Evidence-Based Practice

Two years ago, I started having a neck problem that required physical therapy. My doctor sent me to a practice owned by one of his colleagues. I was treated by a licensed physical therapist.

I promise this relates to dog training. Bear with me.

The physical therapist took my history. She didn’t measure anything. She suggested a short set of exercises, heat treatment, massage, and treatment with a T.E.N.S. unit. My appointments lasted about 45 minutes. I went three days a week.

Each time I went, the therapist would ask me if I had experienced improvement. I would say none or “Maybe a little.” I wanted there to be improvement and kept trying to believe it was happening, but it didn’t seem to be there. She was disappointed and acted perplexed. She subtly pressured me to say I was doing better.

She added another treatment. This was called the Graston technique, where the therapist “breaks up muscle tissue” with a stainless steel tool. She said I probably had adhesions that needed to be broken up. At the time, I also had a transient problem with my elbow, so she did the Graston technique on my forearm as well as on my shoulder muscles near my neck.

The Graston technique hurt and left bruises. At first, the pain of the treatment and the bruises made me feel we were “doing something.” I could feel and see the effects. Unfortunately, my neck didn’t particularly improve. And having bruises all up and down my forearm didn’t fix my elbow.

I looked up the research on the Graston technique and it turns out the evidence for it is thin to nonexistent. The review study found its results to be no better than placebo. I started to have doubts.

One day at the beginning of the third week, I asked the therapist if she could not measure something, anything, about my neck. Could she not measure range of motion so we would be able to judge whether there was progress? She said, “Well, that’s kind of hard…..” Her voice trailed off.

That was it for me. This just couldn’t be right. My subjective responses shouldn’t have to be the only measure of progress for something that seemed so…measurable.

I went back to my doctor and asked for a different referral. I asked him to find me the most hard-ass, science-based PT in my area. He did. I went to a different practice.

Evidence!

At the beginning of my first visit, the physical therapist used an instrument called a CROM: cervical range of motion instrument. (That’s cervical as in neck.) Well, well. Something relevant to my condition can be measured after all! The CROM was patented in the 1980s and experimentally verified in 1990 as a superior method for measuring neck range of motion, so it’s not new on the block. It’s an instrument in the inclinometer family.

CROM: a cervical range of motion instrument that is part of science-based physical therapy

He measured and recorded the range of motion of my neck on three axes before we did anything else. I didn’t ask him to do this. Measurement was the natural first step of a data-driven approach. He told me how much range of motion I had, in degrees, in the axis I was concerned about (side to side). He told me how my results deviated from what was normal for my age. He talked to me about my neck condition and described which muscles I would need to strengthen to alleviate the problem that had developed.

The difference in approach was immediately obvious. I told him about my previous experience. He asked what exercises they had me do and I told him. He said a couple were okay but one of them was specifically contraindicated for my condition and told me why. I told him about the heat treatment. He mentioned that the inappropriate use of heat actually helped keep him in business—it often created problems rather than resolving them.

I didn’t bring up their use of the T.E.N.S. unit, but I have noticed subsequently that in all the times I have gone to the new practice to exercise, I have seen the therapist use T.E.N.S. on only a couple patients. The other practice appeared to use it across the board for everyone. That told me something, too. (Among other things, T.E.N.S. is a billable procedure for many conditions; all the therapist has to do is say it is warranted.)

My sessions at the new practice were completely different. Instead of lying there getting heat, shock, or stainless steel instruments ground into me, I had about 40 minutes of exercises to do, then a cooldown. I was advised to never, ever continue exercising if it hurt. Fatigue was okay; pain was not.

After I finished the allotted sessions my insurance covered, the physical therapist got out the CROM and measured the range of motion in my neck. I had gained 12 degrees of rotation on the affected side. The range of motion was now close to normal for my age. I also gained a 20% improvement in side bending (moving the ear towards the shoulder) on the other side. And my overall neck strength rose from 3/5 to 4/5 on the Muscle Strength Scale.

But this wasn’t the end of my treatment. He explained that it could take more than a year to build the musculature I needed to gain to maintain the joints and get all the range of motion my body was capable of. I had exercises I could do at home, and I joined the “graduate program” at the practice so I could continue to use the gym.

We See This in Dog Training

The difference between the first practice I went to and the second was a difference we also see in the dog training world. The first practice was doing what my friend Debbie calls “throwing sh*t against the wall to see what sticks.” They had a set bag of tricks, most of them passive and palliative for the patient. They offered no way of measuring progress, and no explanation of my physical problem and how it would need to be addressed long term. I was pressured to report improvement. Most of what they used on me was ineffective; some techniques could have been harmful.

There was also no plan beyond the sessions paid for by my insurance. No one sat down and told me that you couldn’t really fix my problem in a few weeks. They implied that it could. This was the medical equivalent of offering a quick fix.

I think I’m a moderately savvy medical consumer. I ask questions. I look up academic research, not to second-guess my doctors, but to know what questions to ask. But like most others without graduate degrees in the life sciences, in the end, I have to put myself at the mercy of the professionals. I had deliberately asked for a referral to a physical therapist rather than a chiropractor, hoping to avoid the “woo” factor. But woo was what I got.

I stayed there as long as I did because my doctor had sent me. There is reasonable deference to authority, but there are also cognitive biases in our responses to authority. I don’t know where I fell along that line. My doctor had a good history of evidence-based practice with me, so I trusted him over what I was witnessing for longer than I might have otherwise. (It turns out that he, in turn, had trusted his colleague, and didn’t himself have direct experience of this clinic.)

But I knew evidence-based practice when I encountered it. At the second practice, I received measured results of the treatment I got. I got knowledgeable answers to my questions. I was told of the limitations of treatment, and I didn’t get any false promises of quick cures. I found out that a lot of the success of treatment was up to my own behavior change (sound familiar?). No shortcuts. And basically, no B.S.

Consumers who are seeking help with their dogs should be so lucky.

Transparency and Regulation

That first practice exists and is thriving even though the world of human medicine is highly regulated. The first therapist had the proper degree and credentials for her vocation. She is required, as are all PTs in my state, to participate in continuing education. But she, perhaps reflecting the ethos of the practice she worked for, was throwing sh*t against the wall. (All highly billable.)

Dog trainers and behavior consultants have no such professional requirements in the United States, except through credentialing bodies that some may voluntarily join. Nothing is mandated at the state or federal level in the U.S for dog trainers, even though they are advising you how to live with a carnivore that can hurt or kill you.

So if the first physical therapy practice can exist in a highly regulated industry and “take in” a fairly educated consumer for a few weeks, think what can happen when such a consumer falls into the hands of an uneducated dog trainer? Their profession is subject to no required education and no effective oversight. There is no requirement of transparency. With my medical situation, I was able to go back to my doctor to ask questions and get another referral. I knew enough to know something was wrong, though it took three weeks. How long does it take people to realize something is wrong with a dog trainer who is peddling platitudes and shortcuts? And to whom do they turn for an alternative?

Most consumers who are trying to find a dog trainer don’t have a true authority who can help them choose. Behavior science is even more of a mystery to most people than a lot of medical practices. Without regulation or at least transparency in the dog training and behavior consulting world, both woo and cruelty will continue to flourish.

References

Cheatham, S. W., Lee, M., Cain, M., & Baker, R. (2016). The efficacy of instrument-assisted soft tissue mobilization: a systematic review. The Journal of the Canadian Chiropractic Association60(3), 200.

Crothers, A. L., French, S. D., Hebert, J. J., & Walker, B. F. (2016). Spinal manipulative therapy, Graston technique® and placebo for non-specific thoracic spine pain: a randomised controlled trial. Chiropractic & manual therapies24(1), 16.

Copyright 2019 Eileen Anderson

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8 Responses to Evidence-Based Practice

  1. marjieal says:

    aaaaaaMEN, sister!

  2. Debbie Lustig says:

    I am going to look into my physiotherapist’s approach! (I also have neck pain.) These people need to be accountable, and use measureable processes! THANK YOU!

  3. Pingback: Evidence-Based Practice — eileenanddogs – The Two Of Us

  4. Thanks for this. I think a lot of people don’t even know that evidence based approaches to dog training are a thing. So it’s important to keep putting info like this out there.

  5. I have been puzzling over data to collect at first sessions of training classes. I do videoing of last sessions, but initial groups tend to be chaotic and not very together and since I am meeting/signing in, checking vaccinations it’s hard to video.

    Unlike your ROM and strength…in dog training I’m looking at two distinct organisms that are supposed to be cooperatively functioning and communicating.

    Is it the handler’s understanding/capability or the dog’s. Is it the practiced items or the ability to deal with new stuff? Based on my observations ( and a couple of studies I read), handlers aren’t very good at translating/generalizing in a somewhat new situation (neither are dogs). And each partner (handler/dog) tends to revert to older patterns when surprised or when in new surroundings. Handlers grossly overestimate their dog’s understanding and capabilities to function in new and distracting surroundings and underestimate the dog’s capabilities to advance in known surroundings. The need to go to lots of new locations is avoided or deemed not important enough to expend the required time/energy to do. Predicting their dog’s patterns is a foreign idea, even when patterns are obvious and coaching has been provided.

    Just like you experienced with the first PT, handlers tend to like to use certain procedures over and over whether they are appropriate or not, whether they cause undesirable side-effects and despite the lack of improvements. The evidence base is non-punitive and largely non-aversive training, most people are comfortable with quite a bit of punitive approaches.

    I wonder why your M.D. chose the first referral for you? Did the prior patients like the amount of clinical equipment used? T.E.N.S., heat & bruising? … Just like so many people like new tech marketed to control dogs?

    Perhaps it is the observable ‘connection’ that I’m wanting to measure.

    • Eileen Anderson says:

      Thank you for your thoughtful and interesting comment, and sorry for my terrible delay.

      Fascinating observations about how we revert to patterns, and how hard it is to step out and observe/work with the actual dog.

      My doctor sent me to the first practice because it had recently been opened by a colleague he trusted. I may have been the first one to give feedback. On the other hand, I do think many people tend not to complain when they get a combination of passive palliative care and discomfort. It’s easier than doing exercises….

      Eileen

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