The Disconnect: Evidence and Physical Therapy Practice

As a student and clinician, I’ve often heard about “evidence based practice”. I even had a class on the topic in PT school. Yet during clinical rotations, I almost never heard discussion of research evidence among clinicians. In fact, some clinicians disparagingly said “Yeah I don’t have time to read research”. Some clinics had monthly journal clubs where clinicians would meet, chat about an interesting paper over lunch, and then go back to treating patients. There appears to be a disconnect between the supposed importance of evidence and how PT’s actually practice.

To help address that disconnect I’m sharing Steven Kamper’s 2018 series (https://pubmed.ncbi.nlm.nih.gov/29852833/)  on how to practically apply evidence to the clinic. I also include my own commentary in [brackets].

***
Why should PT’s use evidence?

-The public expects medical care to be based on science [Ideally. There will likely always be a market for “body workers”, faith-healing, and related practitioners of pseudoscience.]

-If PT wants to be considered a scientific, it must use evidence
[I would argue that being scientific is the ONLY way PT can differentiate itself from the pseudoscientific professions mentioned previously. If we aren’t scientific, we’ll have to compete by developing increasingly strange, “cutting edge” treatment methods.]

-Agencies like insurers and government are trending towards only paying for evidence based treatments

But why can’t we just rely on clinicians using experience?

As clinicians we are subject to biases. First, the confirmation bias. We overvalue information that supports our views, ignore/forget what contradicts our views, and interpret ambiguous information to support our views. Second, the recall bias. We tend to remember extreme events (like a patient who did really well or really badly). [For example, if a patient raved about how they were “cured” by dry needling, we will tend to remember that patient rather than those who had a mediocre response. A related issue is that some patients stop attending PT, but we tend to forget those or assume that they improved.] Third, in clinical observation there is a fundamental difference between change in outcome and treatment effect. That is a treatment’s theoretical effect may not be solely responsible for the patient’s improvement in symptoms.

Why might patients improve regardless of the treatment effect?

-Natural history. Many conditions resolve completely or mostly on their own, especially acute conditions. For example, after a mild ankle sprain a patient will see improvement simply due to the passage of time.

-Regression to the mean. Many conditions are episodic or fluctuating. Patients may visit us only at the peak of an episode, after which point the patient’s symptoms will mostly improve regardless of intervention, since the condition is episodic. For example, some types of back pain are episodic and have exacerbations that will abate, regardless of the intervention given.

-Placebo. Placebo effects are any effects that occur due to manipulation of patient expectations and/or conditioning. [For example, if a patient expects that a chiropractic adjustment will “fix” their back pain, they are likely to feel less pain simply because they expect the adjustment to work. The point is not to disregard any treatment that has a placebo element, but we must examine the research to try to determine how a treatment compares to placebo. This has real practical implications. For example, suppose research shows that a highly “scientific”, intricate kinesio-taping pattern is found to work no better than sham, placebo taping to reduce knee pain. This means that simply applying tape to a patient’s knee will likely give the same effect as using a highly “scientific”, intricate taping pattern. If that’s the case, is it really worth it to invest time and money into a course on taping? Or should we look for treatments that have more robust evidence? Now with the COVID-19 pandemic, is it ethical to tell a patient they “need” a treatment that is known to mostly be a placebo (putting their health at risk)? Is it ethical to knowingly sell a patient a placebo with lots of “scientific” explanations?].

-“Polite patients”. As clinicians we build relationships with patients and sometimes they don’t want to “disappoint” us, so they say they feel better. [I’ve noticed this in the clinic. As a patient, it is very awkward to tell your friendly PT that all their hard work didn’t help you. Even on questionnaires, many patients will state more improvement than has actually occurred.]

The next post will discuss how to identify evidence relevant for a real patient case. As always there are exceptions and nuance to this discussion. All constructive, good faith comments are welcome!

Is Daily Practice Important? Why We Need to “Load the System”

I broke my DuoLingo streak. While studying for the PT licensure exam, I used DuoLingo as part of my Spanish training. Every day, I would hop on the app and do the exercises to hit my daily XP requirements. I built up a 45 day streak. Yet I retained little to nothing from these exercises (despite accumulating almost 2 hours per week). So I deleted the app and broke the streak.

I had been fixated on this idea that I needed to practice every single day. DuoLingo states that “15 minutes a day can teach you a language”. And many people online stress the importance of daily training: exercise, mindfulness training (meditation), etc.

However, if we are overly focused on daily training, we can run into a few issues:

First, adherence can be difficult because there is usually a cost to switching tasks (i.e. to exercise you have to put on exercise clothes, warmup, etc.) Second, sometimes life happens and we don’t get to practice. So we may feel we are failing since we’re not keeping our daily streak. Lastly, certain types of training actually benefit from not being performed daily. For example, most often people lift weights intensely 2-4 days per week. Lifting weights daily can make it harder to bring the necessary level of intensity (i.e. due to motivation, fatigue etc). Training too often can be ineffective and/or impractical.

So what is the alternative to daily training? We need to “load the system” with deeper, more intense sessions. A basic principle of biological systems, like us humans, is that stressors (challenges) promote adaptations. When a person lifts a heavy load they feel tired Their muscles, bones, and tendons have been stressed. They have “loaded the system”. That load provokes an adaptation to get stronger. Now they can lift the same heavy load with less effort.

Similarly, with other types of training we need to “load system”. For example, in language learning we need to reach that point of being challenged in order to progress. When I went to Argentina for a short trip, I thought I would practice a lot of Spanish. I did. However, the conversations were mostly less than 10 minutes and therefore not challenging. When first meeting someone, the conversations are mostly small talk, “what do you do, where are you from, etc”. Only after the 10-15 minute mark do you really get to discuss more in depth topics. And that depth is challenging, which is where the growth happens.

All this being said, daily “low load” training is still beneficial. For example, in addition to lifting weights a few times per week, walking daily is excellent for your health. In language learning, daily immersion is useful in addition to having challenging conversations.

Note that there is a minimum frequency needed for training. For example, although lifting weights for 1 hour, 3 times a week is beneficial, it would be ineffective to lift weights for 3 hours straight, once per week.

In short, not all training needs to be done daily. Rather we need to ensure we “load the system” by working at our limits.

You Are Not Your Grad Program

“You are not your job, you’re not how much money you have in the bank. You are not the car you drive. You’re not the contents of your wallet.”

― Chuck Palahniuk, Fight Club

I’d like to add to that list, “You are not your grad program.” My choice to enter PT school came after a brief career in engineering, so I had a sense of “this is it, I’ve gotta make this work” when I started PT school. During my first summer in gross anatomy, school was the sole focus of my life. I socialized very little. I did almost everything in relation to school-I focused on quality sleep, exercise and good nutrition to enhance academic performance. I had no real hobbies outside of school. During that summer, I occasionally visited my family to recharge but would otherwise go days without calling because I was “too busy” with studying and needed to focus. As I became more focused on school, my performance on each test became of utmost importance. Doing well on a test, meant it was a great day. Performing poorly, would mean frustration and angrily analyzing why I didn’t perform well.

Once anatomy was finished I picked my head up and realized how much I had missed that summer. I hadn’t really explored the new city I found myself in. I had missed great social opportunities. I had made no progress in the gym. Most concerning of all was when I visited friends back home. In conversation, I mostly just talked about PT school. Of course, grad school is a big investment of time, money, and emotional energy-but my identity had become centered around grad school. I looked ahead to the next 3 years of grad school and thought “I cannot just be a PT student for the next 3 years”.

So over the next year I started building up a life again. I actually said “yes” to social opportunities. I started strength training. I picked up sports like volleyball. And somehow my grades stayed about the same (and no I didn’t sacrifice sleep). I realized a few crucial things:

1. The difference between an 89.5% as a B and getting a 90.0% as an A really wouldn’t matter in the clinic after graduating.

2. Diversifying my identity put school in perspective and dramatically reduced the stress of each test, quiz, or project. Which ironically improved my grades, but with less time studying.

3. PT school and my career are long term commitments, so the only sustainable option to thrive long term is to maintain the other areas of life.

Going to grad school and/or having a career I care about is rewarding and an opportunity I am incredibly grateful for. However, career is only a single dimension of a meaningful life-there are parts of us that our careers will never fulfill.

 

The Seesaw of Serendipity and Drive

Confused. What better way to feel on a Friday after work. Coming home from work I didn’t know what to do. So, I started changing clothes for the gym. Next stop, the gym and then…

A sort of emptiness started filling my mind. I had no obligations that evening. I had achieved all I wanted to for the week. Larger recent life events: got my undergraduate degree, got a great job, and began work towards new dreams outside of work. My life is going in a direction I want. Yet the empty feeling persisted.

I have been known to get busy and “productive” to defer that empty feeling. That confusing yet strong feeling that I have diagnosed as PES (Post-achievement Emptiness Syndrome): the inability to engage in activities just for fun, often the result of focusing excessively on achievements. I didn’t want to work, but I had forgotten how to play.

So I started watching Youtube videos about business and fitness. After a few videos I thought about a trip I had a few months before…

My first trip to Spain reminded me of a forgotten attitude. The child’s attitude. That mindset of wandering with curiosity and embracing whatever happens. Travel and other non-achievement oriented activities are the perfect way to rekindle this mindset. I don’t mean traveling with a list of the “must sees” or packing each day full of adventures. In fact, I took the exact opposite approach on a recent trip and had one of the most memorable experiences of my life.

We were going to Spain after graduation. But I was poorly “prepared” for the trip. I knew about 15 Spanish words (10 of which were numbers), I hadn’t researched the “must sees”, and hadn’t looked into hotels (we actually had only booked 4 nights of the 14 day trip). A sense uneasiness set in as I boarded the plane with so much uncertainty ahead.

Upon arrival in Spain it was hard to get into that child like mindset.* When you have deadlines, meetings, and classes 7 days a week it can be hard to adjust to having zero commitments. It worried me slightly that we didn’t have all our hotels booked and that we had no planned activities, would this trip be a waste?

On a train out of Madrid we looked over cities to visit and impulsively chose Sevilla, which turned out to be the highlight of the trip. Sevilla has the variety of options typical of a city, while maintaining the hospitality and warmth of a small town. Also, it turned out the hotel had its own inexpensive bike rental service. And the city happened to have recently finished a tourist bike path. And the city is known for its amazing food. I didn’t even know this city existed until 2 days before we got there.

So where does this musing about Spain and my eccentric Friday evening leave us? The recognition of 2 forces that must be balanced in life; drive and serendipity. We need drive to dream and work towards future achievements. However, we also need serendipity to wander, play, and embrace whatever experiences lie before us. The only problem is that in the modern world, drive is overemphasized to the point that we forget serendipity. Think about mainstream Western schooling. For 8 hours a day, enthusiastic children are forced to sit through a series of regimented learning activities. Even P.E., art, and music are highly structured classes. After school, many kids are ushered into sports practices. Finally, at night they do homework. Lunch and recess only offer a brief time to play for most kids. A similar pattern follows in most jobs. Now this is not say our jobs and school system are completely broken, but they need to allow for more wandering and play.

 Serendipity is not just important, it is necessary. This force helps us:

  1. Develop a childlike curiosity for the world, crucial to creativity and learning.
  2. Be inspired and infuse passion into life.
  3. Prevent burnout due to being in drive mode for too long.

So just play. Stare at the sky. Take a walk. Forget having a reason or purpose. Let the waves of life wash over you like when you were a kid at the beach.

*Note this is a repost from August 2015 from a previous blog I ran.

——————————————————————————————————————————————

Recommended Further Reading:

Leo Baubata’s The Place Where You Are

Charlie Hoehn’s Preventing Burnout: A Cautionary Tale

Why Eating Out is Healthy

Humans are social creatures. Think of the worst punishment that people reference in prison: solitary confinement. We NEED to be around people. I’ve always understood this intellectually, but I often lose sight of it by focusing on other areas like health and school instead. However, I’ve realized that mental and physical health depend A LOT on socializing, perhaps as much as food and exercise affect health.

For example, when I was into the Paleo diet and eating “clean” I rarely shared food with anyone because I was consuming a very limited diet. Yes, I was eating a “clean” diet but I was missing a huge aspect of socializing, which is sharing food with people. Only recently, I realized that there are so many health benefits to socializing that are worth the small intake of junk food.

Consider what is “healthier”: the perfect kale salad with wild-caught salmon and extra-virgin-blessed by a rabbi-organic olive oil eaten alone in your apartment OR a white bread sandwich eaten with friends with a few good laughs sprinkled on top? I would argue the sandwich is actually “healthier”. The sandwich with friends has a lot of benefits: laughing, walking to the café, getting outside, developing deeper connections, and other effects we haven’t discovered. I suspect scientific research will show these effects in the coming years. In fact, some research suggests that simply hugging may decrease levels of cortisol (a stress hormone).

Of course, you can always choose healthier options when eating out and suggest more athletic social activities. But if your filter for social activities is only what fits into the “healthy lifestyle” you follow, your activities will be limited. And unless you are a professional athlete (meaning your income depends on your athletic ability), it probably is not worth it. Basing all socializing on a fitness/health activity, such as Crossfit, means if you get injured, then your social life will be severely hindered. Plus when you meet people outside of that group, it will be harder to connect since you are used to only talking to people in Crossfit. An exercise group should just be just one of the many tribes you are part of.

So as much as eating well and exercise are part of being “healthy”, regular doses of in-person socializing are the supplement most of us need more of.