I recently saw that the APTA is joining forces with a plethora of national medical associations in the “Choosing Wisely” initiative and is among the first 3 non-physician organizations to do so. You can see the announcement here (http://www.apta.org/PTinMotion/NewsNow/2014/5/1/ChoosingWiselyABIMAnnouncement/). A current list of medical practitioner behaviors/medical procedures to avoid can be seen here (http://www.choosingwisely.org/wp-content/uploads/2013/02/Choosing-Wisely-Master-List.pdf). The list is quite expansive. Interestingly, early imaging for low back pain made the top five list for several different organizations, yet many of us in the clinical trenches see that this is not the norm for best practice despite the clinical practice guidelines established by Chou et al (http://www.ncbi.nlm.nih.gov/pubmed/21282698) and Delitto et al (http://www.ncbi.nlm.nih.gov/pubmed/22466247).
I am thrilled to see the APTA pursuing this initiative and look forward to seeing the top 5 questioned procedures that will be added to the current list. With the broad spectrum and scope of PT practice, I feel as though there may be a top 5 list for every specialty in PT. Below are my top 5 unnecessary PT behaviors in the musculoskeletal pain/orthopedic population:
1. Utilizing a strict patho-anatomical/biomechanical explanation for the output result of pain.
· Given best evidence on modern pain literature, we know that pain is not always the result of tissue damage, especially in those with chronic pain. It is time we start realizing what a pain neuromatrix consists of and that pain is an OUTPUT from the brain. For more info, see Joe Brence’s solid write-up here: (http://forwardthinkingpt.com/2014/04/14/the-top-9-things-you-should-know-about-pain/)
2. Assessing for pelvic landmarks, innominate rotation/flares, upslips.
· Let’s be honest here, the literature is clear that the movement that does occur at the SI joint and pelvis is extremely difficult to reliably assess, yielding poor validity. Treatments targeting this region may be effective in some patients, but maybe we should rethink if our treatment intent is really doing what we think. Furthermore, our language when treating this region is less than optimal—see number one again.
3. Utilizing special tests with poor value in clinical decision-making.
I I used to love special testing, utilizing them often without thought. Within a sound clinical reasoning model, one must always be asking if exam techniques are 1—helping guide hypothesis development and 2—helping guide your treatment. After all, that is what the patient is seeing us for—they can careless if they have a positive Speeds test, they just want to feel better. So I encourage folks to think about the utility of special tests in this regard, as there can be some harm in this (think of false positive testing and then unnecessary imaging and what usually follows this)! I see this specifically with shoulder labrum testing (See Chad Cook’s review here http://www.ncbi.nlm.nih.gov/pubmed/22036538), tesing for VBI (Review some of Roger Kerry & Alan Taylor’s work http://www.jospt.org/doi/abs/10.2519/jospt.2009.2926#.U2l_EV6UA3g), and DVT (Homan’s sing—for real??).
4. Not acknowledging confirmation bias yielding a skewed establishment of clinical experience.
Mark Jones, in his 1992 commentary (http://ptjournal.apta.org/content/72/12/875.abstract) on clinical reasoning states that confirmation bias is when “…therapists only attend to those features that support their favorite hypotheses while neglecting the negating features. This can lead to incorrect clinical decisions and hinder the therapist's opportunity to learn different variations of clinical patterns.” Think of your favorite hypothesis/thing/region to treat—how often is this popping up in your thought process. I suffered from this error in reasoning and consistently work to avoid this pitfall in clinical practice.
5. Creating a dependent relationship through suboptimal communication strategies creating a provider of need vs. a provider of choice.
· Watch your mouth and body language! See a previous post here (http://www.pthaven.com/news_article/show/272937?referrer_id=735427-articles) that I wrote last year. Remember patients are always listening—let’s think of those words that harm and heal and those that make patient’s reliant on passive treatments/roles vs. creating an empowered patient taking an active role in their recovery.
I am sure the list could go on—what would you put in your top 5?
Dr. Shepherd is a clinician and clinical educator. He practices in the outpatient orthopedic patient population at Johns Hopkins Hospital where he also serves as clinical faculty for the Johns Hopkins/George Washington University Orthopedic Residency Program. He also is adjunct faculty for Evidence in Motion’s Residency and Fellowship programs where he leads regional management courses as well as mentors fellows in training. Dr. Shepherd is also faculty for EIM's new DPT program. His clinical and research interests include chronic and persistent pain disorders, spinal and extremity manual therapies, clinical outcomes assessment and clinical reasoning in physical therapy.