As some of you may have noticed, we have a strong interest in evidence-based practice. In fact, one of the missions of this website is to increase awareness of the latest literature. However, to what point should we rely on evidence? Having read more than a few studies that showed little support for modalities in general (Yes, there are some pathologies that respond extremely well), you can imagine we would be hesitant to administer things like ultrasound, hot packs, etc. in the clinic. Coming across patients who request these modalities during treatment can be frustrating as we know they often have little effect physiologically. We have all had the experience of a patient saying, "last time I had therapy, the TENS Machine was really what got me through the day." On one hand you know you do not want to spend valuable treatment time performing these interventions, but on the other you feel it may benefit the patient psychologically. So, where do we go from here?
Having recently listened to David Butler's and others' audio recordings from IFOMPT, the importance of the biopsychosocial role really stood out to us. We cannot underestimate the impact of the mind. The neuroplastic changes associated with chronic pain often are as big a part of a patient's complaints as a mechanical component. Patients have been suffering with pain or have had dysfunctional movement for so long that the nervous system has adapted to the new "norm," and it is the true normal movement that feels abnormal. Butler, in fact, states that the biggest predictor of low back pain is depression and that we must explain to patients that the source of there pain is not necessarily mechanical (if a patient is grouped here).
So how does this tie in with evidence-based practice? Knowing how the nervous system can affect the patient's perception of pain, there may indeed be a role for interventions with low evidence, such as certain modalities, if a patient believes the treatment will help them return to function. We are not saying that these interventions should consume a significant portion of our treatment time (or that we should go to them at all), but it is something to consider for a trial to calm the patient's fears and give us time for them to "buy into" our methodology, especially if they made a request for that treatment. That being said, we cannot stress enough the importance of educating our patients. Perhaps spend some time explaining to the patient how physiologically, there is little evidence of changes occurring at the cellular level with that specific intervention and then continue to educate the patient on what the literature shows as having the best outcomes. Obviously, education on proper movement patterns and posture must be included as well. You might be surprised at how literal some of our comments are taken. Consider the idea that you teach your patient to lift with a slight lordotic posture, so as to minimalize the stress on the back. Some patients might incorporate this posture into all aspects of their life, thinking that they should never bend their back if they want to avoid pain. Think of all the compensations that might result! We must evaluate all faulty movement patterns a patient presents with and educate them clearly on better strategies.
Of course, we should still utilize our clusters, clinical prediction rules, and clinical practice guidelines when treating patients, but we must be aware that not everyone falls into those groupings. Some people have a larger biopsychosocial role than others, and it is these patients that we must spend even more time on education. Yes, maybe we should consider the use of interventions with lower quality evidence early in our treatment plans, but in it, we must include education and interventions with higher quality evidence as well so that we can move toward the desired outcomes.
James Heafner PT, DPT, OCS:
Owner and lead physical therapist at Heafner Health, cash-based physical therapy in Boulder, CO. Areas of expertise include orthopedic and manual therapy, functional movement, pain science, and movement science.
In May 2013, I earned my Doctorate in Physical Therapy from Saint Louis University. After graduating from the Harris Health Systems Orthopedic Residency in October 2014, I moved to Boulder, CO. Since living in Boulder, I have started my own cash-based PT practice, earned my OCS certification, and teach for the OPTIM Fellowship and COMT program in Houston TX and Scottsdale, AZ.
Chris Fox PT, DPT, OCS: Physical therapist at Foothills Sports Medicine & Physical Therapy in Scottsdale, AZ and regularly lectures at the Phoenix Campus for NAU's DPT program and for Optim Manual Therapy's COMT program. Completed multiple advanced manual therapy courses implementing aspects of biomechanical analysis. He received his DPT from Saint Louis University in 2013. Completed Scottsdale Healthcare's Orthopaedic Residency (now Honor Health) in July 2014. He became a Board Certified Orthopaedic Specialist in 2015. Level I Expert in FMS and SFMA , Kinetacore FDN Level 1 certification, and IASTM Technique course completion. He would like to pursue further education in McKenzie Technique, Dry Needling, Strength & Conditioning, Orthopaedic and Manual Therapy.
Brian Schwabe PT, DPT, SCS, CSCS:
- Board Certified Sports Physical Therapist (SCS) at Elite OrthoSport in Santa Monica, CA which specializes in treating collegiate/professional athletes and clientele from the Beverly Hills, Hollywood, and Santa Monica areas.
- USC Sports Residency Trained Physical Therapist (<1% of all PT's residency trained)
- DPT from Saint Louis University
- Future plans/interest include:
1. USAW, SFMA & Catapult Systems technology for NBA teams
2. Pursuing a position as a sports physical therapist &/or Strength coach for a Division 1 athletic medicine department or professional sport team.
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