I am a physical therapist. I am a physical therapist who uses manual therapy. One who uses exercise in many forms. I use pain neuroscience and specific treatments to address persistent pain (PNE, graded motor imagery, graded activity and exposure). I dry needle. I use heat, ice and, hell, sometimes I might use ultrasound. However, the most important clinical “technique” of all: the reasoning on how, when and why I use them.
There seems to be much discussion at times about one technique being better than another. How one PT is the expert in “dry needling” or “thrust manipulation” or “corrective exercise” or “[insert treatment here].”
Our profession naturally has many different treatment techniques, some supported by the literature and some not. Some that PTs are biased towards and some that patient’s expect to have integrated into their treatment approach. At the end of the day, it is our reasoning approach that we should value over the technique itself.
After going through a manual therapy fellowship, I can say that my bias is to use manual therapy. But the one thing that fellowship taught me was how to think through when to use it and when to not use it. As a result, I learned a reasoning model that allows me to use any treatment out there and know if it is providing meaningful change for the patient sitting in front of me.
Where I sometimes get concerned professionally is when I see or hear PTs touting certain techniques as if they solve all of our patient’s problems. We need to look beyond the technique and focus on the reasoning behind the use of that technique. Therefore, I hope those reading this post can appreciate this sentiment and understand this concept and the importance of refining our clinical decision making process–challenging our biases and questioning our outcomes that makes us grow and develop as a professional. We shouldn’t have to feel that we are defined by the techniques that we use in clinic. We should lean on sound clinical reasoning that ultimately trumps any one technique.
@ShepDPT
––– Comments
diana schwahn
Commented • August 17, 2017
I couldn't agree more Mark. The client's best interest must always be the right treatment approach. Thanks for sharing!
Edie Benner
Commented • August 14, 2017
Thank you Mark for posting this! It is so good to hear someone write about the importance of clinical reasoning in our profession and how important it is to not be defined by one technique, or for that matter, one technique with the name of a person attached to it.
Mark Shepherd
Commented • August 13, 2017
Thanks for reading and posing these questions, Matthew. I agree that there seems to be this double edged sword to a use of a given technique--one that you may not be defined by and the other that you my be critiqued and challenged by. I do think the latter is important to help challenge the "why" in what we do. Your questions on drawing the line are worth pondering. I think about this from a perspective of where I have come in my clinical career. I was someone who as a novice PT jumped at the trending thoughts and techniques. This could be manual, exercise based fads, etc. If you asked me, I was an evidence-based practitioner. I could site all the articles to support some type of thing I was doing. What I found through a lot of soul searching, constant reflection on my practice and mentoring through fellowship was that my reasoning process was extremely plagued by confirmation bias and driven by the medical literature vs. informed by the literature. I forced patients to fit my comfort zone vs. responding to them. As I refined my reasoning process by appraising the literature and using a test-treat-retest approach on every technique I did, I found that I had a TON of fluff in what I was doing that quite honestly was not making a bit of change in the patient. I learned that less is more. I type all of this to say that to understand where to draw the lines is to stress to ourselves and our peers to have intellectual honesty with what we are doing. To understand where our confirmation bias might be at play. To question everything and to acknowledge the many effects or confounding elements that can occur within a patient session. This process, for me, has helped me draw the line. You bring up some great insight regarding effectiveness and efficacy and the lack or paucity of such evidence. I think on one hand if we wait too long for the research to come around we will be slow to progress. I get worried when people rely on techniques or an intervention to develop the therapeutic alliance. There are much better ways to do this through effective communication and empathy. I do think there is a slippery slope. Hopefully this makes some sense. Thanks for the questions!
Matthew
Commented • August 13, 2017
Hello Mark. An insightful post you have here and one I think should promote an in depth discussion. I agree, we are not defined by our techniques....but we can be defined, critiqued/challenged by our ideas, thoughts and reasoning. Your post brought up a lot of questions. Where do we draw the line? Where do we draw the line on what is used in the clinic? Where do we draw the line on how far we'll go to justify what we do to people? If the evidence for efficacy and effectiveness is absent or lacking can we ethically justify using an intervention for "therapeutic alliance" or patient preference?" How does one document that? This sounds like a slippery slope to me. If the answer is yes, then I question why we continue performing research, if we are justifying our approach based on the patient's wants. What would it take for our profession to eradicate and discontinue practices without effectiveness and efficacy? Am I cynical to think the incentive to continue these practices (full schedule, pay the bills, meet productivity standards, etc) exceeds the evidence and science (regression to the mean, benign neglect, re-assurance)?
Paul Potter
Commented • August 11, 2017
Mark, technique implies technician when used in isolation. The clinical reasoning behind deciding which technique or tool to use makes all the difference in the world. Patients are human beings, not objects to have something done to them.