An OSTEOPRACTOR™ is a physical therapist or medical doctor that has completed an evidence-based post-graduate training program in the use of high-velocity low-amplitude thrust manipulation and dry needling for the diagnosis and treatment of neuromusculoskeletal conditions of the spine and extremities.

Advertisement for certification. How come DO’s can’t attend?

FALSE.

Osteopractor™ is a confusing, misleading, made up certification not based in reality. And, I am confused, saddened, and downright offended that James would choose to blur the distinction between the physical therapy profession and chiropractors. Chiropractic is a field that evolved in pseudoscience, and on the whole, remains there. The chiropractic professions continues to utilize aggressive lobbying and false facts to limit and restrict physical therapist practice.

The foremost skeptics and leaders in Science Based Medicine discuss the (pseudo)science of chiropractic on the blog Science Based Medicine:

• Chiropractic: A Brief Overview: Part I and Part II
• Subluxation Theory: A BELIEF System that Continues to Define the Practice of Chiropractic
• Chiropractic and Subluxation
• The End of Chiropractic

Now, Alabama, where James resides, is one of only two states (the other is Washington State) where physical therapists are formally not allowed to perform spinal manipulation (high velocity, low amplitude thrust manipulation, thrust joint manipulation, Grade V manipulation). What profession and their lobbyists do you think is responsible for that? I’ll give you a hint, it ends in “practor.”

Interestingly, Dr. Dunning has a trademark on the term “Osteopractor.” Details can be viewed HERE. I wonder if that was in any way financially motivated? In Dr. Dunning’s profile he mentions “spinal adjustments.” Chiropractors perform spinal adjustments, not physical therapists. Why would a physical therapist knowingly utilize terminology from the chiropractic profession?

Physical Therapy, as a profession, has enough problems inherently with branding and identity. Our inability to perform manipulations in certain states is ultimately a reflection of this. Identifying one’s self as a “manual therapist” or “certified manual therapist” is likewise confusing and unhelpful. The American Academy of Orthopaedic Manual Physical Therapists gets this, and includes the correct moniker in their academy’s name, as well as in their rank status of Fellow (FAAOMPT). To leave out the “physical therapist” part of being a physical therapist is a very curious choice…

Well, I now consider James Dunning and his institute to live on the fringe of the physical therapy profession, the dark corners that we should approach with extreme caution and skepticism. With the term, Osteopractor™, he earns a classification alongside the other pseudoscience marketers who have abandoned true reason and science. Individuals who are misleading the public, our profession, and other health care professionals whether they recognize and admit it (or not). Craniosacral therapy, myofascial release, sound assisted soft tissue mobilization… now Osteopractor. These theories and certifications further fracture the profession of physical therapy. They create un-needed mystery and are hurling our professional image towards psuedo-science. They bring our profession down. Cerebral spinal fluid does not have a meaningful rhythm, cranial bones can not be mobilized for meaningful clinical effects, fascia is not released, and an Osteopractor™ is a confusing, made up certification.

Strong dissenting opinions are needed to illustrate to James, the public, and other health care professionals that the profession of physical therapy on the whole does not support  this terminology or endeavor. I hope both the American Physical Therapy Association (APTA) and the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) express their opinions publicly. At the very least, advertisements so contrary to the brand of physical therapy should not appear in association-sponsored materials and advertisements in scientific journals.

Please e-mail James your opinions and thoughts. His e-mail (obtained from his public website) is: seminars@spinalmanipulation.org 

PT Think Tank and it’s contributors do not support the term Osteopractor™. We consider it a marketing ploy, and a misrepresentation of physical therapy. It is misleading to our profession, the public, patients, and other healthcare professionals. We urge readers, physical therapists, students, patients, and others to contact James with their concerns. 

I am sorry Dr. Dunning, but there is no line of reasoning, argument, or thought process that can convince me this is a good, or even acceptable idea. Despite your extensive training and supposed commitment to the profession of physical therapy, my respect for you as a professional and physical therapist is seriously, and perhaps irreparably harmed. Please reconsider this course of action.

#SolvePT

Initially, discussions focused on financial issues of physician owned physical therapy services (POPTS), student loans, payment, and educational costs. But, today involvement and content was rich with various contributors and topics. Physical Therapist Twitter regulars such as myself (@Dr_Ridge_DPT), Larry Benz (@PhysicalTherapy) and @SnippetPhysTher were present. @PTThinkTank even tweeted a few insights. Other tweeps included:

• Physical therapists from various states and practice settings
• Professional Organizations: @AAOMPT  @APTACO
• Sections of APTA: @SPTSAPTA (Sports)  @AcuteCarePT
• Physical Therapy Students: @APTASA (Student Assembly) @MattDeBole
• Physical Therapy Programs: @PacificDPTweet

Web 2.0 principles allow us to crowd source and brainstorm with a much wider audience; geographically, practice setting, and expertise. This hashtag will allow for the recording and analysis of a wide range of view points and ideas. We can follow the evolution of topics over time. This stream and  medium could be leveraged by larger, more formal organizations (are you listening APTA?) for idea generation  to guide future task forces and initiatives. In fact, some of the issues, solutions, and thoughts for future direction are solid. #SolvePT is already evolving into a task force.

My Insights and Thoughts

There was a lot of focus on “best practices” in physical therapy. Defining, measuring, communicating, and then teaching best practices is extremely challenging. Todd Davenport of @PacificDPTweet, made the observation that “best practice” is a moving target given the evolution of research, science, and understanding. I agree. Further, who defines best practice? I think we must look beyond a specific patient and episode of care when defining, analyzing, and teaching best practice. In addition, we must look at multi-level outcomes. For example, for an outpatient perspective we can not just look at the patient specific outcome of that episode of care, the time/number of visits, and it’s cost. That is a too narrowly focused frame of reference. We should broaden our lens, and our potential for impact. We need to also need to consider (and target?) recurrence, future health care costs, risk reduction for other medical conditions, and overall health/fitness. Cardiopulmonary fitness is maybe the most dramatic modifiable factor to prevent disease, morbidity, and mortality.

I brought up the topic of physical therapists in hospital intensive care units. Johns Hopkins performed a quality improvement project where they staffed 1 physical therapist for a 16 bed medical ICU. Their estimation is that by decreasing ICU length of stay and increasing patient mobility/function the hospital, and thus the health care system, saved an estimated 5 million dollars over a 1 year period. The internal investigation lead to the hospital staffing 2.2 full time physical therapists solely in a 16 bed medical ICU. This is a dramatic change in practice focused not on productivity or reimbursement, but on VALUE, risk reduction, and other broader outcomes.

Unfortunately, in discussing best practice no attention was brought to the actual content of current PT programs. In my opinion, pain science/physiology, basic neuroscience, critical thinking, philosophy of science, cognitive biases, and metacognition are vastly lacking from our curriculums.

The teaching and study of pain should be integral in all PT education, both didactic and clinical. We have neuromuscular, musculoskeletal, cardiopulmonary, and or medicine tracks in our programs. Why do we not have a specific pain track? Or, at least a focus and integration of neuroscience and pain physiology into our other courses? Regardless of practice setting, the majority of our patients will have a primary or secondary complaint of pain. Joe Brence, who blogs at ForwardThinkingPT, started an online petition regarding this exact topic. I recommend you sign it HERE.

In order to be “evidence based” (or more accurately Science Based) we need extensive training in the philosophy of science and critical thinking including prior plausibility, research design, and article analyses. To assume that students entering PT programs received such instruction as undergraduates is, to put it nicely, a huge assumption. How are we to make appropriate clinical decisions if we do not understand our inherent cognitive traps and biases? How are we to correct them, if we can not even recognize them? The skill of appropriately analyzing a single article based on design, statistics, and results in the context of plausibility, basic science, and the state of other literature AND THEN applying that to everyday clinical practice is what being a master clinician-scientist is all about. And, that is what we need to strive for. The title of Tamara Little and Todd Davenport’s recent editorial in the Journal of Manual & Manipulative Therapy sums it up quite nicely: Should we be expert clinicians or scholars? The answer is yes.

How do we generate results from this passion and discussion?

1. How do you think we should #solvePT?
2. What are the most pressing issues in education, payment, practice, and our evolution?
3. How can we focus some of the general issues and proposed ideas into specific and concrete action; solutions!?

#SolvePT has been thought provoking. Hopefully, it will continue to grow. I foresee big potential in this type of interaction.

*And free

In a previous post, Publishing in Science: Are Industry Standards Serving Researchers, Clinicians, and Science?, @JasonSilvernail and I discussed some of the problems with the current publishing industry paradigm as well as our personal frustrations with the process. These insights stemmed from writing a letter to the editor of Manual Therapy, which is currently e-published ahead of print (in press, corrected proof). A link can be found here: Innominate 3D motion modeling: Biomechanically interesting, but clinically irrelevant.

Well, unfortunately for you, reading that letter will cost you $31.50 unless you have a subscription to Manual Therapy, or are affiliated with an institution with accessing rights. For those of you doing mental math at home, that equates to 6.3 cents per WORD (references included at no extra charge!!) Of course, no abstracts accompany letters to the editor, but they do provide a 29 word preview (essentially 1.5 sentences). My question is: does anyone EVER buy a single letter to the editor? I sure hope not. Logically, I can’t imagine publishing companies profit significantly off 500 word letters to the editor, because I can’t imagine anyone buying them.

Now, if you would like to read our longer, better version that was denied prior to review check out this post:        SI Joint Mechanics in Manual Therapy: Relevance, Please? It even includes links to 2 other blog posts that have healthy discussions happening in the comments section. The references section contains links directly to abstracts.

• Don’t agree? Have other insight? Want to comment? Click the comments section and fire away.
• Want to share? Tweet, link back, Facebook, Google+, e-mail, and re-distribute the link freely.

Putting a 500 word letter to the editor behind a pay wall seems to accomplish nothing for science, discussion, clinicians, or even the publishing companies. We think it’s time for a change...

@JasonSilvernail   &   Dr_Ridge_DPT

The EDGE Tool. Click picture to visit site.

The EDGE Tool is designed to assist with manual treatments. It was designed and is sold by Dr. Erson Religioso III, DPT, FAAOMPT who blogs at The Manual Therapist. For those interested, the Edge can be bought at The Edge Store. Dr. E was gracious enough to let myself and the clinic I practice at demo the edge tool.  Previously, here on PT Think Tank Tyler Shultz wrote briefly on Graston Technique (Registered Trademark) in his post Medieval Therapy Techniques?

Background

There are many “theories” and “schools of thought” regarding the use of instruments in manual therapy. In fact, there is a range of names for various techniques including, but definitely not limited to:

• ASTYM (Registered Trademark)
• Graston Technique (Registered Trademark)
• Augmented Soft Tissue Mobilization
• Instrumented Soft Tissue Mobilization
• Instrument Assisted Soft Tissue Mobilization
• Scraping the Skin with Instruments (STSI)

There is even Sound Assisted Soft Tissue Mobilization (SATSM)! Now, the point of this post is not to discuss in detail the proposed and potential mechanisms or treatment “targets,” but rather the product. What the heck is Graston, ASTYM, augmented or instrumented soft tissue mobilization anyway? Essentially, to me, these are all just fancy ways to say using an instrument to touch and treat your patients manually. For clarity’s sake, you can only say you are using some of the previously mentioned techniques if you are certified or take the courses

Look at those prices for courses and tools! Yikes.

associated with them. To be blunt, I do not agree with many of the proposed theories that most are sold and utilized under. I think many of the websites contain false and misleading information. But, that is a different discussion, for a different time…

Other Tools

There are many other tools on the market to assist with the manual treatment of patients. For the most part, these tools are very expensive. Most are linked to the courses or schools of thought that sell them.  Many, you must take their courses. Some, you have to RENT the tools.

The EDGE

The edge has a very intuitive design. It is easy to grasp and has various surfaces and contours for use. I find it useful in creating even, gentle pressure and stretch. I have even utilized it with movement. At first, I struggled to gauge how much pressure I was providing. But, like any manual treatment the response and feedback of the individual we are treating can be used as a guide. I probably use this tool differently than most. My applications have been mostly for gentle manual work. So far, I have used the edge on the foot, lower leg, arm, and neck with patients. I have practiced on the back, forearm, and rib region of colleagues. I have even used it and felt it on myself.. If utilized correctly I think the Edge can be used safely to deliver manual therapy. I think it is very easy to be too aggressive with such tools (especially given the context and theory many are sold under), but that can be easily avoided with judicious monitoring of patient response.

Overall, I was highly impressed with the Edge. It is extremely well designed and constructed. Maybe the most attractive aspects of Dr. E’s product is the price and availability. It is much cheaper than any of the other products on the market. And, you do not have to buy any overpriced courses to use it! But, like any tool we use whether it is our hands, an exercise, a piece of equipment, or our words it is only as good as the knowledge we utilize to implement it.

Bottom Line

If you are going to use a tool to treat your patients, the EDGE is the most practical, the cheapest, and the best design. Dr. E is not selling mechanisms, courses, or a school of thought, but just a product. Luckily, you can buy the Edge Tool for whatever you want to use it for!

Do you use instruments for manual therapy in your clinic? What tools do you utilize? Have you taken courses? What are you thoughts on if, how, or why we should or should not use them?

Recently, others in the blogsphere have written about the assessment and treatment of the SI joint including Mike Reinold Assessing the SI Joint: The Best Tests. John Childs from Evidence in Motion, in the piece A blast from the past highlights how some continue to cling to old views of pain and “SI dysfunction.”

We feel our original, longer piece (which was denied prior to review) summarizes the issues of assessment and treatment of the SI/pelvis region quite well, while connecting various scientific and clinical issues. We cannot share the piece that is currently in press for Manual Therapy [Ridgeway K, Silvernail J. Innominate 3D motion modeling: Biomechanically interesting, but clinically irrelevant. Manual Therapy (2012). doi: 10.1016/j.math.2012.02.017] as they own the copyright. Although, we will provide the link when it is electronically published. Yet, we can share a completely different version of our letter that we were working on before we modified it for length. To be clear the version below is not the letter that is currently in press.

Here is our best reply, in full, to Adhia et al:

We would like to thank Adhia and colleagues for their contribution to the literature regarding the non-invasive modeling of Sacro-Iliac joint (SIJ) motion. This study is interesting from a biomechanical perspective of the inter- and intra-rater reliability of measuring innominate motion via non-invasive palpation based measurements. However, in our opinion, this study has limited relevance to practicing clinicians and to the overall science and practice of manual therapy. The authors conclude “The results support clinical and research utility of this technique for non-invasive kinematic evaluation of SIJ motion for this population. Further research on the use of this palpation digitization technique in symptomatic population is warranted.” This seems to be a rather large logical leap given the results of their investigation and other data in the literature on the manual therapy assessment and treatment of the SIJ and pelvis region. We feel the clinical utility of SIJ palpatory movement testing has not been demonstrated by other research and we struggle to understand how such an assessment tool assists in evaluation, clinical assessment, or treatment with manual or physical therapy.

Movement of the SIJ appears to be very small, highly variable, and difficult to measure. Although undoubtedly complex, movement and translation of the SIJ is estimated to be small and variable between individuals (Harrison 1997, Goode 2008) while variation in anatomy exists even within individuals (Cohen 2005). Historically, SIJ dysfunction and pain has been “diagnosed” clinically via palpation-based tests aimed to identify hypo/hypermobility as well as asymmetry in anatomical landmarks. (Arab 2009)  From a basic anatomical and biomechanical plausibility perspective, measuring this motion and connecting it to a diagnostic process may be futile given the small amount of motion that occurs at the SIJ relative to other joints and the anatomical variation between and within individuals.

The evidence from diagnostic and therapeutic studies of the SIJ and pelvis area doesn’t suggest a clinically useful role for SIJ diagnosis via palpatory movement. A growing body of research indicates that positional palpation based testing in the spine and pelvis region, including the sacroiliac joints, is unreliable within and between examiners (Goode 2008, Laslett 2008). Investigations that do find some measure of reliability for testing have wide confidence intervals for their measurements, calling into question their applicability (Robinson 2007, Arab 2009). Such testing may not assist clinicians with the clinical reasoning process. Symptom provocation testing, rather than positional palpation, appears to have greater literature support, and in fact is the criteria used in guidelines produced by the International Association for the Study of Pain (IASP) (Szadek 2009). After investigating the reliability of individual provocation testing maneuvers (Laslett 1994), Laslett et al. went on to perform a high-quality double injection study (Laslett 2003) for diagnosis of SIJ related pain. This study examined the validity of provocation and movement testing in the diagnosis of a painful SIJ. In 2 separate investigations, they found that physical testing, specifically a composite of tests, aimed at provocation of symptoms was more useful in identifying individuals likely to respond to diagnostic injection, currently the most commonly-accepted “gold standard” (Laslett 2003, Laslett 2005, Laslett 2008). However, even the use of provocation testing and double injection validation according to criteria used by the International Association for the Study of Pain (IASP) does not conclusively diagnose SIJ related pain. The review by Szadek et al. illustrates some remaining issues and concerns when discussing the complexity inherent in making the diagnosis of SIJ related pain (Szadek 2009).

On the subject of clinical utility, in a developed (Flynn 2002) and subsequently validated (Childs 2004) clinical prediction rule aimed to identify a sub-group of patients who responded to an “SIJ region” thrust manipulation, no palpation based testing of the SIJ were included in the final rule. This rule was constructed via regression analysis and many palpation and movement based tests of the pelvis, lumbar spine, and SIJ region were examined, including techniques and landmarks similar to those used by Adhia et al. The final predictors of response to treatment did not include any SIJ palpatory assessments.  Certainly the failure of these investigations (both double injection diagnosis studies and manipulative treatment studies) to find positional or movement assessment of the SIJ of any clinical value raises serious issues about the validity of such assessments. Yet, it is palpatory assessment which Adhia et al investigate in their paper. Despite rigorous testing in different clinical environments, palpatory movement tests have failed to demonstrate their usefulness in helping clinicians diagnose SIJ related pain or treat pain in the SIJ and lumbo-pelvic area. We stress that overall manual palpatory examination seems to have a valid role in manual therapy in this region, but the current evidence seems to indicate that this validity is related to symptom provocation and mechanical testing (Laslett 2005, Laslett 2008) and/or an impairment-based clinical reasoning approach (Whitman 2006). Such a patient-response, impairment-based approach is quite different from the positional and movement diagnostic process advocated by Adhia et al.

Lastly, this paper seems to further perpetuate an overly biomechanical focus in the assessment, treatment, management, and understanding of pain. Moseley stated “equating pain to activity in nociceptors is seductive” (Moseley 2012), and so too is a strict biomechanically focused clinical frame of reference. This biomechanical model of pain, dysfunction, manual therapy application “target,” and treatment effect appears to have little empirical support in the current literature (including clinical trials) investigating mechanisms of action of and predictors of success with manual therapy treatment (Bialosky 2009). In light of our improved understanding of the multifactorial neurophysiology of the pain experience (Bialosky 2009, Moseley 2012 and Melzack 2001), 3D modeling of small and variable joint motion via classically unreliable, and likely invalid constructs lacks meaningful clinical utility. When taken into account with clinical trial evidence and pain neurophysiology, we do not advocate its use clinically regardless of the precision of any associated biomechanical measurements.

We are not stating that this research is flawed, or even that it is unimportant. Indeed, Adhia and colleagues should be commended on the rigor of their methods. The investigation holds immediate relevance to the non-invasive modeling and measurement of the SIJ, and there may be biomechanical studies of some value that could take advantage of this process.  However, we disagree with author’s conclusion that the investigation results are clinically applicable and we urge the readership to consider the study results in context of the current evidence – which calls into question the reliability, validity, and clinical relevance of palpatory SIJ testing and diagnosis. We are confused as to how we as clinicians could utilize the author’s technique effectively in day to clinical practice, and why, given the current state of the literature, the authors propose we should.

 

Kyle J. Ridgeway, DPT

• Physical Therapist, University of Colorado Hospital, Aurora, CO
• Physical Therapist, Panther Physical Therapy, Littleton, CO
• Consultant, University of Colorado Anschutz Medical Campus: Physical Therapy Program, Aurora, CO

Jason Silvernail, DPT, DSc, FAAOMPT

• Physical Therapist, US Army, El Paso TX
• Adjunct Faculty, Army-Baylor Doctoral Fellowship in Orthopedic Manual Therapy, San Antonio TX

 

The authors of this letter have no financial interest to disclose. The views expressed are those of the authors alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

 

References
Adhia DB, Bussey MD, Mani R, Jayakaran P, Aldabe D, Milosavljevic S. Inter-tester reliability of non-invasive technique for measurement of innomiate motion. Man Ther 2012;(17):71-76

Arab HM, Abdollahi I, Joghataei MT, Golafshani Z, Kazemnejad A. Inter- and intra-examiner reliability of single and composites of selected motion palpation and pain provocation tests for the sacroiliac joint. Man Ther 2009;14(2): 213-21

Childs JD, Fritz JM, Flyn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 2004;141(12):920-8

Cohen SP. Sacroilliac Joint Pain: A Comprehensive Review of Anatomy, Diagnosis, and Treatment. Anesthesia & Analgesia 2005;101(5):1440-53

Flynn T, Fritz J, Witman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 2002;27(24):2835-43

Goode A, Hegedus E, Sizer P, Brismee J, Linberg A, Cook C. Three-dimensional movements of the sacroiliac joint: A systematic review of the literature and assessment of clinical utility. J Man Manip Ther 2008;16:25–38

Harrison DE, Harrison DD, Troyanovich SJ. The sacroiliac joint: a review of anatomy and biomechanics with clinical implications. J Manipulative Physiol Ther 1997;20:607–17

Huijbregts PA. Evidence-Based Diagnosis and Treatment of the Painful Sacroilliac Joint. J Man Manip Ther 2008;16(3):153-154

Laslett. M, Williams, M. The Reliability of Selected Pain Provocation Tests for Sacoiliac Joint Pathology. Spine 1994;19(11):1243-1249

Laslett M. Aprill CN, McDonald B, Young SB. Sacroilliac Joint Pain: Validity of individual provocation tests and composites of tests. Man Ther 2005;10:207-218

Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Australian Journal of Physiotherapy 2003;49:89-97

Laslett M. Evidence-based Diagnosis and Treatment of the Painful Sacroiliac Joint. J Man Manip Ther 2008;16:142-152

Melzack R. Pain and the Neuromatrix in the Brain. Journal of Dental Education 2001;65(12):1378-82

Moseley LG. Teaching people about pain: why do we keep beating around the bush? Pain Management 2012;2(1):1-3

Robinson HS, Brox JI, Robinson R, Bjelland E, Solem,S.,Telje, T. The reliability of selected motion- and pain provocation tests for the sacroiliac joint. Man Ther 2007;12(1):72-79

Szadek KM, van der Wuff P, van Tulder MW, Zuurmond WW, Perez RSGM. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. The Journal of Pain 2009; 10(4): 354-68

Whitman JM, Flynn TW, Childs JD, Wainner RS, Gill HE, Ryder MG, Garber MB, Bennet AC, Fritz JM. A Comparison Between Two Physical Therapy Treatment Programs for Patients With Lumbar Spinal Stenosis. Spine 2006;31(22):2541-2549

And, in the end “Enough is Enough”

Original Tweet

I absolutely love the basis and intent of the tweet! Female athletes exhibit increased incidence of non-contact anterior cruciate ligament injuries, so we need to work to reduce their risk of injury through specific training, performance, and post-surgical rehabilitation programs. ACL injury, reconstructive surgery, co-morbidities, rehabilitation, return to sport, and prevention all are hot topics currently. Studies have investigated risk factors for ACL injury, sport specific rehabilitation and return to play, accelerated vs. standard rehabilitation timeframes, as well as predictors of osteoarthritis following reconstruction. Some investigations attempt to identify individuals who can cope without an ACL vs. those who require surgical intervention. And unfortunately, as ACL injuries occur in younger and younger athletes physical therapists must consider the proper management of ACL injuries in skeletally immature individuals. I posted about fear of re-injury and return to sport following ACL reconstruction.

The link in the tweet is a Santa Monica Sports Medicine Foundation website page that explains the Prevent Injury and Enhance Performance (PEP) Program. But, I had 2 discussion points:

• The PEP may not be the best program
• Prevention may not be the best wording

Based upon my understanding of the literature on the topic, Sportsmetrics seems a superior choice for both injury risk reduction and performance. Second, I do not think we can truly and absolutely prevent injuries. Injury is an inherent risk of sport. Even non-contact ACL injuries are not totally preventable. Now, injury risk reduction is possible and feasible. I believe that the using the term prevention is the wrong nomenclature. It conveys an inaccurate message. Every attempt is made to reduce the relative risk of injury. But, make no mistake, there is no way to totally abolish injury risk. Maybe I am being too fussy…

In a strike of happy coincidence I read the abstract of a systematic review from the journal Sports Health: A Multi-disciplinary Approach the day before through Google Reader. The title of the article is Anterior Cruciate Ligament Injury Prevention Training In Female Athletes: A Systematic Review of Injury Reduction and Results of Athletic Performance Tests. The review analyzed the results of other studies in an attempt to ascertain which training programs decreased ACL injury risk and in conjunction what measures of performance were improved. The conclusion:

Sportsmetrics produced significant increases in lower extremity and abdominal strength, vertical jump height, estimated maximal aerobic power, speed, and agility. Prevent Injury and Enhance Performance (PEP) significantly improved isokinetic knee flexion strength but did not improve vertical jump height, speed, or agility. The other 3 programs (Myklebust, the “11,” and Knee Ligament Injury Prevention) did not improve both ACL injury rates and athletic performance tests.

My initial response

And nomenclature thoughts

A little bit of info from the review

Responses

Other tweets

@PacificTigerDPT brought up some excellent points in our exchange. The importance of marketing to patients and clients to maximize accessing the most effective care was something I did not think about. I really enjoyed conversing, discussing, and learning via Twitter.

Now, I am bias, because my practice location utilizes the Sportsmetrics program. I am most comfortable and familiar with administering Sportsmetrics. But, given the data in the above systematic review, I think Sportsmetrics is overall a superior program. Obviously, you want your injury risk reduction program to reduce the risk of injury! That is priority number one. But, improving performance measures such as power, aerobic capacity, strength, and agility is always at the forefront of any training, recovering, or rehabilitating athlete’s mind. In this regard, the data seems to suggest that Sportsmetrics outperforms Prevent Injury and Enhance Performance (PEP) Program. I would argue the Enhance Performance part of the name should be taken out, given the data shows that it only improves isokinetic knee flexion strength, but no measures of athletic performance.

The interactions on this topic I had through twitter as well as this resulting blog post are a real illustration of how to leverage Twitter, tweet replies, RSS feeds, and blog posts to engage in the analysis of literature, discussion of clinical practice, and comparison of research. I think this is the future of professional discussion, and potentially continuing education.

I was able to engage information from a tweet with replies. I read a website post on the PEP and compared it to the abstract I had read through RSS and Google Reader. Then, replied to the tweet with some of my analyses and a link to the systematic review. Lastly, I expanded upon my thoughts and analysis through this blog post. As illustrated, current technological and social media tool are not mutually exclusively. They can be leveraged together to facilitate networking, discussion, and professional growth.

For more detailed information on leveraging technology check out the entire Leveraging Technology Series:

1. RSS and Web2.0
2. Google Reader
3. Selection of Reader Content
4. Blog Reviews
5. Engagement

1. Web 2.0 and RSS
2. Google Reader
3. Selection of Content

But, research journals are not the only way for us to engage information relating to clinical practice and scientific research. Blogs are another great online resource. With the advent of Web2.0 principles physical therapists, students, and researchers from around the world can critique research, discuss science, and debate clinical practice through the blog format (And, the micro-blog format such as Twitter, but more on that in the next post!). Disagree with a bloggers interpretation of the evidence? Comment on the post! If utilized civilly and with proper logic blogs (and social media like Facebook and Twitter) are a great platform for learning, discussing, and reviewing. And, as I have mentioned in previous posts with RSS feeds the information is pushed directly to you. Then you decide what to skip, what to skim, what to read, what to push forward through Twitter or Facebook and what to comment on!

There are many blogs relating to physical therapy, rehabilitation, training, science, exercise science, training, and research. I stumble upon new ones all the time. Some of them are great, some are bad, and some are just ugly. Below I am going to review some of the blogs that I follow.

I love the interactive nature of the blog format. You can participate in high level discussions regarding research and clinical practice from anywhere in the world. This type of crowd sourcing has the potential to elevate our knowledge dissemination, discussion, and growth. In fact, the proliferation of blogging and micro-blogging will (I believe) fundamentally change not only how information is disseminated, but how we learn, discuss, and collaborate on clinical care and research.

For each blog, I have included the title/subtitle hyperlinked to the actual blog as well as the author(s) twitter handle with a hyperlink to their twitter profile. Please comment on your thoughts of these blogs.

What blogs do you follow? Let us know in the comments section! Speaking of, follow @PTThinkTank as well as all the authors, including the creator @EricRobertson and humble contributors @MPascoe and @Dr_Ridge_DPT

I have to start off with some student blogs. As a student this is how I became exposed to and involved with leveraging technology!

AAOMPT sSIG: Blog of the Student Special Interest Group of AAOMPT

The AAOMPT sSIG Blog is where I got my start blogging about such issues as the doctor of physical therapy degree, direct access, physician owned physical therapy services, and grass roots political advocacy. The blog provides information on the happenings of the student special interest group. If you are a student, or know a student, send them to the blog for more information on getting involved in the sSIG. It is a great group of motivated, high energy students. Unfortunately, the AAOMPT sSIG is not on twitter, but you can e-mail the students directly with comments, suggestions, and questions: ssigaaompt@gmail.com

Colorado Student Physical Therapy Advocacy: Act now to protect the future of your profession

Author: @COSPTAdvocacy

I may biased since these students are from my Alma Matter, but these students are truly organized and accomplished. Not only did they WIN the APTA’s Student Advocacy Challenge they are leveraging technology through Blogger, Twitter, and Facebook to create a sustainable and visible student movement.

Below are some of the blogs that I regularly read and definitely have in my RSS Feed. Most of them deal directly with physical therapist practice, and are authored by physical therapists. Others are authored by other professionals, but still very applicable to physical therapy. Enjoy!

Better Movement: Learn to Move with More Skill and Less Pain

Author: @ToddHargrove

Todd is a Seattle based Feldenkrais Method movement instructor who used to be a lawyer. He writes about a neurocentric approach to movement, training, and pain. In Both Sides Now, he discusses research investigating the training, or treating, one side of the body and the effect on the contralateral side.

Body In Mind: Research into the role of the brain in chronic pain

Authors: @bodyinmind @NeilOConnell

This is the blog of Lorimer Mosely and crew out of Australia. They provide research summaries and discussions regarding the mechanisms of pain and the treatment of chronic. Probably one of the most robost blogs on the net regarding pain physiology and current research. Why Things Hurt is an outstanding Tedx video by Lorimer Moseley on the neurophysiology of pain. They even discuss if Chronic Pain is a Disease.

Categories: Pain Science, Chronic Pain, Neuroscience, Physiology, Research

Leaps and Bounds: Perspectives from a physical therapist

Author: @ForwardMotionPT

Corey provides unique insight into physical therapist practice, and is obviously a very deep thinker. He has produced many videos illustrating the use of novel movements of various body regions. Here is a great post about The Movement Diet.

HealthSkills: Skills for health living for health professionals working in chronic pain management

Author: @adiemusfree

Healthskills is a blog for health providers who want to read about research related to self managing chronic pain. Topics include chronic behavior therapy, measuring outcomes, patient education, and many other topics. The author was originally trained as an occupational therapist. In this post, she discusses what to do when a patient is “inconsistent” with their pain behavior or presentation.

Categories: Pain, Chronic Pain, Cognitive Behavior, Clinical Treatment of Pain

The Manual Therapist: Promoting the highest level of physical therapy practice

Author: @The_OMPT

Dr. E posts very regular providing links to other blogs (including this one, thank you!), videos on techniques he uses, clinical cases, and clinical reasoning. He has a very expansive background being both a fellow of AAOMPT and MDT diplomat. See the post What is the Mechanism Behind Rapid Change? for a discussion we had regarding mechanisms of manual therapy. (Here is the comments section)

Mike Reinold: Rehab | Sports Medicine | Performance

Author: @mikereinoldblog

The most up to date information related to evaluation and treatment of athletes, specifically overhead athletes. Good citation of clinical research for evaluation and exercise treatment. Lots of links to different courses/products. Mike is the head of athletic training for the Boston Red Sox, and is well published on issues regarding the shoulder and injuries in throwers. In the post Rotator Cuff Fatigue Increases Superior Humeral Head Migration, Mike discusses the importance of not training the cuff to fatigue.

Categories: Athletes, Shoulder, Knee, Sports, Orthopaedics

Move It: The New Professional’s Collaboration Blog

A group of young physical therapists (<5 years experience) discuss clinical practice, clinical development, and issues regarding being a new professional. It has been a while between posts, but they have some excellent content. Check out A Generation with Challenges, Vision, and Debt.

Categories: Young Professionals, Professional Development, Legislative Advocacy, Professional Issues

My Physical Therapy Space: Evidence in Motion Blog

Authors: @EIMTeam

• @childsjd
• @PhysicalTherapy
• @TimothyWFlynn
• @SnippetPhysTher
• @PMintkenDPT

The blog of the Evidence of Motion crew. Great information regarding private practice, legislative issues, and research pertaining to orthopaedics. Discussions regarding the overuse of imaging and surgery, as well as the how physical therapists can provide value to society and healthcare. In a Blast from the Past, John Childs illustrates how some clinicians and researchers cling to old models of pain and treatment despite evidence to the contrary. Tim Flynn discusses how access to early, cheap care (physical therapists!) for low back pain is Not Rocket Science, and could have HUGE implications for our society. Larry Benz deconstructs poor logic about Physician Owned Physical Therapy Services (POPTS) that appeared in Advance Magazine.

Categories: Professional Issues, Private Practice, Orthopaedics, Research, Professional Development

The Sports Physiotherapist: Resource for physiotherapists (or physical therapists) with a passion for assessing, diagnosing, and rehabilitating the sports injuries of the world’s athletes

Author: @TheSportsPT

Extremely well cited articles discussing the evaluation, assessment, and treatment of athletes including surgical approaches and their implications on rehabilitation. Their blog and website is maybe the most comprehensive sports physical therapy resource on the net. In this post, they review the diagnostic accuracy of tests used to identify Acetabular Labral Tears of the Hip.

Categories: Sports, Athletes, Research, Examination

Physical Therapy Diagnosis: Make Decisions Like Doctors

Author: @timrichpt

Private practice owner in Florida discusses clinical decision making as well as leveraging decision support tools/software. Lots of discussion of Medicare flaws, clinical decision making, and issues in private practice. Tim recently authored a book detailing bullet proof decision making processes to improve documentation and efficiency in outpatient practices. Tim presents The Art and Science of Physical Therapy by analyzing the Oxford Debate from the American Physical Therapy Association’s Annual Conference in 2011

Categories: Private Practice, Legislative Issues, Clinical Decision Making, Outpatient

Save Yourself: Science powered advice about your stubborn aches, pains, and injuries

Author: @painfultweets

A massage therapist by training who turned to science focused blogging regarding painful problems. Skeptical analysis of pain, pain syndromes, and treatment techniques. Great information for patients and practitioners alike. Although I very much respect Paul’s work and critiques, there is a very apparent bias towards trigger points as a significant pain complaint and treatment target. Paul talks about MRI Overuse and how MRI is too sensitive of a diagnostic tool. He also does a nice job of summarizing some of the Science Surrounding Stretching.

Categories: Pain, Chronic Pain, Manual Therapy, Science

SomaSimple: The so simple body. A place for physical & manual therapy.

@SomaSimple Contributors: @jasonsilvernail @dfjpt @BarrettDorko @wrtrohio @JohnWarePT @ForwardMotionPT among others

You will not find a more thorough or logical analysis of manual therapy, physical therapy, and their relation to people with painful problems anywhere. The folks over there are true skeptics in their thought process, and challenge all. Be ready to be challenged, even if all you do is read the forums! This site is such a density of information and discussion you could read for months. Whether you troll or join in on the discussion it will deepen your analysis and understanding of pain, pain physiology, and clinical practice. Enough is Enough is a well written piece by Jason Silvernail talking about how we need to stop looking for the magical technique or tissue and focus on deeper models of understanding pain. In Crossing the Chasm, he absolutely shines in his ability to tie current clinical research to a deeper, neurophysiologic understanding of pain as he describes his process of evaluation and treatment utilizing sub-grouping in low back pain.

Categories: Pain, Neuroscience, Discussion Board, Manual Therapy

The blogs above are more specific to physical therapy principles. But, it also useful to engage information from other disciplines or sources. For example, decision making, principles of science, behavior, and psychology are all integral parts of physical therapy practice. These topics relate to how we treat patients, but maybe more importantly how we make decisions and analyze/integrate literature.

Science Based Medicine: Exploring issues and controversies in the relationship between science and medicine

I believe this is a must read blog for all health care professionals. It discusses the application of scientific principles to improve evidence based practice. These principles include prior plausibility, physiologic plausibility, and an increased focus on the integration of basic science into the understanding and practice of medicine. Although, much of it is not related directly to physical therapy, the lessons and principles discussed are applicable to research interpretation and clinical practice of all health care professions. In fact, physical therapists receive a mention in the post Subluxation Theory: A Belief System that Continues to Define the Practice of Chiropractic.

Check out these posts:

1. About Science Based Medicine
2. Announcing Science Based Medicine Blog
3. Does Evidence Based Medicine Undervalue Basic Science and Overvalue Randomized Control Trials?
4. Is it a Good Idea to test Highly Implausible Health Claims?

Eric Cressey: Performance and health on a whole new level

A personal trainer with a masters degrees in kinesiology with a highly successful persontal training facility targeted towards baseball players. Collaborates with Mike Reinold. Although targeted for personal trainers and fitness specialists, he provides amazing information on training athletes that is very applicable to physical therapists.

Very detailed information about the training of high level athletes especially baseball players. Eric exhibits in depth understanding of kinesiology, training, and anatomy specifically as it relates to baseball players and overhead athletes. Although, he does seem to have a poor understanding to mechanisms and effects of manual therapy and at times “plays doctor” in regards to client’s pain complaints. In How Much Rotator Cuff Work is Too Much? Eric discusses the implications of training the rotator cuff in throwing athletes both in season and during the off season. He highlights the fact that many throwers overuse their cuff musculature.

Categories: Sports Training, Baseball, Shoulder

1. Do you read any of the blogs above? If so, what is your critique?
2. Did we miss a good resource? Please comment and enlighten us!
3. Do you have a blog? Comment with a link and a brief summary!

Unfortunately, there seems to be a lack of physical therapist focused blogs relating to in-patient acute care, neurologic physical therapy, and in-patient rehabilitation (hint, hint, any takers??). Most focus on outpatient, orthopaedics, sports, and private practice.

I hope you have enjoyed the leveraging technology series thus far! We have covered a ton of information as these posts are are very dense. The next post will discuss the use of social media tools including Twitter, Facebook, and Blog comments to move beyond RSS into active sharing, discussion, and engagement of information! Remember, we always value your feedback and comments.

@Dr_Ridge_DPT

This session was presented by four brilliant researchers interested in brainstem modulation of the motor system. The patient population discussed was spinal cord injury, a condition in which the connection between the brainstem and the motor neurons are disrupted. Each researcher discussed the implications for force generation, spasticity, and locomotion. I’ll summarize their reports below.

Allison Hyngstrom, PT, PhD

First up, Dr. Hyngstrom highlighted a few key researchers that have influenced treatment of patients:

• Sherrington – contributed the concept of the spinal motor neuron as the final common pathway – contributed to the understanding of locomotion by examining “air stepping” elicited by stretching hip muscles of spinalized
• Eccles – introduced the idea that inhibition could sculpt the output of motor neurons, particularly the reciprocal inhibition pathway
• Brown/Grillner/Lundberg – descending input, as well as specific neurotransmitters, could activate spinal networks without sensory inputs

The Dr. Hyngstrom progressed to ‘Motor Neurons 101′, including these key points:

• MNs possess huge denritic trees to receive inputs from several sources (higher brain, local interneurons, afferent)
• Two categories of receptors are expressed on the MN membrane – ionotropic and metabotropic
• The activation of metabotropic receptors by monoamines create persistent inward currents (PICs)
• PICs can amplify the output of the MN
• In acute spinal cord injury there is a loss of seratonin in the spinal cord that decreases the excitability of spinal MNs

Moving to the spinal cord injured cat, researchers have found that by adding monoamines to the spinal cord the cat could walk again [link to article in PubMed]

Next Dr. Hyngstrom described some of her own work on MNs. In her dissertation she was interested in the factors that regulate PICs. One way she did this was by altering the amount of reciprocal inhibition.

In summary

• Monoamines (like seratonin) increase the gain of the MN > which implies PTs could reduce effort for a given movement
• Monoamines facilitate automatic movements
• Dysregulation of monoamines likely contributes to alterations in cellular excitability in chronic spinal cord injury
• Altered cellular excitability not necessarily a bad thing > consider other ideas
• Targeted medications could be used to harness spinal network excitability

Chris Thompson, PT, DPT

Next up Dr. Thompson presented his talk, titled – “Activation of spinal networks in patients with spinal cord injury to improve volitional movements”.

He began with a bold statement – “indiviuals with motor incomplete SCI do not fatigue”. How could this be? It seems that in a repeated stimulation protocol, patients with acute SCI  do not exhibit a reduction in force generating capacity, whereas patients with chronic SCI and healthy controls do exhibit a reduction in the same protocol.

I also seems that people with incomplete SCI have a reserve of volitional force generation – 115% of maximal force can be achieved across the first 4-5 maximal contractions.

In acute spinal cord injury there is a period of spinal shock and spinal reflex responses are suppressed. But after time (chronic) the responses become super sensitive to seratonin.

Dr. Thompson want to know why and he looks to the motor neuron persistent inward current as a mechanism for the following three reasons:

1. There is an increased EMG amplitude across contractions, through increased recruitment and rate modulation of motor units
2. Prolonged torque in response to electricla stimulation using top hat stim protocol, which was abolished when a nerve block was in place
3. There are alterations in motor unit activity due to pharmacological agents (SSRI), which block the reuptake of seratonin

Dr. Thompson concluded by review attempts at translation of the findings in animal models to humans patients. The idea best examined by his lab group basically involves applying a ‘top-hat’ stimulation protocol made popular in cat experiments to human patients. Something very interesting happens when comparing humans and cats. The amount of force and the strength of the persistent inward current are larger when muscles are at shorter lengths IN HUMANS. However, the amount of force and the strength of the PIC are larger when muscles are at longer lengths IN CATS. Explaining this difference is the next task on Dr. Thompson’s plate.

Arun Jayaraman, PT, PhD

Alright, that was a lot of motor neuron physiology and I appreciate you hanging in there so far. So, how can the above information be put into clinical practice? This is what Arun enthusiastically addressed – developing the rehabilitation protocol.

His main question was how can we harness the reserve in force generating capacity seen in patients with incomplete spinal cord injury?

This was tested in 10 patients with chronic motor incomplete SCI in a cross-over design with a two month washout period between the testing conditions. The phenomenon examined was that the harder you work, the more force enhancement you observe in the SCI population. As the time between maximal contractions gets longer, the enhancement in force production becomes lower (15 s is best). This phenomenon is present both concentric and isokinetic contraction modes.

Subjects trained with 65-80% of their one repetition maximum until they plateaued in function. Arun found that just isometric trained alone enhanced berg balance scores and walking distances in the 6-min and timed up and go tasks. Noxious stimulation at an intensity of 50 mA on the stomach skin was not so effective.

A follow up direction Arun is investigating is the use of intermittent hypoxia. It has been shown in rats that electromyography and force measurement improved in a ladder climbing task following a hypoxic state. How will patients with chronic SCI respond to hypoxic conditions during locomotor training? Arun is hopeful that benefits are realized in his patients.

In summary

• Volitional drive can be enhance by working very hard
• Does improve walking and balance
• Can be done at home
• What are long term effects?
• Can this be complimented with intermittent hypoxia?

George Hornby, PT, PhD

The topic addressed by Dr. Hornby at the end of the session was the combination of physical therapy and pharmacological interventions.

It seems that providing glutamate can generate locomotion patterns and we also know that monoamines can excite central pattern generators (CPGs).

There is an increased Babinski Sign in SCI due to effects of monamines.

Seratonin (5HT) is effective in initiating locomotion in rats with SCI.

It seems that humans respond better to 5HT than norepinephrine (NE) when administered.

Lastly, Dr. Hornby has seen that strength, not spasticity, is related to locomotion function.

Photo taken from APTA website

This lecture honors one of physical therapy’s best and brightest – Pauline ‘Polly’ Cerasoli (Feb 25, 1939 – Sept 11, 2010).

Dr. Gordon then wrapped up with his two take-home points:

• A strong academic foundation is essential for achieving excellence in physical therapy
• A strong academic foundation is dependent on three pillars (Education, Research, Clinical Practice), and you need them all

Photo taken from APTA website