regarding challenging beliefs and conventional wisdom. This post ties in perfectly with my last post when I interviewed Professor Timothy Noakes on challenging beliefs as well. I want to introduce you all to Joshua J. Stone, MA, ATC, NASM-CPT, CES, PES, FNS. He is a fellow blogger at Athletic Medicine, and has been receiving a lot of attention lately for taking a stance on the use of ice (cryotherapy) and NSAIDS in treating both chronic and acute injuries. (Also see… Ice: The Overused Modality?)
Q1: Thanks for taking the time to answer my questions, Josh!
Before we begin, how about giving us a background on yourself?
A: I graduated from East Stroudsburg University in 2000 and
completed graduate work from San Jose State’s Kinesiology and Athletic Training
Program in 2003. I spent 12 years in Division I athletics. I absolutely loved
traditional athletic training, but wanted a challenge and left the traditional
scene to partner with a physiatrist in developing a workers’ compensation
business using patented kinesiological testing protocols. This was not the
right fit for me, but I found a great opportunity to work at the National
Academy of Sports Medicine. While there I acted as the subject matter expert
and helped write many of NASMs courses (CPT, CES, PES, FNS, MMACS, YES, SFS,
and WFS). I fell in love with research and writing during my time at NASM. In
2012, NASM made a major organization shift and many of us were left to seek
employment elsewhere. I found the next best thing as an acquisitions editor at
Human Kinetics. Human Kinetics is a leader in Sports Medicine books and
continuing education products. I am offered the great opportunity to
collaborate with industry leaders creating higher educational content.
Q2: Have you always been somebody that questioned
everything or was there a moment in your education or career where you found
yourself starting to ask “why” more often?
A: I have always been a “why” guy, even as a student. I was not
challenging, but rather trying to fully understand why we do what we do. I
think it is important to know the “why” and “why not”. As a clinical instructor
I would often ask students 3-5 “whys”. If they can answer 3-5 whys I know they
fully understand what they are doing and why it is being done. It would
frustrate me when an athlete would get ice, heat, stim, ultrasound, diathermy,
but we couldn’t answer why. Take a look at my 15 minute rehab blog post, I
once unplugged all modalities in the Athletic Training Room and they could only
be used if the “whys” were answered. This may sound like I operated the
athletic training room in a tyrannical manner, but it wasn’t. I just wanted the
best for the students, and athletes.
Q3: Why do you think some people have such a problem when
beliefs are challenged? Perhaps it is because people are afraid of change or
having their ego/pride hurt?
A: Fantastic question, my guess is that change is
inconvenient and uncomfortable. Another reason is fear to accept being wrong. For
years, ice has been used as a treatment modality. It has never really been
challenged, but science gives us an opportunity to ask why. Most literature in
rehabilitative medicine has some level of equivalency. I can give you 5 studies that support my
thoughts and you can find 5 to contradict. There is a lot of positive evidence
for ice; however many studies are laboratory, which does not translate well to
clinical practice. Also, many cryotherapy studies investigate, effects of cryotherapy
used in conjunction with other modalities (e.g. cryotherapy and exercise,
cryotherapy and stretching, cryotherapy and electrical stim, etc). There are
very few clinical studies, blinded, control studies evaluating ice alone vs.
stretching or strengthening alone. The over prescription of a modality that is
surrounded by inconclusive data is my biggest concern and why I wrote the
blogs. This is even more evident with chronic injuries such as medial tibial
stress syndrome, fracture healing, jumper’s knee, runner’s knee, shoulder
impingement, etc. The supportive evidence for cryotherapy efficacy for these
injuries is even more scant.
Q4: Would you agree that challenging beliefs or the
assumptions that we hold true is the core of evidence based medicine/practice
and perhaps the scientific method itself as well?
A: Without a doubt! NATA and the BOC are making the right
move. EBP is underutilized in athletic training. Ask the right question,
evaluate data for appropriateness and accuracy, and then apply the evidence in
practice. I am not saying we do not do this now, but I am saying that as an
entire group, we must get better.
Q5: When and why did you start to question the use of
cryotherapy and NSAIDs? I know for myself the idea of using an evolutionary
perspective has challenged a lot of my own views from nutrition to rehab to
lifestyle habits. Not to mention the notion that cryotherapy and NSAIDs are
about as far as you can get from treating the root source of the symptom seeing
as they only treat the symptoms and not the dysfunction.
A: I was on a two-week trip with our Women’s Volleyball team in
Europe. Our team was addicted to post participation ice. Every day post play
there would be a line of athletes looking to get knees, shins, and shoulders wrapped
with ice. I fed the addiction; I thought it was the right thing to do. The
first day in Switzerland post practice we asked the physios for ice. They
looked at me like I had three eyes. They had no ice, they didn’t use ice. The
athletes were concerned, the coaches were concerned, and I was concerned. We
thought this was the end of the world. But, to our surprise during the two week
trip, the shin splints, the patellar tendinopathy, and the shoulder impingement
began to get better. I began to question why and the answers began to make
sense. So, I asked one athlete with jumper’s knee to stop the ice and NSAIDs.
After a few short days, we had improvement. I tried it on another, again it
worked. I continued to experiment with the no ice theory and more often than
not it worked.
Q6: Writing your blog post about cryotherapy has been a
huge traffic generator for you. Why do you think this is? Is it because the
topic or idea of PRICE/RICE is so ingrained in sports medicine or perhaps
because people are starting to notice and question the abuse of cryotherapy and
NSAIDs?
A: A little bit of both, but primarily because it is contradicts
everything we’ve been told and makes our treatment plans so wrong.
Q7: What kind of feedback have you received from writing
these posts? I am sure there has been both positive and negative feedback
considering when Kelly Starrett first touched the issue he lit a proverbial
fire under the belly of many supporters and detractors of cryotherapy.
A: I’ve had feedback from both ends. Some would say I am nuts and
others would say this makes sense. Those with an open mind saw the possibility.
I find it interesting that those who think I am nuts have a total disregard of
the treatment practices of nearly ¾ of the world population. Eastern Medicine
trained practitioners do not use ice; in fact many of their techniques
stimulate inflammation. Eastern Medical practice has been around for nearly a
thousand years, they must be doing something right. If Eastern Medicine was
ineffective, then why do clinics keep opening here in the US? How can Western
and Eastern medicine be so different and yet both be right?
Q8: In my experience, challenging conventional wisdom or
common beliefs can be difficult and sometimes results in backlash from peers.
What kind of advice would you offer up to others that find themselves
questioning mainstream ideas or experimenting with new ideas?
A: I encourage practitioners to challenge conventional wisdom. Ask
yourself why, and if you cannot come to a solid conclusion, you now have a base
to formulate your thoughts. Then do a critical appraisal of the research. Once
you do this, you can state your beliefs, but there are three things I suggest:
1- make sure you can back-up your statements with facts. 2- Don’t be afraid to
support your stance. 3- Have an open mind, because you will likely be in the
minority and you may not be right. Lord knows I have been wrong before and can
be wrong about ice, even if I don’t think I am.
Q9: I thank you for spending the time to answer my questions, Josh! Is there anything else that you would like to share with myself and my readers before you go?
Q9: I thank you for spending the time to answer my questions, Josh! Is there anything else that you would like to share with myself and my readers before you go?
A: The purpose of evidence based practice is to guide our clinical
decision making. Having an open mind, allows us to ask the questions that
challenge what we do. The questions we formulate and the answers derived will
make us all better practitioners.
I want to thank Josh for answering these questions for me. Please check out his blog if want to learn or read more from him. I know that I personally have questioned the use of cryotherapy and most modalities in general. I find myself relying upon them less and less. I find myself trying to use pain or swelling as an indicator of the efficacy of my rehab/corrective exercises/manual therapy on top of checking it against a movement-based system of assessment such as the SFMA. The point of my previous two posts isn't to suggest were doing everything wrong or that we need 100% evidence to act clinically. However, we should have open minds and not be afraid of questioning the current practices of ourselves and others.
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