The Role of the Clinician in the community; selling meat to vegans.

Following the most recent media craze around cupping and other alternative medicine in MSK rehab, many in our profession have provided commentary on this issue. I feel that this most recent event highlights a bigger issue within our profession, which is the role of the clinician. My opinion on this matter was requested by a colleague of mine on a thread, which realizing how long it became, I felt might be good for blog post. Please, enjoy and let me know what you think!

Though I am more in the lab and lecture hall now as an academic, I still see a few patients and serve as a clinical educator to both students and practicing clinicians. This is my general view of the role of the clinician in communication with patients and the community:

A clinician should be confident in their understanding of the human body, based on the current accepted body of knowledge, while humbly accepting their personal limits of understanding and the current gaps in knowledge. They should also avoid filling those gaps with ideas that escape the realm of scientific plausibility, especially when interacting with patients and their community. The reasoning behind a given treatment is almost as important as the physical act. Our thoughts and words matter, a lot. This is a particularly important concept to bear in mind. Remember when interacting with a patient or the community it is from a position of authority (a clinician is viewed as an expert), in that power dynamic people tend to believe what is told to them. Therefore it is imperative that we strive to ensure that the information which is communicated to patients and the community is as truthful as possible. More on the consequences of failing to do so by my colleague Kenny Venere PT, DPT (FYI he’s a bit blunt).

Clinicians should remain committed to becoming excellent in their field and learning more throughout their career and most importantly doing right by their patients. Sometimes that means being a discerning yet respectful voice of reason to the patient and in community to the nonsense that is perpetually disseminated by others, for whatever reason. A clinician at the core is a motivator and an educator. As an educator sometimes what’s right isn’t popular and it’s not easy to tell or convince someone that they’re wrong. However if someone is wrong it’s important that they are told so but it should be done in a respectful manner. Changing someone’s opinion on anything is incredibly difficult and it doesn’t become any easier by being boorish and discourteous. Always remember to be tactful and be mindful that some people just won’t change, despite how well informed a counter argument might be or the degree of cognitive dissonance present. Clinicians should also learn to effectively communicate, empathize and relate with the different types of people entering into a clinic. Communication and use of language is probably a clinician’s most important tool after what’s between the ears.

Lastly, the majority of patients arriving at a clinic already are confident enough in a providers abilities, as they likely wouldn’t be there otherwise. Even if a given clinic is the only one covered by a patient’s insurance, most have the option of not showing up (trust me I’ve practiced in systems like this and people still don’t show up). Therefore they don’t need to be sold on some esoteric and novel for the sake of being novel treatment, they just want to get better. They are seeking the help and guidance of a clinician to do so and they also want to be listened to by someone who cares. Listening to a patient is not synonymous with doing whatever they want so that they feel better. Listening is using the information they’ve provided to develop the best choices for them to make, we’re providing them guidance and options that they have to choose. It’s a give and take but the role of the clinician is the adviser, that’s why a profession requires so much schooling, training and licensure. Also factor in that most MSK injuries are self limiting, we don’t really need to make rehab too complex or creative. It just needs to be intense enough so the patient progresses to meet their goals in the most effective and efficient manner and creative enough to keep them interested.

In short, keep it simple and use the body of knowledge to inform and guide decision making (not replace it), stay current, be an adviser for patients and community, be careful with use of language and have the courage to offer a discerning opinion and humility to accept one. This is not always easy to do in the clinic while working with individuals with health related problems (who we all want to help get better) who may have been exposed to all sorts of information/misinformation and may take some convincing. However, if a patient doesn’t want to listen to a clinician’s advice they can always go somewhere else. We aren’t short on people needing help and if a patient doesn’t buy in they probably aren’t going to have too much success with that clinician anyway. This is basic marketing/argumentation/social theory, as an example people who are vegans aren’t interested in people trying to sell them meat but there are plenty of meat eaters and they are sure to find those selling meat.

Image: Courtesy of Deborah Dunham 2012; cavementimes.com

 

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

Greetings

Good evening all! This is my first official blog post ever. I was always skeptical of creating a blog because I thought that they create a mentality of isolationism and narcissism. However, today I had rather illuminating lecture from a therapist who clearly demonstrated the benefits of having a blog and proved my presumptions to be false. Those who know me well realize that I can talk ad nauseam on things that I find interesting. What better way to express my opinions on subjects I am passionate about than a blog. So in short greetings blogsphere I am happy to join you. 

The main premise for my blog will be to review articles and topics I have found in the most recent scientific journals and provide you with my opinion. That being said I also will cover topical issues such as injuries and policy affecting healthcare specifically focused around the physical therapy profession.

Thanks for reading!

-Rich