As a growing therapist, I believe it's crucial to take advantage of what the internet has to offer in terms of having access to knowledge of experts around the world. Here is a compiled list of the articles I've read in the month. Feel free to share with me articles that you found insightful and useful for your development as a person and as a clinician!
Probably one of the best posts I’ve. This is pretty much Tim Ferris’s “Tool of Titans” for PTs. THIS IS A MUST READ.
Jarod Hall asked fellow prominent clinicians in the field their thoughts on concepts necessary to understand to be the ultimate clinician. He organized and compiled everyone’s thoughts without changing their words. These are foundational thoughts that from my own experience get’s lost or never is understood by young PTs.
One of the more trendier concepts that has been tossed around during physical therapy school. It seems that a specific generation of physical therapists are still mystified by the magic of fascia. There is plenty of evidence and well written articles like this that helps unveil what fascia is NOT.
“I’m genuinely pleased to see Myers write this (and he must have known when he wrote it that it would be enthusiastically quoted by his critics): “I am so over the word ‘fascia’. I have touted it for 40 years — I was even called the ‘Father of Fascia’ the other day in New York (it was meant kindly, but…) — now that ‘fascia’ has become a buzzword and is being used for everything and anything, I am pulling back from it in top-speed reverse. Fascia is important, of course, and folks need to understand its implications for biomechanics, but it is not a panacea, the answer to all questions, and it doesn’t do half the things even some of my friends say it does.”“
Learning more and more about spinal manipulation and it’s non-specific effects on the body, I’ve become more cautious in implementing it in my own practice. Having been front loaded on the benefits of manipulation, it’s good to come across other evidence that’s contradicting.
“Therefore, no measures, primary or secondary, produced any sign that SMT has any meaningful effect on migraine compared to a sham, and so the authors concluded that “the effect of chiropractic spinal manipulative therapy observed in our study is probably due to a placebo response.””
I’m really enjoying the articles I read from Todd Hardgrove. He discusses in this article why it’s really crucial to understand what and what not the intervention you choose does to the patient. I understand that many things I learn now, will have to receive this same treatment as I grow as a clinician. It’s not about being right on my own beliefs, but about providing the right intervention for someone else.
“There are some good answers to these questions, and the interesting thing I’d like to point out in this post is that quite often, the therapist doesn’t know them. Or even care about them! Or maybe the therapist has heard the good answers, but prefers alternative bad answers that are far less plausible given the current state of relevant science.”
“Of course it’s kind of a bummer to learn that a central premise of your education is incorrect. But the good news is that this doesn’t mean people can’t be helped with your treatment. That is a completely separate issue.”
My buddy David shared this article when we talked about how each generation learns different as the world revolving parents are constantly changing. This concept of how these ‘amazing’ children acquire knowledge is important to keep in mind for when you as a clinician are in a role to impress information onto a patient or fellow colleague, especially if they are already set and protective of their own beliefs.
“The most optimal way to improve your performance is to find a teacher who has been teaching other people to reach the level of performance that you want to attain. This basically means that teacher will be able to tell you the most effective ways to improve. A good teacher will also be able to find suitable units of improvement, so you don't push yourself more than you can do.”
“I believe, however, that there is a way of helping a child get enjoyment from the mastery and the development of an ability. And I would argue that the young musicians who are most likely to succeed as adult musicians are the ones who acquire the ability to enjoy their own music-making. So they can sit down and play music for their own enjoyment.”
Following the previous segment on children learning, Julia Belluz writes about a study done in Uganda where they taught children how to be skeptical about the information that they’ve been spoon fed. In a country where the government and media provides information that deviates from the truth (sounds familiar), she talks about how one could go about training people to question everything. From a PT student perspective, it is clear that majority of us are waiting for answers to be given to us. I’ve found questioning and being critical of each point provides me a path into my own research on whether these claims hold truth or not. Nobody likes to be duped, but not everyone cares to admit they have been.
“The kids are also learning to watch out for the perverting effects of conflicts of interest, and to recognize that all treatments carry both harms and benefits and that large, dramatic effects from a treatment are really, really rare.”
“So whatever the results of the Uganda study, the trial will get us closer to understanding how to prevent bullshit from taking off and how to arm people with the skills needed to protect themselves in the future. That’s something schools everywhere should pay attention to.”
It is interesting that I cannot find the original article in the PT journal website anymore, however this article by Dr. Rothstein covers how in our pursuit of bettering ourselves as clinicians we fall into business shams providing continuing education. As a student, I’ve definitely falling for these gimmicks (you can see it on my resume on the other page). Great read on just figuring out what you’re paying for in terms of continuing education.
“We use CE to “show” the public that we are keeping current—but that is not true. If CE courses really were expected to achieve a worthwhile end (and not just a certificate to hang on the wall), presenters would give more information about content—such as whether the course was based on evidence, clinical experience, or theory—before someone chose to take the course.”
Ben Wobker of Lake Washington Physical Therapy reflects on his journey through the past years after opening a successful practice. I have many years to go before I experience many of these thoughts, but it is a pleasant reminder that behind every patient, clinician, co-worker there is a family member trying to balance work with life.
“Ultimately, as I have gotten older, my most valued resource is time. There is no perfect way to run a facility, and every situation differs greatly. But for our growing family and business, focusing on what we love to do and letting technology or outside partners do the rest has been an excellent way to accommodate all our family goals.”
Hayley Leake discusses about the very common burnout that practitioners experience during their courses of patient care. This is a really important concept to keep in mind considering our own mental health, and how to stay motivated to treat the next patient that comes into the door.
“Emotional contagion is often the driving factor that leads healthcare professionals into their career path. However, to foster sustainable, healthy empathy we are encouraged to practice the latter – empathetic concern. A key aspect of successful healthcare is the therapist’s ability to communicate warmth and understanding. Research indicates that emotion contagion impedes this, while empathetic concern facilitates it.”
This is a long article. It does a great job dissecting the problems with evidence right now. As a profession that has a title of Doctor, evidence is necessary to backup our claims and interventions. It is good to know how the current state of evidence and research, may not be as glamorous as we’d like to think.
“Today, scientists' success often isn't measured by the quality of their questions or the rigor of their methods. It's instead measured by how much grant money they win, the number of studies they publish, and how they spin their findings to appeal to the public.”
“Quite a few respondents in our survey expressed frustration at how science gets relayed to the public. They were distressed by the fact that so many laypeople hold on to completely unscientific ideas or have a crude view of how science works.”
We will inevitably run into patients who bring up these type of medical studies. This is a good article to provide to patients or quote from to help them understand how many of these marketing driven/click bait articles on new advances in medicine should be read with a skeptic eye.
“This cycle recurs again and again. An initial study promises a miracle. News stories hype the miracle. Researchers eventually disprove the miracle.”
“A highly regarded service that vets new studies for clinicians finds — on average — only 3,000 of 50,000 new journal articles published each year are well-designed and relevant enough to inform patient care. That's 6 percent.”
“As we turn away from the magic pills and miracle treatments, I think we'll focus more on the things that actually matter to health — like education, equality, the environment.”
What is also inevitable is facing people who do not understand things even with cold hard facts present to back it up. This is part of the “it works for me” phenomenon. This is an optimistic article providing strategies to help convince a patient or fellow colleague on some of their preconceived notions. Truthfully we cannot change people’s mind. We can only do our best to guide them towards their own self-realization.
1. keep emotions out of the exchange, 2. discuss, don't attack (no ad hominem and no ad Hitlerum), 3. listen carefully and try to articulate the other position accurately, 4. show respect, 5. acknowledge that you understand why someone might hold that opinion, and 6. try to show how changing facts does not necessarily mean changing worldviews.
Orthopedic, Strength & Conditioning
The National Institution for Health and Care Excellence produces an evidence trove of how to treat low back pain. There are a ton of conventional thoughts that are considered ineffective for LBP in this guide, and I think as PTs going forward it is necessary to understand this beautifully put together guide.
Avoid being “that PT.” I find it interesting that every person looks for a person “inferior” to them to validate that they themselves aren’t doing that bad, yet they are still very dated themselves. “At least I’m not doing what Mr. X is doing here, can you believe he still does that?” Jarod Hall provides a great article in attempt to provide great reason physical therapists to focus less on what the others are doing and introspectively improve their craft towards more modern and up-to-date principles.
“These trainers are moving forward and expanding their skill set in their eyes, but in my eyes they are trying like hell to become eerily similar to the half-assed physical therapists we are trying to move away from in my profession. They seem to think that every exercise should be performed on an unstable surface such as Bosu or physio ball.”
“Just like the physical therapists of old, they don’t understand that pain is a multifactorial experience that doesn’t occur solely due to tissue damage, posture, or "poor movement". They tend to have an excessively biomechanical lens they look at all things through, and they likely help to implant nocebos about core weakness, arthritis, disc bulges, and many other things into our patient. I don't believe they are inherently trying to do anything wrongs. They are driven and motivated to be helpful, but are misguided just like many of the physical therapists of the past (and sadly of course the present).”
“Your pelvis is out of alignment.” Heard this throughout my chronic low back pain chronicles. More and more evidence really douses the fire on this concept, please take time to read this so patients aren’t worried about their normal anatomy being a pain causing deformity.
“If your hips could go "in and out of place" with something as simple as manipulation or muscle energy techniques, your body would crumble to pieces under a heavy squat or deadlift. The last time I checked, it doesn't. This is because your body is made up of RESILIENT structures. In fact, your body is so resilient that it takes over 1,000 lbs. of force to deform fascia by even 1% (1). Tell me again how your hands on techniques are causing structural changes? “
Following up the previous article, I have the same suggestion. This is a good example where the biomechanical model has it’s limitations and cannot be the sole explaination for pain.
“Based on these findings, sacroiliac joint pain is probably not caused by hypermobility of the sacroiliac joints and the sacroiliac joint movement is probably too small to be assessed with palpation, especially in weight bearing. Instead, the evidence suggests that a range of physical, psychological, social, lifestyle and hormonal factors may interact in the development and persistence of pelvic girdle pain, and that management should address these factors for each individual.”
“Sitting is the new smoking.” On top of the current culture of posture shaming, sitting is a highly looked down upon activity to take part in. Mike Reinold provides a thorough article that just explains how the focus should shift more to increasing activity than blaming something that we cannot avoid.
“By putting all the blame on sitting, we lose focus on the real issue, which is lack of exercise. So we see a shift in people switching to standing desks at work, still not exercising, but thinking that they are now making healthy choices.”
A doctor provides his recount of his course of physical therapy, and how that cookie-cutter protocols can be ineffective. This isn’t to say that protocols are worthless, but it is more to be aware that each patient is unique, and may need personalized adjustments to those protocols.
“Most people do well with intensive physical therapy, but for me it backfired and set up a vicious cycle of inflammation. I needed a different protocol than the standard one that works for the majority. I needed a protocol for patients with histories and conditions like mine.”
Great reflection by Mike Reinold and pointing to a lot of great resources in experts in the field and how they are consistently improving their practice.
“Notice the underlying themes below. Plus, notice how many of the people you look up to and would consider “experts” have done so much growing this year. If they are always pushing to learn and grow, you should be too.”
This is a must listen. Tim Flynn presents on why exactly PT should be chosen first. If you are not 100% sure why PTs should be chosen first for low back pain, please let him explain it to you. Lots of solid, high quality evidence behind each claim and harrowing statistics behind this opioid crisis.
What this youtube video provides
How did we come to opioid epidemic?
How imaging and biomechanical models are leading to more surgeries?
Why PT first?
Why it is important PTs understand how to treat pain (hint* 3 E’s: empathy, education, exercise)
Todd Hardgrove does it again with this article. He explains how the mind is a predictive organism that will work to confirm your expectations. I honestly still have a lot to understand on this topic, but I feel Dr. Hardgrove does a good job in making it as lay as possible to understand how this prediction and possible prediction error can lead to a patient’s perspective on pain.
“If I pay attention to a certain stream of sensory information, it increases the chance that prediction errors will be noticed and not dismissed. The system can therefore bias perception in favor of top-down or bottom-up factors based on relative levels of confidence or attention to either one.”
“To do this, you need to cause a prediction error by violating your expectation that bending will hurt.”
Joletta Belton concisely writes about common misconceptions about chronic pain. If you’ve read articles on my previous lists, this shouldn’t come as new news, but this does provide another salient article explaining the multi-pronged phenomenon that is pain.
“What we do know is that chronic and persistent pain are most often NOT associated with an injury or tissue damage, even if it began with an injury. Pain is an output of the brain that indicates it has detected some threat to the self. It is a danger signal, but the signal might be off and likely isn’t reflective of the state of the tissues.”
“What this does mean, is that sleep deprivation, stress, depression, anxiety, catastrophizing (believing the worst is going to happen), fear of movement (a lot of pain patients are afraid to move for fear of doing damage or worsening their pain), negative thoughts, and a whole host of other things can make pain feel worse or flare-up.”
Tony Ingram also writes about how to conceptualize the fact that pain is not just mechanically driven. I like how he explains how to prevent the “all in your head” mentality from developing with you and the patient.
“What’s important is that you realize that just because you have pain, it doesn’t mean there is any significant damage or degeneration occurring in your body. Learning this can be very relieving for people who are afraid they might have a serious problem.”
“‘Does this mean it’s “all in your head”? Well, your brain is in your head… but that does not mean it isn’t real. Pain is very real, just as real as seeing colors, being excited or scared at the movies, or being in love. Pain is an important topic, which is why there’s a whole section of this site dedicated to it.”
Monica Noy explains how despite the flack that manual therapy has been receiving in the most critical groups of clinicians, it has a role in modulating the pain experience, and if manual therapy’s effects are understood and effectively communicated they can still be apart of the treatment of pain.
“Ideally you should check in with your medical doctor, but if there is nothing that needs medical management then manual therapy can be applied in many different ways that can positively affect a pain experience. Probably the most important thing is to make sure your therapist is aware of and incorporating current pain science knowledge and understands they can listen to, but not really know your experience.”
Lars Avemarie provides another great article on pain and common misconceptions in health care about it. Using a ton of references he provides you plenty of external links to explore more about how pain works.
“Pain is, therefore, the sum of your environmental context (i.e., a calm or stressed environment; a battlefield, hospital, home), the degree of danger signal (nociception), your beliefs, your expectations, and your past experiences, as well as many other factors. You will experience pain only when your body perceives a large-enough threat in relation to the context (12,13).”
At this point you may be tired of the repetitive articles on pain. The way I look at it, until you are sufficient in explaining pain to your patient, there is no harm in reading more about it. Each professional somehow comes to the same thoughts, but provide their own ways of explaining the concept of pain. Nick Efthimiou provides a challenge to concepts of pain within his profession of osteopathic medicine. He has a lot of gems in this article.
“Unfortunately, many people do not learn about pain when they seek treatment for pain, which leads to incorrect ideas and beliefs, that can make their pain worse.”
“Others, rightly or wrongly, interpret their failure to improve as their fault, if they have been made to believe that exercise is what is needed to fix their pain, due to poor compliance. I often view poor compliance as not as the fault of the client, but of the therapist.”
This is a nice and honest personal recount on breaking free from homeopathy. Aprille speaks from the perspective of many people who are so bought into a culture of homeopathic remedies. As DOCTORS of physical therapy, we really need to step back and consider what spews out of our mouth in terms of advice.
“I stopped living in fear of doctors, medication, and chemicals. I stopped thinking I knew better than super-smart people who have dedicated their lives to studying the human body and disease. I stopped listening to self-important mommy bloggers who were telling me what to eat, what supplements to take, and what oils to use.”
- Dec 12, 2017 Reading List: December Dec 12, 2017
- Nov 1, 2017 Reading List: November Nov 1, 2017
- Sep 1, 2017 Reading List: September Sep 1, 2017
- Aug 1, 2017 Reading List: August Aug 1, 2017
- Jul 5, 2017 Reading List: July Jul 5, 2017
- May 22, 2017 End of Spring Updates May 22, 2017
- Apr 2, 2017 Reading List: March Apr 2, 2017
- Mar 1, 2017 Reading List: February Mar 1, 2017
- Feb 1, 2017 Reading List: January Feb 1, 2017
- Jan 1, 2017 Reading List: December Jan 1, 2017
- Dec 5, 2016 Are Physical Therapists and their Profession Prepared to take on the Opioid Epidemic? Dec 5, 2016
- Dec 1, 2016 Reading List: November Dec 1, 2016
- Nov 1, 2016 Reading List: October Nov 1, 2016
- Oct 3, 2016 Reading List: September Oct 3, 2016
- September 2016