Attention class....

Man it has been a busy couple of weeks at the clinic. Sometimes it's hard to peel away from the daily grind at the clinic to sit down and have a friendly online debate, post on my blog, or just sit and read a good novel.

I've been having a good time interacting with the interesting folks on the SomaSimple website while staying a little more grounded with my roots on planet earth via the folks on RehabEdge. If you are a PT and interested in some spirited debate and good conversation, feel free to join us and let us hear from you.

Later this month I will be bringing in two physical therapy students for a six-week orthopedic rotation. My typical approach to students is the learn-on-the-fly model with very little structured sessions. After reading a post on a PT student's website, I have decided to take a much more proactive approach to the clinical experience. While I'm only in the early stages of planning, I hope to include:

• Specific learning objectives
• Weekly lectures
• Regular literature reviews
• Case presentations

These are things that will undoubtedly increase the demand on the students' attention and focus. I think the end result will be a better learning experience for them and offer me a chance to continue the process of reevaluating my approach to managing my patients....everybody wins.

If you have a novel approach to your students in the clinic, I want to hear from you as well. In my next blog, I will review some exciting literature I've been reading on the issue of OA following menisectomy and its possible relationship with distance running. See you next time!

Interesting Perspectives

I recently discovered the online forum SomaSimple. A collection of very bright individuals including Barrett Dorko, PT and a host of others who challenge many conventionally held paradigms of the orthopedic community, myself included.

Below is a list directly from the website moderator's "Ten Steps to Understanding Manual and Movement Therapies for Pain". I find it a fascinating perspective on the subject of pain as it relates to our daily practice.

There is an interesting irony for me discovering this website. This week I have been referred three individuals in various stages of adhesive capsulitis. Each patient has a remarkably similar ROM deficit including osteokinematics, joint play, end-feels etc... However each patient is remarkably dissimilar with respect to their pain behavior. One is very stoic with a very high tolerance for mechanical mobilization while the other two are...well, not quite as stoic.

This should come as no revelation for anyone. We all experience pain in very different ways and understand that pain behavior can influence outcome. However, there is likely more at play than simply getting our patients to relax enough to tolerate our treatments. Understanding the physiology of pain could allow us to conduct more thorough and effective management strategies of musculoskeletal conditions. This, at the end of the day, should be our aim.

I have doubts (I am after all a skeptic) that a forum is likely to fundamentally alter my approach to my practice. However, I am even more certain I don't have all the answers to every clinical problem that walks through the door. We'll see where the discovery of this and other sites like it lead. I invite you to join in as well and see what's going on.

In the meantime you can also catch me on the Rehab Edge forum for a more conventional or, as one Soma Simple moderator puts it, more "mesodermal" approach. Either way we'll have a good time and hopefully learn something along the way.

PT Education: Do we really need to reinvent the wheel?

I've enjoyed reading the posts on a PT student's blog recently. The posts express a genuine desire to become a good therapist and the confidence to share his thoughts with those who will listen. As much as I admire these qualities, a recent post had me thinking. The post lamented the current state of clinical education for physical therapists, and I would encourage you to read it.

On the surface, I certainly understand the student's need not to simply be a free source of productivity. I personally encountered experiences in my clinical education where I was thrown to the wolves and rapidly had a decent caseload. The process can be stressful and sometimes lead to a resentment of both the CI and the educational process in general.

Upon further review, I might encourage PT students out there to keep things in perspective. Take a look around at other institutions of clinical education: medicine, advanced nursing, dentistry, etc.... These professions have systems of clinical training that produce arguably the finest practitioners you are likely to encounter. I think if you were to speak to a 1st year medical resident (intern), you would hear about how overwhelming, stressful, and emotionally draining the process can be. Three years later, you are likely to encounter a highly competent physician within his/her field who is ready to take on any challenge without freaking out or making a really, REALLY bad decision.

We also have to concede the medical model of education is certainly not ideal. Long hours of trial by fire practice under stressful circumstances can wear the resident down to be sure. However the end result is hard to dispute. Has this system produced inferior physicians? Of course, but it has also produced some of the greatest and most innovative minds of modern medicine. If we look at this honestly, we have to admit that it is the individual and not the institution who is responsible for their training.

The current system of physical therapy education should always be questioned and scrutinized to make sure we give students the best opportunity to become great. However, before you get swept up in the next great reformation of our profession, ask yourself if you are taking every possible step toward making yourself a better student or clinician. To paraphrase a wise Chinese proverb: "Teachers open the door. You enter yourself."

Good luck and I look forward to seeing you in the clinic!

Let's Get Critical

Most therapists I've run into are pretty solid critical thinkers, capable of examining things from a variety of perspectives before jumping headlong into shallow water. Unfortunately, there is a not-too-silent minority of our community that continues to grasp at methods of assessment and treatment that not only aren't consistent with available evidence, they are in direct conflict with the laws of nature and just plain common sense!

I always look forward to a great debate like the one mentioned in an earlier post, but enjoy participating in one even more! The trouble is I find myself often reducing my argument to the level of "Because my view just makes more sense than yours" reasoning that simply doesn't wash with most people. This kind of logic, among others, often irritates and sometimes insults otherwise well-meaning (albeit misinformed) individuals.

Wouldn't you know it but there are actually rules of engagement that can help you get your point across without alienating your fellow coworker or boss. They are brought to us by the late scientist Carl Sagan who offers his criteria for solidifying your logic.

1. Wherever possible there must be independent confirmation of the facts.
2. Encourage substantive debate on the evidence by knowledgeable proponents of all points of view. Arguments from authority carry little weight (in science there are no "authorities").
3. Spin more than one hypothesis - don't simply run with the first idea that caught your fancy.
4. Try not to get overly attached to a hypothesis just because it's yours.
5. Quantify, wherever possible.
6. If there is a chain of argument every link in the chain must work.
7. "Occam's razor" - if there are two hypothesis that explain the data equally well choose the simpler.
8. Ask whether the hypothesis can, at least in principle, be falsified (shown to be false by some unambiguous test). In other words, it is testable? Can others duplicate the experiment and get the same result?

There is certainly a sense of balance we can achieve with respect to our pursuit of gold standards of assessment and treatment. In fact, one of my favorite instructors stated "Nothing is ever proven; only supported."

Here are some questions to ponder the next time you face an argument over a clinical issue: Can you be an evidence-based practitioner without becoming an automaton? Conversely, can you explore creative treatment options without becoming a faith healer? This is an exciting time for our profession. Keep honing your skills and take a critical look at your approach to clinical problems. You may not be the next Carl Sagan, but the exercise will sure do us some good!

What's Your Resolution?

You know...the one you'll keep this year? I really enjoy the first part of the year when I get to map out all the great things that the next 12 months bring. Taking a tip from Stephen Covey, I try to map out the things that will keep me healthy, happy, and wiser at the end of each year. In addition to my standard package of personal resolutions for my family and health, I've got a list of things I thought I might share with you in the hopes you might also consider reexamining your list as well.

1. Begin my doctoral studies. I hope to begin working on my Sc.D from Texas Tech this year. It's a great program and I encourage anyone interested in orthopedics to consider it along with the other great programs that are out there.

2. Earn my COMT for the upper extremity from the International Academy of Orthopedic Medicine. I try not to be a credential-hog with 4000 initials after my name, but the UE courses are outstanding. I took the shoulder and lower cervical courses last year and they've really helped improve my practice.

3. Attend the National Strength and Conditioning Association National Conference in Las Vegas. I was a CSCS before I became a PT and feel like I've drifted too far from my roots in exercise science. I'm fired up about going this year and hope to see you there. Let's have a beer (or nonalcoholic beverage of your choice) together.

4. Begin the process of standardizing my progressions and techniques for both therapeutic exercise and manual therapy. I hope to improve my collaborative efforts with other therapists and maybe begin the process of exploring publication. (I'll get back with you in 2009 on that one!)

5. Rejoin the APTA, Orthopedic Section and become more involved. After reading some compelling arguments both for and against membership, I've decided my arguments against membership simply aren't holding water. The APTA is that nutty uncle that we find ourselves disagreeing with regularly, but still has enough wisdom and family-equity to justify inviting him to the family reunions. I will be rejoining ASAP.

Let's hear from you. What will you be doing to keep your professional life heading in the right direction for 2008?

Orthopedic Protocols: Time for a Change?

According to a recent Cochrane Review, we at least need to consider examining them more closely. This article had me thinking more closely about some of the rehab protocols we use throughout our daily practice.

Two statements from the review caught my eye:

• "This review found no evidence to support one form of exercise programme over another in managing recovery from the injury looking at return to daily activities, work and sporting activities."

• "Limited conclusions in this review are a consequence of the small number of trials, non-standardised exercise programmes and methods of measuring their effectiveness, and poor quality reporting of the results."

I currently utilize several different protocls for rotator cuff repairs of various sizes, ACL reconstruction, Bankart repairs, shoulder arthroplasty, and several others.

I doubt the outcomes of my patients far exceeds or lags behind those of most orthopedic therapists. However, it may benefit our patients and professional standing if we took a more proactive stance in establishing treatment progressions that represent best practice versus simply following the orders of our physicians.

The last half of that sentence might be a tough one. For some of us, convincing an orthopedist to modify or change a rehab protocol could prove to be a daunting task. I know it would be for more than a few of my consistent referral sources. However, despite what we may think, many surgeons are actually receptive to our suggestions regarding the postoperative management of their paitents.

If we can present our referrals with some good evidence supported by clinical reasoning, I think we may find a great opportunity to greater autonomy with our patients and actually enhance the relationships we have with our valued referral sources! It's 2008 and I'm going to give this a shot with at least a few of my regular referring doctors. Hopefully we'll see good things to come down the road.

Turf War: Offense or Defense?

I sometimes wonder how ticked off I should be getting when I hear some of the things traditional or "straight" chiropractors tell their patients. It's hard for me to challenge straight chiros on the grounds of their manual skill set, but should we really be content with allowing another profession to perpetuate the myth that is the subluxation theory?

I know the chiropractic profession is in serious crisis across the country, and sometimes feel I'm kicking an opponent when he's down. However, for the sake of our profession and our patients, I feel obligated to be honest with my patients regarding my opposition to traditional chiropractic. I do feel better in the sense that I don't sound like a evangelical minister anymore when I give these talks to patients. I'm able to present an opposing view to straight chiropractic in a more calm and objective (to me at least) manner.

Orthopedic physical therapists will continue to be at the forefront of rational approaches to the conservative management of musculoskeletal disorders. We need to make sure we are ready to do what it takes to defend our profession, but also be willing to put ourselves out there and take the offensive against quackery. The end result will be better health for our patients and our profession!