Friday, March 20, 2009

Good stuff from the APTA on manipulation

This is a quick-hitter post I thought some of you out there might find interesting. I recently had a pleasant but slightly contentious discussion with a local chiropractor that wandered off into the topic of manipulation and scope of practice.

"I find it curious that PTs are so eager to criticize chiropractic, yet are equally eager to manipulate."

- Dr. Unnamed Chiropractor, DC

First of all, let me please go ahead and thank God for the ability to guide my emotional and physical restraint. Were I a younger man this is something that would have put me over the edge. Fortunately I was able to sit on my hands and restrain my tongue long enough to calmly discuss the issue with him. My talking points included:
  • The physiology of manipulation (i.e. its role as a self-perpetuating "adjustment"versus a means to normalize function).
  • The messages of self-restoration in physical therapy compared to chiropractic (I know - this is the supposed mantra of the chiropractic profession. I guess you only need a lifetime of adjustment before realizing this self-correction...)
  • Unsubstantiated claims regarding risk of a manipulation performed by a physical therapist

The conversation was brief, but I felt amazingly well prepared. Best of all...I carried it off with a sense of satisfaction that I did the right thing for our profession in sending a message to the chiro that we are well trained to perform thrust-mobilization (manipulation) and have a better model of care to support its use.

Right on the heels of this conversation, I received an email from the APTA which I strongly suggest you review if you are close to this situation. The email was from our Advocacy section and outlines some great presentations and handouts regarding PTs and manipulation. I'm a vocal critic of my organization on some issues, but man they do some great things with our dues. It is a tough check to write each year, but I feel more strongly it is the right thing to do everytime I get one of these emails. This will be a great resource for us for some time to come.


Thank you all for the great responses to my first podcast! They were greatly appreciated. Stay tuned and I've got some really good topics on the way. Also, I may be updating the format of my blog to be more user friendly and offer easier access to archived posts and my podcasts. Hang in there and we'll continue to grow!

Sunday, March 15, 2009

Movement Science Podcast: On the Air!

ResearchBlogging.orgOk folks here we are - my first podcast. This episode explores the relationship between motor learning, motor control deficits, and low back pain. I hope you enjoy my rookie effort and will hang in there as I continue to improve this new feature of my blog. Please let me know if you are having difficulty dowloading the podcast and I will get the bugs worked out asap! I hope to be up on iTunes soon so this should add an additional level of functionality to the show.

Topics include:
  • Recent editorials in the BJSM on the role of lumbar stabilization in low back pain
  • Basic motor control theory and the process of motor recovery following an injury including a reduction in cognitive regulation, decrease in visual dependency, and improvements in sensorimotor adaptability
  • How pain influences motor behavior including local and affective influences on muscle activity
  • An overview of what we know and don't know regarding motor control interventions
  • How this information has influenced my approach in the management of low back pain

Articles cited:

Allison, G., & Morris, S. (2008). Transversus abdominis and core stability: has the pendulum swung? British Journal of Sports Medicine, 42 (11), 630-631 DOI: 10.1136/bjsm.2008.048637

Hodges, P. (2007). Transversus abdominis: a different view of the elephant British Journal of Sports Medicine, 42 (12), 941-944 DOI: 10.1136/bjsm.2008.051037

Cook, J. (2008). Jumping on bandwagons: taking the right clinical message from research British Journal of Sports Medicine, 42 (11), 563-563 DOI: 10.1136/bjsm.2008.048629

Mulder T, Neinhuis B, & Pauwels J (1996). The Assessment of Motor Recovery: A New Look at an Old Problem J Electromyogr Kinisiol, 6 (2), 137-145

Hodges, P. (2003). Pain and motor control of the lumbopelvic region: effect and possible mechanisms Journal of Electromyography and Kinesiology, 13 (4), 361-370 DOI: 10.1016/S1050-6411(03)00042-7

Saturday, March 14, 2009

Young Guns

I just wanted to say congratulations to a few former students of mine who recently earned their licenses. They graduated from UTMB back in December and are all gainfully employed! I was very fortunate to have them as students and am now privileged to call them colleagues. Congratulations and best of luck to Anne, Andrew, and Ryan. I'm very proud of you all and wish you all the best.


Put down the barbell and slowly back away...

This may get me in a bit of trouble but here I go. Many colleagues have taken issue with my stance on the role of physical therapists in the realm of exercise as well as strength and conditioning.

My stance is simple and begins with a simple observation: Physical therapists are the undisputed experts of rehabilitation science. Rehabilitation is a sub field within the broader category of movement science and is accompanied by other sub fields such as biomechanics, exercise physiology, neuroscience, motor control, and the like…

As sole title holders of "World Champions" of rehabilitation, exercise physiologists and biomechanists cannot and should not declare themselves rehabilitation experts. This observation is plainly obvious to most physical therapists (just ask one). We are happy to share this with anyone who is willing to listen as well as some who aren't.

So why then do we in physical therapy get so befuddled when those specializing in exercise science question our role in prescribing exercise programs for athletes and otherwise healthy individuals?

A recent discussion on the RehabEdge forum took place in which we debated the merits of athletic trainers in treating a nonathletic population. Without getting into the specifics of the debate, it was generally agreed that physical therapists can’t hold a trainer’s jock (so to speak) in the assessment and management of an acute athletic injury. At the same time we argued that trainers can’t hang with a PT in the majority of rehabilitation settings. To put it succinctly, while there is some overlap in skill set, there is clearly only one professional best suited for the job. Of course, many therapists and trainers are duly credentialed in both fields….all bets are off for you!

We aren't bad...but there is better.

Physical therapists, like doctors and other health care professions, should feel a natural pull toward providing general activity guidelines for patients. In this regard our role in healthy movement should not be underestimated. However it will be difficult to press on and be great in rehabilitation if we are trying to be all things to all people. There is a professional best suited to provide exercise advice and leadership, and it is not us.

Now would be a good time for a wary reader to point out my arrogance in claiming to be both. This would be a fair criticism, but for better or worse, I have graduate degrees and extensive training in human performance and physical therapy. Like those credentialed in both athletic training and physical therapy, I hold titles in both sub fields. With that said, it is tough for me to be good at both. I’m probably a much better physical therapist right now than I am strength and conditioning specialist. That’s OK though…my patients probably would want it that way!

Want to be an expert? Here's how to earn it...

So here’s my official position and recommendations for physical therapists wanting to become exercise professionals:

· Physical therapists are not exercise specialists and should lay limited claim to human performance training unless specific criteria are met.

· The first criterion is achievement of an advanced certification from either the American College of Sports Medicine or the National Strength and Conditioning Association. Sorry to the pretendors that I carefully excluded from this list. These two organizations represent the highest standards of the profession and offer numerous opportunities for increasing knowledge of exercise science.

· The second criterion is a graduate (preferred) or undergraduate degree in exercise physiology or related curriculum. This will provide a solid and specific academic background in exercise science. You can attempt to tell me a physical therapy curriculum is sufficient to achieve this knowledge, but you would also be wrong.

· In the absence of meeting either of the above criteria, the physical therapist should spend at least 2-3 years working in a fitness and human performance setting with a seasoned conditioning specialist. I have a tough time with this one, but realize that it isn’t easy to achieve both of the above criteria. Trying to give a little here…

Bottom Line

If you believe my recommendations to be unreasonable I would challenge you to have a discussion on a specific issue pertaining to exercise science with someone who has met the above criteria. You may think you have sufficient knowledge and understanding of exercise physiology and human performance, but the conversation may cause you to think twice. I strongly encourage those in the rehabilitation profession to do what you do best. If you want to be considered an expert in physical therapy, you know where to go. If you goal is to hold expertise in exercise as well, please apply the same rigor to your standards as we expect from other professions.


The first podcast is currently “in production” and I hope to have it up and running soon faster than I expected. Thanks for visiting and I’m looking forward to talking to you soon. If you have a question or comment, please don’t hesitate to contact me and I’ll try to address it on the podcast. Take care.

Tuesday, March 10, 2009

Class Dismissed...

Just got back from Lubbock and feel like a charged capacitor...

There are so many thoughts and ideas running through my brain that it will be a true test for me to sit still long enough to articulate them. Fortunately my wife, blog, colleagues, and my upcoming podcasts will give me a nice steady discharge of this energy as opposed to blowing all at once!

The origin of my excitement is my experience at a recent contact session for my Sc.D. program at Texas Tech. The title of the course is "Motor Control in Orthopedics" and is basically part two of last semester's "Neuroscience in Orthopedics" course. The weekend began with a review of the motor control principles we independently studied over the last eight weeks. Information processing, attention and memory, peripheral and central contributions to movement, motor learning and practice...these were all reviewed and discussed with our course (and program) director Phil Sizer.

The second component of the course jumped over into practical application where we discussed issues pertaining to motor control and syndromes of the cervical and lumbar spines, shoulder, knee, and ankle. The vast majority of slides and resultant discussion stemmed from the peer-reviewed works of people like Hodges, O'Sullivan, Powers, Hewett, Falla, Jull, Flynn, Childs, and many MANY others. From this standpoint, the information presented was a good representation of the state of motor control as it pertains to our profession.

This information was juxtaposed with Phil's infectious passion for the material and synthesis. The result was the generation of great (raw...but great) ideas regarding management from my fellow classmates. I have to say from this perspective it was very inspirational. I will admit my threshold to excitation is a bit on the low end at times, so take that for what it's worth...

NOW. There were a few occasions on day two where I seemed to scratch my head. As positive as I am about the course, I have some questions/concerns about our integration of these topics. Predictably my concerns pertain to things like the relevance of feedforward TrA activation, hip weakness in anterior knee pain, etc...

  • What is the relationship between lumbar muscle dysfunction and LBP? We know the relationships are there, but identification is not sufficient to place them in proper perspective. Despite our eagerness to dive into and "treat" these areas with various activity programs such as "core training", a stricter adherence to principles of motor control may cause us to rethink our current approaches. (more on this soon!)

  • What are the relationships between hip muscle strength and anterior knee pain? We often see measurable decreases in hip capability in the presence of knee dysfunction. However this observational statement is only the beginning. Is this relationship causal or simply correlative? If it is causal, are we confident which came first? The answers have not been clearly defined and have profound implications for evaluation and management.

I believe the answers will become clearer as we begin to integrate clinical observations (weak hip abductors, functional instability, etc...) with our emerging understanding of neuroscience and motor control. Over the next several weeks, I hope to present examples and arguments in favor of integrating these fields of movement science and the evolution of understanding that they can bring. I am excited to share this with you and look forward to your questions and comments!