Are you CPR Certified?

Fortunately I'm not talking about through the Red Cross. As important as this life-saving skill is, it may be just as important to understand the nature of a more trendy form of CPR in the world of rehabilitation science: The Clinical Prediction Rule.

Prescriptive clinical prediction rules on topics such as lumbar manipulation, traction, and even anterior knee pain have emerged recently in our rehabilitation literature. The fact these reports exist underscore the fact that we are actively engaged in evolving into an evidence-based profession. However as has been recently and contentiously bantered on more than one discussion forum, as evidence builds it will become even more important for us to understand how to interpret and utilize this evidence in the most appropriate manner. In the case of such a potentially powerful tool as a CPR, we need to have a very clear understanding of its potential uses and possible pitfalls.

To this end, I would like to suggest two articles. The first is by Childs and Cleland published in our PT Journal in 2006. It provides excellent insight into the utility, establishment, and validation of a clinical prediction rule. The second article is actually an editorial in the Journal of Manual and Manipulative Therapy titled "The Potential Pitfalls of Clinical Prediction Rules". It is authored by Chad Cook, the editor-in-chief of JMMT, and provides a good overview of the potential misuses of a CPR.

Clinical prediction rules have been around for quite some time and have significant utility in a variety of clinical settings. They will no doubt be powerful allies in our quest for strengthening our clinical decision making. However, the most appropriate use of the CPR will occur with its judicious application and not blind allegiance. Whether we embrace it or not, the age of evidence-based medicine is upon us and is here to stay. Using evidence-based medicine with a clear understanding of what it truly is (and isn't!) will allow us to continue practicing the science of physical therapy without the trappings of becoming an automaton.

Instead of relying on my synopsis, I eagerly invite you to read these articles for yourself with the hope you will use them in the most appropriate manner for your patients. Enjoy!

Childs, J.D., Cleland, J. (2006). Development and Application of a Clinical Prediction Rule to Improve decision making in physical therapist practice. Physical Therapy, 86, 122-131.

Cook, C. (2008). Potential Pitfalls of Clinical Prediction Rules. Journal of Manual & Manipulative Therapy, 16(2), 69-71.

Missing in Action: The Diagnosis of Acetabular Labral Tears

I recently had an interesting hip case come through the clinic. After practicing only six years, I've discovered there are some joints for which I have more clinical intuition, and the hip certainly isn't one of them. As a result I found the need to do some catching up.

Unfortunately, the referring physician was not much help in this case with a referring diagnosis of "hip pain". While interviewing the patient, he revealed the physician had spent approximately three minutes with him and performed no physical exam. The only diagnostic puzzle-piece we had was that he did not have any signs of OA on plain film.

During the examination the patient had focal hip pain that I gradually suspected was intraarticular in nature. I recently posted the case on MyPhysicalTherapySpace.com if you'd like to see it in more detail.

In researching the case, I found a very good article from the Journal of Bone and Joint Surgery on acetabular labral tears. The authors retrospectively examined sixty-six individuals with confirmed labral tears via arthroscopy to determine what clinical variables were most closely associated with the pathology. The clinical findings were as follows:

• 86 percent of the cases reported moderate to severe pain


• 92 percent reported symptoms localized to the groin and that activity worsened symptoms


• Only 39 percent had a Trendelenberg sign or observable limp


• 95 percent had a positive impingement sign of the hip

Although the clinical features of acetabular labral tears were useful, a more telling set of statistics emerged from this report:

• Nearly 20 percent of the patients were referred for a surgical procedure to a uninvolved site


• The patients were seen by an average of 3.3 providers prior to establishing a definitive diagnosis


• The average duration of symptoms from onset to successful diagnosis of the tear was 21 months

The findings of this study were directly applicable to this case. He and I had been discussing the likelihood that this was not a simple muscle strain as postulated during his initial visit. After a underwhelming four week follow-up experience with the referring orthopedist, I referred the frustrated patient to a physician known for performing an actual physical exam. An immediate MRA to the hip was ordered.

Not surprisingly, the MRA was positive for significant intraarticular pathology including a subchondral defect, moderate OA, and a fatty tumor encroaching upon the posterior branch of the obturator nerve. Labral pathology is questionable. The orthopedist suspects one may be present and will investigate this intraoperatively along with a surgical oncologist.

I think this provides a good example of how physical therapists can be a potential diagnostic gateway for our patients. Unfortunately, we can't take for granted the referring physician always brings their A-game to the exam room. Also if we are angling to be direct access providers, our clinical diagnostic skills will need to remain sharp. In this case, my exam certainly wasn't specific for the myriad of pathology present in this gentleman's hip. However it was sensitive enough to detect that there was certainly more to the story. Hopefully this story will have a happy ending.

Burnett, R.S. (2006). Clinical Presentation of Patients with Tears of the Acetabular Labrum. The Journal of Bone and Joint Surgery, 88(7), 1448-1457. DOI: 10.2106/JBJS.D.02806

The Core: From Development, Through Distortion, to a Potential Solution

I began working in outpatient physical therapy as an exercise physiologist back in 1996. At that time, I had no intentions of becoming a physical therapist and was busy trying to carve a niche in my profession as a strength and conditioning specialist. Back then, both the exercise science and physical therapy communities were running wild with this new form of training that would revolutionize the way we manage orthopedic conditions and enhance performance on the field. Like cave dwellers witnessing fire for the first time we all gathered around to learn of this phenomenon called "The Core."

Origins of Core Training

The idea of the spine having "pillars of stability" was proposed by Panjabi back in the early 1990's. The theory was that an integrated system of passive, active, and neuroregulatory factors work together to supply an appropriate amount of stiffness or mobility of the spine during ADL. A failure of one or more of these systems could contribute to an increased risk for many of the commons spinal pathologies we see in the clinic.

After this theoretical basis for spinal stability had been achieved, an avalanche of studies began to support Panjabi's pillars of stability theory. Many studies were based on surface EMG and began to reveal that spinal musculature, specifically the multifidi, transversus abdominus, and quadratus lumbora are integral in supplying the spine with the right combination of mobility and stiffness for effective movement.

This theory was subsequently supported by clinical data that many of these muscles are both histologically and electromyographically-challenged in patients with clinical spinal syndromes compared to healthy cohorts. We began to see consistent relationships between the dysfunction of specific muscles and clinical spinal syndromes and were building a solid foundation of basic and clinical sciences. By the end of the 1990's there seemed to be an established (but incomplete) theory on relationship between clinical spinal pathology, local muscle physiology, and central neuroregulation of these muscles.

Where have we gone wrong?

Simple: Words mean things. Clinical research seems to make a strong case for Panjabi's pillars of stability. However, "core training",as it came to be known, had tragic flaws all too common in our community: lack of a clear operational definition coupled with an overblown marketing appeal. A recent editorial in the Archives of Physical Medicine and Rehabilitation by Marc Sherry, PT, LAT, CSCS* and colleagues illustrates the problems we are having in the absence of a clear definition of "The core".

We are all over the place here. Some refer to the core in anatomic terms. Specific muscles on, near, or sometimes slightly distant to the lumbopelvic complex literally are the core. Others might refer to the core in a more abstract functional context. For example, we've all heard therapists say a patient lacks "core stability" or "core strength" as if these terms were synonymous. Furthermore we therapists often use equally nebulous terminology to describe how we manage this problem. We utilize "dynamic lumbar stabilization" activities or "core strengthening" exercises to help the patients "stabilize their core"...or whatever.

A Modest Proposal

As with many modern clinical issues, communication is likely at the root of both the problem and the solution. I propose gradually working toward a more unified definition of Panjabi's theory in the same spirit as Flynn and colleague's plea to unify our language of manual therapy. As a good friend of mine likes to say, it may be akin to "herding cats" in getting the PT community at large to embrace this kind of unity. However, for all the reasons we need to more clearly define our manual techniques, we may want to pass the same standards on to our exercise interventions.


Barr, K.P., Griggs, M., Cadby, T. (2005). Lumbar Stabilization. American Journal of Physical Medicine & Rehabilitation, 84(6), 473-480. DOI: 10.1097/01.phm.0000163709.70471.42

Barr, K.P., Griggs, M., Cadby, T. (2007). Lumbar Stabilization. American Journal of Physical Medicine & Rehabilitation, 86(1), 72-80. DOI: 10.1097/01.phm.0000250566.44629.a0

Sherry, M., Best, T., Heiderscheit, B. (2005). The Core: Where are we and where are we going?. Clinical Journal of Sports Medicine, 15(1), 1-2.

Evidence in Practice

Wow seems like it's been a while since my last post. Things have been a little busy around here lately, but now settling down. I registered for my first semester at Texas Tech's doctoral program (I'm way too excited by the way), welcomed a new PT student to the clinic from my alma mater UTMB, and had a crazy week of patient care to boot. It's nice to be able to sit in front of the keyboard and get back to plucking some good information that's out there for us as therapists.

I recently came across an interesting PowerPoint presentation from the Centers for Evidence-Based Medicine (CEBM). The presentation was authored by Paul Glasziou of the University of Queensland and Oxford. It is appropriately titled "Evidence-Based Practice" and provides an excellent overview of practicing EBM. Incidentally, the CEBM has a number of excellent PowerPoint presentations available for free download. If you are interested in getting a better understanding of EBM, this would certainly be a good start.

What is Evidence Based Practice?

I've alluded to Sackett's definition of EBM before but it might be good to restate it here. Evidence-Based Medicine is "the integration of best research evidence with clinical expertise and patient values". It's hard to avoid noticing three key elements of this statement:

1. The clinical decision-making process should be guided by the best available evidence.
2. Clinicians are encouraged to utilize their brains during this process and not become slaves to the literature.
3. The patient's values should be factored into the clinical decision-making process.

In this context it is difficult for me to understand some of the most common objections to evidence-based practice. I have heard colleagues complain that EBP encourages protocol-driven health care and is simply another third party cost-cutting tool. If we incorporate statements 2 and 3 above, this becomes an improbable pitfall for us.

By the same token there are risks to an overzealous approach to EBP. I have seen some of my respected colleagues remove their thinking cap altogether and simply practice according to the latest treatment-based classification system. I don't think this is what EBP is about. A PT whom I still call my mentor used to say "We don't treat MRIs. We treat patients". We also don't treat studies, no matter how well designed. Again a brief look back at the definition of EBP allows us to make sure we make decisions with a broader perspective in mind.

On a lighter side...

If you are into a little irreverant PT editorial, I strongly suggest taking a look at the PT "Whore of the Month" award over on the EIM website. Whether you agree with the terminology or not, it does a good job of letting us know we've got some real numb-nutts within or near our profession out there and to stay vigilant in marginalizing them. Enjoy!

Thanks for putting up with the rant. In the coming weeks I will be hitting the topics of lumbar stabilization, the role of training on unstable surfaces in rehabilitation, and the neurophysiology of pain and our sometimes feeble attempts to manage it in the clinic. The research I've been finding on these topics is fascinating and I'm excited to share it with you. Until then, take care!

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.

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!

A Great Debate

I recently listened to a spirited debate on the PT Journal Podcast regarding two approaches to classification and manipulation for LBP. I strongly encourage you to download the file or subscribe to the podcast and listen for yourself. The debaters Timothy Flynn, PT PhD, OCS, FAAOMPT, and Christopher Maher, PT, PhD brought out some very salient points regarding the assessment and treatment of mechanical low back pain.

To be honest, I had to listen to the debate multiple times to pick out some of the really strong take-home messages that emerged from the discussion. While the debate was focused on the assessment and management of LBP, it had me thinking more rigorously about how these themes could apply to other aspect to our practice. In no particular order of importance:

• The widespread use of the term "nonspecific" low back pain is inadequate and misleading. It would be analogous to our medical colleagues using the words "nonspecific" abdominal pain and contributes to further confusion regarding accurate diagnosis and management.

• There is a need to develop standardized clinical practice patterns and a unified language with respect to the dosage and modes of manual therapy we deliver to our patients.

• There is still considerable variation between highly trained individuals regarding the classification, assessment, and management of mechanical low-back pain.

You can download the link by right-clicking here and saving to your hard drive.

I hope you will download this debate and continue to reevaluate your methodology with respect to evaluation and management of not only low back pain, but other complex conditions as well. Our aim as orthopedic therapists should be to continually elevate our standards of practice. Take care and talk to you soon!