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!
Cameron Yuen writes for New Grad Physical Therapist blog. Here he talks about a problem he sees with the current state of physical therapy and the integration of literature in practice. Pulling from skeptic leaders like Harriet Hall, he makes an argument that evidence based medicine is not enough. Evidence-based medicine and science-based medicine are two different things, and we need to consider integrating more SBM into our practices.
“By placing such an emphasis on the RCT and outcome evidence, many treatments studied and implemented by physical therapists bypass the important step of considering prior probability and scientific plausibility, and therefore drift towards very questionable pseudoscientific territory.”
“Science based medicine asks that we restore a skeptical perspective, and use our entire body of scientific knowledge when viewing treatments or claims, instead of asking if there are RCTs to support them. SBM is not a replacement for EBM, and acknowledges that prior probability and scientific plausibility is never sufficient for justifying a treatment, but it is a necessary first step. Justifying a treatment based solely on plausibility is a pseudoscientific practice.”
The Not-So-Humble Healer (5 min read)
Deep down inside, I believe that we all want to be healers. The patient is seeing me because I’m the movement expert right? Though this expertise in important, it is important to know that most of what we know (at least in PT) is not concrete. Impressing the patient with the reasoning as to why their collapse arches are leading to neck pain may seem to be great way to get patient buy in, but is it the real cause of their pain? Is is truly dysfunctional? Paul Ingraham discusses why he chooses to have more of a conservative diagnosis when examining and treating his patients.
“The therapist who claims to understand therapeutically significant connections between parts that seem particularly unrelated is more likely to impress his patients. And to have an ego problem.”
Jarod Hall has a great blog that covers a wide spectrum of topics within the orthopedic setting. This particular article he covers the reality that our treatments as PT have the potential to add more problems than what the patient came in with. What you chose to diagnose and say as a clinician matters.
“I’m no mathematician, but it doesn’t take Sir Isaac Newton to figure out that If poor and overly postural-structural-biomechanical explanations appear to increase medical utilization and subsequent over-treatment we are dramatically increasing our health care costs and over treating our patients.”
“When we create a treatment model and explanatory framework that emphasizes that one’s body is weak, easily damaged, that pain is always directly a result of tissue damage, and that the patient NEEDS someone else (us) to fix them, we steal this internal locus of control. We create a situation in which a patient feels like they have no influence on the situation they are in.”
Nick Tumminello is an elite strength and conditioning coach that writes a great 3 part series on dealing with individuals who are stuck in their ways and why they may believe certain concepts over others. He reveals psychological fallacies that fall upon all of us and provides ways to combat them. Even if you're not a strength coach, this is valuable information to understand.
“We have the tendency to draw firm (complete) conclusions from incomplete information because we seek out and overvalue confirmatory information for any given hypothesis.”
“As a fitness educator (or a teacher in any other field), you don’t necessarily have to provide good information, you just have to put on a good show, and people (just like you and me) will not only like you and perceive you as an “expert,” they’ll also believe that you’ve provided them a substantial educational experience. In other words, the Dr. Fox Effect is very real, and it applies to well-educated adults and to students. And, it’s foolish to believe that you have not been (and won’t be) duped by the Dr. Fox effect.”
“That said, when some sort of alternative medicine treatment or corrective exercise intervention is introduced very soon after a flare up in a person’s symptomology; when you see improvement – as you surely will from something like non-specific low back pain or many other ailments and sickness – you’ll naturally assume that whatever you did when your symptoms were at their worst must be the reason for your recovery. So, every time you get that same issue from now on, you’ll be back to using that same treatment.”
“we know this is a classic example of post hoc thinking and a lack of a general appreciation of the principle of regression to the mean. When people and practitioners ascribe the improvements they’ve experienced in pain levels to some questionable interventions by saying “it works for me,” I say, “I have no doubt you saw improvement, but how do you know the results you’ve seen in-practice aren’t due to the natural history of pain regressing to the mean?” These practitioners cannot answer with any meaningful reply, because with anecdotal testimony alone, they have no reliable means of distinguishing whether they’ve seen improvement through regression to the mean or not.”
“Without objective, corroborative evidence from other sources, or physical proof of some sort, 10 anecdotes are no better than one, and 100 anecdotes are no better than 10. Anecdotes are told by fallible human storytellers, which is why we have sayings like, “the plural of anecdote is not data.” The most to reliable means to determining which health interventions actually do work, and which ones are ineffective, but may still appear to work, is through scientific testing.”
Orthopedic and Strength & Conditioning
Janda's Lower Crossed Syndrome has not been Validated (15 min read)
There is more and more discussion as to whether the upper and lower crossed syndromes are actually a thing to look for in your PT examination. Often these are crutches for PTs to go to, and truthfully biomechanically it makes sense. Greg Lehman challenges how significant are those findings and provides a discussion that maybe PTs shouldn’t put as large of emphasis on them.
“None of these people had "tight hips" or at least not by the definition the authors gave. The authors argued a limitation in hip extensibility was when the Thomas test showed hip flexion of 10 degrees. All of them had hip extension where the thigh went below parallel. Where do you draw the line of what tight is? At what level of "tight" do the hip flexors start inhibiting the glutes if this actually happens. If you just keep stretching and stretching the hip flexors will you keep getting more and more Glut activity? This reasoning doesn't make sense.”
3 Myths of Scapula Exercises (5 min read)
Mike Reinold writes about some common myths revolving around the scapula. He explains some gems from his clinical experience.
[Discussing retracting shoulder cue] “If the goal of this common coaching cue is to improve posture and improve mechanics while exercising the arm, maybe a better cue would be to instruct thoracic extension.”
“In my opinion, scapular position is more related to rib and thoracic position than anything else, including tight muscles and weak or inhibited muscles. The scapula rests on the rib cage and thus moves with the rib cage. Do you need to work on these muscle imbalances? Absolutely. However, proper alignment is needed as well and should be assessed first.”
Back Pain Myths: Posture, Core Strength, Bulging Discs (15 min read)
Todd Hargrove provides a thoughtful article back in 2010 about myths that are still extremely prevalent in physical therapy today. It’s a shame that there has been little progress in understanding these myths from facts.
“There is little evidence to support the idea that we can explain pain in reference to posture or that we can cure pain by trying to change posture.”
“Although some studies have found a correlation between back pain and posture, it is important to remember that correlation does not equal causation. It may be pain is causing the bad posture and not the other way around. This is a very likely possibility. People will spontaneously adopt different postural strategies when injected with a painful solution. Big surprise!”
“The thrust of these studies is clear – although core exercise can improve low back outcomes, it is no better than general exercise. The obvious conclusion is that if core strengthening has benefit, it works because of the generally beneficial effects of exercise (or as a placebo), not because lack of core strength or poor firing patterns are a major cause of of back pain. In other words, despite what we are told over and over, the current evidence states that there is nothing magic about core strength as means to prevent or reduce back pain.”
Tom Goom writes about how he empowers his runners to make decisions in their own rehabilitation. This type of intervention seems to be something that you cannot teach. Mastering the creation of a therapeutic alliance with your patient is the key to the success of the intervention.
“This highlights an issue we face with education; knowing what to do doesn’t mean you’ll actually do it. Increasing knowledge doesn’t necessarily guarantee behavioural change. Therefore, readiness to change training behaviour might be associated with other psychosocial factors beyond just miseducation. Athletes need to see that the pro’s of modifying their training load outweigh the con’s, with a range of psychosocial factors contributing to the balance between the two.”
“Perhaps the answer lies not in telling the athlete to adapt training but in giving them the information to make an informed choice. We may be more successful in creating changes in training behaviour if we express empathy and understanding while indentifying the discrepancy between the athlete’s training goals and their current approach to training. This may mean adjusting to resistance from the athlete, rather than opposing it directly and supporting self-efficacy and positive choices.”
Back pain and running – pain and pacing (15 min read)
Another great article by Tom Goom on pacing for his athletes. This will be a go to reference when treating any of my patients with back pain and are runners itching to return to training.
“Pacing is doing things at the level you can cope with. It means not pushing through pain and understanding your limits. At its best, it's modifying activity to reduce pain but to continue to progress…and it works. In time pacing will reduce sensitivity in the nervous system and reduce pain.”
Corrective Exercise: What are we Correcting? (15 min read)
As trends come and go, it’s good that we talk a step back and learn what’s going on. Ben McCormack talks about how corrective exercises may be viewed in too narrow of a lens. He challenges multiple theories that are currently out there that try to justify corrective exercises.
“Our posture is also influenced by a number of different systems such as the visual and vestibular systems not solely the strength or length of two opposing muscles (amongst many) around a joint. Perhaps just looking at two muscles is an overly simplistic view of posture.”
“We often look to ‘correct’ muscle firing patterns, especially with back pain, with no real evidence of how they should fire in the first place. Here we see two pieces of research that show abdominal muscle firing and function have little to do with getting better from back pain. Perhaps altered muscle firing is a result of rather than a cause of back pain and therefore is not implicated in resolving the pain.”
One of my favorite manual techniques I’ve learned is titled the “psoas release.” Since learning it, I’ve used it often in working with people with low back pain. As I read more about the poor handling of low back pain, I stumble across more and more evidence that challenge things that I thought were sure-shot useful. Paul Ingraham provides a great lengthy article that helps me think more critically about this technique that I choose to use, and understand that it may not be doing exactly what I was taught with regards to this hip flexor.
“Psoas massage is over-rated because it just isn’t needed for most people, most of the time. (Many people would argued that it is never needed, and they might be right.) Thanks to professional folklore and a tradition of psoas evangelism, most massage therapists and many chiropractors believe that the psoas is the missing piece in a biomechanical puzzle, particularly for back pain patients. This is a classic example of “structuralism”: the excessive focus on specific biomechanical origins of pain, especially ones that suggest marketable solutions.7 The message to patients is: “I can treat your back pain, because I understand how important the psoas is, unlike therapists with less insight into the intricate workings of the human body.”
Clearly, Paul Ingraham’s work has been littered throughout my reading list this month. He does a great job updating his blogs periodically as new evidence comes across his desktop. This one is more a stab at the theories behind the subluxation theory with chiropractic care, however it is a good resource to see the most up-to-date skeptical evidence with manipulation. It’s better perform and understand what manipulation is not, than perform it and push a false rhetoric.
“Even if you put aside all concerns about the quality of the theory, there is still not a shred of scientific evidence that any kind of spinal joint dysfunction — no matter how you define it — has any importance to your general health. In more than a century, nothing like that has ever been shown to be true.6 So do chiropractic subluxations even exist? And, even if they did, would they actually cause any problem, serious or otherwise? And how serious are chiropractors about all this anyway? I’ll address these questions over the next few sections.”
"On the other hand, any truly worthwhile benefits to SMT (in any situation) should be obvious and noteworthy. They should pull up the average. I doubt that significant benefits would ever vanish into the statistics. So while I concede that modest real benefits of SMT might get obscured and overshadowed in a big review, I Thus we are still left with SMT being damned with faint praise here. As Neil O’Connell of Body in Mind described these results: “a tiny effect size for manipulation that doesn’t really tickle the undercarriage of clinical significance.”
Greg Lehman talks about how we as physical therapists we are in the position to influence the change of beliefs, specifically with pain, through movement. He provides a concise article that demonstrates one way to apply the biopsychosocial model with a patient.
“This is essentially the biopsychosocial approach. Those three areas are addressed together and they each reinforce one another. No one ignores the bio here. We just amplify the mechanical components of our therapy with the other spheres.”
Bret Contreras calls out all of the continuing educational guru courses that are out there. He provides a comedic check list of things to look out for before signing up for your next continuing education course.
“The physical therapy and personal trainer fields are filled with an extraordinary proportion of suckers who won’t bat an eyelash over your exorbitant seminar, certification, and DVD fees.”
As I am on the verge of entering the clinical environment, I find myself having a steady handle on the possible questionnaires and screens to use in my examination. However, I am definitely not confident in how and when to administer these tools. Bronnie Thompson does a great job addressing this issue and provides different approaches to getting comfortable around them.
“For example, if we see someone who scores very high on the PCS and tends to ruminate or brood on the negative, we can’t go ahead and give that person the same set of exercises or activities we’d give someone who is quite confident. We’ll need to lower the physical demands, give really good explanations, take the time to explain and de-threaten various sensations the person may experience, we’ll probably need to move slowly through the progressions, and we’ll definitely need to take time to debrief and track progress.”
Two following articles are by Joletta Belton. She is the founder of Endless Possibilities Initiative which is an organization geared to empowering those in chronic pain. Joletta has been a wonderful resource to those around her as she openly shares her uphill battle of having chronic pain in today’s medical system. We can read all we want about how pain works, but if we cannot hear the story or empathize with the human in front of us, it is all a waste.
“So pain science education isn’t a magic bullet, but it is a starting ground, a jumping off point, a strong and stable foundation upon which to build everything else up upon.2 It opens the door and lets some light shine in, relieving some of the darkness we’ve been cowering in feeling lost and afraid, not knowing the way forward.”
“It allows us to be ok with a bit of uncertainty because at least we know what pain isn’t. That we’re not damaged, injured, broken, or degenerating. That we’re not fragile and weak. That pain is not a reflection of the state of our tissues.”
Trying to get better while having to prove we’re in pain (10 min read)
“I didn’t lift more than 2o pounds at the gym, just in case I was being watched. I tried not to squat, climb or get in awkward positions in public because I needed treatment, I needed help. My pain was unbearable and I wasn’t willing to jeopardize my case, my care, by doing those things. Just normal, everyday things.”
“People living with pain have lost so much. Careers, career prospects, income, financial security, relationships, identities, worth, purpose, hobbies, physical fitness, mental health, social outings, travel, sport, function…there’s so much loss.”
“What if people with pain were encouraged and supported by their healthcare providers and insurers for pursuing their lives while also still being eligible for care? How much more effective could care be under such an approach?”
5 Ways to Improve Your Pain Neuroscience Education (10 min read)
Cameron Yuen, writing for Evidence in Motion this time, provides a summary of the work of Mira Meeus and Jo Nijs in how to integrate pain neuroscience education into your treatment. One of the main problems with pain science education is the therapists’ delivery of the message. Articles like this one is very important for anyone who is trying to integrate these concepts with their patients.
“The environment in this sense refers to relevant individuals in the patient’s life. This includes family, friends, and especially other healthcare professionals. If the messages explaining the patient’s pain remain conflicting or strictly biomedical in nature, it will be difficult for the patient to internalize the message and move forward with treatment.”
“There is a danger that these new ideas can be applied incorrectly, but there are some guidelines that can help improve the delivery of the curriculum.”
Everyone references Patrick Wall as the guy who discovered the pain-gate theory. He was an MD who studied everything about pain, and as with all information and it’s simplification process, his work has been misunderstood. Many of his discoveries in pain go beyond pain-gate with Melzack. Diane Jacobs does a great job diving into and summarizing one of his articles on her blog.
“It is apparent that the ability to establish a threshold and to estimate intensity is not determined by the properties of single peripheral fibres or even types of peripheral fibre. Rather the periphery feeds information that is then interpreted in terms of threshold and intensity by central structures."
"See what they did? They spotted an inconsistency in the work itself, an oversight, a contradiction between what was actually stated, and how most people went on to blithely interpret it. Then they pointed it out, in writing."
- 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