I fall down a lot
By age 15 I had suffered at least 22 broken bones. There’s nothing metabolically wrong with me or my bones. I like to tell people that I was very good at doing stupid things. For instance, I broke several bones in my hands when curiosity got the best of me and I willfully dropped from the playground apparatus to the ground at age 4. Then there’s me at age 10 chasing a bouncy ball down the stairs and forgetting to walk all the way down . . . my dog-like behavior resulting in a few broken foot bones that time.
You see, I earned all my fractures. Most involved a fall. Some involved collisions. Today I still find that I fall quite a bit. For this I am very lucky. Yes, I’m serious. Falling down can be a good thing.
Kids are meant to fall. A toddler bouncing from surface to surface is a part of motor learning that we all must go through. A toddler probably falls down about 20 times a day, but suffers no lasting injury from the frequent trips to the ground. In comparison, a 60 year old sedentary female is almost assured of a life-threatening hip fracture when she falls. What’s happened in the mean time? Is risk of injury from falling something that increases linearly with age? Or, is there something more simple in play?
The 60 year old woman may not have fallen down in 50 years! Of course, we could not expect her to have any skill at falling, being so out of practice as she was. I’m suggesting falling is a skill, one we could all improve on…if we’re older than a toddler.
In most martial arts, the first session of training usually included instructions to fall. Most extreme sports athletes fall regularly in grand fashion, but rarely suffer serious injury. (Which is what makes Tara Llanes injury so unexpected.) Check out this video of an extreme fall and tell me you don’t see skill at play here (be patient, the skill view is in the last 13 seconds of the video). 50% of people who fall from that height expire. This guy walked off! Personally, I once observed a friend conduct a controlled fall over 500 feet and 30 seconds of a near-vertical hillside and escape injury (though I do refer to that story as "the time Erik went so fast he cried").
We spend hours in rehabilitation clinics and education working to prevent falls. We never practice them. I practice them often. Just about every 2 mountain-bike rides results in a crash of some sort. I still like to play with the dog and dive and fall after him. I think the reason I no longer break bones is that I’ve acquired some skills in falling.
In one glorious demonstration of my falling skills, I found myself out of control on my bike traveling straight down a ski slope during a race. I couldn’t make the next turn, so I plowed head first into the hay bales. I flipped off my bike, becoming detached from it somehow. I landed, flipped, rolled, and ended up on my knees facing back up the hill…just in time to catch my cart-wheeling bike. A quick inventory told me we were both ok (bike and self) and so on I went, earning a noble passage from a stunned competitor following close behind.
The point of this insight into my personal tumbles is that I often think rehabilitation should include fall practice. Perhaps after practicing in a controlled and safe manner, the fall that we couldn’t prevent doesn’t need to become a disaster. The trick would be balancing fall practice with real motor control deficits that have provided the impetus to fall in the first place.
ERIC
Need New Knees? Now May Be The Time
"Need New Knees? Now May Be The Time, " was the title of a press release by the American Academy of Orthopaedic Surgeons last week.
"These results suggest that we might be waiting too long to suggest
total knee arthroplasty as a treatment option for women with end-stage
knee OA," says Stephanie Petterson, MPT, PhD, one of the study’s
authors and a senior lecturer at the School of Health and Bioscience at
the University of East London, "or that women with knee OA are waiting
too long to access the appropriate care."
Hey, marketing and research are two different things! This is a good example of working them both. The release reported the findings of this article in The Journal of Bone and Joint Surgery. The basic gist was that women wait longer than men to seek care and so their outcomes may be worse after TKR. Common sense, really.
Another interpretation might have been, "PT’s not helping prevent progression of knee osteoarthritis." That’s not really science either, but surely must be a more wholesome recommendation than the press release encouraging a shopping spree for major surgery!
Petterson, S.C. (2007). Disease-specific gender differences among total knee arthroplasty candidates.. The Journal of Bone and Joint Surgery, 89(11), 2327-2333.
Physical Therapy on NCIS
I was watching NCIS last night and a large scene took place at a physical therapy clinic. It was a mock-up of the Walter Reed amputee clinic, and was complete with the therapist gait training a patient with a very high-tech prosthesis.
"Don’t be afraid to put weight on it," the therapist urged the patient in the scene.
Shortly thereafter, there was a huge fight in the clinic. PTSD related…but turned out to be steroid-induced psychosis. Pretty cool scene, but sadly no physical therapist heroes, they were quick to defer to the NCIS agents!
ERIC
Tara Llanes would like your help
As you know, cycling of all sorts is close to my heart. Well, a cyclist could use some help. Tara Llanes, a world-class cyclist, is recovering from inj
uries to her spine suffered on Sept 1, 2007. She is paralyzed below her waist. I have been a Tara Llanes fan for a number of years, gleefully watching her tear down a mountain on her bike at several events.
Here’s her story (link to video below).
Playing Games with the Wii
Last week the Nintendo Wii celebrated its first birthday. I’ve been prompted to post about the use of the Nintendo Wii game console in rehabilitation for some time now. The prompting has come from various sources, such as colleagues who hate it, colleagues who purchased one for their clinic, TV commercials, and a startling number of news pieces on the use of the Wii in rehab. I’ve resisted responding thus far, not for lack of interest, but for lack of opinion. More correctly, conflicting opinions. While I appreciate that any press can be good press, is the Wii something good for physical therapists?
At first glance, using a video game in the clinic may seem silly. The use of Wii in rehab is not currently supported by research, and tying the use of a video game console to a billing code requires some stretching. I’m skeptical that the movements required by the Wii are all that functional, and of course, they are not strengthening by nature. If one does not already own the Wii, it becomes a very expensive piece of home exercise equipment. However, the Wii has enjoyed almost viral popularity among game connoisseurs, the media, the elderly, and quite a few rehab providers, even the military.
Are these providers featured in news pieces about ‘Rehabbing with the Wii’ truly leading the charge to incorporate technology into practice, or are they fad followers looking for some cheap marketing?
My guess is that there is some limited utility for the Wii in neurological and pediatric physical therapy settings, but that the rage will fade and physical therapists will realize they possess much more powerful tools with which to treat their patients.
ERIC
The Elusive Search for the Mechanism of Manipulation
Decades of clinical practice by manipulative providers have demonstrated the effectiveness of spinal manipulation as a therapeutic modality. The truth is that the mechanism of exactly how manipulation is effective has remained out of reach and unexplained. As research methods have become more sophisticated and the tool box of measures has increased in size, the prospect of figuring out a mechanism now seems a likely pursuit.
One handy tool that has become very popular in physical therapy research is ultrasonic imaging. Just like any ultrasound study, the clinician is able to observe real-time events. In the case of rehabilitative ultrasound imaging, the therapist is examining muscle activity. Measures of muscle thickness can vary and observable changes have been associated with pathology. For example, patients with low back pain show changes in cross sectional area of the lumbar multifidus muscle. Likewise, other patients with back pain have been shown to have difficulty activating their transversus abdominis muscle.
When this measure was used to study abdominal muscle thickness following a spinal manipulation procedure, an interesting thing occurred. The abdominal muscle activation changed! In a case series by Raney, Teyhen and Childs, spinal manipulation seemed to be correlated with a normalization of abdominal muscle recruitment patterns in patients with low back pain.
Perhaps this is a peek into the mechanism of spinal manipulation’s effects. The subluxation concept aside, spinal manipulation may have more to do with muscle activity, spinal reflexes, and the neuromuscular system than it ever had to do with alignment of the bones. The rapid, short duration of the motion used in manipulation does remind me of testing a deep tendon reflex!
Interesting to note, the researchers examined spinal manipulation in a group of symptomatic patients who met a criteria for a clinical prediction rule that identifies patients who are very likely to benefit from manipulation. Also interesting to note, this case series appeared after an initial case report by different investigators. They found a similar effect in another core stabilizer muscle in their report. Finally, we’re talking case report and case series here, so true causality regarding the phenomenon will have to wait for now.
This study is just one of many new investigations suggesting the role of spinal reflexes in the mechanism of manipulation. We will visit them over time here on the blog, along with some interesting off-shoots of that research.
Here’s the article abstract and citation:
Observed changes in lateral abdominal muscle thickness after spinal manipulation: a case series using rehabilitative ultrasound imaging.
Raney NH, Teyhen DS, Childs JD.
STUDY DESIGN: Case series.
BACKGROUND: A clinical prediction rule (CPR) has been developed and validated that accurately identifies a subgroup of patients with low back pain (LBP) likely to benefit from spinal manipulation; however, the mechanism of spinal manipulation remains unclear. The purpose of this case series was to describe changes in lateral abdominal muscle thickness using rehabilitative ultrasound imaging (RUSI) immediately following spinal manipulation in a subgroup of patients positive on the rule.
CASE DESCRIPTIONS: Data from 9 patients (5 female, 4 male; 18-53 years of age) with a primary complaint of LBP are presented. All patients had symptoms for less than 16 days (range, 3-14 days) and did not have symptoms distal to the knee, satisfying the 2-factor rule for predicting successful outcome from spinal manipulation. The Oswestry Disability Index scores ranged from 8% to 52%. Lateral abdominal muscle thickness was assessed with the patient at-rest and while contracted during an abdominal drawing-in maneuver (ADIM) using RUSI. Measurements were taken before and immediately after spinal manipulation. Patients completed a 15-minute training session of the ADIM prior to assessment, to mitigate the potential for a learning effect to occur.
OUTCOMES: Based on changes that exceeded the threshold for measurement error, 6 of 9 patients demonstrated an improved ability (11.5%-27.9%) to increase transversus abdominis (TrA) muscle thickness during the ADIM postmanipulation. Additionally, TrA muscle thickness at-rest postmanipulation decreased for 5 patients (11.5%-25.9%), while at-rest internal oblique muscle thickness decreased for 4 patients (6.4%-12.2%).
DISCUSSION: This case series describes short-term changes in lateral abdominal muscle thickness post spinal manipulation. Although case series have significant limitations, including the fact that no cause-and-effect claims can be made, the decrease in muscle thickness at rest and the greater increase in muscle thickness during the ADIM postmanipulation observed in some of the patients could suggest an improvement in muscular function. Future research is needed to determine if increased muscle thickness is associated with improvements in pain and disability and to further explore neurophysiologic mechanisms of spinal manipulation.
Citation:
Raney, N.H., Teyhen, D.S., Childs, J.D. (2007). Observed changes in lateral abdominal muscle thickness after spinal manipulation: a case series using rehabilitative ultrasound imaging.. Journal of Orthopaedic and Sports Physical Therapy, 37(8), 472-479.
The AMA: an information-leasing racket!
Daniel Carlat, MD has written a piece in the New York Times that is perhaps the most transparent look into the world of pharmaceutical marketing tactics that I have ever read, "Dr. Drug Rep."
I learned a great amount from this piece about one of my least favorite parts of health care. Dr. Carlat discusses his year long experience as a "drug rep with an MD" and provides quite the insider perspective.
I was most surprised when Dr. Carlat discussed data mining for physician prescription trends and pointed a finger at the AMA as a major player. Information that the AMA leases to marketing companies is critical in providing pharmaceutical companies specific information to target individual doctors.
"The A.M.A. licenses its file of U.S. physicians, allowing the data-mining companies to match up D.E.A. numbers to specific physicians. The A.M.A. makes millions in information-leasing money."
This relationship may be acceptable in other industries, but seems out of place for a professional medical organization purportedly concerned with unethical practices in the pharmaceutical industry. A profession truly interested in health care reform could be expected to make better decisions.
ERIC
NPA Think Tank Poll
I’m trying out a polling/survey program, so check this out:
The Dangerously Informed Patient?
As a follow-up to the previous post, here are two related articles about the informed patient. A NY Times piece, "When the Patient is a Googler," and a blog post from the World Changing site.
Of course, we need not look far for bad examples of "informed" patients…say autism and vaccines for example?
ERIC
The Many Faces of the Electronic Medical Record
The electronic medical record can mean different things to different people. To Microsoft and Google among other Health 2.0 companies, it is a future of their business. To patients, it is concern over privacy and hope for improved care continuity. For medical providers it is an enormous added expense and a headache of technical details to do a job they are already performing.
But, the electronic medical record could also be a way to do business differently, to become more efficient. To do the job better. A couple things are certain: as health reform progresses the electronic record will prevail, and that it might not be so smooth. Just yesterday I read a news piece where electronic claims filing made it easier for Wal-Mart to recoup money paid in an injury settlement, effectively taking one woman’s health-trust and leaving her dependent upon the government for her care. Is this what we had intended when we first thought of the electronic records?
Radiology as a Benefit to Physical Therapist Practice
My personal experience with electronic medical records is with the military health system. It was sometimes slow and tedious, but it was incredibly useful all of the time. In fact, I have a hard time imaging practicing without an integrated medical record in front of me at this point.
Perhaps the most useful aspect of the military’s electronic system, which contrasts most significantly from usual physical therapist practice, concerns radiology reports. Forget for a moment the benefit that military physical therapists have in ordering radiographs (yes, they can order all types of radiographic imaging and may do so as effectively as orthopaedic surgeons) , and just consider the benefit of reading reports and viewing the radiographs themselves. I think this calls for a list:
1. Reduced guess work when patient history is unclear
2. A greater understanding of each patients pathology
3. Patient education opportunities are enhanced in front of their radiographs
4. Observation of what studies have been performed provide insight into thinking and problem solving of other providers
5. Improved prognosis decisions
The radiographic benefit is but one example. The overall message is that despite the many different particulars of the electronic medical record, it is somewhere we are heading. Careful consideration of the pitfalls and benefits of the process will ensure the efficient, timely transition.
ERIC
-
Find It
-
Categories
-
Physio-pedia
The online encyclopedia of Physical Therapy. -
Connect With Eric Robertson
-
-
Recent Posts
-
Blogroll
-
Monthly Archives
