“Expose every belief to the light of reason, discourse, facts, scientific observations; question everything, be skeptical because this is the only chance at life you will ever get.” – James Randi
Magicians have been a part of society for centuries. Although the historical timeline is fuzzy as to when magic first appeared, accounts of the Acetabularii performing tricks with cups and balls is noted as early as 50 – 300 AD.1 Magic shows have served not only as entertainment, but as a distraction from the doldrums of everyday life. They are an invigorating placeholder to divert our attention from important matters at hand.
Unfortunately, today, many of us in the Physical Medicine field are acting as magicians – except capes and top hats have been traded for white coats and reflex hammers. Interventions are often presented to patients as incredible magical tools that will correct any and all ailments. If, for whatever reason, a tool is selected from the magical toolbox that is unsuccessful in reducing patient symptoms or improving function, then another tool is selected – and so on and so forth – constantly increasing patient cost. The choice of using an intervention becomes an unscientific, subjective endeavor of trial and error. Too often we as clinicians select modalities based on unscientific clinical expertise as efficacy for their use. Interventions and their selection criteria is the focus of this blog.
In blog 1 we discussed the fallacies associated with Sackett’s pillars in evidence based practice, specifically as it relates to clinical experience.2 This experience is rehearsal, each time perfecting the magic show, but who is being fooled: the patient or the clinician? Research has demonstrated that increased rehearsal time does not equate to better patient outcomes or improved expertise.3,4,5 Using clinical experience as the rationale for utilizing an intervention predisposes us to employing modalities that have not gone through the rigors of scientific testing. These interventions are often based on ill-founded methodology and, at best, will obtain a dodgy outcome (placebo effect). As clinicians, we should think probabilistically regarding the likelihood of success an intervention will have for a patient’s particular issue. In order to weigh the benefits versus the risk of an intervention, we must understand what an intervention is doing – which requires scientific research. This research provides us with a better understanding if our intervention of choice is doing what we claim and is applicable to a patient population – leading to greater likelihood for a positive long term outcome.
Evidence should guide our decisions about what (if any) modalities to utilize in patient treatment. Otherwise, we fall prey to a post hoc, ergo propter hoc fallacy defined as “after this, therefore, resulting from it”, meaning a causal relationship is erroneously ascribed to two events occurring in sequence. In regard to clinical practice, a patient has “X” symptom/complaint, then we intervene with “Y” modality and subsequently patient’s symptom/complaint improves. We often want to believe we are the cause for change, however, research continuously demonstrates that almost any intervention works in the short term and this often is merely regression to the mean.6 The question becomes, are lasting long term outcomes being achieved in a patient’s issue?
Often, under the guise of evidence based medicine, low quality studies are cited as further validation for an intervention’s use. Although statistical significance is a necessary component to consider when weighing one treatment to be superior to another, statistical significance does not necessarily yield clinical significance.7 If we wish to operate under evidence-based medicine more time has to be dedicated to reviewing properly executed studies’ method sections.
But, we cannot simply blame our faith in clinical experience and lack of scientific investigatory effort for the misguided utilization of ill-founded interventions. Each year, hundreds if not thousands of continuing education courses, which could be more appropriately called conned courses—or for the purpose of this blog con(n)-ed—are offered to clinicians. Granted, not all continuing education courses are conning us, some are evidence based with noble intentions of educating the field, but, unfortunately this is not the norm. Additionally, professional boards require us to take some combination of courses to maintain our licenses. The demand of professional boards to satisfy continuing education hours has opened up a market for courses with no substantial offerings to clinical practice patterns under the guise of evidence.
Con(n)-ed Courses
Con(n)-ed courses have managed to make an exorbitant amount of money off of the idea of developing clinical expertise. Con(n)-ed courses are driven by clinicians who claim to have the ability to obtain objective patient outcomes with their “magical” tools and systems of choice. These magicians often travel the world bestowing upon the course participants their product, all the while charging hefty fees to see their “show.” They espouse their products and systems by using fancy words (functional movement, joint centration, fascial meridian lines, subluxations, myofascial adhesions, detoxification) for unfounded issues, normal variants, or conditions that have already been well defined. These magicians operate under the self-bestowed title of expert or guru and have managed to garner as much support and financial gain as most political campaigns with somehow even less substance.
Many of us enroll in con(n)-ed courses in hopes of finding the “Ultimate Trick” to correcting patient ailments. Unfortunately, this can cause us to become blinded by the enlightened feeling received from participation in the course. Our clinical practice narrows via the courses’ framework as we begin applying the specified constructs to all patient cases. Consequently, we fall prey to the risk of becoming too attached to our modality of choice, self-identifying with the magical tool (joint manipulations, IASTM, K-Tape, cupping, dry needling, etc). Our personal biases developed by this framework mislead us to think the patient’s short term relief correlates with long term outcomes. Instead of evidential support through research, system gurus have been given a powerful stage to dictate what interventions should be utilized.
The sunk-cost fallacy makes it difficult for us or the gurus to admit our losses after spending hundreds if not thousands of dollars for certifications; especially once evidence to the contrary of the system is presented. Instead, patients and clinicians alike continue on, with smoke and mirrors, financially investing year after year under the premise it is making us better. Proudly sporting our acronym(s) of choice after our name.
This shifts the issue from patient needs to our drive for confirmation of our own skills/ability. We want to see our trick work via patient affirmation. Ultimately, this places the locus of control in treatment on we the clinician rather than the patient.
The Process of Modality Selection
The decision making process for utilizing a modality is being approached incorrectly in these weekend courses. Instead of discussions to figure out the best answer to patient issues, gurus are often focused on indoctrination. We as clinicians need to regularly read research on the validity of modalities and question the framework of a modality’s efficacy. We do not have to execute research studies. However, if a guru wishes to sell an intervention, then he or she should be held accountable to present the research first to validate his or her claims. The burden of proof always lies with the person making the claim. Currently, these unsubstantiated claims must reach critical mass before the research-oriented clinicians debunk the intervention and demonstrate the modality or system’s lack of correlation to long term patient outcomes. The research, more often than not, reveals the patient’s original path would have led to health anyway, but that’s not magic, and not nearly as marketable. Unfortunately, by this point, the intervention has misguided an immeasurable number of patients and resulted in increased healthcare costs.
Many passive modalities are being based on the false premise of “Tooth Fairy Science”. Dr. Harriet Hall explains this idea well:
“You could measure how much money the Tooth Fairy leaves under the pillow, whether she leaves more cash for the first or last tooth, whether the payoff is greater if you leave the tooth in a plastic baggie versus wrapped in Kleenex. You can get all kinds of good data that is reproducible and statistically significant. Yes, you have learned something. But you haven’t learned what you think you’ve learned, because you haven’t bothered to establish whether the Tooth Fairy really exists.”8
If we utilize passive modalities lacking evidential support, we are operating under the premise we know which patient issues necessitate an intervention and the effect that particular intervention will have on the patient. In reality, we have mounting evidence proving that the issues we are often intervening on are normative variants that occur regularly in asymptomatic populations.9,10,11,12 Or, through natural disease progression many of the issues being intervened on will with time resolve themselves. The chosen modalities are not acquiring long lasting change, but yet the magic show keeps re-occurring. Most likely the show goes on due to a powerful placebo effect and/or confirmation bias. This is why we need valid scientific research. As Danna G. Young recently stated,
“[Science] is a method of investigation designed to protect us from our most glaring weaknesses: egotism, selective-perception, ethnocentrism, premature closure, and the human tendency to always think ‘I AM RIGHT.’”
Science is the antithesis of magic, and our greatest protection against being fooled.
Over the next several blogs, our hope is to present the evidence or lack thereof for current in vogue passive interventions like: Kinesiology Tape (K-Tape), Instrument Assisted Soft Tissue Manipulation, Cupping, and Dry Needling.
Although magic shows are phenomenal entertainment to distract us from the mundane of daily life, we should not be selling unfounded magical tools to our patients. They deserve better from us as clinicians. We should remember our obligation to patients – ensure our interventions are scientifically founded and guide their path towards long term outcomes. Anything else is confirming our own biases, while inflating patient costs. Remember, as chiropractors, physical therapists, or other physical medicine licensed clinicians, we are not an intervention – we are individual clinicians who comprise a field. Each of us utilize interventions and therefore being evidence-based about the efficacy of an intervention is our duty to patients. Hopefully, together we can answer difficult questions regarding patient ailments, interventions, and achieving long term outcomes.
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References
- “History of Magicians – Timeline | All About Magicians.com.” All About Magicians. N.p., n.d. Web. 23 Aug. 2016.
- “Finding Balance on a One Legged Stool: Part 1.” The Logic of Rehab. N.p., 2016. Web. 18 Aug. 2016.
- Macnamara BN, Moreau D, Hambrick DZ. The Relationship Between Deliberate Practice and Performance in Sports: A Meta-Analysis. Perspectives on psychological science : a journal of the Association for Psychological Science. 11(3):333-50. 2016.
- Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Annals of internal medicine. 142(4):260-73. 2005.
- Whitman JM, Fritz JM, Childs JD. The influence of experience and specialty certifications on clinical outcomes for patients with low back pain treated within a standardized physical therapy management program. The Journal of orthopaedic and sports physical therapy. 34(11):662-72; discussion 672-5. 2004.
- Menke JM. Do manual therapies help low back pain? A comparative effectiveness meta-analysis. Spine. 39(7):E463-72. 2014.
- Zarbin MA. Challenges in Applying the Results of Clinical Trials to Clinical Practice. JAMA ophthalmology. 134(8):928-33. 2016.
- Hall, Harriet. “Another Acupuncture Study – On Heartburn « Science-Based Medicine.” Another Acupuncture Study – On Heartburn « Science-Based Medicine. Science Based Medicine, n.d. Web. 18 Aug. 2016.
- Brinjikji W, Luetmer PH, Comstock B. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology. 36(4):811-6. 2015.
- Andrade NS, Ashton CM, Wray NP, Brown C, Bartanusz V. Systematic review of observational studies reveals no association between low back pain and lumbar spondylolysis with or without isthmic spondylolisthesis. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 24(6):1289-95. 2015.
- Frank JM, Harris JD, Erickson BJ. Prevalence of Femoroacetabular Impingement Imaging Findings in Asymptomatic Volunteers: A Systematic Review. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 31(6):1199-204. 2015.
- Beals CT, Magnussen RA, Graham WC, Flanigan DC. The Prevalence of Meniscal Pathology in Asymptomatic Athletes. Sports medicine (Auckland, N.Z.). 2016.
Interesting comments on our diagnostic and therapeutic guru’s as The Magic Show. For as long as I have been in practice (30 years), there have been gurus in healthcare, and the belief that we have the tools to rehab or treat the problems people have effectively. We as practitioners of most disciplines have failed miserably often not because of the tools, but because of our thought processes based on what we have learned and how we have learned it. This has made care expensive in congregate and has often failed to resolve or eliminate the problems people have. If we are so good at what we do, why our results so uneven is something all of us should ask. Do you?
I use kinesio tape, IASTM as well as myofascial release to good effect, but unless you as the clinician understand why the person is in pain, you are merely throwing your solution, based on your physicians bias (a rampant problem) and getting mixed results. That’s not good enough.
While I appreciate your clinical data, the problem is that we are all built and shaped differently, and it is the mechanism behind the pain that is what is important, while the tools should be used to improve the functional reason for the pain and the problem. Unfortunately, we are taught biomechanics (or at least I was) in a piecemeal approach and we learned to diagnose and treat that way as well. A holistic point of view is the only thing that makes sense because the symptom and the problem are often in different parts of the body and the body has a wonderful way of creating compensations for how we walk and move based on our individual body mechanics.
Not individualizing care is a cardinal sin the current system wants to maintain, which is likely a huge cost driver in the system. The same for one size fits all treatments and screens which as we now know are driving costs, sometimes harming people and fail to address the patient’s symptomatic episode. Yet, it seems, everyone has a cure or a treatment, but 5 years later, the cure or treatment wasn’t. Medicine has failed miserably at this task, and often, so have we, although in the musculoskeletal realm, we have seemed to develop a better track record, or so it seems.
Most of the studies seem to look at what we do in a way that we do not practice. Many of my colleagues may use taping at an event to good effect, but do not expect a long term improvement which is reasonable. IASTM is very effective on fibrous tissues that are dense and it is effective and efficient as well in resolving restrictions of movement from poor fascial adaptation. Myofascial release can be quite effective in resolving a painful area and improving how we move as well.
Symptoms are not our problems. Symptoms are what drives us to see doctors, since if we could figure it out ourselves, we would not need a doctor. The problem of bias is that a chiropractor sees a back often as a back problem, a therapist sees it as a protocol that needs to be done, a medical provider labels most things as disease and throws medications at the problems and the truth is, this approach is wrong, drives costs and simply does not work.
What does work; Treat Test Treat protocols and active evaluation. Use the magic tools to treat, do a great exam and actively evaluate the person rather than the condition and then test to see if mechanically they improved. Are they better and able to do more on the next visit and did your approach using these tools get the job done?
A good history is very important and most of us do not put on our best Sherlock holmes hat digging for facts, looking at the patients postures and what them walk.
More often than not, many of the problems we see are problems with movement and loading. They are not problems in the feet or the knees or the back and there is no fix for poor body mechanics that are inherited, however there is more effective management, and ways to help the patient reimagine their problems using tools such as orthotics, exercises and treatments such as those I have mentioned that can change the way they move to a point.
Unfortunately, the insurance companies reinforce the one size fits all myth, and is constantly trying to box us in as if all patients are all the same and they should only require a short amount of time and your typical intervention which will solve all and then they want it done in a couple of visits and would rather you did not even spend time doing an exam, as we currently see with United Healthcare’s move to a global fee schedule.
We as practitioners need to be great at what we do and being great at instructing, or doing protocols, or adjusting, or doing cupping or whatever does not make you a great clinician. Figuring out the problem, getting the job done efficiently, not being one of the stops the patient has made along away but being the final stop to resolve their problem ultimately is what makes you a great clinician. Getting it much more right than wrong and caring enough to switch it up immediately if the invention you are using did not get the job done is paramount.
Active evaluation and treat test treat is the path forward, which individualized care to the individual in front of you is the way forward. The guru you visit along the way hopefully used judicially is the tool and collectively, it is how the tools are used ultimately can get the patient out of pain and back in action. Testing your work on each visit is important and is like checking your work after a homework assignment. Will we get it right 100 percent of the time, probably not but 80 percent is better than most and is reasonable to shoot for, since sometimes the problem is beyond what we can do conservatively, but most often, we can get the job done if we look at why they hurt correctly.
Your objectivity regarding studies is a great idea, except, you are testing tools, not the way they are used or diagnostic appropriateness, so in my view, the studies are not the whole story and should not be, unless the method itself is ridiculous and does not change anything physiologically or mechanically after we treat.
Basically, we as practitioners need to rethink what we do, the system needs to think what it does, and your patient is not a protocol; they are a person with a problem that is likely unique to them and needs a personalized diagnosis, rather than having their symptom treated. Ask anyone with back pain, plantar fasciitis, tennis elbow, shoulder problems or neck pain that has gone from doctor to doctor or in their case, guru to guru and you can see the frustration. Be the last stop on their journey.
And one more thing; maybe it is time we consider getting rid of insurance companies. Their one size fits all approach means limitations on visits and time when it shouldn’t be (some complicated cases are time consuming), limitations on who you should go to and profits above all, as we all pay more. Unfortunately, doctors will ultimately fall into line with poor reimbursements with an assembly line approach which is ineffective long term and is clearly part of the problem as the incentives to do great manual care is suppressed by the financial needs of the practitioner.
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Thanks for the feedback. Interesting points. To get more to the root of the issue with healthcare today – often what we are making as “problems” have yet to be substantiated as indeed problems or are well documented as normative issues. As clinicians we consistently fail to account for chronic pain science and cyclical variations of pain that will often lead to a regression without any intervention. We have manipulated the public to believe healing will NOT occur unless a clinician is sought for care.
Your statement, “If we are so good at what we do, why our results so uneven is something all of us should ask. Do you?” Is exactly what we are questioning. Hence the need for RCTs to aid improving outcomes.
No one is arguing for lack of individual care. Not sure where you are drawing such a conclusion.
Much of your reference to passive modalities, their perceived effectiveness, and structural rational for basis of treatment are incorrect and unsubstantiated in the research literature.
There are a number of gross over generalizations in your comment regarding clinical professions.
“Getting the job done” can be expedited by using efficacious modalities demonstrated as effective in the research literature without creating a clinician dependency.
Your test and retest approach with passive modalities misses the premise of questioning their usage in the first place.
The studies are indeed testing the tools. Experimental design through randomized control trials is just that – a test. They are failing these tests. Ignoring the evidence and spinning a narrative for their validation is what actually is the problem being discussed in our recent blogs.
Although we appreciate your response – the majority of your points are unreflective of our argument and are misconstruing the evidence. That is the problem with healthcare today. Clinicians thinking they are above the evidence and misunderstanding the application of evidence to clinical practice. Hopefully we can change this paradigm, together. – Michael
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Not sure of what you mean by passive modalities. I usually refer to those as heat, stim, ultrasound, etc. I do not consider IASTM or myofascial release as passive, since I always apply them with motion and treat – test – treat protocols are active.
The problem with our current basis of controlled trials is that it try’s to hard to narrow us down to the modality, when the modalities effectiveness should be just a portion of the days management.
For example, working on certain areas in the legs, retesting ability to get up from sitting to standing and seeing a marked improvement in function, then teaching some exercise protocol to build on it, and then using manipulation to restore motion into the area with the next visit checking to see if what we did still passed the same functional tests and did the patient see improvements in symptoms, mobility, etc. Each visit should build on the last, and it would be reasonable as we during process of elimination from visit to visit restore function, resolve symptoms and change the way the persons body works so we do not see the problem return. I am not sure how you could do a randomized control study for this since it would be too broad.
Also, as I said, the patients body style and unique mechanical function will vary from person to person. In the current world, there is very little or any consideration of this other than comfort and avoid painful activities.
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You may consider the modalities how you like, they are still viewed broadly in the research literature as passive. The treat-test-treat protocol ignores errors and biases that are mitigated with well controlled studies. Your perceived outcomes appear more efficacious than they are given your biases. This is not scientific – but instead bastardization of the scientific method. Yes, each visit should build on itself – no disagreement there. Your last statement about treatment and avoidance of activities is false – a number of clinicians in the physical medicine field seek to listen to, understand, and help patients figure out whatever issue may be ailing them, and work through and/or around said issue. Again, please stop making sweeping generalizations about clinicians – you are implying your experience is everyone’s experience and at the end of the day – experience means very little.
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Well, I hope we all listen to our patients. The problem is that first and foremost, there is physician bias in all professions. We all need to question what we know and when we do not see progression, we need to ask why and keep on asking why until we get the patient to where we they want to be. They are after all a huge part of the equation.
Patients are complicated beings, they do not all comply, they do not all do their exercises, they do not all get in tune with their bodies, some of them have had surgeries that may have altered their body mechanics (abdominal scars are a growing concern) and some of them may be on a medication like a statin that could be torpedoing our efforts. Some may have turmeric in their diets which is known to reduce inflammation and may not even notice if they are in pain until their problem has become good and chronic.
The truth is that often, patient care can be messy and a patients lifestyle and even their job can be a factor in how well we can move them along.
Unfortunately, using studies when all of this is present will affect your outcomes so even multiple studies regarding a condition, a treatment, an exercise may not be so clean. Then of course is the placebo effect as well.
This takes me back to treat – test – treat, is according to Stephen Perle who I discussed this with seems to be the only protocol that has been proven conclusively. How you use this to move the patient forward, with tools like these is dependent on the individual provider and the methods we decide to use. Unfortunately, there are many ideas, some of why have become quite popular but again, it is the proper diagnosis, the understanding of your patients problem and the willingness to check our work, the test, to make sure what we did had the desired effect.
And then there is the patient, their response, their body mechanics, etc. Then there is the insurance, the deductible, the network, the maze they walk through to see us. Messy, isn’t it.
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