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

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

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

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

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

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

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

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

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

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

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

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

 

 

 

 

 

 

 

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

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

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

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

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

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

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

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

 

References:

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

Photo by Vladlane Vadek

Where #GetPT1st Doesn’t Work: The Bottom Line

Paths to Recovery
Used with permission from The Wall Street Journal, WSJ.com. Copyright 2007 Dow Jones & Company, Inc. All rights reserved.

This year marks this image’s 10th birthday. It has been shared, tweeted, and promoted (without proper citation) with reckless abandonment by the physical therapy profession as how things should be. #GetPT1st. It works. We make health care cheaper!

The image is not a bad one. In fact, on the surface it looks quite positive! However, there’s more to it. What we have done is innately human; we have taken the bit of the picture that validates our argument and magnified it to justify our own means, ignoring the overriding argument. This doesn’t mean we’re horrible people, it just means there’s a bigger story. And that story, unfortunately, is the key to why this model has failed to change healthcare as we know it. The image, often credited to the well-known Virginia Mason Study, was actually compiled by the Wall Street Journal and published in a 2007 article: A Novel Plan Helps Hospital Wean Itself Off Pricey Tests.

For those unfamiliar with the Virginia Mason Study, it goes something like this (the full text is available here):

The Virginia Mason Medical Center in Seattle was losing money in 1998. To reduce waste and inefficiency within the system, they started streamlining, using the “lean” methodology of the Toyota Production System. Two years after they implemented the “Virginia Mason Production System,” several Seattle-based employers and their health plans (i.e. major payers such as Aetna) came to Virginia Mason with a complaint: The payer was paying more for care at Virginia Mason than any other health system in the Seattle area.

Thus began what is now referred to as the “marketplace collaborative.” And this is what we all want to hear. Virginia Mason executives sat down with payers & employers to identify their priority areas, as well as develop clinical value streams that enhanced value while cutting out inefficiencies and increasing value to the patient. These value streams helped to standardize care, considering the most efficient way to accomplish a goal, as well as the best evidence-based practice. The low back pain value stream is what the image in question depicts.

The end result? Decreased use of imaging, better patient satisfaction rates, more rapid return to function, and decreased costs. Employers were happy, because they saved money. Patients were happy, because who doesn’t love getting better faster?

So obviously, this is fantastic. Our patients are getting better, evidence-based care, with less unnecessary imaging and quicker return to function.

But it hasn’t been implemented nationally. The answer to the inevitable “Why not?” lies in the WSJ article:

Because Virginia Mason Medical Center lost money.

In fact, not only did the not-for-profit lose money, it was in the red. The much-lauded image (which maybe garners 1-2 lines of actual text in the story) is embedded in an ode to the health care system in the United States. Health care is not incentivized based on patient satisfaction. It’s based on fee-for-service. That means that more service means more money, whether that service is needed or not. And the kicker? Less expensive services, such as therapy, do not garner high reimbursement rates. So, where Virginia Mason used to make $100 on every case that passed through their spine clinic, they were now seeing losses of $200 on every case.

“With each MRI that Aetna and the employers avoided at around $850, Virginia Mason lost about $450 in profit.”

–Fuhrmans, 2007

There are several major points the article makes:

  1. Employers and payers brought about change in the system.

Virginia Mason’s incentive to change their system actually came from their payers saying “You cost too much.” In business, money talks. Health care is a business.

  1. Payers care about cost. Providers care about patient satisfaction.

The article details the initial sit down with Virginia Mason executives, Aetna, and major employers, including Starbucks. In short, chaos erupted when Virginia Mason stated that patients were their most important customers, because guess who’s writing the bulk of the check? Providers, including physicians, were not concerned about cost; they were concerned about quality patient care.

  1. It’s a gamble: payers must be willing to pay more for less costly treatments.

To make this system work, Virginia Mason went to Annette King, Starbucks’ benefits director, and told her the model, while it saved Starbucks & Aetna money, was not sustainable for the medical center. She, in turn, went to Aetna to negotiate higher reimbursement rates on therapy. Virginia Mason broke even. When the article was written in 2007, Aetna was the only payer that had agreed to do this.

The key in this picture isn’t patients. Patients, actually, weren’t involved in negotiating any part of the Virginia Mason study. They benefitted. But it was the employers and payers who made the system sustainable.

So, does #GetPT1st work like we show in this image? No, it’s not that simple (though I wish it was). Direct access is a beautiful thing, and there is merit in marketing our profession to the masses, because we can cultivate a base of support. Improving health literacy so that patients are making educated decisions about their care and advocate for improved access is incredibly valuable. Increasing our visibility and letting people know we exist is a piece of the puzzle. But the Virginia Mason study, or rather its failure to proliferate, teaches us that what it comes down to is the bottom line. Unfortunately, in the current health care system, getting PT 1st is not sustainable. Creating sustainability for this dream system requires a coordinated effort that cuts inefficiency through provider education and streamlining of best practices while simultaneously convincing payers to reimburse less expensive treatments at a higher rate. Clap if you believe in fairies.

The true heroes of the PT world are the policy and payment specialists, because we must get paid. Not just to pay rent, but to make our services a viable option for health care systems to utilize.

Continue to support consumer facing movements such as #GetPT1st and #ChoosePT, because it is a piece of the bigger picture, and hey, it’s easy. But you must understand that if you are not simultaneously engaged in advocacy and payment reform, you have missed the entire point.

References

Blackmore, C. C., Mecklenburg, R. S., & Kaplan, G. S. (2011). At Virginia Mason, collaboration among providers, employers, and health plans to transform care cut costs and improved quality. Health Affairs30(9), 1680-1687.

Fuhrmans, V. (2007, January 12). A Novel Plan Helps Hospital Wean Itself Off Pricey Tests. Wall Street Journal. Retrieved from http://www.wsj.com/articles/SB116857143155174786

Debate and Dissent. Do We Need Contrarians?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What issues with dry needling should be considered?

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

The Acupuncture Literature Applies

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

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

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

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

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

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

If needle insertion, needle location, needle depth, or even using a toothpick do not seem to affect outcomes in acupuncture, I’m perplexed by those who propose dry needling is somehow, in some way profoundly physiologically different.16-18 And furthermore, how anyone can subsequently claim dry needling location, depth of penetration, and other specific factors relating to application technique can robustly impart some important physiologic effect or meaningfully impact on clinical outcomes. Physical therapists should likely temper claims of mechanistic specificity, or effect, and be cautious in citing acupuncture literature to support the practice of dry needling.

Dry Needling Research is Underwhelming and Misrepresented

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

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

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

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

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

These are significant and specific concerns that require careful consideration.

Poor Terminology: Trigger Points, Myofascial Pain, and Needles

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

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

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

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

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

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

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

The Evolution of Manual Therapy: Manipulation

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

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

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

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

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

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

Treatment Targets & Proposed Mechanisms

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

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

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

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

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

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

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

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

Pain Science and Complexity

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

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

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

These issues raise conceptual and clinical implications

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

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

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

Risk vs. Benefit and Invasiveness

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

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

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

Training Cost & Time

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

Bias in Research Interpretation and Conflicts of Interest

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

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

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

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

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

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

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

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

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

Summary & Conclusion

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

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

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

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

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

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

References & Resources

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 36. Dorko B. Incantation. The Clinicians Manual.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Year and a Day Later

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

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

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

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

Better: Performance and Change Through Positive Deviance

Atul Gawande, MD, MPH is a surgeon, writer, and researcher who provides genuine insights into the challenging complexities of medicine. But, he also creates novel solutions like check lists in operating rooms. Dr. Gawande connects reflection on personal experience, processes from other fields, and scientific research into insightful narratives that outline the rationale and concrete action needed for improvement. He contends problems in healthcare are not necessarily conceptual, but rather stem from poor processes. There is a lack of knowledge translation and application. In his book Better: A surgeon’s notes on performance, he explores the science of performance and specific high performing individuals.  At the end, he outlines general advice for improvement. Atul Gawande’s suggestions for becoming a positive deviant:

1. Ask an unscripted question

Ours is a job of talking to strangers. Why not learn something about them? On the surface, this seems easy enough. Then your new patient arrives. You still have three others to see…But consider, at an appropriate point, taking a moment with your patient. Make yourself ask an unscripted question. So ask a random question of the medical assistant…a nurse you into on rounds…you start to remember the people you see, instead of letting them all blur together. And sometimes you discover the unexpected. If you ask a question, the machine begins to feel less like a machine.

2. Don’t complain

We all know what it feels like to be tired and beaten down. Yet nothing in medicine is more dispiriting than hearing doctors complain. Medicine is a trying profession, but less because of the difficulties of disease than because of the difficulties of having to work with other human beings under circumstances only partly in one’s control…You don’t have to be sunny about everything. Just be prepared with something else to discuss: an idea you read about, an interesting problem…

3. Count something

Regardless of what one ultimately does in medicine–or outside medicine, for that matter–one should be a scientist in this world. In the simplest terms, this means on should count something.

4. Write something

It makes no difference whether you write five paragraphs for a blog, a paper for a professional journal, or a poem for a reading group. Just write. What you write need not achieve perfection. It need only add some small observation about your world. You should not underestimate the effect of your contribution, however modest.

5. Change

Look for the opportunity to change. I am not saying you should embrace every new trend that comes along. But be willing to recognize the inadequacies in what you do and to seek out solutions. As successful as medicine is, it remains replete with uncertainties and failure

Simple, applicable, and needed suggestions.

To be sure, we need innovations to expand our knowledge and therapies, whether for CF [Cystic Fibrosis] or childhood lymphoma or heart disease or any of the other countless way sin which the human body fails. but we have not effectively used the abilities science has already given us. And we have not made remotely adequate efforts to change that. When we’ve made a science of performance, however–as we’ve seen with hand washing, wounded soldiers, child delivery–thousands of lives have been saved. Indeed, the scientific effort to improve performance in medicine–an effort that at present gets only a miniscule portion of scientific budgets–can arguably save more lives in the next decade than bench science, more lives than research on the genome, stem cell therapy, cancer vaccines, and all the other laboratory work we hear about in the news. The stakes could not be higher.

More specifically to physical therapy within the realm of healthcare, two of the most profound, if not obvious, examples are the “treatment” of musculoskeletal conditions (pain) and the mobilization of hospitalized adults. The knowledge is present to dramatically improve both. Societally, there is dire need for more movement, whether activity or exercise, in healthy individuals as well as older adults, those with chronic medical conditions, and cardiac & pulmonary disease. Again, the knowledge is there. But, are the processes and incentives for performance available? How can physical therapy as a profession and each of us as individuals move forward to enact meaningful change? Atul comments:

True success in medicine is not easy. It requires will, attention to detail, and creativity. But the lesson I took from India was that it is possible anywhere and by anyone. I can imagine few places with more difficult conditions. Yet astonishing successes could be found. And each one began, I noticed, remarkably simply: with a readiness to recognize problems and a determination to remedy them.

Arriving at meaningful solutions is an inevitably slow and difficult process. Nonetheless, what I saw was: better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.

Ask questions. Sideline complaints without solutions. Count things. Write. Change.

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.

The Right Call. APTA Public Relations Removes Questionable Podcast

A few days ago Move Forward, the APTA’s consumer targeted website, posted a podcast. The premise was inaccurate, and the conclusions appeared potentially damaging for patients and the general public. I posted a link to the original Facebook post with a brief statement of my disagreement. Via Twitter and Facebook other physical therapists expressed their disappointment with podcast.

@SandyHiltonPT expresses her disagreement
@SandyHiltonPT expresses her disagreement

 

Historically, Move Forward has published accurate and useful information for patients and consumers including a podcast with Joe Brence and John Ware on Understanding Pain, a post 9 Things You Should Know About Pain, and publicity regarding Choosing Wisely: 5 Things PT’s and Patients Should Question. Yesterday afternoon, Jason Bellamy APTA’s director of web and new media, removed the podcast from the Move Forward website as well as deleted all related Facebook posts.

 

APTA_Remove

I commend the decisive action by Jason and the APTA. I agree with decision. And further, I’m encouraged by their ability to respond to informal feedback via the conversations occurring on social media. Personally, I participated in a panel at #CSM2014 The Value of Using Twitter for Branding Yourself and the Profession, and was highly impressed with Jason’s commitment to engagement. Jason stressed that he and others at the APTA are “listening” to the conversations, discussions, and informal feedback ocurring in the realm of social medical (even if just lurking). But, he also encouraged members to actively contact the APTA with suggestions, feedback, and insight. They want to hear from concerned members. And, apparently, they are willing to act on those intentions.

The APTA listens, so speak up. Becoming a member is a start. Using your voice is next. What do you have to say?

Feedback? E-mail consumer@apta.org
Feedback? E-mail consumer@apta.org

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

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

Seriously. I don’t. I can’t.

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

Definitions and Terms

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

Healthcare & Empathy: Emotional vs. Cognitive vs. Compassionate

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

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

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

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

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

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

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

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

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

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

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