by Giacomo Rossettini – PhD, PT

‘I definitely feel less pain in my back after the manipulation’. ‘My shoulder has better mobility after the massage’. Phrases such as these, uttered daily by patients in rehabilitative settings, lead clinicians to think that their hands-on treatments are so powerful that they are sometimes miraculous. Although the literature supports a short- to medium-term benefit of hands-on techniques in managing musculoskeletal pain,¹ if we ask why they work, we are often surprised by the justifications proposed by the clinical and scientific community. Indeed, in addition to biomechanical and neurophysiological explanations,² the international literature has recently suggested Contextual factors (CFs) as mechanisms for understanding the clinical functioning of hands-on techniques, regardless of what they are (e.g., joint mobilizations, joint manipulations, soft tissue or neurodynamic techniques).³

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by Chad Cook PT, PhD, FAPTA; Derek Clewley PT, PhD, FAAOMPT

If you’ve seen the movie, Oppenheimer, you may remember him discussing the paradoxical wave-particle duality. This revolved around the finding that light exhibits both wave-like and particle-like properties. In fact, in certain experiments, light behaves more like a wave, whereas in others, it behaves more like a particle. Oppenheimer was perplexed because light shouldn’t have both properties, properties that seem to “depend” on how they are tested.

When you read comparative analyses involving two markedly different treatments that yield similar outcomes, it is likely that you are just as perplexed as Oppenheimer. As we’ve stated before in papers and blogs on this website and others, most musculoskeletal treatments result in similar overall outcomes [1]. In truth, it’s become the norm versus an exception. We could manage this using the current “circular firing squad” method of badmouthing the interventions we don’t like and supporting those we do, OR we can try to better understand why we are experiencing this. We chose the latter. The purpose of this blog is to provide possible reasons we see similar outcomes across studies involving different interventions.

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Definitions Matter

In healthcare, the use of appropriate definitions is imperative. I was recently part of an international nominal group technique (a qualitative study that is used to build consensus) that harmonized a definition for contextual factors [1]. Within the literature, contextual factors have been variably described as sociodemographic variables, person-related factors (race, age, patient beliefs and characteristics), physical and social environments, therapeutic alliance, treatment characteristics, healthcare processes, placebo or nocebo, government agencies, and/or cultural beliefs. Our job was to determine which of these characteristics most accurately reflected a contextual factor. Our harmonization (the paper is currently in review), should improve the ability of two clinicians, researchers or laypersons to communicate what they mean by this critical concept.

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By Chad E Cook PT, PhD, FAPTA; Yannick Tousignant-Laflamme PT, PhD

Background

In 2010, the Affordable Care Act (ACA) was passed with a goal to expand access to insurance, increase consumer protections, emphasize prevention and wellness, improve quality and system performance, expand the health workforce, and curb rising health care costs [1]. Principle to the ACA was the process of shared decision making (SDM) [2]. By definition, SDM is ‘an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences” [3]. Whereas other definitions of SDM also exist, all converge to a similar notion: as a central part of patient-centered care, SDM is a dynamic process by which the healthcare professional (not limited to the physician) and the patient influence each other in making health related choices or decisions [4] upon which both parties agree.

Purpose

Whereas it’s difficult to argue against the principles of SDM (i.e., sharing best available evidence and considering all options), it is worth evaluating whether SDM has made a difference in the care provided to patients with musculoskeletal disorders, particularly a difference in clinical outcomes. The purpose of this blog is to evaluate the current evidence on SDM for individuals with musculoskeletal disorders.

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Author:

Seth Peterson, PT, DPT, OCS, FAAOMPT

The Motive Physical Therapy Specialists

Oro Valley, AZ

We learn from our failures more than our success. In other times, we learn from our “almost failures.” These close-calls are the best events to learn from, really, because they can carry almost the same weight as a failure without the tragic consequences. Police officers hint at their knowledge of this fact every time they let you go without a ticket. There is a hill on my way to work that I always brake while going down, 8 years later; It is a location where I got off with a ‘warning’.

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Author: Chad Cook PT, PhD, FAPTA

Physical therapists commonly compare two or more things to one another. For example, I’ve frequently heard the comparison of the diagnostic accuracy of one test to another, when defending or rejecting the use of a special test. I’ve also heard the reporting that one intervention is more effective compared to another; in most cases, incorrectly. Sometimes these judgments are not apples-to-apples comparisons and markedly depend on the context and type of the compared group. If you indulge me, I’ll give a non-physical therapy-related example to reinforce my point better.

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Author: Dr Angela Cadogan, PhD, NZRPS, Specialist Physiotherapist (MSK)

Musculoskeletal physiotherapists have a therapeutic ‘bag of tricks’ that includes a range of interventions such as advice, pain science education, acupuncture, exercise and manual therapy to name a few. What turns a ‘trick’ into an effective ‘treatment’ is its application within a biopsychosocial framework, guided by clinical reasoning, informed by evidence within a person-centered, shared decision-making model of care.

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Preface

         I have grown to despise systematic reviews/meta-analyses. I do not like writing them, I do not enjoy reading them (any more than I enjoy reading an instructional manual), and I especially hate explaining to people why they have so many limitations. I feel lazy and uninspired when I participate in systematic reviews. I hate that journals clamber to publish them, even papers with notable flaws. I was an author on a systematic review that included zero papers [1]; which I would argue is one of my better reviews. It disappoints me when people on social media assume that a review is biblical and fawn upon findings that support their biases or interests.

I do not like them. My goal in this blog is to explain why I loathe them so much.

Chad E Cook PT, PhD, FAPTA

Twitter @chadcookpt

Professor, Department of Orthopaedics, Duke University, Durham, NC. 27516

Competing interests: A portion of Dr Cook’s salary is funded by the NIH/VA/DoD and the Center of Excellence in Manual and Manipulative Therapy at Duke University.

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In an editorial titled “Science or Cult?” published in PTJ in 1963, Hislop stated, “Observations are the principal data of clinical science. Sometimes observations are inaccurate and faulty. Inferences and concepts can arise from such observations which also may be indefinite and confused. For persons not well grounded in scientific thought and procedure, this kind of muddled thinking can result in the indefensible error of offering explanation and rationalization of undocumented and unproved theory.”¹

• What are our diagnostic paradigms?
• Are diagnostic paradigms based on scientific thought and procedure?
• Are we rationalizing the use of unproven theories in the diagnosis of musculoskeletal disorders?

Sean P. Riley, PT, DPT, ScD

Twitter @seanrileypt

Assistant Professor, Doctor of Physical Therapy Program, University of Hartford, West Hartford, CT. 06117

Competing interests: Center of Excellence in Manual and Manipulative Therapy at Duke University.

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Learners of manual therapy (MT) are required to develop complex hands-on clinical skills underpinned by clinical reasoning, manual/physical assessments and palpation [1]. While much of focus in MT has been either on its effectiveness and/or mechanisms, not much attention has been given to how MT is being taught. Hence, it may be timely to think how to best teach MT as it is more than just techniques.

Dr Kesava Kovanur Sampath, PhD, M.Ost, BPT 

Twitter @kesavasampath 

Senior Academic Staff Member (Physiotherapy Program), Centre for Health and Social Practice, Waikato Institute of Technology, Hamilton, New Zealand. 

Competing interests: part of the Leadership Group, Center of Excellence in Manual and Manipulative Therapy at Duke University.  

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