Posted on

When Does Rehab Stop and Performance Enhancing Begin?

Here is an article about Oscar Pistorius of South Africa, who is petitioning to be allowed to run in the Olympics with two below-the-knee prosthesis. He is, by far, the best para-olympic runner. His time in the 400 is good enough to win the women’s event at the last Olympics. However, rules are rules and there is now a debate about whether or not he should be allowed to run.

As a Physical Therapist I find myself in an uncomfortable place in this argument. I feel professionally bound to fight for the ablement of the disabled. However, I do also respect that in a human competition of physical performance there needs to be a definite line drawn with respect to mechanical aides. Oscar was born without a fibula in either leg, and so learned to walk without legs. This fact probably proves crucial to both his adept running skill and his outlook on the matter.
“I don’t see myself as disabled,” said Oscar Pistorius, a former rugby and water polo player. “There’s nothing I can’t do that able-bodied athletes can do.”

Robert Gailey, an associate professor of Physical Therapy at the University of Miami Medical School was featured in the article as he described the overwhelming mechanical disadvantage it is to run with prostheses. All well and good, except for the fact that the prostheses are performance aids by definition. For now they are a disadvantage, later they may be an advantage. The SPARKy ankle joint is a prime example of a positive energy prosthesis.

I want to be on the side of Mr. Pistorius. I just don’t think I am. That said, we should all take a moment to acknowledge what a gifted athlete this individual truly is.

Labels: ,

Posted on

What I Think About Floyd Landis

Ok, first a disclaimer: I like cycling. I coach cycling. I like when Americans win cycling events. I liked everything I knew about Landis except that he left the Discovery Team to race for Phonak. I think there is no sport more corrupt, backwards, and overall annoying than cycling. I do not trust Anti-doping agencies, in that they only get budgeted by convicting people. In other words, my personal bias is to not believe most of the recent press about doping in cycling. Finally, and obviously, I am not an endocrinologist or doping expert.

Good. Now, let’s have a discussion. As background for our discussion, I will direct you to an excellent blog post on the science behind Floyd’s positive test at Jake Young’s Pure Pedantry blog. It’s a great overview of the case. Next, I also recommend the blog, Trust but Verify, which is dedicated to covering the events of this case.

An excerpt from Pure Pedantry:

"There is a very legitimate question related to the timing of the positive test. Floyd Landis tested positive on day 17 of the Tour de France — right before he made a miraculous comeback to retake the lead. Some people may speculate that testosterone may have helped him do this. This is unlikely to be the case. Testosterone is used during training periods to gain muscle mass. It is not a stimulant like amphetamines. It is not likely that testosterone would improve performance on such a short time scale, nor has it ever been shown to have that effect."
And that is the most poignant question: Why would all the tests he took during the Tour be negative except for one?

Yesterday during his hearing, defense expert Dr. John Amory had the same concerns:

"The case didn’t make a lot of sense to me," Amory said. "Initially when I saw the documents, I thought there were irregularities, first with the handling of the samples, then with the results."The ratios went from 1.5-to-1 and 1.8-to-1 to 11-to-1, then quickly back below 2-to-1 over the span of 10 days.
"I don’t consider those results to be consistent with the use of testosterone gel over that period of time," Amory said.

The only thing I have read that could even come close to offering an answer to this is that testosterone could potentially hasten recovery. This is exactly what the USADA (U.S. Anti-Doping Admin.) tried to argue with the testimony of Joe Papp, a former low-tier pro and convicted doper. His testimony got a lot of press and I cannot understand why. This case represents the career and reputation of a man on the line. Yet, the prosecution sees fit to attempt to make a case on the subjective reports of one guilty cyclist about the effects of a testosterone gel on his recovery.

So What Do I Think About Landis?
It doesn’t matter what I think. The facts of the case are what matters. I do think one must question the strength of any case which is going to rely on non-blinded testers and subjective single case reports! That’s not really science, now is it?

Labels: , ,

Posted on

The Health Effects of a Forest, or Yoga, or Pilates…


Get to the point, originally uploaded by surfwax.

I happened across this unique investigation in the the Journal of Physiological Anthropology today. Sure, this might not be the most widely read journal, but I thought this little study worth some thought.

Shinrin-yoku or "Taking in the forest" was found to be correlated to reduced blood pressure and reduced salivary cortisol secretion (stress hormone). In other words, taking in the forest was relaxing. The study was proud of the fact that it was able to correlate subjective responses to the forest with measurable physiological changes.

I’m happy because I think this may provide all the scientific evidence I need to open a cardiac rehab unit in my local state forest! Not convinced? Well, go check out the multiple citations in Pub Med on the subject of Shinrin-yoku.

This type of thing also calls to mind the practice of Yoga Therapy. This has gotten some pretty solid press lately, in both the New York Times and elsewhere. In both instances, the subjects of the article were keen on selecting a yoga therapist who was also a Physical Therapist.

"I wonder what kind of evidence supports this yoga therapy?", I asked myself.

Well, here’s some evidence supporting yoga therapy for non-specific chronic low back pain (pdf) in a slightly more well-respected journal, Annals of Internal Medicine. Per the NY Times, the National Institutes of Health has allocated $1.2 million for a second study to see, in part, if the results can be replicated on a larger scale. In fact, there is quite a bit of evidence for Iyengar Yoga Therapy in general. I also found this systematic review.

So what’s my point? Evidence is evidence. Sometimes I’m tempted to shrug off research that speaks about walking in the forest. I know that hiking is relaxing without consulting a journal. But, perhaps it is in this "alternative" research where some basic and valuable lessons are learned. Is there enough evidence for me to integrate yoga therapy in my practice? Not sure, but I better keep a look out!

I leave you with a quote from the news article:

“Anybody can hang their shingle and say they are a yoga therapist,” said Julie Gudmestad, a physical therapist who also practices yoga therapy in Portland, Ore. “Buyer beware. I’ve seen some strange things done in the name of yoga therapy.”

Labels: ,

Posted on

AAOMPT Loses a Fellow

Dr. Frank Fearon PT, DHSC, OCS, FAAOMPT has passed away. Read about his life here. Dr. Fearon was an educator, a clinician, and a human being. I did not know him, but I wanted to acknowledge and spread the word of his passing.
From his obituary:
“Frank began a battle with brain cancer in August, 2004. He amazed his team of physicians by courageously persevering through brain surgery, radiation, chemotherapy, and all the associated medications. By the grace of God, he recovered enough to return to nearly all his professional roles. After almost three years of fighting cancer, however, he peacefully accepted God’s call to go home.
In a recent personal letter, Frank said, “But I am convinced that we
are where God wants us…”
Posted on

Move Over Swiss Ball, There's a New Desk In Town!

A new research study by James Levine describes the effects of implementing an upright, treadmill desk for office workers. The desk is designed so that workers can stand up and walk on the treadmill as they do their work. The goal of this is to increase calorie expenditure throughout the year, thus minimizing worker obesity. In the study, workers walked 35 minutes out of each hour, burning about 100 calories an hour more than usual. The Wall Street Journal Health Blog asked Dr. Levine some questions about this.

I encourage you to read some of the highly amusing comments to the WSJ blog on this topic. People are just insanely enthusiastic about it. My favorite comment was by one Marc, who suggested a Green twist to the treadmill desk as he would like to route the output back into the “grid” to save the firm on utility bills! HA! Output! A treadmill is an absolute energy hog, Marc.
I’m sure the real cost of this desk is well above the $2000 list price when you factor in energy costs, a whole new onslaught of worker overuse injuries, and the resulting high insurance premiums “the firm” would then face.
This seems like a perfect example of the media getting hold of a piece of science, overstating it, creating a furor and an instant fad. An excerpt from the interview:
“Q: These desks cost about $2,000 each. Is anyone besides you using them now?
A: Several Fortune 20 companies are involved. One has 20 units, others are being delivered. We’re turning away large companies. The level of interest is far beyond what it is possible for us to respond to. There are several thousand people doing this around the country. I get — at least every day — requests of where can I buy these?”
In James Levine’s defense, I guess his logic is solid. The treadmill project was born after he performed a previous investigation which found obese people spent 2 hours longer a day sitting compared to non-obese people. And to be honest, we should all find more ways to walk in a day.
I’m going to begin calling the companies purchasing these treadmills and offer to provide them on-site clinics to treat sore knees, shins, and feet.
Posted on

The Protective Ability of Radiology or How Radiology Saved My…

The radiological image on the left is a femoral Osteoid Osteoma. On the right is a T8 compression fracture. Both of these images are CT scans. The military clinic where I work affords Physical Therapists the privilege of being able to order imaging like this when needed. This is an ability not available to Physical Therapists who do not work in military settings.

Both of these patients had been referred to me after first seeing their primary care physician. They arrived in my office with diagnoses of “knee pain” and “muscle spasm,” respectively. Since I know that primary care physicians are not musculoskeletal experts, I made no assumptions as I began my examination.

The person with knee pain had displayed a gradual onset of pain in his left knee. He was vague in locating the area where the pain was felt. There was no injury or event that provoked the pain and the knee had some mild swelling despite all special tests for mechanical structures returning a negative result. In other words, my clinical exam could not determine what was wrong.

The “muscle spasm” patient was even more tricky. There was a well documented incident where the patient, a nurse, had assisted in a transfer and felt pain and spasm immediately. The transfer was a simple slide up in the bed and seemed to have no ability to create any sort of serious injury. There was some red flags, however: extreme tenderness and protection upon palpation and the inability to sleep due to aching pain.

On both of my requests for radiology I included the term, “rule out underlying pathology.”

I was glad I did, and even more grateful for my ability to have access to these tests. Neither case was an emergency, but I fear that if I saw these same two patients in a civilian clinic, I might have been tempted to try a few session of therapy before deciding to send them back to their physician for more tests, which might or might not happen, and could take several weeks!

These two cases, at the very least, speak volumes about the importance of a thorough physical examination. It should also speak to the importance of being evaluated by an expert in musculoskeletal care.

The ability of Physical Therapists to obtain radiological images seems like the next logical step in a move towards autonomous practice. There are many hurdles to this concept and a great debate is pending. Stay tuned…
Posted on

What does the NY Times think of PT?


Last week I stumbled upon a fun game. I happened to read this post from Seth Godin, marketing guru of the information age. He detailed the sometimes overwhelmingly positive effects that good press in the Times can have on business. Shortly thereafter, I noticed a piece in the Times about Physical Therapy.

The NY Times has a nice feature where certain words are hyperlinked to other articles on the subject, all within their own website. It’s easy to see what the Times thinks of Physical Therapy, just click on the word Physical Therapy and see what you get. Alternatively, you can search the archives when the short-lived hyperlinks are removed from the article. I did that and found an interesting collection of articles in which the term “Physical Therapy” appeared.

My favorite was written by Jane E. Brody, after she apparently had a personal experience with Physical Therapy. Her article focused on “Good Therapy…”

“I have also learned a lot about how to judge the quality of physical therapy. As one reader, Tina Mosetis of Great Neck, N.Y., noted, “Most therapists do not spend enough time analyzing what is wrong with the patient, and after the initial session they simply direct the patient to do exercises on the gym equipment.”

While interesting, I think the most interesting fact returned by this exercise is that the results returned only 75 articles that included the term “Physical Therapy” since 1981. That same search for “Physician” returns 5,136 articles.

Perhaps what the New York Times thinks of Physical Therapy is that it doesn’t consider us very good promoters of our trade? And, if you haven’t yet noticed, the article pictured above that started this whole game was featured in the Fashion and Style section! What’s that about?

Posted on

Using Evidence to Change Practice Paradigms

Last night, the Midlands District of the South Carolina APTA was treated to a nice lecture from Stacy Fritz, PT, PhD, a professor at University of South Carolina, during our biannual meeting.

Her topic was something she calls Intensive Mobility Training (IMT). It describes a type of Physical Therapy intervention in which individuals with chronic neurological impairments are given intense (as the name suggests!) therapy utilizing some very interesting principles. The therapy essentially pairs components of two unique neurological interventions, Locomotor Training (LT) and Constraint-Induced Movement Therapy (CIMT).

Among the principles that this therapy is based on, one captured my imagination: the concept of massed practice. Essentially, this motor learning theory groups the learning for a task into one small period of time with an enormous amount of repetition during that time. An example would be 2 weeks of 3-6 hours of therapy daily, in which the majority of time spent was performing the desried task repetitvely, i.e., walking. This is in contrast to more traditional rehab schedules, such as 3 times a week for 60 minutes over 8 weeks.

While I was listening to the talk, I had a difficult time wrapping my brain around the possible scenario in which an insurer would ever pay for such time periods of therapy, which sometimes includes multiple therapists working on one patient. Well, research like this may help to answer a question that is just so obvious as to be often neglected:

“What evidence supports how much therapy a patient requires?”

Perhaps research like this might one day pave the way for a “revolution” in how Physical Therapy services are provided with respect to time and dosage. I know one thing for sure: without evidence like this, insurance companies will be all too eager to keep us locked into the current time-based payment scale!

Aside from her informative lecture on IMT, I learned two things I was not expecting to:

1. South Carolina leads the nation in incidence of stroke.

2. The incidence of Spinal Cord Injury in SC is 20% higher than the national average.

Posted on

"Name Your Price, Doc"

At least the drug companies are not alone in buying off doctors. This time it is a criminal investigation into ortho docs who have been paid handsomely by device manufacturers to use their implants. No one is accusing these docs of compromising patient safety, but it is illegal to accept kickback payments AND be a Medicare provider.

This reminds me of a recent conversation I had with an orthopaedic resident (I am summarizing the conversation for obvious purposes):

ME: “How many of these surgeries do you plan to do?”

RES: “Well we’ve not been doing too many, but my attending is good friends with the sales rep from company B, so we will probably stop using company A and do more surgeries with B’s implant.”

ME: “Oh, he’s friends with the guy?”

RES: “Yeah, they go fishing, and my attending stays at his cabin. They go on trips
all the time.”

ME: “I didn’t realize that implant had FDA approval yet!”

RES: “It doesn’t, but I think we’re kind of holding 0ff on surgeries
using company A while we wait for company B’s implant to get it.”

Hmmm.