Decoding the Brain: Will Future Physical Therapists Manipulate Hippocampi Instead of Spines?

Interneurons
Image courtesy NIHCD via Flickr

National Geographic Channel is featuring a slick new program:

Breakthrough: Decoding the Brain” on Sunday, November 15, at 9 pm ET on National Geographic Channel. 

As part of this show’s launch, they’re posing the following question for commentary:

“What if scientists were able to implant or erase memories? For some, like those suffering from PTSD this could be life-changing, or do you think this is scientific innovation gone too far?”

This question is right up our alley!

The Brain and Chronic Pain

The recent meeting of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) in Louisville, KY was a bit unique. Unique, because in contrast to years and years of this conference unsurprisingly featuring scientists purporting the evidence for using manual therapy techniques like spinal manipulation for patients with musculoskeletal pain, this year the conference featured speakers who didn’t use their hands. The conference keynote was delivered by Dr. Peter O’Sullivan, (his cool blog is here) who spoke about his work related to Congnitive Functional Therapy for patients with chronic pain. Other talks revolved around pain science, big data, and a general change in the tenor was noticeable.

Manual therapists have long struggled with patients who have chronic symptoms, as short term gains are quickly realized, but long terms gains are extremely difficult to achieve. So, what prompted the AAOMPT, a scientific academy founded around manual therapy techniques, education, and science, to feature a pallet of speakers speaking about techniques that didn’t involve hands or cavitating  joints? Well, friends, science is always a moving target, and it’s broad, and sometimes you need to look outside your cerebral solar system to learn new things. This is one of those times for physical therapists!

But, perhaps we don’t need to travel too far! This new traditional neuroscience science is now showing up in manual therapy journals like…well, Manual Therapy! In a recent article, entitled, “Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories,” Nijs et al address the concept of movement-related pain memories and exercise for patients with chronic pain. They suggest that clinicians should preempt exercise therapy by first priming the brain via neuroscience education, and then utilizing movements to help the body ‘forget’ those memories associated with those movements and pain. Sounds just like Peter O’Sullivan’s CFT doesn’t it? This work builds on work by neuroscientists who are exploring the role of the hippocampus in generating pain-related memories. This is a wide open field, and the potential of learning how to impact pain related memories is truly astonishing!

Manipulating Hippocampi?

While the concept of having memories erased seems on the surface frightening… (I wouldn’t want to forget that cool downhill bike ride down Mount Snow even though it hurt!)… it does seem that breaking links between pain experiences and memories is one of the keys to managing chronic musculoskeletal pain conditions. Just how we do that best remains to be seen! Will future physical therapists have a cadre of tools that not only allows for mechanical inputs to alter central nervous system activity (spinal manipulation), but also precise strategies to target pain memories and more directly impact cognitive reasoning about pain? I sure hope so!

I’m excited for the new Breakthrough series on NatGeo. It just seems like one of those times when all sorts of science is converging on something…on the true potential of that “3lb mass in our heads!”

 

 

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

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

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

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

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

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

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

What issues with dry needling should be considered?

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

The Acupuncture Literature Applies

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

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

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

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

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

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

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

Dry Needling Research is Underwhelming and Misrepresented

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

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

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

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

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

These are significant and specific concerns that require careful consideration.

Poor Terminology: Trigger Points, Myofascial Pain, and Needles

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

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

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

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

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

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

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

The Evolution of Manual Therapy: Manipulation

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

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

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

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

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

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

Treatment Targets & Proposed Mechanisms

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

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

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

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

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

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

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

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

Pain Science and Complexity

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

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

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

These issues raise conceptual and clinical implications

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

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

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

Risk vs. Benefit and Invasiveness

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

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

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

Training Cost & Time

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

Bias in Research Interpretation and Conflicts of Interest

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

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

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

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

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

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

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

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

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

Summary & Conclusion

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

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

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

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

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

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

References & Resources

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 36. Dorko B. Incantation. The Clinicians Manual.

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

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

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

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

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

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

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

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 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

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

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?

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

Science, Technology, Engineering, and Math (STEM). The Future of Sports Medicine? #APTAcsm #sportsPT

What is the future of sports medicine? How do we get there? Whether considering APTA’s original Vision 2020, discussing the current state of affairs during a break at work, or participating in discussions on Twitter, the future direction of our profession is constantly debated. The past 20 years have contained tremendous growth and the profession of physical therapy continues to mature, however, the question for the future is: how do we continue to evolve in meaningful ways? Who do we need to discuss our clinical challenges with to improve collaboration within research, education, and clinical practice?

A panel discussion at Combined Sections Meeting on Saturday February 7th at 8am will discuss these topics and propose one path for the future of sports medicine. STEM is an acronym for Science, Technology, Engineering, and Mathematics and experts from each of these disciplines will present on how a greater understanding and application of concepts contained within these fields hold the potential to evolve physical therapist education, research, and clinical practice. Future collaboration amongst these disciplines can assist clinicians in hopefully making better clinical decisions and improving patient outcomes. What is the new vision and role for physical therapists in athlete management? Join us at CSM to discuss…

Integration of STEM with Physical Therapy: The Future of Sports of Medicine

Saturday, February 7, 2015
8:00 AM – 10:00 AM
Indiana Convention Center Sagamore Ballroom 5

Panel Members
David Logerstedt, PT, PhD, MA, SCS
Paul Mitalski, MS
Eric Nauman, PhD
Christopher Powers, PT, PhD
Matthew Sremba, DPT
Moderator: Kyle Ridgeway, DPT

To hear a preview of the panel and more about the topic listen to Karen Litzy discus and interview Paul Mitalski, Matt Sremba, and Kyle Ridgeway on her podcast Healthy, Wealthy, and Smart.

Assessing and Integrating the Evidence

Are we teaching it backwards? Without understanding premise or argument validity in relation to research, an individual article analyses may be useless. A study may be flawed on premise alone even with strong methodology and statistically significant results. A valid argument is false. And, inappropriate conclusions will be drawn. Likely, this will lead to misguided justifications and explanations. Such errors can affect clinical practice, education, and future research.

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

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

Is this plausible?

Plausibility must not only take into account previous clinical research and outcomes studies (efficacy and effectiveness), but also basic science and current mechanistic research. Such an approach prevents reinforcing an unlikely or inaccurate explanatory model despite positive outcomes. Unfortunately, physical therapy is likely plagued by positive outcome studies misinterpreted, and thus explicitly or implicitly, supporting a theoretical construct that is (may be) invalid. One example, more specifically, is the variance in explanatory models of manual therapy effect.

What are my beliefs? Biases? Preferred treatment constructs and approaches?

An overlooked area of assessment is ourselves. The person doing the analyzing. It’s imperative that the critical lens of analysis be pointed back upon its user. Rarely will an orthopedic manual physical therapist postulate that manual therapy does not work.  The very best may ponder if the mechanisms are completely outside the current understanding. A physical therapist practicing in an ICU rarely questions the effectiveness of movement and mobility. But, clinicians and researchers should strive to rigorously falsify via the scientific method in order to focus accuracy and understanding over time. Physical therapists are inherently, and understandably, focused on the specifics of treatment that appear most important. What exercise? What technique? What works? Yet, the scientific rigor, and uncomfortable thought, of attempting to prove physical therapy does not work will lead to more specific knowledge on why it does work and the potential attainable outcomes. Seems contradictory, but falsifiability is the basic tenant of hypothesis testing in science. So, ask yourself: what would it take to change my mind? It’s time for some serious critical thinking.

Points to Ponder

  • Hypothesis & Null Hypothesis
  • Plausibility of Hypothesis based on previous research and overall knowledge
  • Methods Critique (utilize checklists)
  • Efficacy vs. Effectiveness Design
  • What is the comparison or control group?
  • Are these groups similar in abstract variables such as frequency, duration, and one on one time?
  • Believability of the comparison or placebo by patient?
  • What the results can tell us given study design
  • What the results can NOT tell us given the study design
  • Plausibility of results from author’s interpretation
  • Plausibility of theoretical model presented or utilized
  • Plausibility of the discussion & conclusion  in relation to understanding on the topic specifically
  • Plausibility based on basic science, physics, mechanics, including tissue mechanics, physiology, psychology
  • How else could the results be explained? Placebo? Regression to the mean? Different mechanisms?
  • Did the authors make the appropriate conclusion?
  • What’s YOUR conclusion and understanding?
  • Overall summary and critique
  • How and why to integrate?

What is the take away?

“That’s valid,” you say, but what do you mean by that? A single statement can be valid by itself if it is a previously proven “truth”, but what about an argument? You remember arguments, right? Premise, premise, therefore conclusion? Funny thing about valid arguments, they have nothing to do directly with truth. Arguments can be valid and false at the same time, just as they can be invalid and true at the same time. What?

Since deductive arguments are the basis of all research, you need to understand this concept. I have quoted before on a podcast, “A flawed study is still a flawed study regardless of p-value or level of evidence. – Erik Meira, When a valid argument can be false

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

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

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

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

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

Conceptual variation is more damaging, and a bigger issue, than perceivable, apparent practice variation. Because of the multi-faceted nature of the mechanisms of effect in physical therapy treatments, especially for pain, striving for observable decreases in “practice variation” may not actually solve many of the issues within the profession. The real problem is conceptual differences. The stark contrast between explanatory models, and stories told, results in significant variance in explanation and education received by patients. Patients are still routinely told they have “bad” posture, an SI joint that is “out” and weakness causing their painful problems. Such unhelpful and debunked ideas are the unnecessary imaging of our profession.

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

Now, to be fair, striving for a decrease in practice variation within physical therapy is a worthwhile endeavor. However, I am not convinced current conceptualizations are the appropriate approach. Assessing variation in medical treatments and practice is likely easier than in physical therapy practice. Why? It’s more concrete. Medical treatment relies heavily on the appropriate diagnosis of essential, or substantial diagnoses. Treatment follows, and is mostly dependent on proper diagnosis. Thus, analysis of timely proper diagnosis, matching of treatment and diagnosis, and actual treatment content is more concrete to study. For physical therapy, a different construct is required. The complexities of the clinical encounter and individual nature of the therapeutic process in conjunction with the many potential and identified mechanisms of treatment effect complicate the study of variance. Striving for utilization of the exact same interventions is likely to be a surface level success. It appears like progress. Therapists are dealing with many nominal diagnoses and messy concepts such as unexplained symptoms, function, and behavior change. (note: medical diagnosis is still very complex and full of challenges)

Specificity should be sought after, but not assumed. As more is understood about the effects of interventions it is becoming apparent that techniques, exercises, and interventions themselves are not as specific as originally assumed. If observably clinicians appear to have no practice variation, but utilize different conceptual frameworks and tell the patient in front of them different stories, gross variation is actually still present. Utilization of similar constructs may result in similar “outcomes,” but with significantly different “interventions.” So, what are the common factors?

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

Measuring Outcomes, Outcome Measures, and Treatment Effects

Measuring outcomes, treatment efficacy, and treatment effectiveness are separate yet interacting constructs. And, it’s more than semantics. Clinically, measuring outcomes masquerades as simple while interpreting these outcomes appropriately can be quite complex. Outcomes bias, or results oriented analysis, presents a significant challenge to the practicing clinician. Outcome measures measure outcomes, not effects of intervention:

Perhaps it is unfortunate that the physiotherapy profession has responded to the perception that physiotherapists must justify what they do by routinely measuring clinical outcomes. The implication is that measures of outcome can provide justification for intervention. Arguably that is not the case. Outcome measures measure outcomes. They do not measure the effects of intervention. Outcomes of interventions and effects of interventions are very different things. Clinical outcomes are influenced by many factors other than intervention, including the natural course of the condition, statistical regression, placebo effects, and so on. (Tuttle (2005) makes this point clearly in his article, in this issue, on the predictive value of clinical outcome measures.)

The implication is that a good outcome does not necessarily indicate that intervention was effective; the good outcome may have occurred even without intervention. And a poor outcome does not necessarily indicate that intervention was ineffective; the outcome may have been worse still without intervention. This is why proponents of evidence-based physiotherapy, including ourselves (Herbert et al 2005), argue it is necessary to look to randomised trials to determine, with any degree of certainty, the effects of intervention. It is illogical, on the one hand, to look to randomized controlled trials for evidence of effects of interventions while, on the other hand, seeking justification for the effectiveness of clinical practice with uncontrolled measurement of clinical outcomes.

Principles of Outcomes Measurement

1. Objective and Measurable
2. Decrease Bias and Improve Accuracy
3. Reliable and Reproducible
4. Valid: Are we measuring what we think?
5. Sensitive to Change: Does the measure detect changes in construct?
6. Patient Report vs. Patient Performance

In addition, measurement of outcomes requires understanding the various constructs and categories that are measurable. This includes, but is not limited to:

Patient Report


Patient Performance

  • Functional Test (5 x Sit to Stand, 6 Minute Walk Test)
  • Functional Task/Activity (squat, stairs)
  • Exercise or Activity Testing


International Classification of Function & Disability Framework

  • Impairments of Body Structure and/or Function
  • Activity Limitations
  • Participation Limitations


Body Systems Level

  • Cognitive
  • Neuromuscular
  • Musculoskeletal
  • Cardiopulmonary
  • Integumentary
  • Psycho-social


Health Services

  • Duration of Care
  • Frequency of Care
  • Number of Visits
  • Future Care Needs
  • Cost
  • Cost Savings
  • Morbidity



These are only a few select constructs and measurements. Another, arguably more complex area of assessment is the narrative and experiential outcome as described by the patient. The patient’s illness narrative, interpretations, and journey through potential suffering.

Differences and disconnect between progression of physical function via patient performance and patient report has been characterized in total hip arthroplasty. “The influence of pain on self-reported physical functioning serves as an explanation for the poor relationship between self-reported and performance-based physical functioning. When using a self-report measure such as the WOMAC, one should realize that it does not seem to assess the separate constructs—physical functioning and pain—that are claimed to be measured.” Both patient report and performance are important. Each can guide further intervention or provide insight into current deficits.

For example, a patient with improvement in performance, but no change in report, may be struggling with recognizing or understanding improvements in certain domains (symptoms, performance, function). Or, perhaps education has not addressed a patient’s main concern or perception. Mistaking outcome measures and measuring clinical outcomes for actual effect of treatment may result in improper (or even pseudo-random) intervention selection and/or patient care approaches. I postulate that this mistake is the prime reason physical therapy as a profession is quick to integrate new, “innovative” treatment “tools” with lack of true prior plausibility. Or, the continued utilization of of interventions in the face of evidence suggesting lack of treatment effect. Mistaking observed and measured clinical outcomes for treatment effectiveness likely results from the post hoc ergo propter hoc logical fallacy.

When we mistake outcomes for effectiveness, we risk assuming causation and subsequently treatment mechanism. Care must be to taken to avoid leaps in logic regarding effectiveness and mechanism of action. A review of the evolution of understanding of manual therapy mechanisms illustrates how continued observation of positive clinical outcomes likely reinforced inaccurate interpretations based upon hypothetical anatomy and biomechanics devoid of true physiology and actual tissue mechanics. We now know much more.

Although, to be fair, construction of care processes, intervention approaches, and treatment paradigms absent of (potential) theoretical mechanistic action is quite challenging. Further, human brains seek explanation for observed clinical events, even within research. So, when treatment X is routinely associated with observed patient report or outcome Y brains will automatically initiate assigning reason Z as the “why.”

Measure everything!

No. Quite the contrary. Clinicians should aim to properly select measures that are relevant to the patient: main complaint, goals, condition, and/or diagnosis (if one exists). In addition, the measures chosen should be sufficiently responsive to change, encompass multiple constructs, and cross domains. While important, relying solely on patient report is an incomplete, flawed approach to measuring outcomes and assessing treatment in the clinical setting.

Two differing scenarios may occur when utilizing outcomes observed or measured in clinic as the primary reasoning for decision making regarding interventions/treatment:

A. Effective interventions may be abandoned when outcome(s) are not improving on the assumption of lack of effect.
B. Ineffective interventions or approaches may be continued when outcomes are improving on the assumption of effect.

In scenario A, the patient may in fact worsen without the treatment. Perhaps progress is predicted to be slower without effective treatment, or natural history suggests a worse trajectory. An effective intervention or process may be ceased prematurely. In scenario B, perhaps improvement is measured. Placebo, non-specific effects, incentives, and/or bias in measuring and patient reporting contribute to the observation of a positive outcome in the clinical environment. “It works!” Or, appears to. But, a multitude of other factors affect the presence of a measured outcome (positive or negative).

The multi-factorial nature of treatment mechanisms, complicate the ability to clinically observe effectiveness. The myriad of reasons why individuals may report and/or exhibit improvements in symptoms, function, and other constructs make “outcomes” a dynamic and complicated subject. Perhaps the condition has a favorable natural history or regression to the mean is present. And, perhaps the patient would have progressed more quickly with a more effective treatment approach. It’s complicated. Don’t take all the credit, and don’t take all the blame. So, what should we do?

Measure nothing, clinical outcomes are meaningless!

No. Quite the contrary. In addition, to selecting appropriate outcomes measurements, clinicians must integrate and understand appropriate current clinical, mechanistic, and basic science research. As science based practitioners, physical therapists are charged to select effective, plausible, safe, and efficient approaches to care that are focused on the individual patient. This is not an argument for the utilization of only specific outcome measurements and interventions with strong randomized control trial level evidence. Plausibility matters. The individual person matters. It’s complicated. And, it’s easy to fool ourselves. Richard Feynman suggests:

The first principle is that you must not fool yourself — and you are the easiest person to fool.

So, measure clinical outcomes. They are important. But, ensure measurements cross constructs and domains. Don’t solely rely on patient reports. And, don’t claim effectiveness based on observation. We must acknowledge the complexity. No one is saying clinical outcomes measurement is not important, or is not illustrative of important concepts. Clinical data and outcomes are vital to self-reflection, integration of evidence, health services, and overall care processes. But, the plural of anecdote is not data, and outcome measures can not illustrate effectiveness. That’s not an argument to not measure outcomes. It’s an argument to improve measurement, and more importantly, understanding.

Resources

1. Evidence Based Physiotherapy: A Crisis In Movement
2. Causation and Evidence Based Practice: An Ontalogical Review
3. Casual Knowledge in Evidence Based Practice
4. Mechanisms: What are they evidence for in evidence based medicine?
5. Placebo use in pain management: The role of medical context, treatment efficacy, and deception in determining placebo acceptability
6. Placebo Response to Manual Therapy: Something out of nothing?
7. The Mechanisms of Manual Therapy
8. The influence of expectation on spinal manipulation induced hypoalgesia
9. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain
10. The contributing factors of change in therapeutic process
11. RehabMeasures.org

It’s all in the incentives

An incentive is something that motivates an individual to perform an action.

And, that something could be anything. Meet the omnipresent influencer of behavior. Frequently, incentive is understood to be associated with some form of monetary compensation for specific behavior. But, incentives are not merely monetary. And, they exhibit influence. Yes. Always. 100% of the time. In any environment, any scenario, any interaction, and every decision including clinical encounters. Incentives can be viewed as any tangible or intangible reinforcement, and thus influencer, of behavior. Theses “rewards” range from monetary to personal, concrete to cognitive-emotional. And interestingly, incentives still affect behavior even when individuals consciously identify and recognize their presence. They are social, contextual, or even cultural. And, they impact decisions and performance.

Incentives are present in a variety of forms and contexts. Most generally, incentives can be assessed via a variety of binary comparisons including: Explicit verses Implicit, Reward verses Punishment, Short verses Long Term, and Immediate verses Delayed. Yet, the content of incentives range from monetary to verbal, and in contexts of private and public. The environment, including people, specific location, and context of the situation, in conjunction with broader constructs such as expectation and culture also matter.

Physician’s prescribing habits are affected by pharmaceutical marketing. Prescribing is affected by the gifts, no matter how menial, of pharmaceutical companies. This effect is observed even if physicians believe the gifts have no bearing on their prescription decisions. The data and incentives lead the Office of the Inspector General to research gifts and payments that promote prescription drugs. In this instance, physicians are Prescribing Under the Influence:

This kind of advertising is crucial to sales. A doctor is not going to prescribe something he or she has never heard of, and it’s the drug representative’s job to get the products’ names in front of the physicians. Maybe the drug representative does that while the resident is slathering cream cheese on a bagel; maybe it’s while the intern is saying, “Oh, what’s this cute little stuffed bear?” Either way, the doctor stops and spends a moment.
In private practice, the little gifts are often even more important. If you’re a drug representative, physicians are usually not interested in talking to you unless you have something to catch their attention. Then you can get your three sentences in: “We’ve got such and such on the hospital’s formulary now.” Or “The new form of this drug can be given once a day instead of four times a day. The patients will love it.” It’s a way to get in the door so that your information rather than somebody else’s reaches the doctor’s brain.

Self-referral, or referral for profit, is associated with increased utilization of lab tests, imaging, and physical therapy. A meta-analysis revealed a 2.48 combined relative increased frequency of referral in refer for profit scenarios. In most cases, I truly believe physicians are not sitting in front of patients actively scheming on how to justify an imaging procedure, lab test, or referral to physical therapy in order to maximize profit. On the whole, I don’t assume the physicians in these scenarios are unethical and overtly over prescribing. But, the incentive is present, and thus behavior is altered. The evidence shows that self-referral invariably leads to higher utilization and higher costs.

What are specific incentives within the profession of physical therapy? What should be modified? Everyday outcome measures are handed to patients, clinical measurements made, and assessments written. What are patients and incentivized to say and do? Or, believe? Administrators, managers, and clinic directors in hospitals and private clinics present data to their staff. Specific metrics are identified and goals are constructed.

Recognizing the development of interaction between personal and environmental (including social, societal, cultural) influences on behavior illustrates the complexity of how, when, and why we behave in certain ways. In healthcare, the layers of systems and hierarchy of influence is complicated. Our decisions and behavior are not nearly as rationale, nor conscious, as they feel to us personally. The interplay of personal, inter-personal, and environmental influences coupled with tangible or perceived rewards influences how people act. In conjunction with individual motivation, incentives, both seen and unseen, are determinants of who will thrive in certain educational and clinical contexts. One such example is the difference between extrinsic and intrinsic motivation. What people do is just as complex as why people think they do it. And, there is a disconnect, a blind spot, between our perception of bias in ourselves verses others.

Unfortunately, incentives have unintended consequences. The cobra effect is an illustration that “incentives don’t always work out the way we expect them to.” Beyond identifying a target metric and outcome, it’s imperative to identify the actual behaviors that are desired. Sometimes a change in a specific measurement (productivity, patient report outcomes, etc) do not necessarily reflect the desired behavior changes. In particular, research investigating payment incentives and subsequent clinician behavior within healthcare illustrate tangible manifestations of “unintended consequences.”

How is the outpatient therapist incentivized if measured and assessed primarily via patient report questionnaires? How are we changing behavior in the acute care therapist by assessing them based on the number of “units” they “bill?” What about the outpatient therapist who receives a bonus based upon units billed? What if changes in the metrics we are utilizing don’t truly illustrate significant change, don’t result in the best care, and don’t reinforce ideal behavior? A health services research article on medicare payment comments:

While some payment methods may lead to excessive utilization, other payment methods may put too much pressure on cost containment and potentially lead to underprovision of resident care (Coburn et al. 1993; Cohen and Spector 1996; Murtaugh et al. 1988)

In addition to tracking specific measures, ideal behaviors need to be identified. To account for unintended consequences broadly identify various behaviors likely to lead to the measured goals. Sometimes behaviors that are actually not desired can cause significant desirable change in target measures. Undesirable action for desired outcome. So, what behaviors can cause a change in the metric? And, what contributes to encouraging such behaviors? But, also, what incentivizes behaviors that change the metric, but may also cause unintended consequences?

If a clinic, hospital, profession, or health care system seeks to fundamentally alter care delivery robust assessment of the current incentives within healthcare, including conflicts of interest is mandatory. Then change the incentives to affect and encourage ideal clinician behavior. A successful approach likely involves a combination of incentivizing important outcomes as well as specific behaviors. Changing the single data point does not necessarily reflect the desired overall change in other measurements or behavior. The depth of affect of incentives in conjunction with unintended consequences illustrate the difficulty in controlling change. A seemingly brilliant idea such as “pay for performance” or outcomes based payment is fatally flawed without a conscientious focus on the many potential behaviors that may result in the specific outcome. Might it even be chaos?

What are the incentives? Identify the answers and then target behaviors requiring alteration. Shift behaviors towards ideal processes. Ideal behaviors will likely have positive unintended consequences. A myopic focus on only the desired numeric change will produce a myriad of potentially paths to “success.” Some of these paths were never the intended action of success. And in fact, may be the opposite of the incentive’s initial philosophical goal.

Physical Therapists in the ICU: ACTION for #ICUrehab #AcutePT

If immobility is pathology, then movement is medicine. But, now that the rationale is present, how is action initiated? Understanding the current literature in regards to mobility and physical therapists in the intensive care unit illustrates the need and the potential for physical therapists. This potential leads to the vision. Yet, rationale and vision do not guarantee action, nor results.

Every patient requires an individualized assessment and interaction to determine the best plan of care, outcomes tracking, and goals. So, does each individual ICU. Evaluation of current practice and culture, barriers to mobility and physical therapy, and a plan to achieve specific goals. Data and outcomes tracking can provide insight into progress.

Research surveying various professions elucidates commonly reported barriers to mobility and physical therapist involvement in the ICU. Yet, many of the identified barriers appear more perception than the reality. Fears based upon “what if?” scenarios. What if the patient falls? What if a line becomes dislodged? What if they decompensate? What’s the worst possible event? Illness severity, safety, and line dislodgment are commonly report. These fears are contrary to the literature on safety and feasibility. Does this indicate these concerns are likely unwarranted?

Barriers: Perception and Reality

Perception is reality. The multi-disciplinary environment of critical care, including the a culture of a specific unit, requires analysis to ensure specific perceptions are identified. Barriers should be overcome with education, discussion, training, and graded exposure. Individual practitioner’s perceptions, fears, and concerns contribute to professional interactions, unit culture, and ultimately patient care. Fear based barriers include illness severity, illness acuity, safety, feasibility, and perceived lack of benefit. Other reported challenges include lack of consults, staffing, knowledge, time, expertise, experience, cost, equipment, and unit culture. All unit specific and individually identified barriers must not only be acknowledge, but adequately addressed. Reported concerns are not to be discounted.

Perceptions

  • Illness Severity
  • Illness Acuity
  • “Too Sick”
  • Unsafe
  • Not Feasible
  • Lack of Need
  • Lack of Benefit

Logistics

  • Time
  • Equipment
  • Lack of Consults
  • Lack of Priority
  • Staffing

Culture, Practice Patterns, & Professional

  • Knowledge of Individuals & Various Professions
  • Experience & Expertise
  • Sedation
  • Current Mobility
  • Current Physical Therapist Presence & Practice

Now, this of of course is not an exhaustive list. A unit may contain unique barriers and perceptions outside of this list. Focused meetings, targeted surveys, and small group discussions can assist in illuminating the beliefs of individuals and the overall culture of a unit. A physical therapist lead quality improvement project to promote early mobility in the intensive care unit utilized a survey of nurses and respiratory therapists to identify current perceptions.

1. Do you think physical therapy should evaluate/screen all intensive care unit/cardiovascular intensive care unit patients?
2. Do you feel comfortable getting patients into neuro chairs without physical therapy?
3. Do you feel comfortable using the mechanical lifts without physical therapy?
4. Do you get patients out of bed/ambulate without physical therapy if they are able?
5. Do you think patients should be getting up on ventilators?
6. What are the barriers to mobilizing patients on ventilators?
7. What are the harmful effects of physical therapy working with patients in the intensive care unit?
8. What can physical therapy do to improve communication with the RNs, MDs, respiratory therapists, patients, families, etc.? Please be specific.
9. What can physical therapy do to improve patient care? Please be specific.

The survey questions revealed many of the barriers listed above. Interestingly, all respondents agreed that every patient in the ICU should be evaluated by a physical therapist.

As much, as soon, as often as we can?

The concept of mobility and rehabilitation during intensive care appears quite important and profound. Therefore, it’s quite obvious that every patient should be out of bed and ambulating at least three times per day. Well, not exactly. Although being in the ICU in the presence of lines, tubes, and life support equipment should not automatically preclude individuals from movement and therapy participation, each patient will present and perform quite differently.

So, what are the specific interventions? How does a physical therapist decide what to do? And, when? What about dosage, intensity, frequency, and duration? Similar to other patient populations (such as individuals with back pain), critical illness is far from homogenous. Even a very specific ICU type contains a range of diagnoses and individuals. Treatment content, duration, intensity, and frequency should likely vary. Further, given the acuity of illness and the medical complexity of patients, close monitoring of many variables is necessary. The specifics of these particular concepts remain complicated and dependent on many variables. At times it appears there are more questions than answers.

Generally, the goal is to decrease sedation, bed rest, and confusion while increasing wakefulness, movement, and engagement. There are nearly infinite options available to accomplish such goals. An approach of “as much, as soon, and as often as possible” simplifies the conceptualization of treatment. But, such an approach is always performed within the specific confines and constraints of the system, staffing, experience, and culture of the current clinical situation.

Response Dependent Progression

An individualized, response dependent approach facilitates proper monitoring from moment to moment and session to session. Decision making requires integration of information from multiple sources to reach an overall assessment that determines progression, pause, or regression. Such a system hopefully decreases the likelihood of grossly “over treating” or “under treating” a specific patient at each specific encounter. The variable nature of medical stability, presentation, and physiologic status of critical ill patients may result in robust, swift changes in vital signs, physiology, and even patient performance. A patient’s specific clinical scenario including diagnoses, physiologic state (labs, medications, vital signs), and current medical goals warrants the a priori construction of individualized safety parameters regarding upper and lower limit values for vital signs.

Response Dependent Progression. Individualized prescription & progression based upon moment to moment assessment.
Response Dependent Progression. Individualized prescription & progression based upon moment to moment assessment.

The research to date suggests that in order to achieve maximum effect physical therapy should be performed in the ICU, while patients are intubated, 5-7 days a week, and in conjunction with or following sedation interruption. Initiate a progressive approach focused on achieving functional milestones such as sitting, standing, marching, transferring out of bed, and ambulating as quickly, but as safely as possible. Exercise testing, prescription, and progression is feasible, effective, and possibly predictive. Although, given the duration of bed is associated with weakness and long term physical impairment suggests functional mobility should likely not be neglected.

Measuring, Assessing, & Planning

An assessment of current and historic practice can include average unit census, average number of physical therapy consults, percent of the unit with consults, and number of patients actually seen per day. Average time from admit to first physical therapy encounter in conjunction with average duration and frequency of treatment provide general insights into current physical therapy practice.

Next, by assessing unit specific data in relation to current practice, predictions for future staffing, equipment, and training can be constructed. Such a model can be further specified based upon targets for the number of patients (or percentage of the unit) to be treated each day, and at what frequency. In addition, the current number (or percentage of) patients who are likely to benefit from, or be appropriate to participate in, physical therapy can illustrate a disconnect between current practice and ideal practice. Identifying a lack of consult standards may shed light on variability in consult numbers, timing, and frequency. Standardized criteria for consults, mobility, or physical therapist involvement provide assistance in decision making. But, each individual patient requires analysis within the framework of guidelines, not decisions mandated by them.

The current demand (consults), physical therapy practice, and provider perceptions are utilized to model need, illustrate the lack of physical therapist involvement, and potentially quantify a current lack of resources to provide appropriate timing, frequency, and duration of therapy. If feasible, informal or formal investigations into factors associated with physical therapy consultation provide further understanding into current practice regarding physical therapy consultation and practice. A disconnect between the research literature and current unit culture, including various professions practice patterns, highlights the need for transdisciplinary practice change and potential quality improvement.

Financial Modeling

Johns Hopkins constructed a financial model allowing prediction of staffing, costs, and potential financial outcomes. By utilizing the number of yearly admits, current ICU & hospital length of stay (for a specific targeted ICU), and direct variable costs of care a very accurate model of staffing, start up costs, and potential cost savings scenarios can be assessed. Varying possible length of stay reduction outcomes allows for a sensitive, yet conservative prediction of cost savings in multiple potential situations. Modeling various outcomes allows for the presentation of worst case, likely, and best case end points. Utilizing actual data from their own quality improvement project and data from the literature they conclude

A financial model, based on actual experience and published data, projects that investment in an ICU early rehabilitation program can generate net financial savings for U.S. hospitals. Even under the most conservative assumptions, the projected net cost of implementing such a program is modest relative to the substantial improvements in patient outcomes demonstrated by ICU early rehabilitation programs.

Measurement and Outcomes Tracking

The potential data and outcomes depend on data availability, program goals, ICU type, patient population as well as any specific research questions. Outcomes can be analyzed at the patient, unit, and hospital level.

Potential construct areas of measurement for ICU mobility, rehabilitation, and physical therapy programs
Potential construct areas of measurement for ICU mobility, rehabilitation, and physical therapy programs

At the patient level there are a variety of impairment, patient report, and patient performance measures, many of which have been specifically investigated for utilization in the intensive care unit.

Impairment based, patient report, and patient performance measures.

Quality Improvement Project Design

Designing and implementing a quality improvement project with a focus on research methodology improves the accuracy of measured results. Such an approach eases discussions with hospital administrators regarding need, costs, and program appraisal. Appropriate planing, background research, and project construction prior to implementation allows for more specific analysis.

Background, Construction, & Education

  • Assess current PT practice, unit culture, clinician perspectives
  • Compare current practice to ideal practice, current program models, and feasible quality projects
  • Construct project goals
  • Model staffing, training, equipment, and program requirements
  • Identify, acknowledge, and address current barriers
  • Identify champions from each discipline: PT, RN, MD, RT
  • Interdisciplinary Meetings & Education: RT, RN, MD, RT
  • Acknowledge, educate, address concerns
  • Join Critical Care Quality Meetings or Committee
  • Identify Lead PT for ICU(s)
  • Assign ICU Unit Based Physical Therapist(s)
  • Identify educational needs of PT and rehab department
  • Identify educational needs of other disciplines
  • Perform education and follow up meetings

Data

  • Identify target data and outcomes tracking
  • Obtain facility specific data for financial modeling
  • Build data tracking sheets & data bases (if needed)
  • Leverage electronic medical record (if able)
  • Train clinicians on documentation and “data entry”
  • “Go live” with documentation and data collection
  • Establish a post documentation training pre-project implementation baseline

Implementation

  • “Go Live”
  • Sustain & Maintain Program via Updates and Meetings
  • Evolve care based on observation, feedback, and data analysis
  • Assess & Analyze Program and Data Collected

The elegance of a quality improvement approach is the potential for an ever evolving feedback loop of assessment, planning, implementation, and analysis. At specified intervals, repeat the process based on current results, identified issues, and current research.

Facility Specific Questions and Issues

1. What if current practice illustrates a lack of consults, infrequent consults, or poor timing of consults (i.e. too late in hospital course)?

Create specific consult criteria. Educate nursing staff and physicians. Provide checklist.

2. What if there is no dedicated physical therapist in ICU?

Quality improvement project focused on unit based physical therapist and increased overall patient mobility.

3. What if patients are too sedated?

Assess RN sedation guidelines and practices. Pair therapy with sedation vacations & awakening trials. Meet with MD’s, RN’s, and RT’s. Work with RN educator to facilitate RN lead project regarding sedation.

4. What if there is a lack of patient mobility outside of therapy sessions?

Nursing staff education. Nurse targeted progressive mobility guideline.

5. How to prioritize if unable to address every consult and patient on caseload in the ICU(s)?

Focus on duration of bed rest, individuals requiring mechanical ventilation, especially those requiring greater than 3 days of mechanical ventilation. Assess last time mobilized and last therapy session.

Quality and Assessment

Obviously, analyzing and interpreting clinically generated data is difficult. Given the complexity of the daily clinical environment and lack of rigor available in a controlled research trial, data can often be inaccurate or even misleading if not understood properly. Utilizing a quality improvement model within the context of critical care is an evolving method for program design and interpretation, but

The results of many quality improvement (QI) projects are gaining wide-spread attention. Policy-makers, hospital leaders and clinicians make important decisions based on the assumption that QI project results are accurate. However, compared with clinical research, QI projects are typically conducted with substantially fewer resources, potentially impacting data quality…Data quality control is essential to ensure the integrity of results from QI projects.

Resources exist for appropriate design, training, data collection, implementation, sustainability, assessment, analysis, interpretation, and translation of quality improvement designs and data.

1. The SQUIRE (Standards for Quality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration
2. Intensive care unit quality improvement: a “how-to” guide for the interdisciplinary team
3. Improving the quality of quality improvement projects
4. Improving data quality control in quality improvement projects
5. How to use an article about quality improvement
6. Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model
7. ICU early physical rehabilitation programs: financial modeling of cost savings
8. Translating research into clinical practice: the role of quality improvement in providing rehabilitation for people with critical illness
9. Quality Improvement Guide

A variety of complex issues affect potential physical therapy and mobility in the intensive care unit. But, it is possible. Change is a process, not an event. One patient, one provider, one day at a time.