On this episode of the #AskMikeReinold show we talk about what to do when physical therapy interventions have little to no evidence showing they are effective. This is actually pretty common, here’s how we decide what to do when there is limited evidence. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 185: Using Physical Therapy Interventions with No Evidence of Efficacy
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Mike Reinold: On this episode of the Ask Mike Reinold Show, we talk about how we choose some of the PT interventions that we do when there isn’t enough scientific evidence available.
Mike Reinold: Trey, are you the question asker today?
Trey: I am.
Mike Reinold: Fantastic. What do we got today? Trey?
Trey: David from San Francisco. How do you determine which PT interventions you perform when there’s little to no evidence available?
Mike Reinold: Ooh, good question. That’s a big one. Yeah, and it’s funny like I kind of got the sense reading the question a little bit too. You know, this is one of the biggest things I’m seeing on social media right now. It’s not the post, it’s the reactions to the post on how confused everybody is.
Mike Reinold: Well, so how do you choose what interventions you do when we don’t have evidence of it. So I’ll start off by by saying a lot of people do have this quest to only do things that have strict evidence-based validity, right? So something that has been shown in a research project to be, you know, valid for example. And everybody has the quest to do that. And I think that’s like a great quest, right? That you should try to do that all the time. But I think the reality of it, especially in our field, especially in healthcare, especially with the way our clinical trials work, it’s nearly impossible to do a well controlled study on the majority of things we do. So even though like we’re trying and we’re doing our best with research, it’s really hard to conduct these studies. So you know, oftentimes we’re faced with things where maybe it’s a new technique or an intervention that people are talking about on the internet or maybe it’s something that’s old but we still haven’t validated in there.
Mike Reinold: How do we decide what we do and don’t use in our clinical practice? Who wants to start?
Dave Tilley: I was just giving a broad overview in saying I’ve always tried to approach it at like 85% of what I’m doing in clinic is what’s available up to this point. Evidence based research from mentors of mine or things I’m reading or good RCTs or whatever, and then 15% you want to be somewhat creative and innovative and have new ideas in mind. Like I remember when blood flow was first coming, becoming popular. I didn’t really know a lot about it, but I knew I wanted at least like try a little bit on myself and like play around a couple of patients who were like pretty safe. And then from there the research flows then you’ll get that becomes part of your 85% as a research gets better, but you definitely should be investing almost all of your time and things we know that are pretty solid scientifically.
Mike Reinold: Right. So 85% of your time, but I’m going to say 85% of what you do is probably not validated through science.
Dave Tilley: Yeah. Well I guess theoretically I would say it’s not like an RCT, and a couple of blind controls, but at least like the sciences, like the histology studies are there, the rat models are there, that something is available that helps you out.
Mike Reinold: I’ll give you that because that is how we determine a lot of like what we do is it’s, but people are going to argue that that’s not scientific.
Dave Tilley: Definitely better than just swinging it.
Mike Reinold: Exactly. So, so I think that’s a good start is like a lot of what do, and like a lot of our protocols that we write for after a surgical procedure are based on some of the understanding of, of tissue, right? And understanding of physiology and how things heal.
Mike Reinold: So we may not know that this is effective at that, but then we have a theory based on some of our basic science that does it. So I actually think that that’s a good approach. A lot of people are going to argue that that’s not valid though. The social media people that are ‘nope there isn’t a trial that says that’s good,’ even if you maybe have like a basic science theory as to why.
Dave Tilley: Yep, And I would say that if you, if you get really honest with yourself and you’re examining what you’re doing and how much like elite level evidence there is, you’re going to have very little to do in the clinic.
Mike Reinold: And I think that’s the main point here. So Dave I think has a great first strategy right there is if we don’t have pure evidence on it, then we base it as much as we can on our, on theories based on what we understand is the basic science, right?
Mike Reinold: So that’s a good first strategy, right there is is we do our best understanding things. That’s why like we do EMG studies, right? And a lot of people critique EMG studies, you know, for various reasons and rightfully so to an extent. But again it’s like we’re never going to know if exercise A is the best exercise for this intervention, right. But we base it on as much sound scientific principles as we can. Dan.
Dan Pope: Yeah, I was just going to say that it would help if who was asking the question?
Dan Pope: David gave us some better information about the specific person from or you know, what kind of intervention their trying, and I can definitely see this. I work with so many fitness people and a lot of times I get jealous of like let’s say baseball players or maybe even runners.
Dan Pope: There’s quite a bit of research on how to treat those problems. You know.
Mike Reinold: Right.
Dan Pope: If I have someone who has like impingement, rotator cuff tendinopathy and all the available evidence is in six year old individuals that don’t do any sort of fitness activity and I got like a 23 year old that wants to like bench press 400 pounds, it’s very challenging. Right?
Mike Reinold: Right.
Dan Pope: And there’s no research out there about people who want to bench press 400 pounds. You know that have shoulder impingement, there is some, some research there, but very, very little. That becomes very challenging. And one of the things I borrowed a lot from you guys is that there is some available evidence for baseball players. You guys have done a lot of that and we can extrapolate a little bit from other populations that are kind of athletic, right?
Mike Reinold: Right.
Dan Pope: So a lot of what I do is take prior research study, so one good example is patellofemoral pain syndrome and runners, right?
Dan Pope: Or let’s say like field sport athletes. I apply a lot of those principles of rehab to my athletes who are squatting. They’re not running, but they have patellofemoral pain from squatting. So we can extrapolate at least a little bit from that perspective. You know.
Mike Reinold: I like that.
Dan Pope: Yeah.
Mike Reinold: So, so taking the basic science right and then maybe taking a similar population or a similar pathology or something. I think these are good strategies, right? Cause again, I think a lot of the students and new grads are saying like, well I want to know if this exercise is good for shoulder impingement in this person. Right. And I think this is, you know, Dan taking like maybe from other sources or from other pathologies and applying that, right? Like if we have a study on tendinopathy in the knee, right? Maybe we can apply that to tendinopathy in the shoulder for example without having a definitive study. Right. Who else? Anyone else want to ..
Dave Tilley: I kind of want to hear what Mike says. Sorry go ahead. But he’s like brand new out of school. So I feel like he’s…
Lenny Macrina: There’s so many variables to try to consider.
Mike Reinold: A few years.
Lenny Macrina: and there’s so many. When you do it, you sit, sit down and try to do a research study. Right? Let’s just go basic. So Mike and I have done a bunch of research on, especially baseball, but various topics and when you’re trying to cope with inclusion criteria and exclusion criteria and all the variables that could be affecting the independent and dependent variables, nearly impossible to control for everything.
Mike Reinold: Yeah.
Lenny Macrina: So if you’re trying to conduct basic research and try and extrapolate that to people who have emotions and stresses and everything else, we throw everything out the window, you just, you got to, you got to be able to interpret it and then you throw it at the wall and see what sticks, with your patient population. And if it works, great. I think it just comes down to movement and education and being good to people. I think that usually is going to hit 99% of,
Mike Reinold: there it is.
Lenny Macrina: Get them moving, get them moving.
Lenny Macrina: Being good to people. Get them moving comfortably and then, and then educating on why we think that that helped and how they have hope.
Dave Tilley: Mike graduated last week so.
Mike Reinold: Mike’s been a therapist for several years now, but Mike any thoughts and now that Dave’s thrown into the fire.
Dave Tilley: It’d be interested,
Mike Scaduto: No, I mean if I’m, if I’m considering a new intervention and I don’t have the years of clinical experience, I only have like a week or two to go back on. So I guess I look at it, like, is there a major safety concern? So something like is there going to be like an ethical issue if I use this on my patient, if not, I’ll go to the best available evidence. Just kind of look at what evidence is there, how we can utilize it and if there is limited evidence then you have to go based on the experience that you have, or you have to consult with somebody and ask their opinion on it, who has more clinical experience.
Mike Scaduto: So for blood flow restriction for example, which is relatively new and a couple of years old in the literature and yes we’ve been using clinically, we’ve been using it for a little while and that kind of like asked you guys like what what your opinion on it is like what some of the signs you kind of take a step back. So I think it doesn’t have to necessarily be one study that says ‘this is the best intervention for X’ and you can use a couple of different resources to kind of like form your opinion on it and then you can try it and form your own experience with that modality if it’s modality and you can see if it works for your population.
Mike Reinold: I think that’s great.
Mike Reinold: I think it’s a great approach, too, because I don’t know how else you do it. I mean there’s, there’s so much gray out there. So I go, I always call it like the light system. I call it like a red light system, right? But essentially like if there’s a, if there is a trial that shows that you what you want to do is ineffective and it shows ineffective, not lack of conclusion but ineffective, then you shouldn’t do it. There’s a trial that shows that it is effective, then you should do it, but 85% using Dave’s number something. It’s all going to be in the middle and you’re going to have to like play with that a little bit. But one thing I want to caution everybody, maybe we’ll end the episode on this. One thing I want to caution you on is that a lack of a conclusion does not show in effectiveness and I think that’s one of the things that we’re struggling with right now, especially on social media because I’m not kidding.
Mike Reinold: We’re seeing things like systematic reviews that show that like manual therapy doesn’t work for shoulder pain, but what does that mean? Right? How do you define manual therapy? Who did the manual therapy? What type of manual therapy, were they all the same experienced person? Was this like this? You combine all these studies on manual therapy, but how do you define that and then how do you define shoulder pain, and then what was the diagnosis? The right patient population? I just wrote an article, I think it was the impingement article, but I did a system that showed a systematic review. I think that the patient population range from 25 to 68 that’s absurd. That’s absurd. So of course the conclusion is is going to be, it’s inconclusive that they couldn’t find anything. It’s so diluted of a study, that you’re not going to find any.
Mike Reinold: So a lack of a conclusion. Right. So inclusiveness does not mean it’s ineffective.
Mike Reinold: And I think that is where the majority of young clinicians are struggling the most right now is that they’re getting confused by a systematic review or a meta analysis or whatever that may show that there was a lack of findings and then they’re saying then it must not be effective. That’s not what that study says. It either didn’t have the right power, it didn’t have enough control or it’s too diverse of a patient population for the subjects in that study. Right? I mean, but I mean like you guys agree, right?
Dan Pope: Yeah, it makes sense.
Mike Reinold: I mean, so we’re seeing that quite a bit and then people are saying, well manual therapy doesn’t work for shoulder pain and whoa, there’s like lots of complications in that. So I’m not saying you know, pro manual therapy or anything. I’m just saying that studies like that are not helpful and a lot of people are taking that to the wrong endpoint. If that makes sense. So keep that in mind and I think that’s what you do. You do your best. Mike I think laid it out really well. Everybody has some good stuff. Dan, you want to add to that?
Dan Pope: One thing I will say, and I know we don’t want to drone on for too long, but I think when people are so evidence-based, they stop critically thinking. And the problem is that we got to use our brains to figure out why this person got hurt. And you can also use your brain to figure out how to get better based on the principles you know, as a therapist, and when you’re always looking at literature and you’re not doing anything that’s not evidence based, I think we lack the ability to use our brains to that point. We’re not actually utilizing all of our critical reasoning skills to get that person better. When you know, evidence helps with that process, it shouldn’t hinder you.
Mike Reinold: Yeah. Evidence has to drive us, but you also can’t be paralyzed by a lack of evidence. I think that’s like the biggest take home. So, awesome. So great episode. Another good question. I think a lot of people have that question. And I think that’s a pretty common thing. So good one. We really appreciate it, David, right David? We appreciate that one. If you have a question like that, you can head to mikereinold.com click on the podcast link and fill out the form to ask us more questions and we will try to answer it on a future episode.