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!
Tearing Down the Pillars of Evidence Based Practice (10 min read)
Evidence-based practice is a buzz word that is tossed around a lot. As a PT student you hear it all of the time. Though this is a great notion that should be understood by all clinicians, the concept derived by Sackett has been mangled, shredded, and painfully simplified. Kenny Venere speaks on why it’s called EVIDENCE based practice and not EXPERIENCE based practice.
“The concepts of evidence, clinical experience/expertise and patient values do not exist independently from one another. Nor can we pick and choose which of the three best suits a particular set of beliefs. In fact, we should stop referring to evidence based practice in terms of “pillars” altogether. It is an unhelpful metaphor that only serves to perpetuate a misinterpretation of the philosophy of evidence based practice.”
“How can a treatment we often see a “benefit” from actually be ineffective or harmful? Because clinical experience is muddled with confounding variables and humans are easily deceived by things such as placebo, natural history, regression to the mean and other biases.”
“However, we should not misuse patient choice as justification for a treatment that evidence suggests is rubbish. It is important to consider how the patient came to choose this particular treatment in the first place and what else might have contributed to the patient experiencing “success” with this treatment.”
The Ethics of Healthcare Advertising (15 min read)
Erik Meira has been under fire for a while now for taking a skeptical and logical stance behind the ethics of GetPT1st. I think he provides great points as to why this catchy hashtag can misinterpreted by the public, and how we may be doing a disservice for overall public health. He explains how the APTA lacks a clear and definitive code of ethics which gives unrestrained freedom for our profession to advertise our services whether or not it is of medical necessity.
“I know, you REALLY want to tell the general public that they should “GetPT1st” for all of their musculoskeletal needs but it just doesn’t work that way from an ethical position. It is considered an unprofessional stance by our medical peers. How would you feel about a campaign called “GetPrimaryCare1st” or “GetOrthoSurgeon1st”? It’s misleading isn’t it?"
R.I.P. Prescriptive Clinical Prediction Rules (10 min read)
Clinical Prediction Rules in theory make sense, but I’ve sat in class looking at these documents provided by the APTA and scratch my head wondering the validity of everything. Chad Cook writes in the Body in Mind blog about how most of these rules are ineffective. Granted I’m a new grad, I think it’s important to know what options I have, and the CPRs provide that; however, I need to be aware that this isn’t a hard set way of treatment.
“the natural history of many musculoskeletal conditions-such as acute low back-is so favorable, that patients require interventions that have very high treatment effects to provide any noticeable between-groups difference. Most physiotherapy interventions fail to provide very high treatment effects."
Orthopedic and Strength & Conditioning
Biomechanics Matter Even When They Don’t (15 min read)
Erik Meira writes an article trying to keep the pendulum from swaying too far. He writes about how physical therapy has caught onto a trend of pain science. As expected, the original messages are misconstrued and people now camp out in the pain science, psycho-social application to pain. Erik spends time explaining why biomechanics are still extremely relevant, and how psychology and biomechanics are not mutually exclusive.
“The analogy here is that if a postoperative ACL reconstruction subject lacks the tools (parachute) to manage the forces coming at them in their sport (biomechanics) it is ridiculous to believe that their fear simply needs to go away. They may be afraid because they can feel, consciously or unconsciously, that their muscles have limited strength or that they have a very low rate of force development or that their nervous system is still unorganized around that knee or some other impairment we haven’t accounted for. The fear is based in something, real or imagined. You must look for the root cause of their fear.”
I think one of physical therapists largest weakness is the ability to provide adequate dosage of exercise to their patients. Which is ironic… we are movement specialists, yet we do not know how to prescribe properly. Scott Morrison provides a really great framework to work with in terms of using different approaches to help design a program that can be systematically progressed.
“The main concept here is that there is a need for an approach that can integrate feedback into the daily programming. This ensures that appropriate intensity levels are reached while respecting the individual’s readiness.”
Great guest post by Simon Bartold. He’s a podiatrist and gives his opinion about shoe categories and the evidence behind the reasons why they don’t matter. Working at as an aide at a clinic that caters to runners, I always hung my hat up on knowing the specific specs of running sneaks and how each construction for a specific foot motion. As Bartold quotes a paper, the oversimplification “is overly simplistic and potentially injurious.”
"it is not possible to “control” motion.. not with a shoe or an orthosis at least. It certainly is possible to create influences, but in the context of the Motion Control discussion of the last 35 years, this is a fallacy. A highly pronating foot will continue to pronate happily inside the most heavily “Motion Controlling” shoe until the cows come home.. and.. the result of the interaction between foot and footwear is heavily case specific.”
Mike Reinold touches upon a relatively new trend in the rejection of rehab protocols. As with anything people want a black and white situation. He does a good job explaining why rehab protocols are necessary and how they act as guidelines and less so as concrete rules. It’s interesting as a soon to be PT, I come across a lot of therapists with experience who talk down on rehab protocols. Usually they talk about a time of a bad prescribed protocol, adds an eye roll, and continues to glorify how they changed up the protocol. These clinicians have years under their belt where they can discern between specific patterns, and make clinically reasoned decisions on the care of the patients, but I think it’s irresponsible to display that disdain to a student. Students, always looking for the short cut, will drink that up and then form this foundation-less opinion about protocols.
“A common misconception regarding protocols is that they are concrete rules, instead of guidelines. All of the nonoperative rehabilitation protocols that we have produced over the years are intended to be a way of guiding you through the steps of returning a patient from an injury.”
“As a young clinician, it’s also hard to prioritize the precautions and restrictions of complicated patients. For example, our rehabilitation protocols have 13 variations of rotator cuff repair protocols and 16 variations of ACL reconstruction protocols. We change the guidelines based on several factors and concomitant injuries. This is a must.”
Tissue Homeostasis and its Role in Exercise Dosage (15 min read)
Jarod Hall has been ramping up the posts the past couple of months, and amongst many of them this one on Tissue Homeostasis is terrific. Referring to a lot of the work of Scott Dye, he shares a summary of how tissue homeostasis applies to nearly every patient we see as orthopedic physical therapists. As with many things, I wish this was taught more in school. Understanding this concept definitely helps the integration of the BPS model into treatment transition more smoothly.
“To drive the envelope of function up and to the right, the clinician must determine the optimal load that will adequately load and stimulate positive tissue change without superseding the tolerable limit and perpetuating a maladaptive response. This load reflects the individual’s current physical state, including, but not limited to, level of fitness, mental status, health status, sleep state, nutrition, predisposition to inflammation, pain catastrophization, etc. This is why progressive overload is so fundamental to exercise prescription.”
Greg Lehman gives his two cents and a whole lot of evidence when dissecting a recent Huffington Post article titled “Stop Stretching your Hamstrings.” He goes through what are unsupported and supported claims in the article, and through this gives you a good sample of what the most current opinions and theories are on hamstring length, stretching, and their benefits and limitations.
“we don't have clinical trials suggesting posture can change very readily and we don't have biological plausibility or evidence to suggest that connective tissue will respond in the manner that would lead to these proposed changes.”
“Again, we have no evidence that there is selective muscular shortening from periods of sitting. If you aren't doing anything to increase your ROM then you will lose it. Nothing special about sitting."
Injury and Healing: Redefining Terms (15 min read)
Well written thoughts by Curtis Tait on how he had to reconceptualize his definitions of injury and healing to help fit it into a model that could be welcomed by most patients while not blasting them with “pain science.” He highlights many strong concepts in the importance of the catered patient-clinician interaction, and shares how he best choses to communicate to them to optimize their rehab.
“Instead I had to re-define my terms of “injury” and “healing” to speak with my patients in their terms while at the same time find a way to present pain science concepts. “
“I would also argue that our concept of injury should consider a loss of confidence of the individual, particularly in the movement and activities our patients love to do (see figure 3). As physiotherapists, this is likely where the psychosocial is so important! We can’t assume that altering someone’s pain, or restoring tissue resilience, will automatically give them the confidence to return to their desired activity!”
Screening Basketball Players to Reduce Injury Risk (20 min read)
I came across Trent Salo’s blog through the wonderful world of twitter. This therapist has a lot of really great thoughts, and having a background in basketball, this article was one of the first I decided to read. With a huge list of references, he lays out an awesome way to provide a program that may reduce injury risk for basketball players. The algorithm he used isn’t something new, but he put in the work to make it applicable to basketball players with a ton of great sources.
“Reducing injury risk basically boils down to the human body's ability to absorb force. If the force from a jump, cut, etc. is greater than the capacity of a tissue (bones, ligaments, muscles) to handle said load, then injury occurs. So basically, we could say simply monitor load in athletes and we can reduce injuries. It's that 'simple.'”
Tissue Changes and Pain: Explaining their Relevance (15 min read)
Greg Lehman as always delivers sobering messages in his articles. It’s important to understand that MRI findings may not be as important as some medical professionals believe them to be, BUT it is also important to not throw out everything that is found by this findings. As a growing clinician, I find that it is easy to try to just take on hardline side to different topics, but I think the key is to understand that there will always a gray.
“If I am very honest, I don't want to. In my practice, I've been saying for decades (and yes we have know it that long) that you can have big degenerative changes, disc herniations, muscle tears and tendinopathies without pain. That is a great message is still very true. But its not clinically honest to say that those changes are wholly irrelevant. We just don't want to say that they are destiny”
Elicit a Prediction (10 min read)
Cory Blickenstaff writes about the importance of motivational interviewing. He explains why it is essential to have the patient realize their situation instead of us telling them what they have going on. This not only builds therapeutic alliance, but also helps the therapist shape their interventions based off the words and thoughts of the patient.
“Why is this important? In my last post I talked about some of the problems with trying to disconfirm a maladaptive belief. Beliefs are slippery. They are very difficult to pin down and therefore very difficult to change and are very prone to bias. We have confirmation bias working against us here and if we try to change a belief by just presenting contrary evidence we might even make things worse through the backfire effect! This is why we need them to come up with the prediction (instead of it being dictated to them) and it needs to be specific enough that it can be shown to be wrong (much more on this in the next installment). This is consistent with the concepts and processes of expectancy violation.“
Symptom Modification: The Next Question (10 min read)
Cory Blickenstaff writes about expectancy violation and how it is necessary to artfully conduct an examination and treatment with patients to help them come to new conclusions that may change their preconceived notions as to why they are in pain.
“A modification of symptoms MAY be able to serve in this role of belief disconfirmation, which is potentially great! But, it is also obvious that there are scenarios where a modification of symptoms may only serve to strengthen the maladaptive belief! “I wasn’t safe to move until the pain was better. So, pain does equal damage!” or “When the therapist popped my back I felt better. A bone must have been out of place after all!”"
“Beliefs tend to be tough to pin down. We (all humans) tend to actively seek out information that confirms our existing beliefs and ignore evidence to the contrary (confirmation bias) or we alter the incoming information to match our beliefs. So, beliefs tend to be pliable, slippery, and bias filled and often make life a living hell for a anyone trying to change them.”
“However, if the symptom modification refutes a specific prediction, then it can be very useful in my view. To be defensible, it also needs to support or build self efficacy, and be focused on a relevant and valued goal of the patient."
Does Bad Posture Cause Back Pain? (20 min read)
Stumbled across this 2014 article written by Todd Hargrove. Every time I go to some PT program facility for a continuing education course, I find that same APTA postural alignment propaganda on the walls. “Good” posture is branded into society, it’s hard to really challenge these misconceptions. I feel as physical therapists, being the movement specialists, we have a great opportunity to empower people with strength and movement. I feel at times that most of us students are enrolled in the posture police academy.
“The above research indicates that if any correlation exists between posture and pain, it is weak. These results are striking given that many studies have found other factors that correlate with low back pain, such as exercise, job satisfaction, educational level, stress, and smoking.”
“don’t worry too much about trying to change your static posture to conform to some ideal. It is not a likely contributor to back pain. Instead, stay comfortable, keep moving, work to improve your function, and make sure to use good alignment and form when engaged in strenuous exercise.”