“No Brainer” Exercises

As I was recently reading Dr. Dan Vaughn’s last editorial in JMMT, “A Lasting Legacy“, I was struck by a magnifying statement that he made concerning past treatment approaches.  Dr. Vaughn, as many were in that time (I wasn’t born in 1978 but taking his word for it!), were using William’s Flexion Exercises as the typical approach to treating low back pain.  He explains that the thought at that time was that these exercises were “no brainers” and should be the norm.  We now know that is not true.  Honestly, I do not know who does the William’s Flexion Exercises anymore…does a dead bug maneuver sound enticing to you?

Not to discard the focus in this article illuminating Robin McKenzie’s work for our profession, but this statement struck me.  Not because my high school baseball coached half-spit, half-yelled this phrase; but it strikes deep, just as it did for Robin.  During the time of McKenzie’s ‘invention’, he was on the far left side of the curve.  He can also known as a, no, the innovator for low back treatment.   Refer back here to which side of the curve do you practice?

What do we do now in treatment that we perceive as “no brainers”, but in reality will look back on in the future and slap ourselves?  For the modern age, we may even give these a hashtag of #SMH #whatwasIthinking

So, I would like to take a poll?  It doesn’t have to be for back pain, but what exercises, approach, etc. do you think we will look back 20 years from now and hide in our memory???

 

 

Xtension Desk in Advance Magazine for PT

The workspace literally hasn’t changed since cubicles came into the picture over 30 years ago.  Physical therapists need to be front runners in the prevention of musculoskeletal injuries from the prolonged effects of desk sitting.  Our field is lucky that we are able to move with our patients and not be stagnant during the day.  Think about how awful you feel when you for a 3 day weekend course and have to SIT the entire time…then do this 5 days a week for 30 years.

If we do not promote a workspace that moves with you, some other profession will (hopefully not kinesiotherapists…who are they by the way?).

 

 

Check out a recent article here in Advance Magazine for PTs by Craig Dye, the Founder and CEO of the Xtension Desk,  and myself discussing the impairments associated with prolonged sitting and promoting a more active lifestyle while you get your work done!

Remember, the best posture is the next posture. You can find the article on page 22.

 

 

 

Goniometer Apps

Looking for the right goniometer application? I am in the middle of a “systematic review” with the Medical App Journal. A few of my reviews have been published on its site here. Scan below for the latest 3 and be sure to check out the Medical App Journal if you are looking into purchasing an application for healthcare as they are all peer reviewed, and many more being added daily!

Photogoniometer

PhotoGoniometer

Joint Goniometry

Joint Goniometer

 

Simple Goniometer

Simple Goniometer

 

What do you think of the reviews?  Do you use a goniometer application instead of standard goniometer in your practice?

Sitting WILL become our population’s demise

Sitting. This is the new smoking as experts may say. It will become the demise of the general population, either through musculoskeletal injuries as we see daily to significantly higher cardiovascular risk.

I am the healthcare representative of the Xtension Desk; a product designed to make the static desk job…well LESS static! The company is utilizing a form of crowdfunding to raise the final funds to make the prototype reality. I am not a salesperson, actually did not take over my family’s three generation store to become a physical therapist.

However, I am a believer. I believe in this product, this concept…and most of all the negative effects of prolonged sitting. As a musculoskeletal expert and practicing clinician, just like all of you reading this blog, I see the ill effects of sitting in all my patients over the years. It is an opportunity to become more active in our prevention, and treatment, of MSK disorders. It may be that final straw to get someone over the hump for improved health.  The 10 reps of standing lumbar extension or trip to the water cooler is just not going to do it…

There are plenty of products on the market, but none that can be promoted by the professionals who know their stuff….US. Check out the Xtension Desk’s website and let me know what you think. You can even find an article in the upcoming Advance for PT magazine (I’ll link out when it becomes digital).

In the meantime, check out this infographic that I got from a recent Slate magazine article.

Medbridge: sale ends Wednesday!

Be sure to visit Medbridge before Wednesday, July 31, as sale for 60+ CEU courses is only $200!

This is by far a great deal to some of the best content on the web. The courses are taught by leading faculty and instructors in all realms of therapy, not just orthopedics.

Let me know what you think!

This is rewarding and disturbing all at the same time

I had a past DPT intern contact me after starting another internship following our clinical. I cropped out a few jokes and other personal information, but read the following:

This is rewarding and disturbing all at the same time! Rewarding in that my hard work and preparation of providing the best clinical internship combining the 3 pillars of EBP has been welcomed by the future of our profession. But mostly disturbing in that the intern’s experience as described is exactly what I hear way too often.

I won’t blab on my soap box here but if you’re going to take a student, step up your game. I can certainly remember my clinical experiences (as I can remember my 2nd grade teacher), so you are making a dynamic impact on an individual. Remember, the ~$70 grand that is spent on the DPT degree only has about 5-6 internships. This is a low number for field work that a student experiences. These observation patterns and reflection for a student can mold practice patterns for years to come.

One of my favorite quotes:

“Nothing will impede our progress towards Vision 2020 more than a group of students having evidenced-based practice in adequately modeled in clinical settings” -Steven George, Guest Editorial

Are you, or did you, have a BAD experience as a student?  How can we improve our clinical education???

 

The Foundation’s new major fundraising campaign : An Interview with Bill Boissonnault

During the Foundation for Physical Therapy’s Annual Gala held at APTA’s Conference in Salt Lake City, the Foundation announced a major fundraising campaign to establish a new Health Services and Health Policy Research Initiative. The press release announcement from the Foundation can be found below (and linked from FPT site here). I had the pleasure to speak with the Foundation’s President, Bill Boissonnault, concerning the mission of the Center of Excellence and how this project will impact the profession of physical therapy. The interview is not verbatim, but an overview paraphrasing our conversation.

Harrison: For those who do not know much about the Foundation, what is it and it’s purpose?
Bill: The Foundation for Physical Therapy was established in 1979, an organization with 30 plus year history. It is a non-profit, charitable organization designed to improve the quality and delivery of physical therapy services. It is not a political entity, but has the role of raising money for research and researchers. So in short, it’s mission is two-fold:
1. Raise money for researchers within PT
2: Increase number of researchers in profession.

Harrison: How is this initiative different than ones in the past?
Bill: The Foundation was initially established for two reasons:
1. The profession did not have nearly enough evidence for what we did
clinically and
2. The profession did not have enough therapists with
clinical research skills

This was the need in 1979 and over the past 30 years we have funded over 500 PT researchers and provided $13-14 million to these researchers, but we are now learning that success within the clinical research arena doesn’t necessarily translate to the health services and policy arena, the arena that drives patient access, effectiveness, resource utilization and reimbursement issues. We need more data on patient access to rehabilitative services and its cost effectiveness. We need more data and results in the health services and policy realm. And again, just as in 1979, we do not have a sufficient number of PTs that have the skills to do health services and policy research. We need more data in the role of rehabilitation in health services, as well as more researchers in this field too.

Harrison: Other than the mission for this campaign, why is this announcement such a big deal?
Bill: By far, this will be the largest single grant the Foundation’s ever awarded. We raised $1.4-1.5 million to fund a clinical network a few years ago, and as stated we have funded over 500 PT researchers over the years, but this will be the largest single award the history of the Foundation! >

Harrison: It seems as if you are well on your way to meeting your goal of raising $3 million, how is this possible so quickly?
Bill: This is an urgent matter. High quality health services and policy data is needed for us to present a strong case for the role of physical therapy in the health care delivery landscape. The goal is to raise 3 million (already have 1.9 million) by the end of 2013. APTA spear headed this campaign with a $1 million pledge that has advanced this timeline. We are right on schedule . There is urgency behind this and the Foundation is working hard to make up for lost time. This should have been started years ago.

Harrison: What are you looking for from readers of this blog and physical therapists all over the country?
Bill: There are several stages of raising money. The initiative so far has been behind-the-scenes until it was publicly announced at APTA Exhibition in Salt Lake City. We need to continue to raise money before we begin accepting applications for the most qualified institutions and researchers to lead the training program. We are expecting to raise the remaining money by the end of 2013. Donors can visit our website foudation4pt.org to learn more.

I can understand the urgency by Dr. Boissonnault here! If anyone has to deal with the Medicare (G-Codes especially) changes over the past few months, then you know our profession is, for some reason, under the radar. It doesn’t seem to be leading in the right direction but I do believe an initiative such as this will propel us down the right path.

I want to thank the Foundation and Dr. Boissonnault for the time to speak to me. Please share via social media to assist in getting the word out to all.

Here is the Press Release for you to read as well:

The Foundation for Physical Therapy Announces Fundraising Campaign for a Major New Health Services Initiative

ALEXANDRIA, VA (June 13, 2013) – The Foundation for Physical Therapy announced today that it will launch the public phase of a campaign to establish the nation’s first center dedicated to expanding the number of physical therapy scientists in the field of health services and health policy. The announcement will take place at the Foundation’s annual gala at this year’s APTA Conference and Exposition on June 27-29.

The mission of the Center of Excellence (COE) is to train the next generation of physical therapist investigators who will gain skills necessary to examine effective delivery, organization, financing, and analysis of outcomes.

The campaign for this 5-year initiative has surpassed the half-way mark, with $1.7 million raised toward the goal of $3 million. Its progress so far is due in large part to a generous leadership pledge of $1 million from APTA and through 100% participation in the campaign from the Foundation’s board members.

Other significant contributors include the Magistro Family Foundation, APTA’s Tennessee Chapter, Wisconsin Chapter, Section on Geriatrics, Home Health Section, Neurology Section, Orthopedic Section, Private Practice Section, Section on Research and the Sports Physical Therapy Section.

“This fundraising campaign will support the largest grant in the Foundation’s history,” said Foundation President William G. Boissonnault, PT, DPT, DHSc, FAPTA, FAAOMPT. “We are extremely pleased that APTA has made this generous pledge to help the Foundation launch the COE. And we are grateful to its chapters and sections that have committed to helping us move forward with this initiative. We will soon be reaching out to additional APTA components, individual members and organizations outside the profession in order to make the center a reality.”

High-quality health services data is more essential than ever to the profession for 2 reasons: (1) to investigate evolving practice models that focus on the prediction and achievement of optimal patient outcomes, appropriate resource utilization, and cost effectiveness related to physical therapy practice, and (2) to help the profession make a strong case for the role of physical therapy in health services delivery as health care reform is implemented in legislative and regulatory settings.

“The physical therapy profession is in great need of scientific data defining and supporting physical therapists’ role related to health services delivery,” said Boissonnault. “While we have made strides in this area, there is a tremendous call for outcomes data associated with the most effective ways to deliver, organize, and finance health care delivery.”

The Foundation will award a $2.5 million grant to the most qualified institution or health systems network to set up and manage the training program, which will expand the number of physical therapy investigators conducting health services and health policy research. The request for applications for this opportunity is currently under development.

This new cadre of physical therapists will specialize in studies focusing on the many areas of health services and health policy research, which could include resource utilization, costs, and quality, and will work to identify the most effective ways to deliver, organize, finance, and assess outcomes. The training these scientists will receive will allow them to:

● Answer key questions related to best physical therapy practice principles and models

● Assess information from electronic health records and other large scale databases and registries

● Build capacity for creation, dissemination, and application of health policy knowledge among practitioners, policymakers, payors, and other stakeholders

“We fully expect this initiative to change the face of physical therapy and its role in health care delivery. Through the generosity of our contributors so far, we now have great momentum, and we look forward to working with more of our supporters to reach our $3 million goal,” said Boissonnault.

Knee pain case report using MDT

I recently read a great case report in the most recent JMMT. As mentioned before here, if you don’t read case reports and only stick with “higher level evidence”, you will only set yourself back as this level of evidence is significantly important in opening up your vision. I know case reports will not change our reimbursement rates and some of the more new issues along this realm that we need to address, but I feel that if our results continue to improve through cases like this, then it will elevate our status in the medical field and continue to push us to be the primary choice for musculoskeletal care.

I applaud the authors (Greg Lynch and Steven May) for writing this case up to be published as it certainly should get into the hands of all physical therapists. Here are some points that I will like to add to this report:
1. Cookie Cutter Approaches do NOT work. Ugh, I get on my soap box with my interns over this (enough that veins come out of my forehead!) but won’t spend too much time on it as I’m preaching to the choir. Nevertheless, the screenshot above of what was performed prior to this bout of physical therapy is true cookie cutter. In short, it pisses me off.

2. Simple management concept: Restore ROM first. Especially extension.
As mentioned in the article, the directional preference for this case was knee extension. I would definitely say this is the movement that is we need functionally and the best choice for success overall. Did the previous physiotherapist feel performing hamstring stretches and ultrasound was going to get this? Only in simple cases, and this is where Google Search for a client will get themselves better on their own.

3. Directional Preference is a high percentage shot.
Directional preference is classically thought of for the spine but as show in this article, it can be of significant benefit in the extremities. As I teach my interns, look into finding this first as it is similar to making a lay up instead of 3 pointer. It is a high percentage make and can get results, or points on the board. If not found, go on to other basic movements or manual therapy. And if found, great, go with it and then add other basic movements and manual therapy. Just don’t leave this simple concept out to dry.

4. Less is more.
I love that the authors only prescribed passive knee extension in several type of loaded positions! Wow, and the patient got better?! Once you restore ROM (reduce the derangement, improve arthrokinematics or however you want to look at it); the body can mend itself. Look at this past report on myself. The body just needs that simple mechanical stimulus. That stimulus doesn’t have to be 1 hour in the physical therapy clinic and 10 exercises for home. Less is more=greater compliance

5. You don’t have to be McKenzie trained to perform this strategy and execute in this manner.
I am not McKenzie trained, nor taken one single course. For those who are, you may frown upon me but I understand the concepts. I love the assessment process, and I use a mutt approach with it through my own assess / re-assess model. Would I benefit greatly from taking courses? Absolutely and will probably be on the calendar in the future but don’t limit yourself to great results if you don’t have a practitioner’s name behind your degree. McKenzie doesn’t own the term directional preference as chiropractors do not own the term manipulation. Use it and develop it further to add in your go to treatments based on your clinical experience and the patient’s circumstances right in front of you.

Oh, one last note: if your go to treatment is ultrasound and hamstring stretches, refer back to #1 and retire already. And this was done overseas, I thought physiotherapists didn’t do this stuff, only physical therapists?

Law of Compensation

Looking back at the roots of orthopaedic manual therapy takes you through the streets of osteopathy and in some instances, chiropractic. These streets, to an extent, helped paved the manual therapy path for our past legends especially, but also current practitioners and future leaders. Even though we have not stayed on these roads directly, we can’t deny our current practices on these professions’ history; both the positives and negatives.

That being said, it is interesting to read about the roots of Andrew Still and Daniel Palmer & their respected concepts. These guys looked at treating the patient through the joint and we now know their philosophies are flawed, I am assuming it was somewhat of a breakthrough in the late 19th century. They had the, well male body parts, to come up with “Laws” to define their work. Osteopathy was known as the “Law of the Artery”, whilst Chiropactic was known as “Law of the Nerve”. These theoretical basis are the cornerstones of what was wrong with patients and how their treatments healed them.

The question to myself after learning this is, “what is the law of physical therapy”. Considering our field is very broad, I will rephrase this to, “what is the law of orthopaedic manual physical therapy”. In one word, can we come up with a phrase?

I am recommending, “Law of Compensation”. I say majority of my spine pain cases do not have a direct mechanism of injury, it simply arises out of thin air. Patients wake up with it one day but have known for years on one side of the spectrum that they should have been more active or on the other side of the spectrum, cross trained to avoid overuse. For simplicity sake, our bodies are always in survival mode. We have a niche to be in homeostasis and some areas will compensate to cover others. Simple examples are shoulder shrug sign while trying to elevate the arm and compensated trendelenburg during gait. In reference to sports, this is similar to someone on the team stepping up and “carrying the other members on their back”; no pun intended. One day it will have enough, boil over and let the brain know it is time to seek help. Pain hits the clock alarm and wakes the patient out of deep sleep. Hopefully the brain will also send the patient to a physical therapist to find this compensation or ugly ducking of the group. It is our job to provide instant, rapid relief; but dig deep to find the weakest link. If you just crack, needle, massage or mob without finding the mole; you might as well keep the book closed as you are not in shape to move on to the next chapter.

The initial philosophies of these guys may be what we will see on late night TV now, but it did give them a framework that has allowed these professions to stand for over a hundred years. Even though the TV tray’s legs may be wobbly, patients still seek out their care. Unfortunately for us, it is sought out more frequently and their history gives them more substance in treating musculoskeletal pain.

Maybe we need a Law?

What do you think should be our Law? What do you think of Compensation?

The Power of Manipulation

The witch on your right should stir more!

I am not speaking of the force a practitioner needs to provide in order to manipulate a joint, but, the commanding value of manipulation on patients.  Let me explain further.

I recently had a past patient of mine call to schedule as he recently (within 2 days) hurt his low back while lifting a small object at home.  He described it as giving way and he thought something was ‘out of place’. He was under my care about 6 months ago for a different condition (3 visits for mid-thoracic spine pain) and one of the interventions provided was manipulation, which he enjoyed and attributed to his success.

Now even though in the last episode of care and this one, I combined the effects of manipulation and exercise, the patient’s values and perceptions really played a large role in his successful outcome.  I knew deep in my head that he would need more than manipulation to the low back, but it was a factor that would be idiotic to leave out. I would probably say only ~20% of my treatment is manual whilst 80% is assessment and exercise-driven, but that 20% (or if you want to think of simply one manipulation…5%) of the total treatment time when I saw him 6 months ago is what stuck in his head.  This is what he remembered.  It was possibly the mechanical stimulus needed to get neurophysiological effects and even affect descending signals from the brain, who knows.

Nevertheless, when he injured himself at home, he knew directly who he wanted to see….his physical therapist.  Not his massage therapist, chiropractor or primary care physician.  The physical therapist.

I don’t normally “use all my tools” (even though I really don’t like this term!) on every patient, it is something to think about when providing an intervention.  We do know there are subgroups of individuals who benefit from manipulation (or mobilization, traction, etc.) looking through impairments, but don’t forget the patient preference. That 3rd aspect of evidenced-based medicine may be what is needed.  Don’t forget its power.