To improve is to change; to be perfect is to change often.
— Winston Churchill

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!


Paradigms

The Wellness Epidemic: Why are so many privileged people feeling so sick? Luckily, there’s no shortage of cures. (20 min)

  • “Four decades later, wellness is not only a word you hear every day; it’s a global industry worth billions — one that includes wellness tourism, alternative medicine, and anti-aging treatments.”

  • “Spend a little time in the wellness world, and it seems like everyone has an official diagnosis.”

  • This lengthy article touches upon different ways “wellness” has flourished. As a physical therapist, I believe the concepts of wellness is so important; however in a world of people addicted to looking better, looking younger, and feeling more healthy, the wellness industry looks to capitalize off of everyone. It’s too bad that there is so much distraction from the truth and the facts of what people can actually do to make improvements in their lives without the BS alternative supplemental products.

Flush Your Stool Down The Funnel (10 min)

  • “EBM is another epistemology. Those three concepts are NOT equal components that are weighed individually. They are a series of epistemological principles to guide the provider to the most accurate objective information regarding the patient in front of them. The patient’s values and circumstances are then applied for final decision making.”

  • “Now that you have all that evidence you must make sense of it collectively. As I mentioned before, you can find evidence to support anything. The goal isn’t to find support for an idea but to find the most accurate understanding. The most accurate understanding will stand up to all of the evidence.”

  • Erik Meira breaks down the problem with current EBM from the point of view of physical therapy. As I am about to become licensed PT, I’m aware that there will be biases in every clinic I work for. I understand that “it works for me” will almost always take priority over any other rational thinking. I also understand that these are people just trying to do their job, lead happy lives, provide for a family, etc. Aiming to be a leader in the field, I aim to do my best to keep my practice updated based off the current evidence and hoping that I can positively influence other PTs.

Burnout lessons from a Navy SEAL (15 min)

  • “They don’t fight against the way their brain is wired — they build their lives around it. They play offense, not defense.”

  • “But when I reframed hard work from causing burnout to giving me more energy, it started a snowball effect on how I prioritized, and everything changed.”

  • Ramit Sethi is one of the most influential thought leaders that has written books and blogs inspiring individuals to be smart with their money and also help shape them into better thinkers. In this blog he talks about burnout and how he reframes his perception of hard work. I believe over the past years, I’ve been able to recalibrate what hard work means to me and understands that it doesn’t have to equal exhaustion, negativity, or harm. 

Placebo effects are weak: regression to the mean is the main reason ineffective treatments appear to work (20 min)

  • “So the placebo effect, though a real phenomenon, seems to be quite small. In most cases it is so small that it would be barely perceptible to most patients. Most of the reason why so many people think that medicines work when they don’t isn’t a result of the placebo response, but it’s the result of a statistical artifact.”

  • Great article explaining the concept of “regression to the mean” and how it can apply in healthcare. Understanding that most of the time the patients will get better over time is a very important thing to keep in mind. Patients will come to us as clinicians looking for help when they are at their worse. It is likely whatever we do to them will result in a decrease of symptoms simply because the body’s way of adaptation and healing itself. We are not gods of movement. We just spent extra time in school understanding it a little better than the average human.

I’m just a physio… (10 min)

  • “Unfortunately most physios seem to think if they are not doing something to someone then they are not true physios. It appears that most physios suffer with inadequacy issues, inferiority complexes, or small person syndrome. Many physio’s feel the need to exaggerate and inflate what they do to make themselves feels more important and more worthwhile in the eyes of their patients, their peers, and other healthcare colleagues. Most physios do not see the value in good, simple, honest, education and exercise.”

  • Adam Meakins reminds us what our primary goals are as physical therapists. Despite his strong stances on many controversial topics in PT, I believe he is a solid example of how physical therapists should be. At the end of the day we are physical therapists. Patients can call us whatever they want, but we need to remember that we’re just a bunch of sherpas helping people get better. Our basic skills and knowledge of movement and exercise is plenty enough to help someone get back to what they love doing.

The Devil Is In The Dosage (15 min)

  • “We want to be the ones to “fix” patients instead of helping them realize it will be the patients who ultimately heal themselves. The best we can do is shift the odds of an outcome in the most favorable direction.”

  • “The emphasis on diagnosis in our education leads us to think we can have more influence over long term outcomes than has been shown to be the case in the literature. Unfortunately, this has created a situation where efficacy of treatment methods and physiology are sorely lacking in clinician education.”

  • “To tell an athlete that we can prevent injury is a lie, and that lie is told far too often in the training and rehabilitation community. We are not fortune tellers, but risk managers”

  • The team at The Logic of Rehab lay down a nice article about our role as clinicians working with patients, clients, and athletes. They do a great job breaking down as to why we can’t necessarily “prevent” injuries and reframing our role with the rehabilitation of those who come to us.

Orthopedic/Strength & Conditioning

The corrective exercise trap (5 min)

  • “Corrective exercise is built on wishful thinking. Screening for movement dysfunctions has been failing one fair scientific test after another. The importance of posture has been wildly exaggerated. The importance of anatomical variation has been virtually ignored.”

  • “The practical implications of this are that the fitness professional should not immediately qualify a movement pattern as a dysfunction just because it does not fit within certain standards of a given corrective exercise evaluation, and that fitness professionals can better appreciate that exercise in general is far more valuable from a therapeutic perspective than is often thought in corrective exercise belief circles.”

  • Paul Ingraham gives a brief summary of the work of Nick Tumminello’s and Jason Silvernail’s recent work with the NCSA. They break down the myths and misleading dogma of corrective exercises and functional movement screens that has been plaguing the fitness and rehab fields. Each of these authors are incredibly respectable individuals, and I plan on reading the full text via the NCSA soon. 

6 Keys to Shoulder Instability Rehabilitation (10 min)

  • “Conversely, a patient presenting with atraumatic instability often presents with a history of repetitive injuries and symptomatic complaints. Often the patient does not complain of a single instability episode but rather a feeling of shoulder laxity or an inability to perform specific tasks. Rehabilitation for this patient should focus on early proprioception training, dynamic stabilization drills, neuromuscular control, scapular muscle exercises and muscle strengthening exercises to enhance dynamic stability due to the unique characteristic of excessive capsular laxity and capsular redundancy in this type of patient.”

  • “If the patient frequently performs an overhead motion or sporting activities such as a tennis, volleyball or a throwing sport, then the rehabilitation program should include sport specific dynamic stabilization exercises, neuromuscular control drills and plyometric exercises in the overhead position once full, pain free ROM and adequate strength has been achieved.”

  • Heading into my last affiliation in an outpatient orthopedic setting, I had to review the basics. Mike Reinold is always a great resource providing straight shooting information on how to treat the orthopedic patient.

Rehabilitation, Restoration, and Reconditioning with Doug Kechijian (15 min)

  • “While physical therapists are licensed medical providers, they don’t “fix” medical problems. They’re effectively movement teachers with a license to touch people and evaluate the neuromuscular system.”

  • “There is nothing wrong with chasing pain to provide relief to athletes and patients. Without an objective and systematic process that a clinician trusts, however, pain can be too confounding an outcome measure from which to gain meaningful insight. To be clear, pain education alone is not a good physical medicine.”

  • “This story is worth telling because extreme aversion to imaging is just as egregious as its overutilization.”

  • Freelap does an interview with Doug Kechijian who goes into different topics covering physical therapists vs personal trainers, pain science, and imaging. It seems that the therapists who really get it are those who don’t swing the pendulum too far in one direction. He notes multiple times of the current understanding and trends in the field and really recognizes it is important to be aware of the biases that come forth with those beliefs.

Isometrics for tendon pain - is the hype justified? (10 min)

  • “probably the best thing to do is experiment with load (regardless of contraction type) and find the ‘entry point’ to achieve a positive response from an individual. Some patients need a softly softly approach, others you can escalate load sharply, others need lots of reassurance/education. Be prepared to play and try things! For example, some of my patellar tendon patients may spend 15-20 minutes gently developing load intensity to allow a positive response from load.”

  • Peter Malliarias is reviews an article on the effects of isometrics and it’s temporary benefits. What I liked about this post is that he spends time finding related research to form the idea that there isn’t one way to do something, and in this case isometrics doesn’t have to be this panacea. His last point that I highlighted in the quote above really just shows how he recognizes the limitations to research and the importance of clinical expertise. It’s always humbling to see someone like Peter who takes time to be humble and transparent about his practice and show how much he’s still looking to learn.

Pain Science

Elicit a Prediction (10 min)

  • “The point is for us to use our skills of interaction to assist the patient in coming to an idea that will be helpful to them.”

  • Cory Blickenstaff writes a 3 part series on interacting with the patient to help them overcome their own biases and expectations. In this first installment he discusses how it’s important to listen to the patient thoroughly, but also guide them to a specific conclusion about their aches and pains that can proven wrong in order for them to change their understanding of their pain.

Set up an Experiment (10 min)

  • “I have also long argued that our role as therapists is not that of one who makes the change for the patient. We don’t take pain away or heal pain. Instead, we set up the scenario in which the patient comes to their own conclusions and makes their own changes. We are context architects.  We don’t perform the experiment. We set up the lab for the patient to run their own experiments. We are Alfred, not Batman.”

  • The concepts covered in this blog are one of the first things I’ve learned from Cory. In the second part of his series, he talks about about how after you establish a specific understanding of the patient’s pains, work to create activities that will challenge that notion. When I say challenge, I don’t mean to put them into pain, but more so to give them different positions in which the specific motions that hurt them don’t. Context architects largely defines what we do as physical therapists.

Build Confidence (10 min)

  • “First is that the prediction is not staying static. It gets updated based on the new information. We have a role here in continuing to elicit the changes in the predictions in a measurable way.”

  • “What is very cool is that we can teach this process of “predict -> test -> repeat” as a skill to our patients. We can help them use their creativity to come up with ways to test and progress on their own.”

  • Pulling from the Craske paper on maximizing exposure therapy, Cory talks about the driving home factor of his 3 step process: refuting expectation. It’s important to instill new confidence in the patient, and show them through movement that their idea of what causes pain may not be as accurate as they think it. As movement specialists, I think this is our bread and butter of our intervention. Strengthening and conditioning of course is a huge component to what we do, but if we cannot get them to take that first step because of pain-avoidant behavior, we are rendered useless in their recovery.

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