Accepted!

I received some great news today. I have been accepted to the post-professional doctoral program (ScD) at Texas Tech! Some of you who know me understand I have gone through quite a bit of soul searching to decide what direction I wanted to take my academic career. I strongly believe this program has the balance of academic and clinical education for this stage in my PT career.

If you are unfamiliar with the ScD designation as it relates to other doctoral degrees, I've included a Wikipedia reference to it. (Note: I don't make a habit of referencing Wikipedia, but it did offer a good description of the title.)

I'm sure there will be many challenges along the way and I won't always be this giddy about the process. Presently however, I am extremely excited about the opportunity and look forward to sharing my experiences along the way.

Thanks to all my family, friends, and colleagues who provided counsel to me in making my decision. You know who you are! Take care and see you at the next update!

Rethinking Functional Training...again.

In a previous entry, I mentioned I was going to rediscover my roots in exercise science. In reviewing many of my posts, I realized I hadn't posted much on the topic of training and exercise physiology. It's time for that to change!

Back in 1995 when I was just entering the world of exercise science, functional training was rapidly becoming the latest craze among fitness professionals and strength coaches. Before you could say "bosu ball", every strength coach and personal trainer had their clients standing one-legged on a foam roller juggling three medicine balls...blindfolded. Not to be outdone, physical therapists also jumped on the bandwagon.

Nearly fifteen years later, we've finally tempered enthusiasm for this "new" form of training with the realization that motor control strategies and functional training may not always be in sync with one another. For a time it seemed we were drifting into a dimension of training-to-train more than training for skill acquisition and enhancement. While "functional" activities such as destabilization training on physio balls and dynadiscs seemed to serve some purpose, their role in enhancing motor control strategies fell under justifiably intense scrutiny.

Steven Plisk, MS, CSCS recently wrote a NSCA Hot Topic article titled, appropriately enough, Functional Training. It is certainly worth reading and has very strong implications for what we do as both as strength coaches and physical therapists. Physical therapists in particular can be a trendy lot and I think articles such as Plisk's can offer some much needed perspective on physical training as it applies to clinical and athletic performance. In fact, Plisk notes the distinction between athletes and non-athletes may not be so clear cut.

"...it’s helpful to rethink the traditional distinction between athletic and nonathletic activities. Indeed, many sport movements (e.g. running, jumping) are simply high-powered ADLs where the issue is one of degree more so than fundamental difference. Furthermore, considering how recreationally active many “non-athletes” are, the role of functional training becomes even more apparent for overall quality of life and injury prevention."

Plisk goes on to deconstruct the principle of specificity in a way I found to be very eye-opening. He breaks specificity down into mechanistic, coordinated, and energetic fronts, helping the reader understand the need to give more than just lip service to this key training principle. He follows with a very interesting perspective on development of motor learning throughout the lifespan:

"Training should, therefore, be viewed as a long-term curriculum where acquisition of movement competencies precedes performance. Movement mechanics and techniques, as well as basic fitness qualities (i.e. “general preparation” tasks) are priorities early on. The intent is to progressively automate these so athletes can focus their attention capacity on tactics and strategies (i.e. special preparation”) as they advance through the syllabus."

Although a fairly brief treatment of the subject, Plisk does a very good job of connecting the dots between functional training, motor learning, and skill acquisition. He concludes that functional training modalities play an important role in training and skill development. However we should not sacrifice basic principles of motor learning at the altar of functional training. Great stuff Mr. Plisk!

The Centralization Phenomenon: Prevalence and Predictive Value

A recent research report in JOSPT investigates the centralization phenomenon including its prevalence among cervical and lumbar cases, and its relationship to treatment outcomes. In keeping with the spirit of standardizing and refining our methods and language, this article is definitely a step in the right direction.

In this study, centralization is characterized as "spinal pain and referred symptoms that are progressively abolished in a distal-to-proximal direction in response to therapeutic loading or movement strategies". Werneke points out that despite being a fairly well-defined concept, varied methods of classifying centralization lead to significant difficulty in comparing treatment outcomes. The objectives of the study were:

• Determine the association between age, symptom chronicity, and prevalence of centralization among cases of nonspecific cervical and low-back pain
• Determine if classifying patients into centralization and noncentralization subgroups can predict functional status, pain, and numbers of visits at discharge
• Compare clinically meaningful changes between patients placed in either the centralization or noncentralization subgroups.

The study examined 418 adults between the ages of 19-91 years of age (mean age of 58 and SD of 17 years). Two therapists performed a standardized examination, and patients were classified as either centralizing or noncentralizing. Patients in both groups were assessed for changes in functional status and pain reports. The authors discovered some very interesting findings:

• The prevalence of centralization was only 17% for the entire population
• The highest prevalence of centralization was seen in patients between 18-44 years of age at 30-32%.
• The lowest prevalence of centralization was seen in patients between 65-74 years (8-14%%) and over 75 years of age (0-1%)
• Patients with acute symptoms had higher rates of centralization (23-28%) compared to those with chronic symptoms (6 -11%)
• A higher percentage of patients who centralized had minimally clinically important differences (MCID) in functional status and/or pain intensity than noncentralizing patients.

The authors conclude that centralization was useful but declined in significance for older and more chronic patients. Secondly the use of an operational definition of centralization had predictive ability and associated with pain and functional outcomes in this study. Lastly, the use of centralization could improve clinical classification and assessment of outcomes.

This was yet another fine example of the positive direction our profession is moving with respect to research. It certainly doesn't provide all the answers we need to manage this population, but it provides a good foundation for further investigation into perhaps standardizing our treatment methods as well. As always, I welcome any thoughts or questions!

Werneke, M.W. (2008). Centralization: Prevalence and Effect on Treatment Outcomes Using a Standard Operational Definition and Measurement Method. Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2008.2596

Diagnosis of Patellar Malalignment: A Work in Progress...

If you've been reading my previous blogs, you'll see that I often need to be dragged kicking and screaming into a adopting traditionally held beliefs of the physical therapy profession. As much as some of my colleagues would like otherwise, I will likely hold on to this stubborn characteristic until the day I croak. The upside to my eternal skepticism is the drive to finding evidence supporting or refuting specific approaches to a clinical problem.

I have previously admitted having guerrilla hands with respect to palpation and assessment of the SI joint. I have another confession: I have the eyes of a fruit bat when it comes to visually assessing patellar alignment in patients with anterior knee pain. I assure you I will try to cease comparing various parts of my anatomy to jungle beasts. It's probably just a phase.

Today's research comes to us from the JOSPT on diagnosing patellar malalignment. Patellar malalignment is thought to be at least one of the mechanisms at play in anterior knee pain. However, in this clinical commentary, Wilson raises considerable questions regarding it's usefulness as a diagnostic tool

• Contrary to popular belief, the existence of patellar malalignment in subjects with PFPS is uncertain. In fact, the weight of evidence currently suggests otherwise.


• The non radiological clinical tests most commonly used have been shown to be lacking appropriate scientific qualities and have been deemed clinically unacceptable.


• Until more scientifically robust measurements have been developed, we should be aware that many of our beliefs with regard to the role of patellar malalignment in the etiology of PFPS are based largely on assumptions and not on evidence. (Wilson, 2007)
  

If the diagnosis of a patellar malalignment is found to indeed lack clinical utility, shouldn't this also cast equal doubt on the mechanisms surrounding treatments designed to alter the supposed malalignment? Many of us "stretch" the ITB and lateral peripatellar retinacular tissue and "strengthen" the medial quadriceps in an effort to normalize this malalignment, but what if patellar malalignment is not the problem to begin with?

We know many of our treatments seem to lead to positive outcomes for our patients, but we seem to have a long road toward understanding the physiologic mechanisms surrounding the improvements. The solution to conservative management of anterior knee syndromes will likely begin by establishing clear operational diagnostic criteria. This makes a stronger case for continually refining and sharpening our clinical skill set.

Wilson, T. (2007). The Measurement of Patellar Alignment in Patellofemoral Pain Syndrome: Are We Confusing Assumptions With Evidence?. Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2007.2281

Guide to Evidence-Based PT Practice

I recently got a copy of this recent publication by Dianne Jewell, PT, PhD, CCS, FAACVPR. In the coming weeks, I will provide some highlights of this textbook. My hope is that I can generate enough interest in the full text for you to consider picking it up. It is the first full-text I've been exposed to attempting to apply principles of EBP directly to physical therapy. There may be others, but this one looks to be a great treatment of the issue.

The book is very well organized and provides a systematic way for the practicing physical therapist to understand and implement principles of evidence-based medicine into daily practice. One of the first things that jumps out at me as I am reading the first part of this text is the careful choice of words used in defining Evidence-Based Practice:

Evidence-based physical therapy practice is "open and thoughtful clinical
decision-making" about the physical therapy management of a patient/client that
integrates the "best available evidence with clinical judgement" and the
patients/client's preferences and values, and that further considers the larger
social context in which physical therapy services are provided, to optimize
patient/client outcomes and quality of life.

Jewell goes on to clarify the quoted aspects of this statement in a very thoughtful manner that leads the reader to understand EBP is not about molding practice patterns solely on published articles or clinical guidelines. Rather, it is a dynamic process of appraising, understanding, and utilizing evidence to the benefit of your patients well-being.

She also takes time to outline the role of evidence in clinical decision making, stating that the use of evidence is a "movement away from unquestioning reliance upon knowledge gained from authority or tradition." Taken in this context, it is difficult to justify avoiding it's use in our daily practice. As always, I do welcome opposing viewpoints on this matter.

Chapter one concludes by advising the practicing therapist that implementing EBP into your daily routine is not a simple process, particularly if you are not accustomed to doing so in the first place. It will require some cortical and habitual effort to begin consciously moving away from easier tradition and authority-based decision making.

I hope you will join me in this process of challenging yourself and refining your practice patterns to the benefit of your patients. You may find nothing changes in your day-to-day practice. If you are like me however, you may find some aspects of your daily practice that should be intensely challenged and refined. It isn't easy and will be downright humbling at times, but the end result will be well worth the effort!

Jewell D. (2008). Guide to Evidence-Based Physical Therapy Practice. Jones and Bartlett Publishers: Sudbury, Massachusetts.

Live from Lubbock

I'm sitting here in the lobby of a palatial La Quinta Inn near the Texas Tech Health Sciences Center in Lubbock, TX. This is my first visit to Lubbock and I have to say, it's both much smaller and nicer than I expected! If you want a good taste of West Texas culture, I strongly suggest a visit.

I am attending yet another course through the International Academy of Orthopedic Medicine. If you have not had the opportunity to attend one of these courses, I highly recommend them. They are a refreshing immersion into evidence-based concepts of orthopedic diagnostic and management techniques.

I just finished my most recent research-based blog (please see below!) and have to say starting this blog has been a truly enriching and invigorating process for me. This blog represents a major and fairly recent transformation I've had with respect to my career goals. I must admit to having some degree of professional burn out a few year ago...it's good to be back.

After only four months of beginning this blog, I've managed to find an equilibrium between editorial pieces such as my post on cults and my research-based posts. I imagine this will be a dynamic equilibrium hopefully favoring neither one nor the other. Regardless of the tenor or themes you see when you visit this site, I appreciate your stopping by to share in this personal journey to become a better physical therapist. Hopefully I can play a small part in yours as well. Take care!

Rod

TKR: How much motion should we expect?

I'm not sure how this happens, but certain diagnoses seem to come to my clinic in clusters. I see a fair amount of primary TKR in my clinic. For the most part, patients undergoing primary arthroplasty seem to do very well in our clinic subjectively and functionally. Fortunately for all of us, I doubt my outcomes far exceed or lag behind many of you treating the same population.

In spite of the numerous successes we see with primary knee arthroplasty, you may share my frustration with those patients who do not fair so well following this procedure. Although many variables often contribute to a poor functional outcomes, few are as fundamental to a patient's recovery as restoration of adequate ROM. Restoring functional ROM following arthroplasty can often be a routine issue for patients and therapists, but there is an unfortunate minority who are not so fortunate.

Today's research again comes from our colleagues in orthopedic surgery. The article's authors are examine the various factors that contribute to less-than-optional ROM following primary and revision TKR.

Ritter and colleagues recently published an article in The Journal of Arthroplasty retrospectively examined 5622 TKA performed on 3672 patients between 1972 and 2002. The relationships between preoperative and postoperative flexion contracture, pain scores, functional scores, gait speed and stair climbing ability were examined using logistic regression analysis.

Noteworthy findings of this study were:

• The severity of the postoperative flexion contracture strongly correlated with the severity of the preoperative flexion contracture for moderate to severe contractures of 20 degrees or more.
• A mild (5-19 degree) preoperative flexion contracture had only a small effect on pain and functional scores. The authors explain this by the fact that many small knee flexion contractures are corrected intraoperatively.
• A preoperative hyperextension of more than 10 degrees had a negative effect on postoperative pain and functional scores. The authors do not provide explanation for this finding.

An earlier study also performed by Ritter and colleagues attempted to predict postoperative ROM after revision TKA using cluster and log-linear regression analyses. The variables used to predict ROM were preoperative flexion, intraoperative flexion, preoperative alignment, patient demographics, type of posterior soft-tissue release, previous prosthesis type, and revision prosthesis. For this study, 355 revision arthroplasties were examined with the following findings:

• Preoperative and intraoperative flexion were the most important variables predicting postoperative flexion
• Constrained and hinged prostheses had a negative effect on postoperative flexion.

The authors conclude that a patient with high preoperative flexion, middle aged or older, with a nonconstrained prosthesis has the best predicted postoperative flexion. Conversely, low preoperative flexion, younger age, and constrained prostheses had the worst postoperative flexion. Improvements in flexion following a revision were lower than following a primary TKR.

What can these studies tell us?

After wading through the data of these two article, a few important take home messages came to mind. One is the compelling case for preoperative physical therapy for primary and revision TKR. With the right approach, a well-trained therapist should be able to partially address preoperative ROM deficits.

Secondly, these papers lend support to not simply breezing through the history of a patient with a TKR. Factors such as age, preoperative ROM, and even knowing the prosthesis type may provide valuable information for you regarding your patient's rehab potential. I hope you find this summary helpful and as always welcome your questions, comments, and contributions.

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RITTER, M., LUTGRING, J., DAVIS, K., BEREND, M., PIERSON, J., MENEGHINI, R. (2007). The Role of Flexion Contracture on Outcomes in Primary Total Knee Arthroplasty. The Journal of Arthroplasty, 22(8), 1092-1096. DOI: 10.1016/j.arth.2006.11.009

Ritter, M. (2004). Predicting range of motion after revision total knee arthroplasty Clustering and log-linear regression analyses . The Journal of Arthroplasty, 19(3), 338-343. DOI: 10.1016/j.arth.2003.11.001