Redefining ‘Evidence’ in EBP: Why "In My Experience" Doesn’t Cut It
Kenny Venere is in his final year of the DPT Program at Northeastern University in Boston. His interests include pain science, neurophysiology, burn care, and acute care. You can follow Kenny on Twitter @kvenere
As a student, I often get asked questions about my experiences in previous settings. I have been fortunate enough to work in two fantastic hospitals. One of which specializes in pediatric burns, and the other an inpatient rehab hospital where I was a member of the spinal cord injury unit.
When I talk about my time spent in these settings I detail stories of resilience, perseverance, and achievement. I speak of a child who, after seeing his newly reconstructed and grafted face for the first time, cracks a smile and asks “Hey! I look pretty good now, huh?” I share details of a father getting to throw a baseball to his son for the first time since his life altering spinal cord injury. These are happy moments, moments I cherish, and moments I will carry with me for the rest of my life.
I get the same reaction to these stories every time– “Oh, isn’t that sad?”
I am currently on a clinical rotation in a small outpatient clinic with a typical musculoskeletal population. Certainly not a population where anyone would react with a sigh and ask if my work is “depressing” or “difficult”. Here, I see a patient who is now on their 62nd visit for shoulder pain after surgery who has experienced moderate relief at best. Here, I see a patient with neuropathic neck and upper extremity pain being treated with ultrasound, theraband exercise and massage, who is still unable to tolerate typical work activities after many months of various conservative and surgical treatment. Here, I see a patient with chronic medial knee pain have their MRI report read to them, describing “SEVERE tricompartmental degeneration” and be told that they have plateaued in therapy and their best option is an injection and a home exercise program.
No one ever asks “Oh, isn’t that sad?” when I talk about those patients.
But, isn’t that sad?
I decided to start my reflection on my first clinical education experience with a short essay I was inspired to write after having a particularly frustrating day in a clinic. I feel it succinctly depicts my experience with not only my CE1, but a majority of my educational experience. In school, I was taught to identify a hypomobile segment and apply a specific P/A glide to a zygapophyseal joint to free up its motion. I was instructed that when someone is acutely inflamed, I should utilize ultrasound at a 50% pulse rate to calm their tissues down. I was educated to stretch someone’s pecs and strengthen their periscapular muscles to fix their faulty posture. At my university, we are even offered the opportunity to take a course on Graston, with hopes of breaking up adhesions and remodeling connective tissue. Throughout all of this education, the utilization of evidence based practice was emphasized to me, so I must ask: where’s the evidence?
Or more importantly, where’s the critical thinking?
It’s unfortunate to see such biologically bankrupt concepts, explanatory frameworks, and interventions being perpetuated. Day in and day out, I observed forms of practice that research had rightfully dismissed, but are still inexplicably ubiquitous in our profession. How does one justify the use of ultrasound when the biophysical (Baker et al 2001) and clinical (Robertson et al 2001) effects have been so thoroughly disproven? Why are we still taught that we are molders of connective tissue, when the forces required to create plastic deformation of connective tissue ranges between 50 and 250 pounds of force (Threlkeld 1992)? When are we going to accept the fact that our palpatory exams lack reliability (French et al 2000) (Lucas et al 2009) and validity (Najm et al 2003) (Landel et al 2008) (Preece et al 2008)? When will we stop telling students, colleagues, and patients that pain is related to their posture, muscle length, muscle strength, or biomechanics (Edmondston et al 2007) (Lewis et al 2005) (Nourbakhsh et al 2002)? When will we cease blaming pain on something found on an image (Reilly et al 2006) (Beattie et al 2005) (Borenstein et al 2001)? When will we stop thinking that we can change someone’s static posture with strengthening (Walker et al 1987) (Diveta et al 1990)?
When we teach these things to students and say them to our patients, it is misleading at best and fear inducing and hurtful at worst (Zusman 2012). How this dogma persists in physical therapy education and practice in spite of current research is beyond me. Perhaps it has to do with the reverence of those who paved the way for physical therapy (the Kendalls, Cyriax, Kaltenborn etc), or maybe it has to do with willful ignorance and a lack of consequence.
Regardless of the why, the fact remains that the current state of affairs is unacceptable. Consider the evidence available for Graston, one of the advanced electives offered to us. A quick PubMed search reveals a handful of case studies offering a cocktail of interventions in addition to Graston, a positive study in rats, and a negative study in rats. Would this lack of scientific rigor be acceptable when administering a pharmaceutical to a patient? Or when educating a group of medical students on its use? If you use a little bit of critical thinking and scientific reasoning, it seems obvious that there is little prior plausibility in the Graston Technique.
I have no doubt that there are numerous testimonials of patients getting better with Graston (or ultrasound, or laser, or TrA strengthening, or whatever the current passive modality of choice is), but as Mark Crislip of Science Based Medicine says:
“In My Experience” remain the three most dangerous words in medicine.
This is perhaps even doubly so in the world of physical therapy, given the litany of non-specific effects that go into a treatment encounter (Hall et al 2010) (Miciak et al 2012). When we use empirical observations and experiences to justify things like Graston, or ultrasound, or ascribing the experience of pain to elaborate biomechanical narratives, we are directly contradicting ourselves and it is the patients who suffer because of this. It certainly feels like thoughtfulness and theory have died in physical therapy, despite the words of Jules Rothstein (Rothstein 1996).
This is something I saw every single day of my clinical. People with painful problems were treated with what had worked in the past or what they were taught during a hopelessly outdated education. Sometimes it worked, but a lot of times it did not. This lack of effectiveness was never the catalyst for introspection and examination of why the treatment encounter failed, but was a matter of a patient “plateauing” due to bone on bone knees, or flat feet, or those pesky little bone spurs.
We as a profession fail those who need us most because we have failed to adopt science based medicine, critical thinking, and current neuroscience. Instead we opt to lob outcome studies at one another, buy into whatever new, trendy continuing education is making the rounds, and continue to look for a simple solution to a complex, emergent problem. Physical therapists are in a unique position to make a significant impact on the burden of chronic pain, however, we fail to live up to our potential by holding onto a postural-structural-biomechanical model that has been proven ineffective and incorrect (Lederman 2011). To quote Steven George, PT, PhD:
“What we spend 95% of our time teaching our students have no bearing on outcomes. I’m really glad we are so good at measuring joint ROM though.”
My clinical education has been very helpful, though not in the way I am sure one would come to expect. I have not left feeling that I have improved my talents in identifying a hypomobile segment, or releasing a trigger point, or fixing a flat foot. I have, however, learned this: If you are not learning about pain, you are not treating it. When talking about pain, you are talking about the brain and the nervous system. Pain is an emergent experience that relies on countless biological, social, psychological, cultural, and environmental variables. Pain does not come from flat f
eet, or a weak transverse abdominus, or a tight hip flexor.
If we, as a profession, want to have an effective role in the management of chronic pain, we need to let go of the dogma so prevalent in our field. We need to stop telling our patients that their anterior pelvic tilt is a defect needing to be corrected, or that their knee is bone on bone and is the cause of their pain. We need to familiarize ourselves with the work of people like Ronald Melzack, Patrick Wall, Louis Gifford, David Butler and Lorimer Moseley. We need to be skeptical, we need to ask why, and we need to refuse to perform an intervention solely because “it works”.
That’s not good enough anymore.
We can do better.
We have to.
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