Leveraging Technology VI: Case Example: ACL Injury “Prevention”

Recently, I stumbled upon a website post via Twitter:

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:

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

January 29, 2012 | Filed Under Evidence and Technology, Physical Therapist 2.0, Physical Therapy, Research, Science, Sports

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Leveraging Technology V: Beyond RSS to Engagement

This is the 5th in a series of posts investigating how to leverage technology:

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

In the previous blog posts I have outlined how information is pushed directly to you via RSS feeds and Web 2.0. I explained how to access information from journals and blogs without searching the net. I even discussed which journals and blogs you may want to follow and why. But, to truly engage, retain, critique, and apply this information to our clinical practices and research we must move beyond just reading. We need to discuss and analyze and integrate….but…

How do we do this when we are sitting by ourselves on a computer? There are a variety of built in tools that we can utilize to accomplish this within Google Reader, in the comments sections of blogs, via Twitter and Facebook. Most of the technology presented in this post series can be linked and utilized simultaneously. All of this from you office, laptop, tablet, or smart phone. In this post, I have bolded words, phrases, or concepts that I think are important throughout this post. This includes the concept of “pushing” information, modifying a tweet, micro-blogging, and discussion via blog comments.

The exact topic of blogs and the discussions stemming from them was recently written about on the CasesBlog: Medical and Health Blog. In the post, Blogging is good for you – and for most people who read blogs it is stated:

The back-and-forth between bloggers resembles the informal chats, in university hallways and coffee rooms, that have always stimulated economic research, argues Paul Krugman, a Nobel-prize winning economist who blogs at the New York Times. But moving the conversation online means that far more people can take part.

The post links to an article from the Economist Website titled Economic Blogs: A less dismal debate. Interestingly, they assert that papers that are blogged about and/or authors who blog may be considered more respected:

Academic papers cited by bloggers are far more likely to be downloaded. Blogging economists are regarded more highly than non-bloggers with the same publishing record.

I wonder if in the future, features such as track back or blog presence will be utilized to calculate a journal’s impact factor or rate researchers and academics.

TWITTER, with it’s 140 character limit for tweets and profile descriptions, is truly a micro-blogging medium. Everyone who is on Twitter is a micro-blogger. It forces succinct communication. Twitter offers a variety of opportunities and ways to access and discuss information. Obviously, you can read the tweets and go to the links that others post. You can reply to tweets to initiate a dialogue. RE-TWEET is when you tweet someone else’s tweet with RT before their twitter handle (name).

Here I re-tweeted @BodyinMind's link about research and blogging. The link is the article I mention earlier in the post.

Now, you can also tweet a MODIFIED TWEET (MT). Essentially, with an MT you are changing or editing the content or message of a tweet. Below is an original tweet about manual therapy from @DenverDPT regarding manual therapy effects from the 2011 AAOMPT Annual Conference:

I then modified the phrasing and content to deliver a similar, but more specific message based on my understanding of manual therapy. I preceded the tweet with MT to communicate that I had modified an original tweet by Denver Lancaster.

I view FACEBOOK as a personal mini-blog. Links, videos, and articles can be posted with ease. Similar to a blog, friends can comment and discuss. Through pages, individuals can connect on a specific topic, cause, or organization. For example, the American Academy of Orthopaedic Manual Physical Therapists has a Facebook Page: AAOMPT Facebook Page. Beyond networking and professional connection, Facebook is an also a means to access, read, and talk about information.

It is not necessary to have your own BLOG to utilize the medium to discuss and learn. You can utilize BLOG COMMENTS to write your insights and questions. If you disagree with a conclusion you can formulate a more thorough, researched response. Often, I find myself more intrigued and challenged by the discussion that happens in the comments section of a blog post. Especially if you do not publish your own blog, posting well researched and thoughtful comments is essentially blogging! You can have online discussion with links to other blogs, research articles, and online resources with the blog’s author and commentors. Professionals, researchers, and students from across the world can have in-depth, passionate debates at their convenience. Want to stay plugged into a debate? Many blogs offer the option to SUBSCRIBE TO COMMENTS via e-mail or RSS. You will automatically be alerted when a new comment is posted.

After dabbling in blog engagement, you may even desire to publish your own blog. This process is actually quite simple. There are many free resources including Blogger and WordPress. Blogger is Google’s free blog hosting service. A very professional looking blog can be started in an afternoon utilizing free templates and helpful layout designs. As I have mentioned previously, I am disappointed in the lack of blogs surrounding neurologic and acute care physical therapist practice. I remain hopeful that this segment will grow.

PUSHING is an interesting concept in the current social media landscape. All of us has experienced pushing whether we realize it or not. E-mail is a pushing service. Information is pushed to our in-box, and we push information to others. As discussed in previous posts, we utilize Google Reader to have information pushed directly to one location (our RSS Reader). Further, information chosen specifically by our Facebook friends and the tweeps we follow on Twitter is pushed automatically to our news feeds. Conversely, we can push information between our social media accounts through certain applications or linkages. For example, I have a twitter application that allows me to push any tweet to my Facebook account by putting the hashtag (#) FB at the end of my tweet > #fb.

Some pushing and linking features are automatically available. You can “like” an item on Google Reader and then make comments. Then, individuals who follow you on Google Reader can see your comments. Information can be pushed or shared directly from Google Reader to Facebook and Twitter (via the “Send To” button). A post can also be made directly to Google+. There is even a button to e-mail the link!

Most journals are now publishing content and articles online before the print version of the journal is available. E-PUB AHEAD OF PRINT simply means that article was electronically published online ahead of the print version. Journals, including Physical Therapy Journal, even have RSS feeds for E-Pub content. Now, people can blog, comment, Tweet, and Facebook about articles before the print version is published. By the time someone who subscribes to a print journal reads an article, it has probably arlready been shared, critiqued, analyzed, and discussed for weeks to MONTHS.

Interestingly, as widgets and applications evolve the line between various forms of social media and Web2.0 principles becomes more blurred. For example, Twitter feeds and tweets can be seamlessly integrated on the sidebar of a blog. Applications allow for the automatic pushing of tweets to Facebook profiles. And with tools such as HootSuite you can control both from one dashboard. Many Twitter applications allow the scheduling of Tweets into the future, so you do not overload followers with 1,249 tweets in 5.9 seconds. Facebook also allows users to create a badge, or snapshot, to have the sidebar of blogs.

Imagine networks of students, researchers, and clinicians connecting through Google Reader, Twitter, Facebook, and blogs to diseminate and discuss research, blog posts, newspaper articles, and legislation. Imagine the proliferation of professional networking, learning, and discussion. The potential exists for clinicians to collaborate remotely on patient care and research projects. If you have not already, check out PHYSIOPEDIA. Physio-pedia is the model for the future fusion of technology with education, learning, and research.

All of these tools have the ability to elevate our individual knowledge base, care delivery, and research. On a grand scale, it gives us the opportunity to improve professional growth and patient care for all regardless of geographical location. I imagine technology integration and colloboration as the basis for the future of “continuing education” and professional learning…

I envision a future where professionals from across the globe are accessing, disseminating, discussing, critiquing, and even performing research and clinical practice.

In the next post, I will illustrate these principles from a real life scenario. As a preview, I responded to a Tweet that linked to a performance and injury risk reduction program aimed at decreasing ACL injury rate AND improving performance. In that interaction, I utilized and pushed an article via Google Reader to Twitter. I was able to engage in a virtual conversation with a handful of individuals regarding the topic. After I present the interaction, I will discuss and analyze the encounter and research evidence surrounding the specific topic of ACL injury risk reduction and performance improvement.

January 17, 2012 | Filed Under Evidence and Technology, Physical Therapist 2.0, Research, Science

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Leveraging Technology IV: Blogs

So, this series has had a long, long hiatus between posts for which I apologize!! Time to start the new year off right. This is another dense post with a ton of resources and links. I hope you enjoy. In the previous post, I presented which research journals publish the most and highest quality clinical trials of interventions. I also discussed what research journals we should consider following. The preceding posts in this series were:

  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

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

January 14, 2012 | Filed Under Evidence and Technology, Physical Therapist 2.0, Physical Therapy, Research, Science

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AAOMPT 2011 | Anaheim, CA

October 29, 2011 | Filed Under AAOMPT, Physical Therapy, Research

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Leveraging Technology III: Selection of Content

In the first two posts of this series I discussed the concepts of RSS and Web 2.0 as well as detailing the set up of Google Reader.

  1. The Basics: Web 2.0 and RSS
  2. Google Reader

This post will discuss which journals we should be following and reading as physical therapists. Obviously, there is Physical Therapy Journal as well as population and practice area specific physical therapy journals published by the sections of the American Physical Therapy Association:

Click on the picture to visit the Acute Care Section's Website!

Definitely subscribe to some (or all!) of those journals via RSS. Remember, if the journal website does not have an RSS icon or url, you can create an RSS  for a PubMed search for that specific journal. I outlined how to do this in my previous post.

Following physical therapy specific journals seems quite obvious. But, an interesting article published in Physical Therapy Journal detailed some specifics regarding journals that publish physical therapy and rehabilitation specific trials. The article, Core Journals that Publish Clinical Trials of Physical Therapy Interventions, analyzed journals that published clinical trials of physical therapy interventions. The journals were then ranked by

  1. Total Number of Trials
  2. Quality of Trials ranked via PEDro Score
  3. Impact Factor

Most Trials of Physical Therapy Interventions

  1. Archives of Physical Medicine and Rehabilitation
  2. Clinical Rehabilitation
  3. Spine
  4. British Medical Journal
  5. Chest

Highest Quality Trials Based on PEDro Score

  1. Journal of Physiotherapy
  2. Journal of American Medical Association
  3. Stroke
  4. Spine
  5. Clinical Rehabilitation

Highest Quality Trials from 2000-2009

  1. Journal of Physiotherapy
  2. Journal of American Medical Association
  3. Lancet
  4. British Medical Journal
  5. Pain

Highest Impact Factor: 2008

  1. Journal of America Medical Association
  2. Lancet
  3. British Medical Journal
  4. American Journal of Respiratory and Critical Care Medicine
  5. Thorax

The authors conclusions:

Surprised? The only physical therapy specific journal is the Journal of Physiotherapy, which is published by the Australian Physiotherapy Association.

NOTE: Take into account the data is only in regards to Randomized Control Trials (RCT’s) of interventions. It does not include information regarding articles on basic sciences, physiology, or neuroscience. Further, it does not include case reports, clinical perspectives, and other manuscript types. Regardless, it provides us with guiding information on where we should be looking for research to guide our practice and understanding. In addition, I believe it reiterates the point that we need to continually look to other areas of research to deepen our mechanistic understanding of physiology especially neuroscience. I think it is absolutely imperative we stay up to date on basic science research especially as it relates to neuroscience, the physiology of pain, and exercise science.

For example, in October of 2009 Critical Care Medicine devoted an ENTIRE supplemental issue to Intensive Care Unit Acquired Weakness (ICU-AW) including clinical and physiologic studies examining neuromuscualr impairments, clinical examination, and clinical treatment. In all, there were 20 articles, reviews, and manuscripts in this supplement. That sounds like something a physical therapist practicing in acute care should follow!!

Now, although Physical Therapy Journal failed to make the Top 5 in any of the categories above a recent investigation in Journal Citation Reports gave PTJ high marks: #1 Among physical therapy specific journals. #3 Among ALL rehabilitation journals. #7 of 61 Among orthopaedic journals. Please visit this post via PT in Motion: News Now for a summary. Paul Ingraham, a massage therapist and writer covering science based pain care over at Save Yourself, compiled his own Top 10 List based on the results of the PTJ study. His list is very similar to the ones above.

Below you will see journals that I think are applicable to clinical practice and scientific understanding. I organized them by a few practice areas and topics. I also provide the RSS link next to the journal name. I did not include any of the physical therapy specific publications, but the links to those journals are earlier in the post. In the instances where the journal does not have an RSS, I have included an RSS for the PubMed search for that particular journal. If you want to follow any of the journals below all you have to do is copy and paste the RSS url into the ‘Add Subscription’box of google reader! I have also hyperlinked to the journal websites, so please also visit the journal websites to explore other potential RSS options on content including online ahead of print and podcasts.

General Clinical Practice and Basic Sciences

Medical Journals

Acute Care

Neurologic

Orthopaedics: General

Manual Therapy

Sports

Now, this is not an exhaustive list. Depending on your practice area and the populations you work with other journals may be more applicable. For example, if you work at a rehabilitation hospital that specializes in the treatment of spinal cord injury Spinal Cord and Journal of Spinal Cord Medicine are obviously more applicable journals. Also, I did not include lists for Pediatric, Geriatric, or Women’s Health practice areas. But, if you practice in these areas or have suggestions please provide us some information by leaving a comment!

Hopefully, the information and journals listed were helpful. Spend some time over the next week analyzing which journals you subscribe to, follow, and read. Ask yourself “WHY?”

In the next post, I will provide a brief overview and evaluation of some of the blogs I follow. Do you have favorite blogs that you read? Please comment and let us know. Stay tuned!

August 19, 2011 | Filed Under Evidence and Technology, Physical Therapist 2.0, Research, Science

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Manage the Evidence Like a Pro

The problem. You are trying to stay current with the literature because that’s a great way to ensure quality treatment of your patients OR your a student in a physical therapy school that has a strong evidence based practice curriculum AND you end up having a hard drive littered with PDFs, like this:

Image by mekentosj.com

The solution. Papers2 by software developer mekentosj. This app makes it dead simple to organize your PDFs. Think of it as iTunes for PDFs, where instead of double clicking a track to listen, you double click to open the PDF in your favorite PDF viewer. You can search for articles quickly, email them to a colleague, even takes notes, all within the app. There are so many neat features I just had to put together a brief screencast demo, which you can view below:

Managing Physical Therapy Articles Like a Pro from Mike Pascoe on Vimeo.

In this 5 minute screencast, I show off some of the key features of Papers2. This video is directed toward those with a physical therapy background.

Papers2 can be downloaded here:

http://www.mekentosj.com

April 7, 2011 | Filed Under Evidence and Technology, Health IT, Research

3 Comments  

From Bench to Bedside: Spinal Cord Physiology -> Clinical Interventions

Having just defended a dissertation in the field of neuroscience, this session was my guilty pleasure. I felt right at home hearing about the modulation of intrinsic motor neuron properties. But, the question I’ve had since graduate school was the focus of this session – how does the lab work in cat/rat/monkey motor neurons translate to human patients?

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:

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

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

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

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.

April 5, 2011 | Filed Under APTA, CSM 2011, Physical Therapy, PT Think Tank, Research

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CSM 2011 – The Pauline Cerasoli Lecture

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).

The Cerasoli lecture began with a tribute to Polly by a long-time friend and colleague Bette Ann Harris in which we learned more about the places she spent time:
  • Northeastern University (1967-1981)
  • Massachusettes General Hospital (1981-1987), doctorate in education
  • University of Colorado Denver (1988-1996), director of physical therapy program
We also learned of the major contributions made by Polly to the physical therapy profession:
  • Started the Boston Education Consortium in the 1970s
  • Published a landmark paper titled ‘Research experience in an undergraduate physical therapy program’– [pubmed link]
  • First appointed clinical specialist at Massachusetts General Hospital in 1981
  • Mentored a blind physical therapist in 1992
Next, APTA President Scott Ward asked for a moment of silence, as it was the first Cerasoli lecture since she passed away in Sept of 2010. Dr. Ward announced that the 2012 Cerasoli Lecture will be given by Christine Baker from UT Galveston.
Dr. Ward then introduced us to the 14th Cerasoli Lecturer – Dr. James Gordon. Dr. Gordon is associate dean and chair in the division of biokinesiology and physical therapy at USC.
Dr. Gordon’s talk was titled ‘Excellence in Academic Physical Therapy – What Is It and How Do We Get There?’I’ll try my best to summarize the talk below.
We (physical therapists) must accept the challenge that lays before us – pursue excellence.
On January 15, 1921, that 30 PT aides formed the APTA at the Keene’s Chop House in NYC. Now, a century later, Vision 2020 is lies ahead. It is the challenge.
What is needed to meet this goal is a strong academic foundation. It is in the academic setting that the physical therapy profession does its thinking.
Dr. Gordon defined a strong academic foundation as having three pillars – Education, Research, and Clinical Practice. All three pillars need to be in place. A classic three legged stool analogy, the foundation will topple with the absence of just one of the three pillars.
Dr. Gordon stated that excellence today is the norm for tomorrow. Excellence is the engine of the train, accredidation is the caboose (crowd chuckles).
So what is the agenda to achieve excellence? It is fulfilling all three pillars of the academic foundation.

1. Education

The most urgent task is to standardize curricular competencies. There is “unwarranted variation in physical therapy practice”. For example, there is large variation in the prerequisites, and program length. An emphasis on preparing generalists is the problem. Accreditation offers a list but no priority. Curricular competency needs to be standardized. Students need to have the ability to treat a patient with a defined condition under a defined set of characteristics (settings, acuity, age).

2. Research

Not much to say here. All programs should be involved and the big should help the small.

3. Clinical Practice

All programs across the country need to be involved. Currently, only 22% of programs have any form of program sponsored practice. Practice is important because it enhances teaching and provides a venue for research.
Lastly, Dr. Gordon addressed the infrastructure requirements to achieve program growth. Of the 213 accredited physical therapy programs in 200 institutions, 206 offer a DPT degree. Currently, 75% of faculty are PhD-level prepared. Many of these programs are very small. 50% are in Universities with research institutions and 35% of physical therapy programs are in medical centers. The average class size is 42.5, and 20% of programs have class sizes less than 20.
Why emphasize program growth? Dr. Gordon argued that this will bring a greater breadth of knowledge, support more research, and meet the need for more physical therapy students.
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

April 1, 2011 | Filed Under APTA, CSM 2011, Physical Therapy, Research

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Fear of Re-Injury and Return to Sport Following ACL Reconstruction

Fear of Re-injury and Low Confidence 1 Year after ACL Reconstruction: High Prevalence and Altered Self-ratings: CSM2011 Sports Section Platform Presentation
Trevor Lentz, PT, CSCS

This study won the Excellence in Research Award from the Sports Section of the APTA. Trevor’s primary clinical and research interests include rehabilitation of shoulder pathology, especially of the overhead athlete, and ACL rehabilitation including advanced rehabilitation timeframes. He is part of the research group at University of Florida that includes Dr. Steven George PT, PhD. Dr. George has been involved in a large magnitude of research related to psychosocial variables in musculoskeletal conditions. His primary research interests involve the common theme of utilizing biopsychosocial models to prevent and treat chronic musculoskeletal pain and dysfunction. So, I am not the least bit surprised he is involved in this line of questioning.

Background:

34-47% of individuals do not return to prior sports participation following unilateral, isolated anterior cruciate ligament reconstruction. This number maybe up to 70% for contact sports.

Clinical Factors Associated with Disability Following ACL Recon:

**Multiple studies have supported those findings**

Differences Between Individuals Who Return to Sport and Those Who do Not:

Fear of movement and re-injury consistently associated with self-reported function. But, not routinely measured or addressed in post-operative care.

Essentially, the group wanted to study whether fear of re-injury and or fear of movement was present, and a factor, in return to sport following anterior cruciate ligament reconstruction. They included individuals in their study who had isolated, unilateral anterior cruciate ligament reconstruction. Return to sport status was measured 1 year post-operatively. Roughly 100 participants were enrolled. They gave participants a questionnaire asking if they had returned to sport. If the answer was no, they gave a list of reasons including pain, weakness, lack of ROM, lack of clearance by MD, fear of re-injury/movement, and some other variables…

Findings

A subset of the population may not only benefit from, but require, fear of re-injury interventions. Addressing psychosocial impairment may aid in function and return to sport status. But:

The speaker did a nice job of pointing out that we need to do a better job of operationally defining and measuring “return to sport.” For example, return to any sport? return to their sport? I would go one step further and say return to previous level of function (40 yard dash time, vertical leap, strength)? Previous level of performance (minutes played, game statistics, self-perceived ability)?

In my opinion, future investigations MUST specifically tease out return to sport and return to previous level of sport performance. It is useful whether measured subjectively through self-perception and self-report OR objectively through playing time, statistics, etc. Any athlete, especially high performing athletes, will tell you that there is a difference between playing/participating in their sport AND performing at their pre-injury level.

As far as intervention, it may range from graded exposure of feared activities/sport specific tasks or graded activity progression. [Many of these cognitive behavior approaches are being utilized and studied in patients with chronic and persistent pain] Some may require even further intervention (psychological or otherwise) for their biopyschosocial impairments and barriers for return to sport.

So, fear of re-injury has been identified as present following ACL surgery and a very real, patient perceived barrier for return to sport. Now, we need to figure who develops it and why? What are the risk factors? When do we intervene and how? And, what are the long term consequences of this impairment? Looks like we have some work to do!

February 14, 2011 | Filed Under APTA, Research, Sports

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American College of Radiology Appropriateness Criteria for Imaging

Integrating the American College of Radiology Appropriateness Criteria for Imaging for Musculoskeletal Conditions into Physical Therapist Practice

The presenters of this session discussed the decision making process of when a patient seen by a physical therapist may require (or benefit) from further imaging studies. They provided evidence for not only when a patient needs imaging, but what type of imaging has the best sensitive or specificity. Real patient scenarios were also presented to illustrate the decision making process, and statistics.

One of the problems that plagues physical therapy decision making in the clinical setting is the routine (and accepted!!) use of clinical tests (i.e. Homan’s Sign in screening for DVT) that actually have poor statistics and poor clinical utility. Below I will briefly summarize some of the material presented, as well as provide links to some great websites to help with a decision making process founded on proper statistical studies and grouping of findings.

Before, I get started one of the biggest take home points was a concept that is taught to all physician residents. Do not order a study or tests unless the results will alter the course of treatment or diagnosis. On a side note, I think this a concept we need to incorporate into physical therapy clinical examinations and clinical reasoning more rigorously. How many clinical tests or measures are we performing that do not alter our treatment or decision making? Major Michael Ross adapted the above principle to the physical therapist’s perspective and role in imaging:

Use imaging ONLY if a positive test will result in a change in treatment

I will expand upon this by saying that physical therapists will also be referring for imaging or further work up if they need to rule OUT a more sinister cause of the patient’s presentation before initiating, or while concurrently, initiating PT treatment. So, if you can not sufficiently rule out a DVT, fracture, or other occult pathology in your clinical examination using the best available clinical tests and statistics then we must refer that patient for further testing. Obviously, a positive test for DVT, a visualized fracture on CT, or a tumor on MR are going to change (or halt) physical therapy treatment.

Fractures

[Disclaimer, I have not thoroughly reviewed the statistics for overall sensitivity and specificity of plain films vs. MR for fractures OR the statistics for various body regions. But, this aligns with what I knew previously. I am presented the information as it was presented. Citations in their handouts if you have access to them. Please comment if you have references that suggest otherwise.]

Avascular Necrosis

Cauda Equina

Shoulder: Rotator Cuff Tears

Low Back Pain

We are obviously (hopefully!!!) preaching the choir in regards to over-imaging in individuals who have low back pain. There has been an explosion of data over the past 5-10 years illustrating the presence of unnecessary and over-imaging. But, far more scary, is the findings that more imaging in low back pain is correlated with more invasive procedures and higher health costs. That is something to shoot from the rooftops: There is the potential for increased exposure to more invasive and potentially less successful treatment approaches with unnecessary imaging. Remember an image is never going to make your pain go away. One last sickening statistic. More dollars are spent each year on spinal fusions that on cancer. Here are the American College of Physicians Recommendations.

Physical Therapists can and do utilize imaging for different reasons than physicians.

Sometimes it is important to know the relevant pathoanatomy. This may guide the application of our manual therapy treatment. It may also help us make better recommendations on pursuing surgery or not. Many times we are requesting or using imaging to rule out sinister causes of a patient’s presentation.

What I think is most exciting about the ACR guidelines is that they are readily available online and there is also a Mobile App!! There is also a great website, MDCalc, that integrates current evidence into decision tools that you can use instantly on the web:

As Albert Einstein said: Intelligence is not the ability to store information, but to know where to find it!

What a great way to leverage technology to utilize the best evidence for imaging and referral appropriateness. I do not think there is any data on this, but I would assume that clinicians that leverage this tools in clinical practice make better, and better informed decisions. For those of you familiar with Dr. Tim Richardson’s blog Physical Therapy Diagnosis: Make Decisions Like Doctors, he is actually developing clinical decision making support tools that can be easily integrated into EMR programs. Exciting times!!

February 13, 2011 | Filed Under Research

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