It's Not Just Consumers Who Must Think Differently About Pain
by Steven Z. George, PT, PhD
The United States is in the midst of a costly and deadly opioid epidemic. There are no easy answers to this problem, but physical therapists could be a big part of the solution. Physical therapy's potential for effective pain management has already been recognized by a Centers for Disease Control and Prevention (CDC) initiative indicating that physical therapy should be a front line option for patients with chronic pain conditions. In response, APTA initiated the #ChoosePT campaign to let patients and providers know that physical therapists are a viable early option for pain management.
These are exciting developments, and they bring new opportunities and challenges to our profession. The opportunity is clear: a move away from widespread opioid use could allow more patients with pain to benefit from physical therapy, which offers pain relief that is effective and does not carry the risks associated with opioid use.
The challenge is that if our profession is to become more adept at pain management, we will need to think and act differently about pain. In particular, physical therapists must be willing to change theories and clinical practices that have persisted despite their lack of evidence as being part of an effective pain management strategy.
When I delivered the Maley Lecture at the 2016 NEXT Conference & Exposition, I warned against “silver bullet” treatments – sometimes involving special training, techniques, or equipment – that focus on complete relief of chronic pain. Not only do these approaches risk giving patients unrealistic expectations, they also fail to deliver when tested rigorously in clinical settings, and we end up offering nothing new or improved to our patients.
Physical therapists are uniquely situated in most health care systems to exert considerable leverage for improving acute and chronic pain management. However, to have the largest impact there must be a revolutionary change in our education and practice. Physical therapists must also consider that our biomechanical tendencies are not always well aligned with progressive pain management.
Most immediately, physical therapists must acknowledge that pain is a complex, individual experience, and pain can be affected by many factors in a person's life. In my lecture, I explored the pain experience of someone getting a tattoo to illustrate the profound influence of context on pain ratings.
We know that physical therapy is a safer choice than long-term opioid therapy. But for physical therapist treatment to be solidified as an effective first choice for pain management, we need to ensure that clinical behaviors align with a nuanced understanding of the pain experience.
We need a pain management revolution.
Steven Z. George, PT, PhD, is director of clinical research, Department of Orthopaedics, and director of musculoskeletal research, Duke University Clinical Research Institute. For more of George's perspectives on pain management, watch the video from NEXT 2016's Rothstein Roundtable, "Opioids Versus Physical Therapy: Should Physical Therapy Be the First Choice for Pain Management?"
Cupping: Why We're All Seeing Spots
By Daniel Cobian, PT, DPT, PhD, and Bryan Heiderscheit, PT, PhD
At the 2016 Summer Olympics, Michael Phelps added to the collection of medals that make him "the most decorated Olympian of all time." But the medallions hanging around his neck weren't the only "decorations" that generated attention. The media and public also became fascinated by the tennis ball-sized red circles on his upper back and shoulders.
These welts are the result of cupping, a technique dating back to ancient Greece (making it an appropriate topic during the Olympics) that is common practice in traditional Chinese medicine.1 Dry cupping involves the use of negative pressure to create a suctioning effect without any skin perforation.2 Wet cupping also uses skin suctioning, but with added superficial skin incisions to induce bleeding.3 Cups typically are left on the skin for 5-20 minutes, creating a circular-shaped ecchymosis, which may last for days or weeks. Increasing the time and/or pressure exacerbates the ecchymosis.2
Thanks to Phelps, an ancient technique seemed new again. And, in a cycle that's all too familiar, viewers became intrigued by some "sanctioned," never-before-seen performance enhancer that gets worldwide exposure on the Olympic stage. In 2000, it was Australian sprinter Cathy Freeman's hooded bodysuit. In 2008, it was multicolored kinesiology tape, the Rorschach-like patterns adorning the bodies of volleyball, basketball, and track athletes. Now in 2016, it's the dark circles evident of recent cupping treatments.
Such things naturally draw our attention. And since the top athletes in the world are using these treatments, credibility is inherent or implied, right?
Not always so.
Injury preventing and performance enhancing approaches that rapidly gain widespread popularity will always outpace scientific research. It takes years to systematically investigate the physiological effects of various stimuli with strong scientific methodology, data collection, and analysis, and determine if these interventions are appropriate, how they should be dosed, and who is most likely to respond.
Despite the long history of cupping therapy, there is a noted lack of published evidence supporting it as a treatment for musculoskeletal conditions or defining the mechanisms by which it may have therapeutic value. The suction created by the cup produces a tensile stress on the skin and underlying tissue, along with compressive forces underneath the rim of the cup. These tensile stresses are thought to cause dilation and rupture of the superficial capillaries, creating the reddish-colored circles.2 This may reduce discomfort in the target tissues by stimulating inhibitory neural pathways.4 In this way, cupping may create a "counter irritation" effect that temporarily increases pressure pain thresholds.5,6 Additionally, altered local metabolic activity may contribute to this effect.7 However, these potential mechanisms of action are speculative and have not been thoroughly investigated.
Recent research published in journals of complementary and alternative medicine report that cupping may be beneficial for low back and neck pain,6,8-10 carpal tunnel syndrome,11 and knee osteoarthritis.12 At face value, these results appear quite promising, but they should be appropriately tempered due to the studies' methodologies.13 In each of these investigations, the comparison group received either no treatment or minimal intervention such as the single application of a heating pad.11 Without a true control group that mimics the potential psychological stimulus of a unique and impressive intervention such as cupping, we cannot differentiate true physiological alterations from placebo effect.14
When hundredths of a second are the difference between gold and silver (Phelps won the 200m butterfly by 0.04 second), athletes are looking for any potential real or perceived advantage and often explore alternative approaches. However, this is not done in lieu of the proven standards. Indeed, Phelps and his teammates are privy to round-the-clock medical attention from a team of sports medicine experts, including physical therapists. Olympic athletes regularly receive care that is well supported by strong scientific and clinical evidence. Evidence-based physical therapist treatment for musculoskeletal shoulder dysfunction involves therapeutic exercise,15,16 manual therapy,17 and movement and postural education.18
It's easy to understand why the media and public became fixated on Phelps' use of cupping—the welts were impossible to ignore. But while cupping is an adjunctive treatment that may, through currently unclear physiological or psychological means, have a short-term effect, we must be cautious that the general population doesn't see cupping as a silver-bullet treatment for musculoskeletal conditions.
Olympic athletes might include cupping as part of their extensive physical and mental maintenance to train and compete at maximum capacity, but an underlying theme of the Choosing Wisely campaign is the benefit of active therapy over passive treatments: www.choosingwisely.org/societies/american-physical-therapy-association/. As physical therapists, we want to maintain our position as evidence-based experts in the restoration, maintenance, and promotion of optimal physical function. To do so we must continue to uphold the value of well-established and rigorously investigated interventions in the face of the latest fascination in sports medicine.
Daniel Cobian, PT, DPT, PhD, and Bryan Heiderscheit, PT, PhD are members of the University of Wisconsin-Madison Department of Orthopedics and Rehabilitation.
- Turk JL, Allen E. Bleeding and cupping. Ann R Coll Surg Engl. 1983;65:128-131.
- Rozenfeld E, Kalichman L. New is the well-forgotten old: The use of dry cupping in musculoskeletal medicine. J Bodyw Mov Ther. 2016;20:173-178.
- Arslan M, Gokgoz N, Dane S. The effect of traditional wet cupping on shoulder pain and neck pain: A pilot study. Complement Ther Clin Pract. 2016;23:30-33.
- Musial F, Michalsen A, Dobos G. Functional chronic pain syndromes and naturopathic treatments: neurobiological foundations. Forsch Komplementmed. 2008;15:97-103.
- Lauche R, Cramer H, Hohmann C, et al. The effect of traditional cupping on pain and mechanical thresholds in patients with chronic nonspecific neck pain: a randomised controlled pilot study. Evid Based Complement Alternat Med. 2012;2012:429718.
- Markowski A, Sanford S, Pikowski J, Fauvell D, Cimino D, Caplan S. A pilot study analyzing the effects of Chinese cupping as an adjunct treatment for patients with subacute low back pain on relieving pain, improving range of motion, and improving function. J Altern Complement Med. 2014;20:113-117.
- Emerich M, Braeunig M, Clement HW, Ludtke R, Huber R. Mode of action of cupping--local metabolism and pain thresholds in neck pain patients and healthy subjects. Complement Ther Med. 2014;22:148-158.
- AlBedah A, Khalil M, Elolemy A, et al. The Use of Wet Cupping for Persistent Nonspecific Low Back Pain: Randomized Controlled Clinical Trial. J Altern Complement Med. 2015;21:504-508.
- Chi LM, Lin LM, Chen CL, Wang SF, Lai HL, Peng TC. The Effectiveness of Cupping Therapy on Relieving Chronic Neck and Shoulder Pain: A Randomized Controlled Trial. Evid Based Complement Alternat Med. 2016;2016:7358918.
- Lauche R, Langhorst J, Dobos GJ, Cramer H. Clinically meaningful differences in pain, disability and quality of life for chronic nonspecific neck pain - a reanalysis of 4 randomized controlled trials of cupping therapy. Complement Ther Med. 2013;21:342-347.
- Michalsen A, Bock S, Ludtke R, et al. Effects of traditional cupping therapy in patients with carpal tunnel syndrome: a randomized controlled trial. J Pain. 2009;10:601-608.
- Teut M, Kaiser S, Ortiz M, et al. Pulsatile dry cupping in patients with osteoarthritis of the knee - a randomized controlled exploratory trial. BMC Complement Altern Med. 2012;12:184.
- Kim JI, Lee MS, Lee DH, Boddy K, Ernst E. Cupping for treating pain: a systematic review. Evid Based Complement Alternat Med. 2011;2011:467014.
- Ernst E. Testing traditional cupping therapy. J Pain. 2009;10:555.
- Haik MN, Alburquerque-Sendin F, Moreira RF, Pires ED, Camargo PR. Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials. Br J Sports Med. 2016.
- Marinko LN, Chacko JM, Dalton D, Chacko CC. The effectiveness of therapeutic exercise for painful shoulder conditions: a meta-analysis. J Shoulder Elbow Surg. 2011;20:1351-1359.
- Camarinos J, Marinko L. Effectiveness of manual physical therapy for painful shoulder conditions: a systematic review. J Man Manip Ther. 2009;17:206-215.
- Lewis J, McCreesh K, Roy JS, Ginn K. Rotator Cuff Tendinopathy: Navigating the Diagnosis-Management Conundrum. J Orthop Sports Phys Ther. 2015;45:923-937.
Confessions of a Tech-Challenged PT: Sweet (Evidence) Dreams Are Made of These
By Stephanie Miller, PT
Want to know how tech-savvy I am? I'll give you a couple of clues. First, let's just say it's been "a few" years since I graduated from PT school. Second, I don't have TV or Internet at my house. So when it comes to technology, I know that I probably have a lot of … catching up to do.
I never wanted my non-techiness to stop me from progressing in my field, though. I didn’t want it to be a barrier. But to be honest, it was.
I’d see a patient with a diagnosis or procedure I hadn’t encountered for a while, and I would want to find the latest information and research on the topic. I’d type a few words into a search engine, cross my fingers, and hope I got something. Either I got no relevant results, or when I finally found a gem of an article it would tease me with the abstract, then take me to a subscription page. (And the worst was when that new page wouldn’t allow me to get back to my original search, no matter how many times I clicked the Back arrow.) To find a full-text article that I didn’t have to sell my soul to get was nearly unheard of. Then, if by some slim chance I did find one, I often wanted to find another article that was referenced within it, only to start the self-defeating process all over again. I found it completely frustrating, and after hours of searching and bouncing around from site to site, I would still come up nearly empty-handed.
I kept wondering, why couldn’t someone come up with an easy-to-use, one-stop shop? Well, they did. It's called PTNow, and, best of all, it's free to APTA members. It has changed my world as a health care professional and I hope that it does the same for you!
I’ll dive deeper into all that this site offers in future blogs. But just to give you a taste, you have access to: various search engines, clinical practice guidelines, free full-text articles from tons of publications (yes, I said free), access to and permission (yes, you read correctly, permission!) to use various tests and tools for patient examination, and clinical summaries. There's a new point-of-care resource called the Rehabilitation Reference Center that delivers need-to-know-now information. And there’s even MyPTNow, a space for you to save searches and clinical collections for future access. But I don’t want to get ahead of myself, and, honestly, I’m still learning all of the new features.
You know as well as I do that our treatments and documentation are being subjected to more and more scrutiny. I can’t see that lessening in the future. To continue to justify that we give the best care (as we know we do), we need the research, tests, and quality measures for support. PTNow is a great, easy-to-use place to find them.
I’m looking forward to bringing you more tips and tricks in the future, as well as learning and growing with you along the way. In the meantime, I challenge you to try out the site until you hear from me again. If you’re intimidated by it, don’t be: there’s a great tutorial video that will walk you through some basics, and there’s even access to a librarian who can assist you with questions along the way.
Take it from me, one of the most un-techy people you'll meet: this is something worth plugging into.
Stephanie Miller is a staff development specialist with Celtic Healthcare.
Explore other posts from the "Narrow the Gap" series.
Sneaky Bias: What You Don't Know May Hurt You (and Your Patients)
By Hadiya Green Guerrero, PT, DPT
"Now that I know better, I do better."
– Maya Angelou
Recently, PT in Motion News reported on a study of 2008-2010 data from the Medical Expenditure Panel Survey-Household Survey that contained a telling conclusion. Study authors Sandstrom and Bruns reported that when it comes to outpatient rehabilitation therapy, their analysis "confirm(s) a reduced likelihood of an office-based therapy visit for Black Americans with arthritis when controlled for income, insurance, and education."
The question we need to be asking ourselves is, why?
As human beings it is unrealistic to think we can rid ourselves of all our biases, but as health care providers it is our duty to provide the utmost care to facilitate maximum outcomes for all patients. As PTs, we know this. And yet, disparities in treatment persist.
For many of us, the first thing that happens when we think about bias is to get defensive. We think about all the things we're not: all those dirty words like "racist," "bigot," "(choose your word)-phobic."
But the reality is that while we may not be any of those ugly words, we all possess biases that impact every interaction we have with our patients. We all have subconscious attitudes that can affect our behaviors. These are called one's implicit biases.
Implicit bias refers to attitudes and beliefs, both positive and negative, that occur outside of our conscious awareness and form a person's evaluations of others.
In some ways, implicit bias is like our fight-or-flight response – something that's triggered almost before we're aware of it. While it's true that these subconscious attitudes exist, they can be recognized, and the subsequent behaviors can be tamed and managed to elicit optimal patient interaction and outcomes.
It's not just health care providers who have implicit bias: it's everywhere – and when these biases meet each other, watch out.
Scene 1: You're a PT who's African American. You walk into the treatment room and introduce yourself to the mother of the nonverbal 3-year-old patient. The mother and patient are members of a white, rural family that homeschools their children. Several siblings are also present in the room.
You start working with the child and talking. You're talking a lot to the child. You're laughing in a forced way. You may even be acting a little silly.
Finally you say to the patient, "You must think I'm just crazy, don't you?"
The patient's 7-year-old brother says, "No, he's probably looking at you like that because you're dirty."
Look at what just happened: The therapist assumed/assessed subconsciously that the white rural family with multiple children who are homeschooled would be uncomfortable with her, so she became overly jovial and self-deprecating. At the same time, the patient's brother, under 8 years of age, associated brown skin with being dirty. The result: the therapeutic relationship suffers, and the mother is embarrassed by her son's offensive comment. Has the patient received the best possible treatment? And how do you think it will progress from here on out?
Of course, sometimes the implicit bias can run in just 1 direction.
Scene 2: Your patient is 6 feet tall with the build of a world-class boxer. His paperwork says his name is Cassius Clay, Jr. He asks you to call him Muhammed. You keep calling him Cassius and apologizing. What's really going on here? I mean, what's really going on inside of you? Maybe you were a victim of identity theft and this name business stirs up feelings of mistrust. Or maybe you have a fear of Muslims based on images or your experiences.
Whatever the underlying reason, your implicit bias or attitude affects the way you treat this patient. You hurriedly get through the session because you know that, ethically speaking, you have to. But really, you just want to be done with it.
Scene 3: Your patient is a 12-year-old girl in the hospital for an unknown metabolic disorder. She calls her mother "Mommy," and you assess that she is cognitively immature. You share your assessment with a colleague during rounds. Your colleague asks where the family is from. Your colleague explains that in some cultures, no matter how old you are, it is considered rude and offensive to call your mother anything but "Mommy." Given the patient's medical disposition and your implicit bias, you may have inappropriately carried out this patient's course of treatment and goals.
There are plenty more examples of implicit attitudes, but the important issue is that we can and should tease these biases out of ourselves, so that we become more aware of how they might be impacting the ways we treat our patients.
One way to begin is with an online test of implicit bias. There are several out there, but Harvard's Implicit Association Test (IAT) is a popular (and eye-opening) one you may want to try.
After that, think about getting training on implicit bias and more general cultural competence. APTA has some resources to get you started on your cultural competence journey – check them out.
In the meantime, in your day-to-day practice, try to ask yourself these questions about every patient you see:
- Did I do all that I would normally do for that condition?
- Did I elicit the patient's personal goals or just what I think they should be? (To do this you have to engage beyond the superficial level.)
- Did I order or recommend all equipment that was necessary, above and beyond, or could I have recommended something and for some reason just ... didn't?
From a big-picture/systems perspective, there are also things we can do to help minimize the effects of implicit bias, or at least make our profession more sensitive to its effects:
- Infuse cultural competence in PT and PTA schools.
- Expose young (elementary school-aged) children to the field of physical therapy as a viable option for a career to promote and facilitate diversity in applicants and students.
- Where possible, standardize personal practice. For example, if you always recommend x-rays for patients who objectively score positively for possible ankle fractures, don't avoid doing it this time just because your patient has Medicaid.
We may never rid ourselves completely of implicit bias, but we can be honest with ourselves and do whatever we can to see to it that our biases aren't making treatment decisions for us. Our patients – all of them – deserve at least that much.
Hadiya Green Guerrero is a senior practice specialist at APTA.
Explore other posts from the "Narrow the Gap" series.
N Marks the Spot: A Few Thoughts on Research With Low Participant Numbers
By Alan Jette, PT, PhD
Is research weak just because it involves a smaller number of subjects?
In the case of experimental investigations, the honest answer is: it depends.
One of the biggest factors has to do with on the type of research question researchers are trying
to answer with the sample. For instance, if researchers are trying to draw inferences on the
likely impact of an experimental intervention on a group of patients, sample size is very
important. If the sample is so small that it reduces the study's ability to detect a statistically
significant difference across study groups if one actually exists (called statistical power), a small
sample is a problem.
Here's an example of how problems can arise. Let's say we're presented with an investigation
with a small sample size, and this investigation does not detect a statistically significant
difference between study groups (ie, inability to reject the null hypothesis). It becomes difficult if
not impossible to infer the reason for the lack of difference: is it because no difference actually
exists, or is reduced statistical power keeping us from detecting one? In this case, we're looking
at an underpowered experiment that is not interpretable.
But that doesn't mean we should disregard all investigations with small subject numbers. Again,
it's a good idea to look at what question is being investigated. For instance, in pilot studies,
where the focus is on establishing the feasibility and safety of conducting a particular
experimental intervention, a small sample is perfectly acceptable. In fact, one might argue that
the smaller size is preferable to establish safety and feasibility before launching a fully powered
So the next time you look at research involving a small number of subjects, don't judge a paper
by its N. Dig a little deeper and find out what the researchers were aiming to do, and remember
that, sometimes, good experiments come in small packages.
Explore other posts from the "Narrow the Gap" series
Ready to Narrow the Gap?
This summer APTA launches "Narrow the Gap," a new educational series that will explore the divide between evidence and actual practice behaviors in the clinic.
Let's be clear: There is not a single gap; there are many, in all different widths. They can occur among any of the pillars associated with evidence-based practice—the application of research, consideration of patient values and circumstances, and the clinician's own expertise and experience. They may come and go, and you might not even be aware of a gap at all.
But this much is certain—every PT, PTA, and student is faced with situations in which there's a space between what's “out there” and what the practitioner is actually doing (or would do) to improve patient outcomes.
Take scientific research. The widely accepted idea is that there's a certain lag time between the establishment of a research-based practice recommendation and the actual widespread adoption of that recommendation—some say as much as a 17-year delay. What can we do to decrease that gap?
Or what about the gaps that might exist between the guidelines we read about and the daily realities of the unique people seeking our care? Are we recognizing—or even capable of recognizing—and fully using the information they're giving us, both in their records and by way of their own personalities, cultures, and stories?
And what about clinicians' understanding of the evidence right under their noses—the personal biases, competencies, skills, and deficits that should be informing practice?
"Narrow the Gap" can't supply all the answers. But we hope that through a set of diverse author voices, we can help raise awareness, encourage self-reflection, and start a dialogue.
So stay tuned, and don't be shy about adding your voice to the mix.
Coming up tomorrow: Are small subject numbers always a sign of weak research? PTJ Editor-in-Chief Alan Jette, PT, PhD, provides his take.
Moving Toward Arthritis Pain Relief
By Julie Keysor, PT, PhD
More than 50 million Americans have been diagnosed with arthritis.
That's a massive patient population, but that isn't the only reason it can be a difficult population to treat. When pain gets in the way of daily living, encouraging people with arthritis to improve their health through movement and exercise can be a challenge.
Arthritis steals movement and sometimes the things we love to do-but we can help our patients get it back. Exercise is one of the best ways to improve pain, stiffness, and decreased range of motion, which are common symptoms of arthritis. Many people with arthritis think exercise will be painful-probably because they've tried and it was! But extensive research has shown that people with arthritis can exercise without worsening their pain!
And as we come to the end of National Arthritis Awareness Month, it's a good opportunity for physical therapists to remember that we don't need to rely solely on our one-on-one time with patients to improve their quality of life.
The Centers for Disease Control and Prevention (CDC), with APTA support, created resources to help clinicians find community-based physical activity programs to help people manage their arthritis and other related chronic conditions outside a therapeutic setting. You can find those on the APTA website: http://www.apta.org/Arthritis/
Meanwhile, APTA offers extensive information for the public at MoveForwardPT.com's Health Center for Arthritis.
Let's finish May by making a difference in the lives of our patients and clients by helping them change their behavior, allowing them to improve their pain and quality of life through movement. After all, movement is great medicine.