Interview with Scott Epsley, PT, RMSK, SCS - February 2015

The following is not original material. This interview is reproduced with permission from Cinema, a former Twitter personality & blogger who left the social media world years ago. The reproduction is intended to preserve & share Cinema's insightful interviews.

Some of you may have heard of Scott Epsley, many of you haven’t – and I think you should! Scott is a Physical Therapist with experience in private practice, research, sports PT, as well as strong interests in the use of diagnostic ultrasound in PT, Dry Needling, and more. He currently works as the Physical Therapist for the Georgetown University Athletics Department. You can read a short bio here

The world of Physical Therapy is studded with remarkable individuals, and Scott is one of them. I learned a lot from this interview, and I believe you will as well. Enjoy!

Let’s start with your professional beginnings. What drew you into the wonderful world of Physical Therapy?

I think it’s fair to say that Physical Therapy found me.  I’ve always loved biology and the human body.  In Australia Medicine used to be a six year undergraduate degree.  I intended to do Medicine however the year that I graduated High School Australia switched to a US styled post-graduate Medical degree.  The truth is I didn’t put Physiotherapy on my University application.  At the time it was the most difficult degree to get into at the University of Queensland, my Alma Mata, and required the highest graduating score from High School.  When I achieved the entry criteria I called our Career Guidance Officer immediately and changed my application to put Physiotherapy number one.  I still intended to return to Medicine after practicing for a couple of years.  However I began working with professional and representative teams and had an aptitude and passion for it.  The rest is history as they say.  I still haven’t ruled out Medicine one day.  If ever I lose the passion and don’t feel sufficiently challenged it’s time to move on.  Needless to say I’m still finding plenty of both as a Physical Therapist!

You had your own physio practice in Australia for about 6 years. Given the benefit of hindsight, what were the biggest lessons you learned from those years in private practice?

 I read a lot of marketing books.  I came across the concept of “Surpetition” by Edward De Bono.  The premise is that one doesn’t attempt to compete with others, but focuses on being better than oneself, while still being aware of what your competitors are doing.  This has since become not only my philosophy in business, but in life.

I learned a lot about people and teamwork.  I discovered that if you find someone’s gift and give them responsibility they will usually surprise you with their capability.  This requires anyone in a leadership role to be very secure in themselves.  It is also important to support them if they make a valiant attempt and things don’t go quite as planned, because confidence is a great motivator of future efforts.

We never made any decisions purely to try to make money.  We made decisions that led to better patient care, improved customer service, and the highest level of practice possible.  Our mission statement was to give each and every person the same care afforded to the Olympians we treated.  As a result we averaged 25% growth per year and had a very profitable business.

William Osler said “The value of experience is not in seeing much, but in seeing wisely”.  I hired young therapists who were passionate and demonstrated sound critical thinking, and then trained them well.  I’m far less concerned with how many years someone has been practicing than how they think.  Young therapists are the future of our profession.

Finally, success in business isn’t in the deals or things you do, but in those that you don’t do (which is over 90% of things that come your way).  I felt so validated when I read that this was Steve Jobs’ philosophy!

You’re lucky enough to have worked in both Australia and the US! What are the biggest differences you’ve noticed? And, what can the American Physical Therapy Association learn from its Australian counterpart?

This question is perhaps a little unfair if considered in the context of a profession functioning in isolation of societal and political influences.  Many of the differences I believe are reflections of different public attitudes toward health care and the healthcare systems themselves.  Furthermore understanding that there are distinct sociologic differences between the two countries is key to understanding the professional differences.

Australia is a very egalitarian society where people in positions of authority such as politicians and doctors are not revered quite as they are in the USA.  It is also a society where invasive (eg. surgical) or pharmacologic intervention is generally less adhered to as the “gold standard”.  This has helped Physiotherapists become high profile providers of direct access medical care.  The USA has long been doctor-centric whereby allied health may be seen more as an alternative to medical or pharmacologic intervention rather than a primary intervention in and of itself.  This attitude is changing however.

In the context of universal healthcare in Australia it is important to know that except for a select few conditions (where a limited number of treatments are approved) Physiotherapy is not covered.  Patients with private health insurance are afforded some coverage as an amount of the total treatment cost, with the remainder being their responsibility.  The predominant provider of outpatient care is private practice, and a large percentage of that is direct access.  Public choice of a provider is therefore partly driven by the cost-benefit theory of economics.  Therapists need to offer a better service in order to win business, thus improving the standard of the profession as a whole by increasing intra-profession competition.

In the USA improving the status of Physical Therapists to a highly sought-after member of the medical fraternity with the reputation for being the premier musculoskeletal experts should, I believe, be our goal.  While I understand the move to a DPT from a political perspective, this is an extrinsic change.  True change has to occur within the profession, enacted by each and every one of us.  It means no longer seeing ourselves as subservient to referrals with incorrect diagnoses and requests for outdated interventions.  As in any relationship, we will be treated as we wish to be treated.  It means raising the bar for ourselves, and then proving we can live up to that standard.

In my experience across two continents the formula for achieving this is the same despite the different social and political environments.  Why?  Because people are essentially the same anywhere in the world.  We can all begin today by building better relationships with our medical colleagues and our patients.  It is up us to engender trust, and trust I believe will fan the fire of change.  Fire purges and allows for new growth.  Let’s be the spark in our own communities and before you know it we will have an irresistible inferno!

RMSK. What is it? And, why are you so passionate about it?

RMSK (Registered in Musculoskeletal Sonography) is the credential in diagnostic ultrasound earned by passing the certification examination through ARDMS (the American Registry for Diagnostic Medical Sonography).  To date this is a credential attained by only a handful of PT’s in the country of which I’m proud to be one.  It’s fair to say that I’m passionate about ultrasound as a tool for improving practice, and the RMSK is a vehicle enabling me to be credentialed in this area.  Therefore I will direct my answer more specifically toward the question “why am I so passionate about ultrasound?”.

Ultrasound is a non-invasive, low risk tool for imaging musculoskeletal tissue in real time in order to aid rehabilitation, provide for early appropriate referral, assist in clinical decision making, and improve the efficacy and safety of interventions such as dry needling.  It has the major advantage over all other imaging modalities of being capable of providing for dynamic assessment.  As experts in movement the ability to perform dynamic imaging fits perfectly well within our scope of practice.

As a direct access practitioner and one who works in an elite athletics setting the precision in practice provided for by the use of ultrasound as an adjunct to a thorough examination enables me to improve outcomes and better manage expectations.  By developing my skills with ultrasound guided needling I have been able to treat conditions and obtain outcomes previously unattainable.  Rehabilitative ultrasound has aided in identifying unique patterns of muscle dysfunction that one is otherwise unable to appreciate, and induce a positive change where other methods of exercise have failed.

In short, proficiency in this skill further supports and improves our position as musculoskeletal experts.  This is why I’m so passionate about it!

“Evidence-Based Practice” has been the physio mantra for the last few years – and rightly so! Given your experience in research, private practice, and working with very high-level athletes, what are the limits and short-falls of being 100% EBP? (Also, is it possible to be 100% EBP?)

If one wishes to be 100% EBP then stay home, grab a cup of coffee, and enjoy your Netflix subscription!  If you look at the Cochrane Collaboration little of what we do has much if any effect.  Systematic reviews and meta-analyses, although considered the highest level of evidence, can dilute the value of good individual RCT’s.  RCT’s unfortunately  negate the clinical decision making process used when determining an intervention by reducing conditions to a defined set of symptoms, and treating those identically.  And finally case series’, while a great way to present consistent clinical observations, are not scientific evidence of a true treatment response.  They do however help the clinic to drive research and as such are incredibly valuable.

When I’m considering my own treatments I look for them to fulfill two criteria: i) A valid physiological basis for how the intervention may work, and ii) uphold the existing evidence.  If there is evidence without a sound physiologic basis, or a sound physiologic explanation that contradicts all existing evidence, then I would question the validity of that treatment.  I don’t however believe that a treatment is invalid because there isn’t an RCT or systematic review supporting it.

One final note.  I firmly believe that there exists an intangible “energy” interaction during treatment.  It is for this reason that two clinicians can administer ostensibly identical interventions to the same patient and get two completely different responses.  While I am a seeker of evidence from the physical sciences to support my interventions, I cannot discount the metaphysical.  The best scientific explanation I can muster for this lies in quantum entanglement, but this is purely supposition.

“Are Biomechanics Obsolete?”

I love this question, thank you!  It has been said that “to someone with a hammer everything looks like a nail”.  That is how our profession has become.  We are very good at addressing biomechanical issues, therefore everything has been reduced to biomechanical causes.

For those who don’t know, my research has been into Medial Tibial Stress Syndrome (MTSS).  I have read hundreds of papers pertaining to this topic.  Contrary to colloquial wisdom there is very little evidence for any consistent biomechanical “cause” of MTSS.  If you have seen enough athletes, especially very good ones, you would have seen a huge variance in mechanics even at an elite level.  Mechanics themselves don’t cause injury (short of catastrophic tensile load to failure such as an ACL rupture).  The biochemical response to tissue load is the cause.  Understanding mechanotransduction (how cells regulate protein synthesis in direct response to tensile, compressive, or shear forces) and the chemical pathways that ensue is the only complete way to describe and consider injury.

This is why I have coined the phrase the “Biomechemical” approach to injury.  It is how the mechanics cause the upregulation or downregulation of proteins that is the ultimate determinant of injury.  If you do not exceed the body’s physiological ability to adapt, or happen to have the right physiology, you will not get injured.

Truly understanding injury means extending our paradigm far beyond biomechanics and returning to basic science.

Favorite books and/or authors?

My favorite book and author are in kind.  “The Alchemist” is my favorite book, by my favorite author Paulo Coelho.  It is the story of Santiago a shepherd boy who goes in search of his dream, facing many challenges and the temptation of an easier life but persisting in order to realize his “personal legend” or life’s purpose.  I feel a deep connection to the parallels drawn by this book to my life.  In his many works Coelho articulates almost cathartically the struggles of humankind across the ages, while placing meaningfulness to the pursuit of Love, self awareness, and providing for a spiritual context to life.

I’m also very interested in the reconciliation between science and spirituality.  This has lead me to explore quantum physics and Buddhism.  I’m currently reading “The Quantum and the Lotus” by Ricard and Thuan.  The gap between science and spirituality seems to me best explained by quantum theory, and while I no longer identify with organized religion, the tenets of Buddhism blend best with my scientific mind.   Other books that I have read in this vein include “The Universe in the Rearview Mirror” and Deepak Chopra’s recent release “The Future of God” in which Chopra proposes a new model for God that transcends religion.

High Intensity Interval Training, Crossfit, P90X, and other extreme exercise routines are are the rage these days. What are your thoughts on such aggressive training?

The businessman in me thinks there should be more of it!  It’s great for job security!  Seriously though, I really think the appropriateness is as much dependent on who attempts these programs as the regimen itself.  I firmly believe that not everyone is designed to run marathons, and not everyone should be snatching hundreds of pounds.  Exercise pursuits tend to self select individuals.  For example a person with hypermobile shoulders is likely to gravitate towards swimming and away from football (if for no other reason but that they keep dislocating their shoulders playing football!).

One of the key considerations missing in the decision to undertake such exercise is past training history, childhood activity levels, and “training age”.  Physiologic changes occur in the musculoskeletal system beginning in childhood that determine how we respond to exercise later in life, and many of these also pertain to future injury risk.  This ranges from bone density to the responsiveness of muscle to training, and the sensitivity of tendon to load.  Someone who has been inactive as a child or adult for an extended duration should be much more cautious about participating in aggressive training of any kind than someone with a lifelong history of relevant exercise.  By relevant I mean that the training history should be somewhat consistent with the type of exercise to be undertaken.  In this sense I don’t think that the exercises themselves are necessarily inherently bad for the right individual (if performed correctly of course).

Finally one needs to understand that not all exercise is necessarily “good for you” and there may be repercussions that persist years beyond cessation.  I think the obsession with these forms of exercise frequently has little to do with the physical and more to do with the psychological.  Excessive exercise is socially acceptable, alcoholism isn’t, and yet both can be abnormal coping strategies or manifestations of other organic disorders.  In these states one frequently is blinded to future consequences, and there is positive societal reinforcement for the behavior.

Speaking of exercises, how many exercises do you usually include in an HEP? Why?

Three, maybe four, tops.  I mean, if you have an ACL reconstruction you have to have the gamut.  But I’m against giving exercises for the sake of it.  I work with division one college athletes in a highly academic school.  They have class, lift, practice, games, treatment, homework, internships etc.  The last thing they need is to be overburdened with exercises.  However I extrapolate this philosophy to treating all of my patients.  Your exercises should be addressing neuromuscular control, strength, mobility, and pain.  Giving one exercise for each of these categories and then progressing them appropriately is far more effective than a generic program.  I see far too many patients with redundant exercises.  In contrast I am very specific and targeted.  Furthermore there is much written about compliance.  I believe this optimizes compliance.

Staying in the world of Physical Therapy, what important truth do very few people agree with you on?

This was perhaps the most difficult question to answer.  I tried polling my colleagues, but of course they weren’t game to tell me even if they did disagree!!

One of the paths our profession has chosen to take is that of “Clinical Prediction Rules” (CPR’s).  Perhaps this is one of the things I am most vehemently opposed to, and certainly an area I have had many disagreements with colleagues over.

Phil Plait is credited with the quote “Give a man a truth and he will think for a day, teach a man to reason and he will think for a lifetime”.  In this way teaching young therapists CPR’s stunts their clinical reasoning, perhaps irreparably.  It is not the rules themselves that are the problem, they can be a great informative guide for an experienced therapist.  It is how they are taught and implemented, and when.  Clinical reasoning is like a developmental stage.  If one does not learn it at the appropriate time I have observed that it is very difficult to teach later.  The appropriate time to foster this reasoning is in the education system.  By relying on CPR’s at this stage, one will have great difficulty moving beyond them.

Today there is much less value in teaching facts because information is so readily accessible.  The true value of education for the future will be in teaching people how to think.

You’ve just traveled back in time to when you were 20 years old, and are sitting face-to-face with yourself. What advice would you give yourself?

I doubt my 20 year old self would listen!

I think one of the most difficult things to come to terms with in Sports Medicine (and perhaps life) is that no matter how much you know, how hard you work, how technically sound you are, or widely read you are, not everyone is going to be happy with your advice.  There are many varied personalities, from coaches to trainers, athletes, parents, and other medical professionals.  It comes as no surprise that not everyone involved in athletics is always rational, and you can’t logically reason with irrational people.  Therein lies a common source of contention.

People generally behave irrationally in response to uncertainty.  Being  comfortable with uncertainty requires a strong sense of self, but does not insist that those we interact with have yet similarly evolved.  Our response to this is key in determining the outcome of such conflicts.  If one acts indignantly or feels insulted you are likely to lose traction with your argument.  Accepting that rejection of our advice or treatment plan is not a reflection of the advice itself, but of many other factors, is key to moving beyond such disagreements.

Not everyone we can help necessarily wants the type of help we desire to give.  If I’d learnt to accept this at a younger age I would have significantly diminished my sleep debt!!

Life is an adventure. Tell us about one of your most memorable adventures so far.

My most memorable adventure was moving countries and re-establishing myself professionally on a different continent.  This is why I identify with the book “The Alchemist”.

Since my first trip to the USA playing basketball in 1995 I had a sense that I would someday return.  After being encouraged by a number of Australian professional athletes that resided here but would see me when in Australia for treatment, I decided that it was time for a new challenge.  I had conquered private practice, worked at a professional, national, and international level in sport, all by the time I was thirty years old.  I had no idea the trials that awaited, which is just as well, because if I had I probably wouldn’t have  embarked on the journey!  People see me treating professional athletes or lecturing around the world, but very few know what it took to make that dream a reality.

Firstly there was the loss of my identity as a Physiotherapist when I was unable to get my license to practice here initially.  I sat six CLEP exams, taught myself economics, and attended a night chemistry class while working by day, all in an attempt to fulfill the requirements.  Despite that I was again failed by the Foreign Credentialing Commission by 1/4 of a point.  An eleventh hour trip to the DC Board who subsequently gave me a license meant that I remained in the USA.

My first job here was not a good fit and after many months of distress, having lived in the USA for only one year, I made the decision to return to Australia.  I believed so firmly in my heart that I was meant to be here, but between the job and difficulties obtaining my license I was faced with the possibility that I had been wrong.  At the time I was volunteering in the athletics department at Georgetown.  Upon hearing of my imminent return to Australia they advised me that they were unable to hire me due to budgetary constraints.  Two weeks before I was due to leave, my belongings booked to be shipped to Australia, a moment occurred that changed my life forever.  An interaction with the head basketball coach, and his subsequent intervention, (perhaps buoyed by a recommendation from a former Secretary of State), saw them create a position for me.

After cancelling the shipping and placing my belongings in storage, I returned to Australia temporarily to obtain the appropriate visa.  When I next landed in Washington DC I had the strongest sense yet that this was home, at least for a while, and that my dreams could become a reality.

From this experience I learnt some of the most important lessons in life: 

  1.  If you have a dream, hold onto it, believe in it, and don’t let it go, even when everything before you seems contrary to your vision.  It only takes one little miracle and it can all change in a second.
  2.  Be willing to forgo who you think you are to be who you want to be.
  3.  Persist, and when you are done persisting, persist.  It is likely that this is when the breakthrough is nigh.
  4.  Making the right decision for you, even if it seems like a step backwards, is often the inertia that the universe requires to bring about the positive momentum to move forward.

I’ve still many dreams left to fulfill, but I’m living the life I imagined!

Scott, thank you for this fantastic interview! I appreciate all the knowledge and lessons you shared. Maybe I’ll see you in class sometime!

Follow Scott on twitter: @ScottEpsley

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