Author’s Note: On 9/22/2016 I had the honor of participating in the Florida Physical Therapy Association’s Oxford Debate. This is the closing argument that was presented by myself on behalf of the Con side for the argument “Should Physical Agents/Passive Modalities be used in Physical Therapy Practice?” I have had some requests (mostly from friends who enjoy hearing me rant more than anything else) for the notes of the debate. Seeing as how Mike and myself have a blog now, this is as good a place as any to share those thoughts. This was written as a speech so grammar was not a priority and sometimes liberty was taken for emphasis. The Con side did emerge victorious, although the Pro side did present some excellent thoughts. Enjoy.
Well, I have 8-12 minutes with which to sway your decision which means I have exactly one billable unit that I need to make count, so long as you don’t have Medicaid. If so, this one’s on me. I actually fully agree with the Pro side that if there is evidence we should use passive modalities. This entire debate hinged on a false premise before we ever started, because, absolutely if we want the betterment of Physical Therapy we should use the evidence. But, there is a second question in that statement which is “what is quality evidence?” Now, luckily I have a unique title that not too many Physical Therapists hold to help me expand on this topic. It was bestowed upon me by the Universal Life Church; the good title of Reverend. So, for our closing remarks today, I would like to take you guys to church. From where you are sitting in this room it would appear some of you have already heard and accepted the good word of evidence, but let me see if I can increase the fold. For today’s closing sermon we need to first talk about who we are as a profession in order to determine what we should do as professionals so let’s get going….
Over the last decade the profession has moved increasingly towards a Doctoral level degree but have you ever stopped to reflect what it means to be a Doctor? The word has its roots in Latin meaning “to teach.” To be a doctor should be to assume an active role in our patient’s care, not slap a machine on them with no efficacy and walk away. For decades our profession has been passive, advocating bed rest, taking orders from other professions. It is time we embrace the fact that passive does not work, either with modalities or the betterment of our profession. Even the slogan for the profession implies we need to “move forward.” Moving forward as educators, as teachers, implies that WE are staying current with the best evidence regarding what we have to teach our patients. Breaking up fascia, increasing blood flow, whatever words used to describe what passive modalities are doing are, at best misdirection, at worst lies. But they are the communion that much of the profession partakes in. How can we expect to ever move the profession forward when we constantly are anchored to the past by our own confirmation bias?
In 2005 Harry Frankfurt wrote a philosophical essay that perfectly defines what is being espoused with passive modalities, it’s called “On Bullshit.” I realize I shouldn’t use that kind of language in church, but it’s time that people start standing up and exposing these modalities for their complete lack of substance. A bullshit statement is defined as neither “true nor false” which sounds a lot like “due to the high level of bias and low quality of studies, no claims can be made to the efficacy of the intervention at this time but I’m going to use it anyway.” The aim of bullshit is to impress the listener with words that communicate an impression that something is being or has been done, words that are neither true nor false, and so obscure the facts of the matter being discussed.
By ignoring the evidence or acknowledging that there is little evidence, and not conceding that what little exists does not add strength to passive modalities use, are we not bullshit artists? We sit with our patients and tell them that things are out of alignment and need put back in, knowing full well there is no evidence for that. We tell them increasing blood flow to tissue will help them heal when literally moving increases blood flow to tissue. We can’t even decide if we think inflammation is a good or bad! We do one intervention to increase blood flood and inflammation to help with the healing process then turn around and do another telling them we are helping decrease the inflammatory process. In reality we are just spitting polysyllabic bullshit to our patients without regard for Truth or the fact that the patient is now scared of inflammation and stress when those two are necessary for healing and adaptation.
We tout a paper that claims:
“Recent studies demonstrate that dry needling combined with mechanical and/or electrical stimulation may reverse PKC-mediated peripheral hyperalgesic priming by normalizing nociceptive channels, to include EcoRI, HinDIII, TaqI, and Sac1. Electrical DN (EDN) stimulates immune cells, fibroblasts and keratinocytes to release CGRP and substance-P, altering the stimulation of TTX receptors to reverse hyperalgesia.”1
If you agree with the use of that modality then you read or hear a sentence like that and think “yes, dry needling works” but in reality I changed out the channels listed for restriction enzymes we use to develop plasmids at my old biochemistry job and no one knew. That entire sentence said absolutely nothing, but with those enzymes I can construct a plasmid to turn cellulose into ethanol. (I’m still working on water in to wine).
This is the issue! We hunt for papers, if we bother to look, that only confirm what we already believe and do not take the time to actually question our own beliefs as clinicians. What is the state of our profession when evidence based medicine is constituted more from likes on a Facebook page than a thorough perusal of the evidence? If we all agree that the fascia blaster is ludicrous, but only some think the majority of passive modalities are, where do we draw the line?! We have a generation of therapists stuck in the “it works for me” mode and the new graduates not knowing who to trust so they turn to tank top wearing gurus on the internet because 10,000 likes and a helluva graphic designer mean they must know what they are talking about. It’s okay though, because he’s not wearing a polo which for some reason has become a sin within the profession. #nopolo.
I would like to propose a thought experiment for the audience to reflect on the current state of practice that I call Miles’ butter knife.
This is a take on Russell’s teapot and Schrodinger’s Cat. There exists a butter knife inside a remote, closed clinic. You cannot find this clinic, but the butter knife can release all of the fascia so long as it is inside the clinic. Also in the clinic is a randomized, double-blinded, placebo controlled trial showing the butter knife does not work. If one opens the door to the clinic the paper is immediately published showing the knife does not work. Unfortunately, we cannot find the clinic, but a guru has been there and seen it. Due to the transitive property of quantum guru bullshit the butter knife both works and does not work. If you pay $500 for a continuing education course you can procure a replica of the butter knife so long as you promise to never look for, or open the door to the clinic yourself. For an additional $1000 you can obtain a theoretical drawing of the inside of the clinic. For $1500 with a renewable $500/year charge you can even place three letters of your choosing after your name to show that you have met with the guru.
I could stand up here and go paper by paper on why the majority of passive modalities have no place within the profession but that method obviously doesn’t work. We have well conducted, high power studies like the OPTIMa trial that showed no efficacy for passive modalities but those have gone ignored.2, 3 It’s easier to advertise our supposed knowledge with letters after our names than words coming out of our mouths. We justify case studies and case series as foundations for treatments. Well, case studies are essentially stories, so I would like to offer my own story, or case study if you will on the problem with continuing to both use passive modalities in clinic and teach them in school.
I have a 60-year-old, female athlete sumo deadlifting 205# for a triple weighing 165#. She has been diagnosed with OA, scoliosis, hallux valgus and a host of other conditions. Since she hit three reps lets point out the three glaring problems many clinicians are struggling with in their minds right now.
- They don’t know what a sumo deadlift is (much less are able to differentiate between sumo, conventional, and Jefferson)
- They assume heavy weight is harmful (or for that matter can define what constitutes “heavy”)
- If that patient came in to clinic, many clinicians would advocate for the use of a passive modality because they do not understand the technique, nor any principles of periodization. Or even worse, they would tell her she should never lift again, especially not that much weight.
We are “physical” therapists who are being out educated on exercise prescription by people offering weekend courses on functional hypertrophy, whatever the hell that is. If we keep perpetuating non evidence based, passive modalities in clinic and even more so in the classrooms of doctoral level programs, then we cannot expect to gain ground in advocating for our services being better of those of our peers. Earlier this year there was a study in Spine that posed the question “How Effective is Physical Therapy for Common Low Back Pain Diagnoses?”4 The answer, 28.5% of patients met the minimal clinically important difference on the ODI at follow-up. Maybe we should start there. This is the result for those patients who we’re providing services to on, at best, the bare minimum of evidence. That “it works for me” or “it’s what my patients want” obviously doesn’t work. Yes, 60% had a MCID change in numerical pain rating scale, but that shouldn’t be taken as a win for us. That’s barely 7 percentage points above Shaquille Oneal’s career free throw average. Everyone wants to punch up to the big leagues and advocate for us being more effective, well guess what, physicians are going to punch back. It’s time we start tying up our own loose ends before we start going after anyone else.
But what even is Physical Therapy? We say #GetPT1st but how comfortable are you just telling a family member to go to PT on the other side of the country? I get these requests all of the time from athletes, but how do I know what their clinician is going to do? Are they going to use non-efficacious passive modalities, butter knives, and manual therapy or are they going to get my family member strong and independent? I would venture everyone in this room has ran in to this conundrum of hesitancy referring out randomly to the profession. If that is the case how can we really advocate that we are the best? If we continue to offer passive modalities as treatments are we really “moving forward” or are those clinicians actually holding us back? Once again, I will concede, if there is quality evidence for their use then absolutely they should be implemented in to practice. But this bullshit argument of clinical practice being ten years of clinical evidence has to end.
If we continue to try and build fictitious bridges to nowhere how can we truly advocate to #GetPT1st? Let’s be completely honest with ourselves, this isn’t about the evidence, this isn’t even about patient outcomes, it’s about us being comfortable in our ways. We enjoy the convenience of passive modalities because we don’t have to think. But, if we can only truly get patients better by changing their behaviors, we have to first start with our own and perpetuating this bullshit isn’t going to fly.
This debate was lost by our side before it ever began with the argument we had to defend against. Should physical modalities or agents be used in the profession? If there is quality evidence, absolutely! I concede defeat with my closing statements. The issue is that for the common modalities being used now that evidence is absolutely none. The absence of evidence is not the evidence of absence, and I agree with that, but the absence of looking for evidence or trying to interpret it is ruining our profession.
With my closing remarks I invite you still seated on the pro side to join our ranks amongst the evidence based. I have found that some passive modalities can have a place in life. If I need to place some butter on bread, I now have a very expensive tool with which to do so. If I need a vessel with which to drink I now have a cup with which to drink. These two devices have no use for our patients though so let’s please stop lying to ourselves and our patients. It is a sin after all.
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- Dunning J, Butts R, et al. Peripheral and Spinal Mechanisms of Pain and Dry Needling Mediated Analgesia: A Clinical Resource Guide for Health Care Professionals. Int J Phys Med Rehabil. 2016. 4:2
- Dion S, Wong JJ, et al. Are Passive Physical Modalities Effective for the Management of Common Soft Tissue Injuries of the Elbow? A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.
- Wong JJ, Shearer HM, et al. Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? an update of the bone and joint decade task force on neck pain and its associated disorders by the optima collaboration. Spine J. 2015 Dec 17. pii: S1529-9430(15)01234-6
- Eleswarapu AS, Divini SN. How Effective is Physical Therapy for Common Low Back Pain Diagnoses?: A Multivariate Analysis of 4597 Patients. Spine. 2016 Aug 15;41(16):1325-9.