What angle are you addressing your patients?

There is an old saying in the orthopedic manual world that goes to the tune of:”You can teach a monkey how to manipulate, but not why and when to manipulate”

Any clinician who has been around the realm of manipulation in clinical practice can relate to this statement. However, I think it can apply to other aspects of our care too. Let me give you an example.
During one of my recent e-mentorship sessions, my mentee was providing me a story of a patient who is seeking his care after failure to improve following 4 weeks at another facility. This individual is diagnosed with achilles tendinosis.
What comes to mind when treating this diagnosis?
I guarantee a large percentage of you, including myself, jolt with excitement and say, “eccentric training!”

We say it without much thought as it is what the research says works. The highest of the evidence pyramid glows with excitement.  

But in this case…it didn’t work. The patient wasn’t satisfied…the outcomes were not positive. The patient decided to seek out a cash based service.  

Fast forward a few treatments — patient recovered and returned to soccer.

So what was the difference?

I can’t take the credit as my mentee did a full examination and came up with a plan of care. He did it all and came from a different thinking process.  I can say that the treatment was based on concepts and principles. These concepts and principles that have been around for decades and do not fail.  

So what’s the moral of the story?
“You can teach a monkey to read the research, but not why and when to use the research”
Literary articles are intended to be another layer to your treatment to justify it even further based on your assessment using concepts and principles. In this case, the research was the first layer versus secondary or tertiary layer.  In this age of evidence , I continue to urge the importance but at a different layer.  
If you find yourself doing the following:

Give my e-mentorship program a shot. I personally believe you are attacking the problem from the wrong angle. 

Let’s work together to get your patients better— quicker — give them that experience we all look forward and spread the good news.  
Next time you want to spend $100 on a local continuing education course for a day, give me time once/week for a month.  I guarantee it’ll change your thinking process and up your game.  Contact me so we can work together personally to make you a better clinician and get the outcomes your patients deserve. 

APTA Launches #ChoosePT Opioids Campaign

All,

Just received email from APTA promoting a new campaign to position PT as a safe and effective intervention for chronic pain instead of opioids.

In case you do not get emails from APTA or follow through social media, I am forwarding the email below.

I deal with chronic pain on a daily basis and it is an uphill battle of course but we have the best measures conservatively to help our patients with minimum to no use of prescription medication.  Continue to aim high!

———————————————————————-

 

Hi, all:

 

Today, APTA launched a campaign called #ChoosePT to position physical therapists as a safe and effective alternative to prescription opioids for long-term pain management. For the past six months, we’ve been planning the campaign, which includes elements of paid, earned, social and owned media. Here is a link to the press release, http://prn.to/1X72HPe.

 

While APTA will initially focus outreach in states where the CDC has identified high abuse and opioid prescribing trends, this is a nationwide effort to position PT as part of the solution. Coincidentally, opioids have taken a tremendous toll on families and communities in Tennessee, so we strategically chose to launch the campaign in Nashville, while we’re in town for NEXT Conference and Expo. We’ve placed four outdoor billboards in high traffic areas on I-40 going into and out of Nashville and they will be up through July 6. The Country Music Festival and Bonnaroo attracts hundreds of thousands to this area during this time.

 

Other elements of the campaign include a print PSA distributed nationally to small community newspapers,  a national digital ad buy targeting websites where consumers are searching for health information, a professionally produced and nationally distributed television and radio PSA, social media promotion and engagement, and targeted media relations outreach to reporters covering the opioid epidemic. We will be working with chapters and sections to generate local support for the campaign, specifically during Pain Awareness Month in September and National Physical Therapy Month in October.

 

Please consider supporting this campaign by tweeting and blogging about how PTs treat pain through movement and the importance of patients and health care providers discussing and choosing safer alternatives, including physical therapy.

 

#ChoosePT is both a theme and call-to-action and will be a central part of our consumer campaigns going forward. Here is a link to the landing page, featuring patient tools and resources, www.MoveForwardPT.com/ChoosePT.

 

Let me know if you have any questions.

 

Thank you,

 

 

Erin Wendel-Ritter, APR

Senior Media Relations Specialist

American Physical Therapy Association (APTA)

erinwendel@apta.org

Phone: 703/706-3397

Fax: 703/684-7343

Web: www.MoveForwardPT.com

Introducing my E-Mentorship Program

I have been fortunate over the years to have fantastic mentorship from clinicians, both in the clinic and through formal education.  It is even one of my “5 L’s—Lean” that I have written about in the past.  I find that mentorship, or apprenticeship, is a key component of clinical care that is lacking in our current clinical education system and even more when entry level DPT students graduate.  Granted, the residency and fellowship programs have blossomed over the years, but not everyone is at the financial or family state to go that route.

I continue to strive for more knowledge and gain insight from others, younger and older than I am.  I really enjoy continuing to mentor DPT students and current DPTs in my clinic.  It is a passion of mine and we both, as well as the patient, gain from this experience!

I know others outside my clinic seek out mentorship, either in their clinic or social medium. I  see cases written on the DPT student Facebook Page and other social mediums asking other professionals opinions on diagnostics and treatment options for difficult cases.  Therefore, I know it is a continued need in our profession.

I am now introducing an E-Mentorship Program that I am providing digitally.  It is something I have wanted to provide for awhile, but never got around to do it.  Here are the basics:

• I plan to run it just like I would with a DPT student, entry-level clinician or fellow in training—-no gimmicks, not selling “an approach”, or formal lectures through powerpoint—but straight up clinical mentorship with cases that you are seeing right now.
• My entire career so far has been in a rural environment treating chronic pain and spinal conditions.  No offense if you see mostly post-op (as I don’t…), so not interested in mentoring TKAs—but I specialize in the assessment and treatment of headaches, dizziness and all spinal conditions—-the ones that YOU will be the primary clinician for as not appropriate for surgery and want to get off of medications.
• If you want lecture format and an 8 hour day course—go to a weekend con ed course.  This will be simple hustle and old school apprenticeship — just in a modern environment that is now available digitally compared to having to be in the clinic with you.

If you would like more information, visit my E-Mentorship Program page and/or contact me at harrisonvaughanpt@gmail.com or call at 919-728-0035

 

Finally…Solving the Doctor – Physical Therapist Confusion

Degree.  

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Profession.  

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Simple.        Elegant.       Straightforward.

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  Problem Solved. 

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Get one for your office.

 

STAND: The Haiti Project

I want to share this video that was just released by the STAND Haiti Project, an organization in which I have written about in the past and fortunate enough in my short period to meet and get to know the organization’s prime move, physical therapist—Dr. Justin Dunaway.  This video WILL move you, no matter who you are and where/how you practice within the field of physical therapy or medicine.

It is a collection of fantastic footage of the organization’s trips to Haiti and I am proud—-no honored—to know several of the Fellows that you will see in the 14 minute film.  If you have the drive and opportunity in your life that matches your beliefs, capabilities and heart to volunteer—-that is allowed by your financial and family conditions—I strongly recommend this group.  I have not had the chance to attend due to aforementioned conditions but if interested in seeking out opportunities outside of the states—please do contact this group.

Best to all,

Harrison

Updated website

To all readers,

Thank you for your continued support and following over the past 7 years!  If you have visited my page in the past few days, you may have noticed some changes.  I am currently tackling a huge task of overhauling my blog site and make it more professional and up-to-date with the times.  I am also moving away from solely a blog but more of a physical therapy camp for me personally as I continue to treat but also provide research and information related to the field. I apologize if you follow me on social media and received all kinds of updates as I am learning the new system as I speak!   In short, it is still “under construction”.

I hope you enjoy the new look and options.  To fill everyone in, here are the major updates:

• Treatment option page.  This page is intended for current and potential patients of mine.  If you know someone who could benefit from physical therapy services in North Carolina or Virginia, feel free to send them my way.
• Mentoring page.  I have been fortunate enough to provide mentorship to DPT students over the last 7 years.  I am always learning and find this as an opportunity to teach what I know to you, but also create relationships and constructive conversations in the field of physical therapy. This site is intended to expose my availability to mentor current students, young graduates and fellows-in-training of the American Academy of Orthopaedic Manual Physical Therapists.  If you would like to know more about mentorship options, feel free to contact me.
• Consultation page.  I have in the past and currently provide consultation services in the field of physical therapy on products, books and the like.  If you or a company would like to consult with me, feel free to contact me.
• Course Offerings. This page is dedicated to any teaching topics and courses I plan to handle in the near future.  It is always updated so feel free to browse at any time.
• Research Portfolio on Orthopaedic Manual Physical Therapy.  This is a new adventure and way for me to translate research to you and the community.  It is a project that will continuously be updated with focus on manual therapy research for musculoskeletal conditions.  Considering it does not update through my “blog format”, if you want to know when information is updated, feel free to add me on any of my social media mediums (twitter, Facebook, LinkedIn).
• Blog.  And of course I can’t forget the reason I started this…blogging!  Even though posts have been more scarce as of late, I will continue to update the blog as I can.

I have fallen behind in the blog scene as a frontrunner in the PT blogging field but proud to say this site continues to be one of the oldest single author in the physical therapy community. Thank you again for your continued support over the years and hope you enjoy the new look and upcoming growth!

Kindly,

Harrison

AAOMPT Conference 2015 summary: Technique doesn’t matter, or does it?

The title to my blog is, “Physical Therapy Blog on Evidenced-Informed Orthopedics, Manual Therapy and Knowledge Translation from Academia to Clinical Practice” with a primary emphasis on the bolded phrase.  With the blog and intern teaching, I try to mingle all 3 aspects of EBP but especially giving a fairness to the two that most of us fight over presently, and more than likely until the end of time…which are “current literature and expertise“.

The separation of research and clinical practice was quite evident this past weekend at AAOMPT conference 2015.  If you haven’t been to a conference before (this was my first), this is the general set-up:

• There are several presenters (researchers) who give lectures on their topic based on a common theme to the entire audience in one room.  Then, there is a roundtable discussion with hot questions aimed at them on their opinions of clinical practice, manual techniques, etc. with regards to current research.
• The other aspect includes break-out sessions presented by clinicians based on a topic of choice.  These usually include some type of clinical reasoning, technique, and/or differential diagnosis on a topic related to OMT and orthopaedic practice.

To summarize briefly, the main lectures presented by researchers examined information on big data and how whole health services research will help in managing low back pain. Two main points came out of it:

1. Outcomes improve the earlier someone sees a PT.

2. The OMT technique doesn’t matter.

To summarize briefly, my experience listening to lectures in break-out sessions presented by clinicians:

1. Case studies / series showing results & outcomes of specific techniques / approaches when other general PT failed.

2. The OMT technique does matter.

But now this can’t be right.  Big data research shows technique doesn’t matter—get patients in, move them, and move on.  But clinicians presenting show specific techniques/approaches and wail that technique does matter…

If the national conference in OMT doesn’t agree, then how can I, in rural Virginia, extrapolate the information given to me by experts in the field?

How do I know what to turn to, research or expertise?  Which mainly drives my practice? In 2013, I asked readers of this blog a very similar question.  Here are the results.

Now granted the big data research topic involved low back pain, which we all know may not the most suitable subject for this talk….

We all want to balance being a clinician and researcher (clinical researcher), just like a collegian balances being a student and athlete (student athlete).

To paraphrase an expression from a good colleague of mine, Dr. Eric Jorde:

…just like student is first in a student-athlete, should clinician (expertise, gut feeling) be first in clinical-researcher?

Interesting reads from some of our own on this topic:

Should we move beyond the technique?

Should we move away from the product?

 

What are your thoughts?

 

APTA Advocacy App for Android and iOS

The following post comes from Brandon Whittington (twitter / google plus), a soon to be graduate from Lynchburg College DPT program.  He has interned under me for the past 16 weeks, a real tech geek and wants to share the following information to the physical therapy world.

As a student physical therapist I like to stay involved with advocacy in the profession of physical therapy, however, sometimes (often) I find that things like emailing legislatures and keeping up with relevant topics and upcoming meetings gets overlooked.  Recently I came across this gem of an app below called the APTA Action app.  The application is featured on the APTA website and is available for Android and iOS devices for download.  This app really has made my ability to quickly keep up to date and take legislative action quickly and easily. I particularly like the Action Center feature, where you can take action as an APTA member or patient. The app does all the work, fills out the whole form and sends the email on your behalf with minimal work required for the user. I’m hoping for push notifications when new actions become available but for the time being, there is nothing like it to stay involved easily and quickly. Check it out, show your patients and spread the word!

 

 

Note from Harrison: Thanks for the post Brandon and great job! The limitations in getting involved with legislative action and advocacy within our field is barriers with time and access.  I am guilty as most of us are! I do think this application is concise and considering we all have phones, a quick and easy way to stay up to date.

Using tuning fork in addition to Ottawa Ankle Rules

I had a female patient come into the office the other day complaining of left ankle pain following tripping on the ice the day before after leaving her home having an inversion ankle injury.  She was currently being treated in our clinic for balance and hip pain, but hasn’t sought care from a medical physician for current complaint.

Upon examination, she was able to walk into the office but marked antalgic gait pattern using a standard cane (which she always uses).  She acknowledged that she was able to walk immediately following the accident and feels symptoms are getting better.  She had apparent swelling in the lateral/inferior aspect of the rearfoot with ecchymosis noted in this region as well (black/blue, not yellow).

Notable objective findings:

Positive Ottawa Ankle Rules with Bone Tenderness at B, but negative for other realms of the guidelines.

courtesy: http://www.bmj.com

She also had negative provocation to moderate depth palpation to the anterior talofibular ligament and posterior calcaneofibular ligament.

Additionally, she had negative pain provocation with 128hz tuning fork at location B and ~4” above this location along fibula shaft.

My course of action was education that I did not think she had a fracture, but I could not rule it out 100%.  She had a positive finding on the Guidelines and it would be best to seek out a plain film radiograph.

Outcome:

She sought care from PCP, had x-rays and they were negative.

Clinical reflection

Therefore, it got me thinking more about how to fine tune the specificity of the Ottawa Ankle Rules, as they only have ~32% specificity, which is very low.  I would suggest the probability of an ankle fracture arriving in a physical therapy office is much lower than at an emergency room (where initial rules arose), therefore, the specificity of this test would be even lower.  So, the average 13% of inversion injuries that are fractures could be more around 5-7%, even lower! Therefore, the rate of false positives would be even higher.  After speaking with her, examining her walking in the clinic (more than 4 steps), the time frame from injury over 24 hours ago and her opinion that it was only a sprain—all gave me a hunch that she did not, but went with the clinical guidelines.  Therefore, I did some research.

I came across this article by Dissman and Han in 2006.  They examined the result of tuning fork test on the tip of the lateral malleolus and distal fibula shaft and compared it to lateral & A/P x-rays following an inversion injury.

 

Based on Table 3 above, the sensitivity was still at 100% but specificity increased to 61% to the tip of the lateral malleolus and 95% to the distal fibula shaft, therefore, the specificity increased 3 fold if positive tuning fork test to distal fibula shaft and two-fold to tip of lateral malleolus.

This was only a pilot study and had large confidence levels, so take what you want from it.   I have seen several cases in the past where I did not think there was a fracture, the patient did not think there was a fracture, but the guidelines are unable to rule out.

So, my question to you….do you utilize all 3 aspects of evidence-based practice or rely just on the research guidelines?  I know it is best practice for this case to refer out for imaging, but what about other diagnostics that are less sensitive…such as clinical instability tests and/or vertebrobasilar insufficiency?

 

 

Dissman PD, Han KH. The tuning fork test—a useful tool for improving specificity in “Ottawa positive” patients after ankle inversion injury. Emerg Med J. 2006 Oct; 23(10): 788–790.

doi:  10.1136/emj.2006.035519

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579601/

45 years later, reality may finally set in

Any manual therapists in the physical therapy / physiotherapy world should know the influence of Dr. James Cyriax.  Essentially, he can be the reason that our profession has the ability to perform manual therapy, especially manipulation.  He has been quoted to say, “physiotherapists were the most apt professionals to learn manipulative techniques”.  Some may say that he was light years ahead in current thinking in regards to care for musculoskeletal conditions, especially in regards to clinical reasoning biomechanics, anatomy and physiology.

I recently read one of Cyriax’s column, entitled Manipulation by Physiotherapists in The Australian Journal of Physiotherapy in 1970.  Yes, 1970…45 years ago last Sunday!  You may find the cropped sentence below interesting.

 

I’ll highlight the sentence worth mentioning, …“the successful candidates were placed on an official register of manipulating physiotherapists to which doctors refer when seeking such treatment”…

The summary of the column is exactly what is in the title: Manipulation by Physiotherapists.  Cyriax makes the argument that we can the best advocate of this intervention and if we do not perform it, then patients would seek out other practitioners (in this article, bone setters, hence its age) to have manipulation.

The bottom line is, why not have specialized physiotherapists who have been successfully trained and have the foundation knowledge in the sciences, as well as connection with the medical field?  If appropriate, these specialists can be referred to specifically by medical physicians or sought out personally by consumers?  Cyriax had this dream 45 years ago, now is it a reality?

If you want the following article, email me and I’ll send you a copy. 

Cyriax J (1970): Manipulation by physiotherapists. Australian Journal of Physiotherapy 16: 32-36.