A growing interest in Regenerative Medicine has been moving into physical therapy as highlighted in the March 2016 PT in Motion article. While, I will agree it is very exciting to think of some of the potentials that come with advances in this field and its implications for many of the patients we in physical therapy work with daily, probably not all to surprisingly I’m also a bit concerned. The excitement of regeneration is very alluring to anyone. Since the days of Ponce de Leon and the search for the Fountain of Youth (and probably before), humankind has searched for ways to turn back the clock of time in regards to our bodies. My main concern is not so much with regenerative medicine in the areas of brain recovery, wound care and cancer treatment, but in the area of musculoskeletal injuries.
The use of stem cells, PRP injections and even other modalities within PT that are seen as potential “healers” of common musculoskeletal injuries. Hearing about the excitement and exuberance of some therapists over treatments such as Instrument Assisted Soft Tissue Mobilization (IASTM), Dry Needling (DN) and biophysical agents (ultrasound, e-stim, laser, etc.) concerns me. Now before anyone gets too up in arms, I’m not saying that IASTM, TDN and biophysical agents don’t have a place in therapy and that everyone thinks that these ancillary treatments are “healing” injuries when they use them.
The human body has an innate ability to heal itself and anything we can do to assist this process that provides for better recovery long term should be studied and if significantly better than what we are doing should be used. But let’s please remember the one thing that seems to show the most promise in this area – exercise. The problem is that the marketing cart usually gets way ahead of the research horse in many of these “new” healing modalities. I know people argue that research takes too long and research can’t prove everything. Those that say that are absolutely correct, research does take time and it does not prove anything to be true. Research is meant to prove things false (helping us be less wrong) and it takes time to make sure we don’t make mistakes by doing studies multiple times to make sure errors aren’t made somewhere along the way.
Part of my concern with some of these treatments and claims, is that those that are supporting them might still be connecting a direct link to pain and injury together. Why do I think that they are making this fundamental flaw? It’s based on what the anecdotes and patient testimonies that they use to support these treatments. “My patients’ feel and get better faster when I provide these treatments.” First of all, feeling better means the patients are reporting less pain, which unfortunately not is not always the best predictor of tissue health especially as pain persists. Second, how do we measure “get better”? Do we have an objective measurement in our clinics that we can tell the tissue is actually “healed” better from the injury? Sure, we can see the person function better but does that mean the tissues are “truly” better? I’m always drawn back to the Coombes study, that showed us patients getting corticosteroid injections (a treatment that was meant to speed the healing process) did better short term (less pain and better return to function) but ultimately did worse long term. Maybe what was thought of as better wasn’t really better. So in that study “better” faster did not equate to actually better in the long run. Also many times we use rat studies to justify that tissues are healing better with our treatments because of some increase in markers with blood chemistry or other tissue changes found in the rat. These are important studies to try to find mechanisms why these treatments might have value but we need to be careful about getting to excited about the findings for a few reasons. I think most of us would agree musculoskeletal injuries that turn into persistent pain problems is a bigger burden on our society then acute injuries that recover normally. Keeping that in mind, is our understanding that rats in experimental pain studies or even in life don’t seem to develop persistent pain like humans do (I’m thinking of writing a book “Why Rats Don’t Get Persistent Pain”, what do you think?). Lastly, these changes in tissue healing with the use of external interventions don’t seem to clinically make much difference. I might as well add in the findings specifically related to degenerative tendon injuries that the degenerative tendon component doesn’t and doesn’t have to change to recover, it is more important to work on the “doughnut” and not the “hole.”
Many of these treatments make patients “feel” better (aka have less pain) we have to be very careful to always equate that with the tissues are better. Just because a treatment helps a patient have less pain it may not be the best treatment, especially if it is under the guise of tissue regeneration and improved healing. Patients should be able to make an informed decision regarding the treatment they receive. It is an entirely different context for a patient to make a decision on the care they are about to receive if I use two different explanations:
- “This treatment X will help your tissues heal faster and better and you will notice decrease pain.” Followed with a bunch of mumbo jumbo to make treatment X sound like it is vital to their outcome and without they may not heal as good.
- “This treatment X you may have heard will heal your tissues faster and better, actually the research doesn’t support that claim very well at this point. People do report feeling better after getting it but it is probably due more to non-specific or placebo effects. This is what happens when people feel better simply because they have a positive attitude that they will get better. The good news is tissues heal whether you do treatment X or not. We do know with a pretty high level of certainty that the most important part of recovery is to calm the area down a bit and then gradually load it back up to tolerate the activities you want to do. It requires a bit of work on your part, but I guess that is why they say those that work hard will be rewarded. By doing treatment X it may take away from the exercises that are probably more important to your long term recovery.” Then we can see if patient is still interested in treatment X or not.
Tissues do get injured, but they also heal and may not require all sorts of external attempts to improve this healing outside of our traditional use of gradual loading of the tissues through exercise. We have to be ever on guard against the false belief that decrease pain means improved tissue healing. Even if some of these outside interventions do show (which to date I think we have to say is questionable at best) to improve the healing process, is the 10-20+ minutes of treatment time worth it? Would spending that time on good education and loading of tissues maybe a better use of that time? We need to consider self-efficacy and locus of control with our interventions as studies have shown when we increase these in our patients they have improved outcomes, better quality of life and reduced costs. When picking your treatment intervention is it building more self-efficacy and keeping the locus of control with the patient? Is that treatment really healing and regenerating them better? Just because they have less pain does not mean the tissues are regenerating better.
Okay your turn: – What say you?
Via Dr. Kory Zimney, DPT
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!
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