During my childhood, I would occasionally ask my mother a question which I can now see was… well… a silly question. Often it was something like, “Where is my other shoe?” She would reply that it was probably where I last placed it. I think that is the reply listed on page 13 of the international mother's manual. When I moaned or whined at that answer she would say, “Ask a silly question, get a silly answer.” That statement was forever imprinted in my brain and I have found myself using it throughout my adulthood.
In the late 70s, I was employed at a Private College in New York. Since I had played field hockey and basketball in college, I was excited to be the coach of the two respective teams at the collegiate level. As such, I attended quite a few coaching clinics and watched sports every weekend. I soon began to hear what I thought were silly answers to appropriate questions. For example, a question often posed to a coach is, “What does your team have to do to win?” Following are a few of the answers I have heard, and continue to hear.
“We have to score points.”
“We have to stop the other team from scoring points.
“We have to not commit errors.”
“We have to put the ball in the hoop.”
“We have to not take bad shots.”
Perhaps it is just my way of looking at things, but, those seem to be silly answers to me. Indeed, they seem to be in the “Well…. Duh!!!” category. Answers like that do not seem to me to be a good reflection of a profession that really does require a significant amount of thought into strategy development, as well as teaching each member of the team to perform at her/ his potential. It may be unfair to the profession as a whole, but I do think that the public sentiments toward a profession are influenced by the words of its representatives.
I wonder what our responses would be, as Physical Therapists, if we were interviewed by reporters and asked the question, “What are you going to do to make this patient's condition better?” I know I have heard some comments that seem to be nonverifiable to me, which then places them in my “silly” category. Following are a few of the statements I have heard.
“I am going to release the adhesions between your organs.”
“I am going to change your flow of energy.”
“I am going to change the rhythm of your energy.”
“I am going to change the permeability of your membranes to promote healing.”
Several years ago I asked a surgeon if he thought we could release adhesions through external mobilization, and he replied no as he has to use a scalpel during surgery. Regarding the concept of energy flow, the only reference to energy in every textbook I read includes the calculation of ATP in the Krebs Cycle. The amount of ATP generated during various exercise types can be calculated with valid and reliable techniques and each researcher arrives at the same number of molecules with the available measurement systems. This consistency allows me to be confident in the type of exercise I perform, and advice for others to perform in order to accomplish goals. Also, there is scientific evidence that I can cite when I am asked questions about the amount of energy used during exercise.
When I ask for definitions of energy flow or for the mechanisms by which therapeutic ultrasound works, or for the techniques to measure the phenomena, I end up with more questions than answers. As therapeutic ultrasound was a technique taught to me in PT school I was taught about cavitation and microstreaming. However, in 2001 I read an excellent review in our professional journal in which the authors provided evidence that cavitation and microstreaming are not occurring with therapeutic ultrasound.1 Indeed the authors wrote, “This review indicates that the biological effects of ultrasound are unlikely to be beneficial. This conclusion is based on the absence of evidence for a biological rationale for the use of therapeutic ultrasound.”
When I have discussions with colleagues regarding the efficacy of various techniques that do not have good reliability measures, I am often told that perhaps the measurement techniques are just not available at this time to measure a particular phenomenon (eg, energy flow). Personally, I question how one can state that they can change the flow of energy when they also state that it is a phenomena that cannot be reliably measured. I think that a statement by Portney and Watkins is particularly appropriate in this situation. They wrote, “In situations where the efficacy of a treatment is being questioned because current knowledge is inadequate, it may actually be more ethical to take the time to make appropriate controlled comparisons than to continue clinical practice using potentially ineffective techniques.”2
Additionally, Levin and colleagues wrote in a manuscript regarding research methods for complementary and alternative medicine, “If one can reliably measure an independent variable whose validity can be verified by experts, then indicators can be incorporated into standard research designs. Reliability can be ascertained regardless of the unconventionality of the phenomenon being assessed provided the respective complementary medical system has an identifiable, systematic, and consistent set of rules for assigning values to quantify attributes of the phenomenon. This is the standard definition of measurement.”3
As I look back to the most recent and most-watched game this year (the Super Bowl), I am not really upset at the outcome as I do realize that football is just a game. It has no effect on my well-being or my ability to function each day. What we do each day in our clinics, or in our research labs, are not games. The treatments we choose for patients should be based upon good answers to good questions. And, when asked what you are going to do to make a patient's condition better, I hope that you will be able to answer the good question with good evidence. This will be a very positive reflection on our profession.
Toward that end, I want to take the opportunity to announce that we have added two new members to the editorial staff of the JWHPT. Diane Borello-France, PhD, PT has been appointed as the Senior Editor for the JWHPT and Wenting Wu, PhD is our new statistician. Dr. Borello- France has been a practicing clinician and now is an associate professor at Duquesne University in Pittsburgh, PA. Dr. Wu is currently the lead statistician for the Department of Health Sciences at the Mayo Clinic in Rochester, MN.
The editorial staff is committed to ensuring that the Section membership receives well-reviewed information that each of you can use as you develop your plans of care. In addition, we will strive to continue with the goal of providing you with valid and reliable evidence and good answers to questions that you encounter each day.
This issue contains several good answers to good questions.
- Do female athletes demonstrate increased levels of muscle activity in their pelvic floor muscles than non-athletes?
- What research must be performed in order to apply to the American Board of Physical Therapy Specialists (ABPTS) for approval of specialist certification in women's health?
- Was there excellent information presented in the poster and platform presentations at CSM 2008? The answer to this is overwhelmingly, Yes!
Nancy C. Rich PhD, PT
1. Baker KG, Robertson VJ, Duck FA. A review of therapeutic ultrasound: biophysical effects. Phys Ther.
2. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice.
Norwalk, Conn: Appleton & Lange; 1993:29.
3. Levin JS, Glass TA, Kushi LH, Schuck JR, Steele L, Jonas WB. Quantitative methods in research on complementary and alternative medicine: a methodological manifesto. Med Care