obtain the same outcomes in 6-8 visits versus 10-12, your patients will be happier, and your referral sources will be impressed. In return, you see a higher volume of new evaluations – which means more and more happy patients.
  • Incomplete metrics: Other metrics that are commonly applied to individual PTs are actually “incomplete,” or too variable to apply to individual performance. For example, scheduling related metrics, such as cancellation and no-show rates, are mostly out of the control of the therapist and do not reflect on the quality of care provided. Obviously, a good clinician that creates buy-in, demonstrates value, and has good outcomes will generally have a low cancel rate. But, cancellation rate does not always reflect productivity – a clinician with a cancellation rate of 4% does not mean they are more effective than a therapist with a cancellation rate of 10% – this variation could easily be due to scheduling, clinic hours, weather, traffic, or an entire host of other variables.

Action Metrics: Action metrics are the data that should be used to evaluate therapist performance and patient outcomes. These metrics help the decision making process, and can demonstrate value to your referral sources and the general public.

  • Plan of Care (POC) complete to Discharge: Perhaps the most under-tracked, but most important data point is patients who complete a POC to discharge. Generally this happens when appropriate care is provided (regardless of number of treatment sessions), goals are met, and functional limitations are eliminated. The therapist and the patient are on the same page, and the patient is happy with the care they receive. And happy patients produce more business – not only by word of mouth and leaving reviews online, but also by telling their physician about the quality of care they received. A high percentage in this metric indicates that the clinician provides quality care and communicates well with their patients.
  • Units/visit: Another metric that is highly variable depending on the patient population and insurance type, but useful nonetheless is units per visit. Tracking units/visit at the provider and company level is beneficial – this serves to make sure therapists are not under-billing; which is all too common in PT practice. It also allows therapists to make sure they are not over-billing, which may make you more susceptible to audits. This metric also allows for more accurate clinic budgeting and forecasting income.
  • FOMs: Tracking change by using functional outcome measures is critical to evaluating therapist performance and patient outcomes. Functional outcome measures should be used with every patient, every time. However, accuracy requires that valid measures are being used, and that measures are used with the correct patient population. Understanding MCID and MDC for each measure is also important. These metrics should also be used to support Functional Limitation Reporting. In addition, physicians and referral sources often use and understand these measures, easing the communication gap while marketing to potential referral sources.
  • New patients per therapist/requested therapist: Another under-tracked and under-utilized metric is new evaluations per therapist. Particularly, patients who request a therapist by name are often more satisfied with the care they receive and more likely to complete their recommended course of therapy. I find this number often correlates with patients who complete their POC to discharge, looping back into the cycle of happy patients and word of mouth referrals.

When extrapolated across a group of therapists in a company or clinic, action metrics provide a more meaningful picture of how valuable our services are. Individually, vanity metrics can be misleading and provide little value as to the value and productivity of a therapist.  Eric Reis encourages us to “measure what matters” – meaning that more data is not always better, and argues that the key to having actionable metrics is “having as few as possible.” It can be tempting with EMR to look at a seemingly endless set of metrics, but narrowing our focus on a few can provide better insight into therapist, clinic, and business performance. How do you use metrics in your clinic? Which ones are used to evaluate individual performance?

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.

Dry Needling Research is Underwhelming and Misrepresented

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

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

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

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

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

These are significant and specific concerns that require careful consideration.

Poor Terminology: Trigger Points, Myofascial Pain, and Needles

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

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

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

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

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

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

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

The Evolution of Manual Therapy: Manipulation

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

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

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

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

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

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

Treatment Targets & Proposed Mechanisms

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

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

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

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

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

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

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

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

Pain Science and Complexity

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

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

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

These issues raise conceptual and clinical implications

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

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

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

Risk vs. Benefit and Invasiveness

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

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

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

Training Cost & Time

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

Bias in Research Interpretation and Conflicts of Interest

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

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

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

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

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

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

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

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

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

Summary & Conclusion

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

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

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

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

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

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

References & Resources

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 36. Dorko B. Incantation. The Clinicians Manual.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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