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Thought of the Week: Connect

Recently, the physical therapist social media world has been a buzz with #SolvePT. I added my thoughts on this in a separate post. This movement made me reflect on a Ted Video I watched and enjoyed recently. It got me thinking and it spawned this week’s thought.

Inspired by the video below by Brene Brown, we need vulnerability to connect. I believe the recent #SolvePT is a nice illustration of connection, albeit virtual, happening within the physical therapy profession. Now, taking the leap to join social media, and then leaping into the conversation means putting yourself out there in a virtual, but very real sense. It means expressing thoughts, views, and ideas. Ideas the world and other PT’s can read (and critique!). It is social media vulnerability, but we need it to truly connect.

Connect!

Now, what about in real life; what about the patients we serve? Many, if not all, come to us in vulnerable circumstances. Sharing their stories, their illness narratives, they are vulnerable. Are we, individually and collectively, creating an environment that welcomes and nurtures vulnerability in order to facilitate connection, understanding, and transformation?

You need vulnerability to connect. What can we do better in our personal and professional lives? Individually and collectively? What can we do better in education of our students and patients?

Thoughts? @Dr_Ridge_DPT

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Can we use Twitter to #SolvePT

Recently, a new hash tag has emerged in the physical therapy twittersphere: #SolvePT. Selena, via the Evidence in Motion Blog, shared her thoughts in a post The Pulse of Physical Therapy. Dr. E of the Manual Therapist also briefly highlighted this new hash tag in a post.

#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:

Topics discussed today were extremely broad and covered many areas of practice:
  • Education: Cost, Length, Effectiveness, Organization
  • Clinical Education: Models, Need for change, Payment
  • Financial: Debt vs. Income, Payment by Setting, Incentives, Payment Models. You may seek Professional Financial Solutions if you are struggling with your financial liabilities.
  • Best Practice: Defining, measuring, incentivizing, and teaching
  • Outcomes: Which ones? How to Measure?
  • Value: Cost Savings, How to measure, How to communicate
A very interesting question that I took from the discussion was: Who is the physical therapy consumer or customer? I made the point that physical therapy has many consumers at various levels of the care delivery process. An individual receiving care from a physical therapist is an obvious and direct consumer. But, other customers of our services include referral sources, other health care providers, payers, hospitals, entities we work for, the health care system, and society as a whole. Our care, but also our knowledge or advocacy, can directly or indirectly affect these various stake holders.

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.

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Thought of the Week: MOVE

Our inaugural PT Think Tank Thought of the Week was BE YOU.  This week’s thought stems from a video that has been circulating over the past few months. Inspired by the video below, this weeks thought is:

MOVE

Slow movements, fast movements, weird movements, new movements!! Time to get moving. Obviously, this video discusses some of the health implications of not moving, and the benefits of daily activity. As physical therapists, we are always trying to assist our patients with movement. How can we best assist them to not only become themselves (per the previous thought of the week), but MOVE more to illicit potentially powerful health, wellness, and quality of life benefits? Your thoughts?

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500 Word Letter to the Editor? $31.50…

…real scientific and professional discussion? Priceless.*

*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

 

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Thought of the Week: Be You

We are starting a new, original feature on @PTThinkTank called Thought of the Week. Other blogs have weekly links, videos, songs, fun posts, and other various features. This will be ours. Since this is a Think Tank, we figured it should be a statement, a thought.

Thoughts may be funny, serious, analytical, and or insightful. Hopefully, they will provoke thought. Posts will likely include links, pictures, and videos that illustrate (or even inspired) the message.  As always, sharing, comments, and discussion are not only allowed, but highly encouraged.

Inspired by the video below (and credit to my graduate school neuroscience professor and faculty advisor @RGisbertDPT) the first PT Think Tank “Thought of the Week” is:

BE YOU.

http://www.youtube.com/watch?feature=player_embedded&v=K5s7y83ZhW4
Now, the thought could have been MOVE or DANCE or FREEDOM. But, in the end you can move, dance, and be free to become yourself. So, BE YOU. How can we assist our patients to be themselves? Or, more importantly have them change and move to become the selves they desire?

Your thoughts…?

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Product Review: The Edge Tool

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?

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Publishing in Science: Are Industry Standards Serving Researchers, Clinicians, and Science?

Recently, @JasonSilvernail and I wrote a letter to the editor of the journal Manual Therapy entitled Innominate 3D Motion Modeling: Biomechanically Interesting, but Clinically Irrelevant. The article is currently in press [Reference: Ridgeway K, Silvernail J. Innominate 3D motion modeling: Biomechanically interesting, but clinically irrelevant. Manual Therapy (2012). doi: 10.1016/j.math.2012.02.017]. The letter was a response to a recently published article on the non-invasive 3-D modeling of SI joint and pelvic motion, which in our humble opinions lacked any clinical utility or relevance.

Our submission was denied prior to review 2 separate times because of word length. The (we feel arbitrary) word length for an editorial or letter to the editor is 500 words. Despite multiple e-mails explaining why our piece should be considered in it’s entirety, the editor (through the Journal manager) insisted on a 500 word maximum before being considered for review. The original submission was just over 1,100 words.

We were faced with some decisions. Increasing the scope of the piece to a different manuscript type such as a “masterclass” or “professional issue” was discussed. But, these pieces are usually 3 to 4,000 words and are beyond the scope of what we were trying to convey. We also debated about submitting to another journal, such as the Journal of Manual and Manipulative Therapy. In the end, we decided to cut the length to 500 words, publish our original piece (in it’s entirety) HERE on PT Think Tank, and start a discussion regarding the original topic as well as our current peer review and publishing system. We thought it was an ideal time to explore whether the current journal peer review system is working for clinicians and scientists and what, if anything, we should do about it.

The original piece can be found in it’s own blog post HERE. An excerpt is at the end of this post. Feel free to comment and distribute freely. We would love discussion surrounding the actual issues the letter raises, and some of our criticisms of the research.

In the end, our goal was to express our interpretation of the study Inter-tester Reliability of Non-invasive Technique for Innominate Motion by Adhia et al, including it’s relevance in the context of the current scientific research on the topic and modern clinical practice. We hoped to facilitate scientific discussion and discourse surrounding the topic. Yet, arbitrary word lengths and overly specific categorization of manuscript types actually hindered REAL discussion. For this, we are disappointed. We were not requesting 4,000 words in the journal for an unsolicited narrative review of an area not relevant to the readership. We were seeking consideration for an 1,100 word response letter to an article Manual Therapy had published. A response that in our minds was well written (you be the judge!!) and presented some key issues beyond the study itself that would be of interest to the readership.

We think it is likely that Manual Therapy and it’s editorial staff are forced into industry-standard practices that currently define the for-profit publishing industry.  We have every confidence that the clinicians and scientists on the editorial staff of Manual Therapy are as interested in professional discourse as we are, but are hindered by the system. We do not doubt their scholarly curiosity or suggest any bias against us personally or our perspectives. In many ways they are as hindered by the system as we were. In fact, perhaps more so.

Many people feel the current medical publishing industry does not support clinicians and scientists, but in many ways is primarily about making money for publishing conglomerates. There are many well educated, well published scientists who have raised these concerns, including the people at Body In Mind. A group of scientists the New York Times featured is actually boycotting the publisher Elsevier. Interestingly, Elsevier publishes Manual Therapy. As again highlighted by the New York Times, the Office of Science and Technology Policy is currently debating the issue of access to publications, research, and data that are federally funded.

So, what are the problems?

Access. Most clinicians do not have access to the plethora of articles from countless journals across disciplines that could affect their practice. Thus, how are they supposed (or even expected) to provide evidence or science based treatment? Secondly, how are they to intelligently discuss the literature with other colleagues or scientists? At BEST, they are left to skim abstracts. Chad Cook, the editor of the Journal of Manual and Manipulative Therapy, discusses some of the biases and problems within the PT literature regardless of some these publication issues in his piece Don’t Always Believe what you read… on Joe Brence’s Blog Forward Thinking PT. How do you think research and readership biases are compounded when many (most?) clinicians have limited, if any access, to full text publications? Especially, when abstracts can drastically misrepresent not only the results, but clinical implications of a study. We highlight this issue in our letter regarding Adhia’s et al’s piece; the abstract and conclusions far outstep the data and study design.

Time. From submission to review to dissemination is a LONG process, especially for larger studies. Originally, we began work on our letter in the beginning of DECEMBER. Our first 2 submission were February 14th and 15th, with the final submission on February 24th. Our piece as accepted February 29th (yay leap year!!). Manual Therapy provided proofs  for review March 14th. We are still unsure of when the letter will be electronically published. And, this is just for a 500 word letter to the editor!

Now, we fully understand the time required for adequate peer review in order to ensure proper scholarship and science in large scale trials that involve the presentation of large data sets and sophisticated statistical analyses. But, is there a better way? Does the current system allow for broad access, discussion, and connection? And, really, who benefits?

So, what needs to change?

(Un)fortunately, more people will likely read, access, share, and comment on our original, longer piece published via this blog than the published letter to the editor in Manual Therapy. So, it appears the system is changing right before our eyes. The strength of Web2.0 is that discussion can happen right now. The process is dynamic as knowledge grows over time or people understand differently. I conceptualize this as real time peer review. Researchers, clinicians, students, and even those from other disciplines around the world can access and comment. This creates a vibrant, robust, and expert community of minds that are not limited by word count, publishing rules, or location.

A discussion on “Trigger Point Dry Needling” on @MikeReinoldBlog is an interesting case example. The post has generated 217 comments to date, some of them well researched, articulate, and publishable in our opinions! Imagine that type of discussion playing out in the literature of the current publishing system and paradigm? Unfortunately, the current literature at times is not as robust as these real time, remote, technologically driven interactions.

Fortunately, technology has afforded us the ability to highlight some of the pitfalls of the current publishing system, highlight our frustrations with our experience, and disseminate our original piece. Hopefully, this spawns discourse on scientific research and publishing, including open source and open access issues. Also, we would desire further discussion regarding the actual content of the research article as brought up in our response.

Interestingly, this entire project came about because of Web 2.0. Dr. Ridgeway stumbled across the abstract in his RSS feeder. It was e-published ahead of print. The article seemed out of step with the research evidence, and the author’s conclusions were in our opinion not supported by their study design and the current state of the literature regarding SIJ mechanics, treatment interventions, and lastly (but certainly not least) pain neurophysiology. So, @Dr_Ridge_DPT pushed a link of the abstract to both Twitter and Facebook. Dr. Jason Silvernail commented over social media and suggested a letter to the editor. The rest, as they say, is history. And oddly, despite their collegial nature Kyle and Jason have never met face to face! In total, 10 separate versions were created. The 10th version is the one that will be published in Manual Therapy at a mere 500 words. The 8th version, our best, can be read, in part, below:

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…CLICK HERE TO CONTINUE READING…

We thank you for reading, and urge you to comment with your views of the current publishing standard. In addition, what is your interpretation of the original Adhia et al article, and our reply?

@Dr_Ridge_DPT      Kyle J. Ridgeway, DPT

@JasonSilvernail      Jason Silvernail, DPT, DSc, FAAOMPT

 

Resources

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SI Joint Mechanics in Manual Therapy: Relevance, Please?

In a separate post Publishing in Science: Are Industry Standards Serving Researchers, Clinicians and Science? Jason Silvernail and I outline some of the perceived cons of the current publishing paradigm. We describe our experience writing a letter to the editor of Manual Therapy. In the end, our goal was, and is, to express our interpretation of the study Inter-tester Reliability of Non-invasive Technique for Innominate Motion by Adhia et al, including it’s relevance to the context of the current scientific research on the sacroilliac/pelvic region, pain, manual therapy, and modern clinical practice. We hoped, and continue to hope, to facilitate scientific discussion and discourse surrounding the topic.

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

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And, in the end “Enough is Enough”

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#CSM2012 Day 1 Programming

#CSM2012 is off and running! Over 10,000 physical therapists from across the nation are moving around the Chicago area. Conference programming officially started today. @MPascoe, @EricRobertson, and myself @Dr_Ridge_DPT have attended various sessions. Mike is utilizing Cover it Live to live blog during sessions. Check out his sessions HERE . You can ask questions or comment. Or, feel free to engage the content after the talk is over. This morning he was living blogging from Engaging Students in 140 Characters or Less.

I attended educational sessions on Physical Therapists in the Emergency Department, the Mechanisms of Manual Therapy, Glenohumeral Internal Rotation Deficit, ACL Rehabilitation, and The 2nd Annual Acute Care Lecture. Great variety today. In my downtime, I was able to read quite a few posters and interact with the authors. I even utilized my iPhone to send them e-mails with my virtual business card that contains my contact information, social media links, practice areas, and interests. Who needs paper? So if you got inspired by this, you can easily avail those virtual business cards online. Not only are they extremely convenient, but they’re also affordable. You won’t believe how much sense of professionalism they convey and how effective they truly are.

Well, I am off to the @AAOMPT Social located at The Scout Waterhouse on 13th and Wabash (1301 S. Wabash). If you are reading this then come on down!!!

Stay tuned tomorrow for more live blogging as well as blog posts about various talks and events. Keep moving and learning!

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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:

  • 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.

Leveraging Technology Series

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