Jason Silvernail is a Doctor of Physical Therapy and works for the U.S Army. I´ve been following Dr Silvernail for a good while and enjoy his evidence-based approach. I was happy when the good doctor agreed to answer a couple of my q´s – big thanks Jason!
Please tell us a bit about the job you do at the U.S Army. What does a typical ”day at the office” consist of for you?
Well it varies based on what job I’m in, actually. In the US Army you move about every 18 mos – 3 years to take a new job. I’ve had a variety of positions, mostly in clinic as a DPT, but I’ve been a clinic manager, served on hospital credentials review committees, deployed to hostile fire zones and traveled around a combat zone taking care of Soldiers, done research as student, been in a staff position where I created public health and fitness products while travelling and teaching, and now I’m the Chief of Physical Therapy at Walter Reed National Military Medical Center, in Bethesda Maryland. I’ve been in the US Army for almost 24 years now.
You (probably) work with a lot of soldiers with combat experience / trauma – what is that like? What´s the biggest (life, or otherwise) lesson / take away you´ve gotten from your current work?
Well the military certainly is a different culture, but you’d be surprised probably about how ordinary common musculoskeletal problems are – Soldiers have the same kinds of issues any healthy athletic person does. There is a far amount of combat trauma and stress – often that translates to people telling you things the average PT wouldn’t hear about that time. I spend more time with people than most health care people so often a Soldier will open up to me about an issue they are having that they haven’t told anyone else. Our system works very well so that I can discuss with them what the problem is and get them the help they need. We have very knowledgeable and caring people in the behavioral health area that I refer to to help those Soldiers. In terms of a take away, it might sound like a cliche, but I would say the biggest life lesson I’ve taken away is to be thankful for the time you have and spend it doing the things you want to do with the people you want to be with, and appreciate how lucky you are. Not everyone I went to combat with came home, and that kind of experience certainly changes your perspective. I’ve spent 21 months in hostile fire zones and traveled all over southern Afghanistan to take care of Soldiers – but I was never hit by an IED, shot at, or had to fire my weapon in self defense. Talk about being lucky!
What would you consider the biggest downsides / issues currently both within the fitness industry and physical therapy?
Well I would say the biggest issue in both areas is special interest influence and failure to follow good evidence where you can. I can’t speak for Finland, but in the US, medicine is driven and controlled by a few rich groups who lobby legislatures to keep special privileges and shut others out of access to patients and out of being paid for their work. They also continue to secure payment for risky, invasive, and expensive procedures (like elective orthopedic surgery, injections, imaging, and medication management) that we know is no better or worse than more conservative approaches (such as those we use in Physical Therapy). So that is a good example of both special interest control shutting out patient choice and of failure to follow the evidence. In medicine overall (and PT is no exception), we are not very good at following the evidence and much better at just doing what we always have done or what we are comfortable with – this is practitioner centered, not patient centered, care. I’m disappointed about how rarely people are offered compassionate and evidence-based care in medicine, and sadly Physical Therapy isn’t an exception to that overall rule.
I try hard to stay on top of the latest evidence and to train students, residents, and fellows about the importance of finding and following good evidence in patient care and rejecting fads, trends, and the latest cool looking thing in the industry. When you look at the evidence for improving fitness and body composition you see some pretty ordinary things – good consensus on progressive weight training with a clear range of volume and load, aerobic training at intensities and frequencies that are fairly standard across systematic reviews and professional association guidelines, and moderation and long term behavior change in nutrition. Yet how many people are being set up on programs anywhere close to that? Or are they being offered cool-looking trendy things that fail to provide the volume, load, and progression of exercise that we know are associated with improvements?
Same in Physical Therapy. There is always a pressure for the next best thing or the more exciting new process. But if you look at successful randomized trials of PT, you see similar things: simple, well-dosed, and progressed ”plain vanilla” therapy exercises that have solid track records of success across time, usually provided in 2-3 visits per week for 4-6 weeks. Yet people seem so excited for these complicated exercises that patients struggle to complete correctly and are often not directly addressing their issues. When I am called in to consult on a case of a patient not improving, there are some very common errors being made:
1. Patient has not been carefully examined to determine where the problem lies
2. Too many exercises are prescribed and they are so complicated the patient can’t produce them well on their own
3. Exercises are exacerbating symptoms and are too advanced
4. Movements and exercises that initially seemed to help were abandoned in favor of trying something new instead of being fully progressed.
5. Interventions are chosen based on what the practitioner likes to do instead of what the evidence indicates is a good choice for the patient’s problem.
I think that often, therapy is doing a good job at simulating the exact issue that brought the patient in: they have a movement problem they are loading with exercise that is making them symptomatic. A problem that imaging and medication won’t solve. A problem that might get worse or no better with elective surgery, if the imaging reveals any common degenerative abnormality that might give a surgeon the green light to cut something open. And what do we all too often do in physical medicine? We don’t fix the movement problem and we load them with vigorous exercise! And then our colleagues wonder why the patient doesn’t improve. An expert does the basics well – in this case it’s a thoughtful interview and medical screening, a detailed examination, and simple exercise progressions and manual therapy that are tailored to the patient and dosed and progressed appropriately. You can read more about that process of care here.
What is / are the biggest myth(s) within the fitness industry / physical therapy you´d like to bust?
Oh there are so many! I’ll just pick one. One of my pet peeves is the expression ”He needs surgery” or ”She’s been needing this surgery for a while now”, when it comes to elective orthopedic surgical procedures. The evidence is showing that elective orthopedic surgeries are usually no better than rehabilitation or conservative management when they are studied head to head in randomized trials. Some studies show a slight benefit to rehab, others to surgery, but overall it’s about the same. So we need to get rid of this idea that surgery is somehow a step up in problem solving from rehabilitation. It’s a step up in cost, in risk,and in complication rate and severity, but not of efficacy.It also is very likely a step up in placebo effect as well! The idea that when rehabilitation fails, surgery is the ’big gun’ that will fix the problem is a major myth being perpetuated by both surgical and conservative medical practitioners and is of course a common belief among laypeople. People often talk about the need for more research in physical medicine to help solve some of these questions – but I disagree. We obviously aren’t following the evidence we have already, why would generating more help?
Why do you think people get so caught up in topics such as fascia, ”self-myofascial release” and the likes, sometimes lapping up popular ideas on a subject without any criticism? Is it a lack of education at the receiving end, a problem with gurus getting more airtime than the critics, or something else?
Generally, these ideas sell because people have failed to do the three things I emphasized in my talk at the 2015 San Diego Pain Summit. People don’t know their basic science well, they don’t apply a critical thinking process to what they do, and they don’t use claims responsibly. Most of those guru methods are just not plausible to anyone who knows the basic science well – but you have to know it first! I think these issues are more common among groups with less formal education and less rigorous education standards because they don’t have the science base to know better. But many who should know better make those mistakes because they have failed to think things through and use a critical thinking process. And of course both buyers and sellers of those ideas haven’t been taught to limit their claims to what they could defend with evidence! I do agree with some people who have said those on the science based side need to do a better job of showing positive passion for what we know and how it helps our patients and clients.Too often we come across as negative wet blankets instead of positive voices for patient centered care. For more on my talk at the Summit, and to purchase the video if you’re interested (full disclosure – I do NOT profit from the sales) go here.
On a related note, how do you think we could be more effective in doing away with hucksters and promoting an evidence-based way of approaching things within our respective fields?
I think our programs and our cultures in fitness and physical medicine need to reflect those three principles: knowing the basic science, applying a critical thinking process to everything we do, and using claims responsibly. Until we do that in a consistent way across disciplines, we will continue to see the problems we have now. When I went for specialty fellowship training in manual therapy at the Army-Baylor Doctoral Fellowship in Orthopedic Manual Therapy, the training I really got was a rigorous self examination and critical thinking process – it just happened to use manual therapy and physical medicine as the vehicle for that education. So coming out the other side of that training, perhaps without meaning to, I had absorbed those three principles well. I think we need to do a better job of making them explicit in our programs and a required part of our culture. I think the information age has made this easier and I think it will continue to improve.
On a totally unrelated note – what in your experience + opinion would be the best way to prevent LBP in the general population?
I don’t think there’s any evidence that we can do much to prevent low back pain. I think we can do a lot to improve how we deal with low back pain as a culture, how we can avoid overtreating it, how we can reduce the threat value it has for people, and how we can improve our disability, medical care, and management pathways to move towards a healthier approach.
Thanks for this opportunity to talk to you, Juhani!
Jason Silvernail DPT, DSc, FAAOMPT
Doctor of Physical Therapy
Board Certified in Orthopedic Physical Therapy
Certified Strength and Conditioning Specialist
The views expressed are Dr Silvernail’s alone and do not reflect the official policy or position of the United States Army, the Department of Defense, or the United States Government.