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111 thoughts on “Visceral Manipulation Embraced by the APTA

  1. ErikMeira says:

    @Jon Newman-
    Academic institution (employer) is to continuing education company
    Professor (employee) is to woo peddler

    See how the regulating body does not play into it? You are talking employment law. An employer can FIRE someone with cause (actually, here in Oregon you don’t even need cause). You CANNOT block (restrain) someone from being hired by someone else or from competing in the free market (applying their trade) unless you can demonstrate IN A COURT OF LAW that their actions are explicitly harmful to society. Not so successful against chiropractors (Wilk v. AMA). For example: You have to demonstrate that the reason you are stopping a con ed group is because they are EXPLICITLY DANGEROUS to society. In a court of law you cannot claim that they are inappropriate for your profession if A LARGE PORTION OF YOUR PROFESSION SUPPORTS THEIR ACTIONS.

    Groups like the AMA and the APTA are chipping at the grey areas. The goal of http://www.apta.org/ContinuingCompetence/ (click ALL the links) is to take another step towards controlling what kinds of courses clinicians can take (they cannot use that wording, however). The Continuing Competence gang (APTA and FSBPT directors) have been working with other groups FOR THE PAST THREE YEARS on many concerns including “…the economic and legal implications of implementing continuing competence requirements.” Don’t argue with ME about it (why AM I discussing this here?). I am not a lawyer. Just know that there are some very bright people in YOUR association working very hard with high paid lawyers on this exact issue. This is not a hidden, behind the scenes program. As an APTA member, I get an email update on the program from time to time.

    Want to keep talking policy? Go ahead. Just talk to Continuing Competence. I know from my interactions that they are doing their best and there is not much more that I can add to their work without extensive legal knowledge. Changing the culture is something that we as practitioners, educators, and professionals must do in our day-to-day interactions with our peers and patients and with our activity in our professional association.

  2. Jon Newman says:

    I think I need to draw out my analogy more. If nothing else, it will expose where I’m misunderstanding the process.

    Suppose a professor wants to teach content such as VM, faith healing, etc. The course does not get approval because it doesn’t meet academic standards. The next step, I think, would NOT be to then fire the person and keep them from gainful employment. The professor, if so willing, would continue to teach courses that pass muster, her personal/private views are irrelevant. Or, in a more liberal learning environment, maybe the professor just has to re-work the course so that certain caveats are met and it fits under a title like “From Acupuncture to Z-health: various practices considered by physical therapists worldwide.” One other option is that the professor could be really passionate about a narrow bit of content and goes out on his/her own and markets a course for people to take. Maybe she charges for it, maybe she doesn’t–it depends on the demand and her marketing ability. It would be ironic to me if she would then go apply for CE credit and get paid to teach the content for credit while she couldn’t otherwise do so, but that’s just me.

    Regardless, blocking employment or who she can associate with due to his/her personal beliefs and interests is not a consequence of deciding whether the course will become a credit worthy course.

    I’ve been to a variety of public lectures some of which I’ve paid money to attend. None of these lectures offered me CE for my profession and yet I attended them. I’m free to go and they’re free to give the lectures. No one is trying to unfairly stop this interaction.

    To my mind, a CE provider is someone that is a public lecturer who has a fairly narrow target audience he/she is interested in. If VM didn’t get CE approval they are still free to target that audience and that audience is still free to take those courses. No one is preventing that from occurring. And if PTs really are hungry for this stuff (as has been claimed in this thread), they’ll go anyway. For example, I’ve been to a couple of years of American Pain Society Conferences for which I was offered no CE credit for PTs (why is that?) but I had to pay plenty.

    The CE credit sort of plays a role similar to JCAHO. It’s a voluntary process an institution submits to in order to market themselves to the public (I’m not sure of the reimbursement side of things). It doesn’t prevent you from being a health care provider nor does it prevent you from simply providing excellent care. Essentially, it’s an endorsement that says “this place is ok”. CE credit seems to do the same for the provider. It’s just the standards seem A LOT easier to meet.

    One thing that might help me understand how the current CE approval filter is working would be to see a list of courses that got rejected despite the provider successfully completing the CE submission process in an accurate and timely manner. Perhaps, like unpublished studies, this is a long list that would be very reassuring to people like me. Does anyone have examples?

    This would be a good place to straighten me out on my understanding of story of CE credit and the approval process and the consequences of someone not getting approved.

    Thanks for the conversation.

  3. Diane Jacobs says:

    What a good, deep think you just wrote down there, Jon. Thank you.

  4. ErikMeira says:

    **My final comment** I have enjoyed this discussion but must move on. If I can ever be of any more insight for anyone, please feel free to contact me. My name is unique and I can be found easily via your favorite search engine (not posting my email in a comment thread as I get enough spam already).

    @Jon Newman- I am not going to answer you directly. Instead I will give you some resources. You are passionate and I appreciate that. Hopefully I can give you the proper channels to result in some change:

    1. The pain conference and CEU: It does count for CEU of some kind (at least some of it). Call your STATE LICENSING BOARD (not APTA chapter) and find out why. Your discussion with them will shed some light on the subject of how CME/CEU is awarded. In short, legally, approval means very little if required at all. You just need to demonstrate that it applies to your practice. In Oregon, it is a STATE LAW that all medical providers attended a state developed “Understanding Pain” course plus additional “pain related” con ed of the provider’s own choosing (legally required to add that second part which, yes, kind of defeats the first). Freaking EVERYTHING counts. In most states, “independent study” counts for something (see Category 2 below).

    2. Look up the difference between AMA/PRA CME Category 1 and Category 2 and ask why there needs to be two categories. Is there a legal implication for the existence of Category 2? Why does the AMA define categories but not set requirements (leaving that to individual state licensing boards)? Why can’t providers of Category 2 advertise that they are Category 2? Why is it just assumed? Why are Category 2 definitions so vague? APTA/FSBPT Continuing Competence is working towards some kind of Category 1 designation as far as I can tell (similar to AZ’s Cat A designation). There will always be “other categories”.

    3. This stuff is very complicated. There is a reason that lawyers are paid high salaries to understand the details. I’m sure that you remember that the APTA and Ortho Section were jointly sued in the past couple years by the NATA for trying to dictate who can teach what to who. It was a restraint of trade case dealing with manual therapy.

    Take care! Go check out Crislip’s most recent post!

  5. Jon Newman says:

    Hi Erik,

    Actually, I realize I can jump through a few hoops to get credit because I’ve done it in the distant past. It’s just that the APS offers credits up front to physicians, psychologists, nurses, and pharmacists. What happen to PTs in this otherwise interdisciplinary team of people? The point is really a pet peeve and not particularly relevant to the discussion.

    Anyway, following is a link to what the Independent Investigations Group discovered about the status of continuing education regulation for nurses in California. The problem seems universal.

    http://www.iigwest.com/investigations/cbrn/index.html

  6. Diane Jacobs says:

    From Jon’s link (excerpt):
    > “We then decided to see for ourselves just how lax California’s CEU provider application process really is. We created a CEU provider called the California Foundation for Institutional Care or CFI-Care and sent an application with the $200 fee to the CBRN. We called our course “Feng Shui for Home Care Providers” and listed IIG investigator Karen Kensek as the instructor because she teaches architecture at the University of Southern California and thus meets the qualifications of a certified instructor. But we didn’t stop there.
    The following sections appear on our application for this course aimed at professional nurses:
    1. Möbel Kinesiology (Möbel is the German word for furniture, so möbel kinesiology is, essentially, furniture moving.)
    2. Feng Shui (a practice in which a structure or site is chosen or configured so as to harmonize with its qi, or life energy)
    3. Chinese ShŽyu (translation: snake oil)
    4. Vapor and Reflective Surfaces (another way to say smoke and mirrors)
    5. Apophenia (the experience of seeing patterns or connections in random or meaningless data)
    6. Anthropomancy (divination through human entrails)
    7. Canupiary Flexibility (The word canupiary exists in no language we could find. We made it up.)

    … After much discussion about how to use our newfound state-sanctioned authority to disseminate false information, we decided to teach the class as-applied-for at the Center for Inquiry/Los Angeles. Part of the class would include revealing our motives to embarrass the CBRN into recognizing the flaws in its continuing education system. We certainly wouldn’t want to see a class like “Feng Shui for Home Care Providers” taught for real… We taught the class anyway, with no promise of CEUs, to an amazed and incredulous crowd. The handful of nurses who attended the class with around seventy-five others were appalled that the class’s ludicrous content had been approved by the board. Jim Underdown reaching into an anatomically correct rubber corpse and flinging an armful of bloody latex entrails onto the stage to read the future was particularly memorable.”

    WOW!! Hilarious. And sad it came to that.

  7. Kate says:

    So, I haven’t read all 106 responses, but I found your original post very interesting… as a new physical therapist finding my way in the profession … and as APTA member (also finding my way in the profession). Though I like to think I embody everything it means to be a pure bred physical therapist of the “evidenced based practice generation,” (and thus would be very unlikely to utilize something like viceral manipulation in my practice until I saw any sort of concrete evidence) I do think the immediate critique of the APTA’s “endorsement” was a tiny bit harsh. I can’t vouch for the personal opinions of individual members, but I do think the board of directors should be more careful what they “endorse,” especially since they make such a fuss over us being respected as doctors of physical therapy and moving toward a medical model based around evidence based practice! They can’t have their cake and eat it too!

    HOWEVER, I think there is a delicate (and interesting) balance that has to be maintained. Physical therapists have lost huge chunks of our scope of practice because we have turned our noses up to practices that are too new agey or based purely on anecdotal evidence or too cutting edge…. chest PT went to respiratory therapists, dry needling to acupuncturists, wound care to WOCs, etc. And now all of a sudden rolls in concrete evidence about the effectiveness of dry needling and we’ve already lost it in many states. Thus, I do think there is some pressure not to let our profession slip away to new specialities popping up as we WORK TOWARD building a stronger evidence base for a profession that was originally built on nothing but anecdotal evidence… a profession that is now inherently in a state of tension between the old and the new (and the proven and the unproven).

  8. wfeather says:

    The American Physical Therapy Association (APTA) and APTA’s Section on Women’s Health (SoWH) leadership have been following this blog post, comments and the excellent questions that have been raised. Clearly the challenge of various standards for continuing education unit (CEU) credits is a shared concern among the chapters and sections of APTA as well as within healthcare as a whole. This is an ongoing process and enthusiastic dialogue such as generated here is welcomed.

    The APTA and its components embrace the direction of moving consistently towards evidence- and science-based theories, techniques and communication. APTA’s Standards of Quality for Continuing Education Offerings (BOD G11-03-22-69), states in part:

    “Each CE offering must be based on referenced scientific evidence, reflect evidence
    in practice and clearly label personal experience or hypotheses.”

    The SoWH is following the current guidelines and will continue to update and revise courses as part of the continuing effort to stay current with emerging evidence as well as including the interests of the members of the section. The goal is to provide the most current evidence and content areas in need of investigation for existing and emerging practice.

    Evidence-based practice is often defined as the integration of best research evidence with clinical expertise and patient values. Evidence-based practice also means using the best possible evidence and recognizing that not all evidence is created equal. The scientific evidence needs to be combined with clinical experience to determine how it will fit into the management of an individual patient. The evidence one chooses needs to take into account the patient’s problem and, just as importantly, their values.

    Physical therapists need to commit to providing patients with the treatments that have the greatest chance at being effective. It is incumbent upon physical therapists to start with treatments supported by high level methodologies. We must search for, and employ first, those interventions that have been shown to have a statistically significant treatment effect with well-controlled research studies. If there are no systematic reviews, or meta-analyses, then one may look for guidance from lower level methodologies.

    Although one should look for the highest levels of evidence possible when attempting to answer a clinical problem, ultimately the physical therapist and the patient judge the applicability or generalisability of any intervention to a patient. The most important factor is to continue to look for the best and most effective intervention, especially as new knowledge is developed.

    In our opinion, portions of the theory underpinning the writings of Barral clearly are not biologically plausible. The visceral mobilization (VM) class taught through the SoWH focuses on urogynecological anatomy and physiology, normal respiration, kinesiology, and palpation skills. The SOWH does not utilize the VM content for preparation for the Certificate of Achievement in Pelvic Physical Therapy. The American Board of Physical Therapy Specialties likewise does not utilize the VM content in certifying Women’s Health Clinical Specialists, since certification of clinical specialists is based upon classes that are regularly reviewed and updated to reflect current science and evidence. The VM class is not included as it clearly is based on case studies, which at best constitute level 5 evidence using Sackett’s classification.

    The ideas for establishing a graded CEU scale are intriguing and could be explored. The APTA and component sections remain dedicated to pursuing change as new information emerges.

    On the subject of advertising, there are advertisements for educational courses with various levels of evidence across the APTA and its components. APTA and its components will continue to adhere to our policies on advertisements (http://www.apta.org/Advertise/Policies/) and continue to be open to input on these policies.

    Thank you to those who participated in what we consider to be an interesting discussion that has generated ideas for improvement in evidence-based practice across the profession as well as providing an example of the level of rigor which should be applied across healthcare.

    R. Scott Ward, PT, PhD President APTA
    Wendy M. Featherstone, PT, DPT, President, Section on Women’s Health APTA

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