On The Cause of Diversions

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Each time I encounter a post or comment by a clinician regarding an approach to rehab or an explanation for treatment effect or diagnosis, I wonder what experiences led them to their decision and perspective. I analyze this for all posts irrespective of accuracy and my own biases. Overall, the majority of thoughts appear to subscribe to contemporary scientific explanations. However, there is a significant faction within our field that does not. (Bear in mind this analysis acknowledges that there will be slight differences in approaches which can be substantiated by evidence.  This is both expected and good for the profession.) Given that for the most part our education/training are similar from primary school through graduate school, access to scientific literature is fairly available to all and clinicians must stay current with CEUs, what are these deviations attributed to? What is the cause for the pseudoscience and in some cases anti-science pervasive within our profession?

However does this matter? Is there actually an ethical dilemma?

Clinical outcomes are important, as are experience and findings of research report typically represent the significant averages. There will always be individual variation and guidelines are meant to be just that, they are not intended to replace clinical decision making. In a sense summary findings of a meta-analysis or clinical practice guidelines should not be viewed as dogma and unalterably infallible. However, ascribing a treatment effect or diagnosis to something factually inaccurate and contrary to the contemporary understanding of physiology is not ideal. Especially considering that an explanation of observed responses to treatment should be disseminated to the patient throughout the course of care. If we are not providing patients and the community accurate explanations for what is occurring with treatment yet they still improve is that ethical is that justifiable?

Case example of many…..

A patient is referred to a clinic for chronic headaches and the clinician provides cranial sacral therapy which results in a positive outcome for the patient. The clinician attributes this beneficial effect from the cranial bones being misaligned and then subsequently being reduced with this treatment. Though the patient’s status improved, the explanation has no substantive evidence to support what was disseminated by the clinician. Is that ethical despite the good outcome? What would the best way to explain the response to this treatment?

 

Let’s hear your thoughts!

On Truth (Quick Post)

truth

 

I came across this photo earlier and after viewing some discussions regarding EBP I decided to write a brief post on it.

 

People often attempt to conceptualize and understand complex topics to fit their world view and biases. This is human nature; as it is difficult to deconstruct information and assess it critically while acknowledging and remaining critical of one’s own biases. This is true for both patients and providers. The attainment of truth and knowledge is a difficult task but necessary. However in this current healthcare system untruths, oversimplifications, obfuscations, conflations and care lacking a trace of plausible evidence is reimbursable. Obscure, esoteric and novel (for the sake of being novel) methods and treatments are also easier to market; as are panacea. Imagine the perspective of the patient and their expectations. This is why the guru and missing link nature is so prominent and pervasive, which is not isolated to chiropractic. Until this issue and it’s multiple components is addressed as a society this issue will continue to perpetuate.

 

Simply put: “The truth defies simplicity”

On Physical Therapy residency programs

The topic of physical therapy residencies came up on a DPT student facebook page and I decided to share a brief article I wrote for the Wisconsin Physical Therapy Association’s student corner. Enjoy and comment.

Residency education in any section whether it be orthopedics, cardiopulmonary, sports, neuro, etc offers a competitive edge to clinicians, particularly entry level DPTs. Fast tracking to specialization, direct mentoring, opportunities for research, teaching responsibilities are not typically offered in most places of employment (especially to new grads) and rarely if ever provided in combination. Additionally in certain areas of practice (pediatrics, cardiopulmonary, women’s health and clinical electrophysiology) it is rather difficult to obtain the necessary hours needed to sit for board specialization. For those sections residency training is almost necessary to practice.

That being said if you are unsure after graduating as to what sort of clinician you aspire to become or what area you want to practice in, I would caution against pursuing a residency. As with a residency you are in effect “building on” clinical skills and knowledge more so than “building up”. The extent of that will vary from program to program and amongst sections but in general I feel that is the case; and as sparse as the spots are nationally, they very well should be. Residency training is not mandatory and neither is specialization, although that hopefully may change. So as with anything in life if you are uncertain, avoid making a rash decision and wait. Along those lines if you do decide after graduating and passing the NPTE that you do not wish to pursue a residency immediately, I would strongly recommend limiting that waiting period to 3 years post graduation. By that time you should have your own identity as a clinician, earned at least your first promotion and possibly been a clinical instructor. Instead I would then consider sitting for whichever board specialization you desire as an independent.

In choosing a residency I feel that the best programs are affiliated with a DPT program or a university. Private clinics lack the opportunities for research, teaching and collaboration with other providers that all university based programs offer. Again the importance of this varies between residents but I feel that a program should offer more than just mentoring. A residency should offer pathways to different aspects of the field and develop a therapist into a leader in their section not solely a “clinical expert”. Again this is my opinion alone, talk to other residents in order to gain as many perspectives as possible which will help you make the best choice for YOU. Ultimately it’s your professional life, goals and aspirations.

Jump training and knee valgus angle: A review and opinion

ACL injuries and other such knee ligamentous pathologies are by far some of the more common and more devastating injuries in sports. Each year 2,220 ACLs are expected to be torn just in female college athletes alone with basketball players having the highest percentage. Some people attribute this preponderance of injury in women to a number of factors including narrowness of the intercondlylar groove of the knee, strength, flexibility and endurance. However, the current literature seems to consider jump landing strategies as function of neuromuscular control to possess the strongest causal link. This idea is reasonable as the mechanism of injury for ACL tears are deceleration/change of direction non-contact injuries with the foot planted. Thus if an athlete lacks control at the knee each time he/she lands the force from impact would be placed passive structures since the active structures don’t fire correctly thus potentiating the risk of injury to ligaments etc.

Due to this knowledge jumping programs focusing on correcting the valgus angle or frontal plane strategies have been initiated. These programs have had success but what researchers, therapists and coaches have trouble with is finding a way to fit these jumping programs into existing strength and conditioning programs. Most studies for valgus prevention utilize programs that last 6-8 weeks and each session can last 20min-1hr, which in the realm of athletics is too long to add to what typically is a very tightly scheduled regimen and programs that long may present problems with compliance . What Lee Herrington’s study examined was whether or not a program in 4 weeks, 2 times a week, for 20min per session could result in the same benefits of the longer jumping programs.

The study took place in Manchester, UK and the subjects were 15 female collegiate basketball players with no history of ACL or other such knee pathology. He evaluated knee “function” through three measures; 1) knee valgus upon landing from a depth jump to simulate a player landing from grabbing a rebound or finishing a shot, this was done via a digital video recording 2) He had the players run from half court to the foul line and shoot a jump shot, this was done to evaluate the players in a functional movement pattern specific to their sport and since the players would more likely concentrate on making the shot it than jump “correctly” which would expose their more normal jumping and landing strategies. Again the valgus angle was recorded via a digital video recording 3) The players were tested on lower extremity power by having them perform a cross over jump test. The test required the players to jump on one leg on diagonals across a line three times with the goal of traveling the farthest possible with 3 reps/jumps.

All subjects were evaluated on all 3 measures at pretest and then initiated a jumping program where they were first educated on how to land correctly with the knees in line in a “sagittal plane strategy” and performed all exercises with close monitoring for form. The program consisted of various plyometric and agility exercises with some basic strength components as well. All subjects completed between 10 to 12 sessions and were all instructed not to perform additional training on the day of each session. The researchers evaluated the test retest reliability for each measure on 5 players independent to the study to evaluate for error and all were found to have high reliability and very small amounts of difference between measure for each recording. The minimal statistical change for the depth jump was 1.2deg, 2.2deg for the jump shot, and 79cm for the cross jump test.

Upon post-test the results were quite impressive. The valgus angle during the depth jump on average decreased by 9.3deg on the left and 12.3deg on the right; the the jump shot valgus angle on average decreased by 4.3deg on the left 4.5deg on the right; for the cross jump test the left improved by 111cm and the right improved by 110cm. All of these results were significant to a p level of 0.05.

Though the subject size was relatively small and this was only tested on women it is not completely generalizable but for the athletic female population this is very applicable. And again other studies that had similar programs but were longer in duration produced benefits of similar magnitudes which suggests that these results are reasonable. The fact that this duration is effective also falls inline with accepted contemporary theories on strength training in that the early gains (under 6-8weeks) in strength and function are more based on neuromuscular adaptations rather than muscle hypertrophy. One must also consider again that since this study was done in a much shorter amount of time future programs like this should have less of a problem with patient compliance. In the future I would like to see a study that evaluates the results of a jump training program conducted in 4 weeks and evaluate the valgus angle 4 weeks after completion of the program to asses the retention of these skills and compare those to a training program under a longer treatment duration. A study analyzing the trend in valgus angle decreases after a 4 week program that continues to 8 weeks would be useful as well to see if the benefits constantly improve with training or if they plateau and to see if the problem lies within motor control vs muscle girth/weakness.

From a clinical aspect these results have huge ramifications for our profession. Injury prevention and performance are two avenues where therapists have the best skill set to make the highest impact. These results can be used as a selling point to coaches because not only do programs such as this prevent injury they have also demonstrated improved performance in relatively a short amount of time. Personally I would like more research to be conducted to further justify this compressed training schedule and programs for other joints such as the shoulder, back and hip. The more we can demonstrate the benefits of preventative interventions the more likely insurance will cover it especially if we can reduce risk with less cost per patient. This will not only provide more avenues for business but it will help our patients in the long run. Research drives reimbursement from insurance and reimbursement drives practice.

I have always stood by the belief that its cheaper and more efficient to prevent a problem than to fix it. Think about it, if you maintain your car and check the oil regularly and brake fluid it will cost you substantially less than paying for it when one of those components fails or in the worst case you have an accident. The same can be said about the human body, if you maintain the body and keep it healthy you can prevent tissue failure and prevent serious injury.

Included are some images of the results on pre and post test. More images to follow.

here is a link to the article

http://www.ncbi.nlm.nih.gov/pubmed/20664369

Have a great day!

-Rich