Critical observations of health, science, and the physical therapy profession.
Did you catch the latest APTA press release last week? The section on Women’s Health getting some press.
Also, check out the 20 Most Popular Health Sites on Constructive Medicine 2.0. How many of these sites have you visited?
Finally, go visit (or wait for her to visit you) Shanna Johnson and her Rolling Rehab RV. Physical Therapy: Delivered!
A very nice profile of physical therapist, Betsy Baker of Everett, WA, who works with the US Ski and Snowboard teams.
"Her training and own skiing experience allows her to advise the
athletes on how to avoid injury by strengthening and preparing their
bodies and in coaching proper technique."
Many professional sports teams have PT’s on staff, but it always works better when that PT has personal knowledge of the sport. One reason why that Bike Fit push by the APTA last year seemed a bit uncomfortable.
ERIC
By age 15 I had suffered at least 22 broken bones. There’s nothing metabolically wrong with me or my bones. I like to tell people that I was very good at doing stupid things. For instance, I broke several bones in my hands when curiosity got the best of me and I willfully dropped from the playground apparatus to the ground at age 4. Then there’s me at age 10 chasing a bouncy ball down the stairs and forgetting to walk all the way down . . . my dog-like behavior resulting in a few broken foot bones that time.
You see, I earned all my fractures. Most involved a fall. Some involved collisions. Today I still find that I fall quite a bit. For this I am very lucky. Yes, I’m serious. Falling down can be a good thing.
Kids are meant to fall. A toddler bouncing from surface to surface is a part of motor learning that we all must go through. A toddler probably falls down about 20 times a day, but suffers no lasting injury from the frequent trips to the ground. In comparison, a 60 year old sedentary female is almost assured of a life-threatening hip fracture when she falls. What’s happened in the mean time? Is risk of injury from falling something that increases linearly with age? Or, is there something more simple in play?
The 60 year old woman may not have fallen down in 50 years! Of course, we could not expect her to have any skill at falling, being so out of practice as she was. I’m suggesting falling is a skill, one we could all improve on…if we’re older than a toddler.
In most martial arts, the first session of training usually included instructions to fall. Most extreme sports athletes fall regularly in grand fashion, but rarely suffer serious injury. (Which is what makes Tara Llanes injury so unexpected.) Check out this video of an extreme fall and tell me you don’t see skill at play here (be patient, the skill view is in the last 13 seconds of the video). 50% of people who fall from that height expire. This guy walked off! Personally, I once observed a friend conduct a controlled fall over 500 feet and 30 seconds of a near-vertical hillside and escape injury (though I do refer to that story as "the time Erik went so fast he cried").
We spend hours in rehabilitation clinics and education working to prevent falls. We never practice them. I practice them often. Just about every 2 mountain-bike rides results in a crash of some sort. I still like to play with the dog and dive and fall after him. I think the reason I no longer break bones is that I’ve acquired some skills in falling.
In one glorious demonstration of my falling skills, I found myself out of control on my bike traveling straight down a ski slope during a race. I couldn’t make the next turn, so I plowed head first into the hay bales. I flipped off my bike, becoming detached from it somehow. I landed, flipped, rolled, and ended up on my knees facing back up the hill…just in time to catch my cart-wheeling bike. A quick inventory told me we were both ok (bike and self) and so on I went, earning a noble passage from a stunned competitor following close behind.
The point of this insight into my personal tumbles is that I often think rehabilitation should include fall practice. Perhaps after practicing in a controlled and safe manner, the fall that we couldn’t prevent doesn’t need to become a disaster. The trick would be balancing fall practice with real motor control deficits that have provided the impetus to fall in the first place.
ERIC
"Need New Knees? Now May Be The Time, " was the title of a press release by the American Academy of Orthopaedic Surgeons last week.
"These results suggest that we might be waiting too long to suggest
total knee arthroplasty as a treatment option for women with end-stage
knee OA," says Stephanie Petterson, MPT, PhD, one of the study’s
authors and a senior lecturer at the School of Health and Bioscience at
the University of East London, "or that women with knee OA are waiting
too long to access the appropriate care."
Hey, marketing and research are two different things! This is a good example of working them both. The release reported the findings of this article in The Journal of Bone and Joint Surgery. The basic gist was that women wait longer than men to seek care and so their outcomes may be worse after TKR. Common sense, really.
Another interpretation might have been, "PT’s not helping prevent progression of knee osteoarthritis." That’s not really science either, but surely must be a more wholesome recommendation than the press release encouraging a shopping spree for major surgery!
Petterson, S.C. (2007). Disease-specific gender differences among total knee arthroplasty candidates.. The Journal of Bone and Joint Surgery, 89(11), 2327-2333.
I was watching NCIS last night and a large scene took place at a physical therapy clinic. It was a mock-up of the Walter Reed amputee clinic, and was complete with the therapist gait training a patient with a very high-tech prosthesis.
"Don’t be afraid to put weight on it," the therapist urged the patient in the scene.
Shortly thereafter, there was a huge fight in the clinic. PTSD related…but turned out to be steroid-induced psychosis. Pretty cool scene, but sadly no physical therapist heroes, they were quick to defer to the NCIS agents!
ERIC
Last week the Nintendo Wii celebrated its first birthday. I’ve been prompted to post about the use of the Nintendo Wii game console in rehabilitation for some time now. The prompting has come from various sources, such as colleagues who hate it, colleagues who purchased one for their clinic, TV commercials, and a startling number of news pieces on the use of the Wii in rehab. I’ve resisted responding thus far, not for lack of interest, but for lack of opinion. More correctly, conflicting opinions. While I appreciate that any press can be good press, is the Wii something good for physical therapists?
At first glance, using a video game in the clinic may seem silly. The use of Wii in rehab is not currently supported by research, and tying the use of a video game console to a billing code requires some stretching. I’m skeptical that the movements required by the Wii are all that functional, and of course, they are not strengthening by nature. If one does not already own the Wii, it becomes a very expensive piece of home exercise equipment. However, the Wii has enjoyed almost viral popularity among game connoisseurs, the media, the elderly, and quite a few rehab providers, even the military.
Are these providers featured in news pieces about ‘Rehabbing with the Wii’ truly leading the charge to incorporate technology into practice, or are they fad followers looking for some cheap marketing?
My guess is that there is some limited utility for the Wii in neurological and pediatric physical therapy settings, but that the rage will fade and physical therapists will realize they possess much more powerful tools with which to treat their patients.
ERIC
Decades of clinical practice by manipulative providers have demonstrated the effectiveness of spinal manipulation as a therapeutic modality. The truth is that the mechanism of exactly how manipulation is effective has remained out of reach and unexplained. As research methods have become more sophisticated and the tool box of measures has increased in size, the prospect of figuring out a mechanism now seems a likely pursuit.
One handy tool that has become very popular in physical therapy research is ultrasonic imaging. Just like any ultrasound study, the clinician is able to observe real-time events. In the case of rehabilitative ultrasound imaging, the therapist is examining muscle activity. Measures of muscle thickness can vary and observable changes have been associated with pathology. For example, patients with low back pain show changes in cross sectional area of the lumbar multifidus muscle. Likewise, other patients with back pain have been shown to have difficulty activating their transversus abdominis muscle.
When this measure was used to study abdominal muscle thickness following a spinal manipulation procedure, an interesting thing occurred. The abdominal muscle activation changed! In a case series by Raney, Teyhen and Childs, spinal manipulation seemed to be correlated with a normalization of abdominal muscle recruitment patterns in patients with low back pain.
Perhaps this is a peek into the mechanism of spinal manipulation’s effects. The subluxation concept aside, spinal manipulation may have more to do with muscle activity, spinal reflexes, and the neuromuscular system than it ever had to do with alignment of the bones. The rapid, short duration of the motion used in manipulation does remind me of testing a deep tendon reflex!
Interesting to note, the researchers examined spinal manipulation in a group of symptomatic patients who met a criteria for a clinical prediction rule that identifies patients who are very likely to benefit from manipulation. Also interesting to note, this case series appeared after an initial case report by different investigators. They found a similar effect in another core stabilizer muscle in their report. Finally, we’re talking case report and case series here, so true causality regarding the phenomenon will have to wait for now.
This study is just one of many new investigations suggesting the role of spinal reflexes in the mechanism of manipulation. We will visit them over time here on the blog, along with some interesting off-shoots of that research.
Here’s the article abstract and citation:
STUDY DESIGN: Case series.
BACKGROUND: A clinical prediction rule (CPR) has been developed and validated that accurately identifies a subgroup of patients with low back pain (LBP) likely to benefit from spinal manipulation; however, the mechanism of spinal manipulation remains unclear. The purpose of this case series was to describe changes in lateral abdominal muscle thickness using rehabilitative ultrasound imaging (RUSI) immediately following spinal manipulation in a subgroup of patients positive on the rule.
CASE DESCRIPTIONS: Data from 9 patients (5 female, 4 male; 18-53 years of age) with a primary complaint of LBP are presented. All patients had symptoms for less than 16 days (range, 3-14 days) and did not have symptoms distal to the knee, satisfying the 2-factor rule for predicting successful outcome from spinal manipulation. The Oswestry Disability Index scores ranged from 8% to 52%. Lateral abdominal muscle thickness was assessed with the patient at-rest and while contracted during an abdominal drawing-in maneuver (ADIM) using RUSI. Measurements were taken before and immediately after spinal manipulation. Patients completed a 15-minute training session of the ADIM prior to assessment, to mitigate the potential for a learning effect to occur.
OUTCOMES: Based on changes that exceeded the threshold for measurement error, 6 of 9 patients demonstrated an improved ability (11.5%-27.9%) to increase transversus abdominis (TrA) muscle thickness during the ADIM postmanipulation. Additionally, TrA muscle thickness at-rest postmanipulation decreased for 5 patients (11.5%-25.9%), while at-rest internal oblique muscle thickness decreased for 4 patients (6.4%-12.2%).
DISCUSSION: This case series describes short-term changes in lateral abdominal muscle thickness post spinal manipulation. Although case series have significant limitations, including the fact that no cause-and-effect claims can be made, the decrease in muscle thickness at rest and the greater increase in muscle thickness during the ADIM postmanipulation observed in some of the patients could suggest an improvement in muscular function. Future research is needed to determine if increased muscle thickness is associated with improvements in pain and disability and to further explore neurophysiologic mechanisms of spinal manipulation.
Citation:
Raney, N.H., Teyhen, D.S., Childs, J.D. (2007). Observed changes in lateral abdominal muscle thickness after spinal manipulation: a case series using rehabilitative ultrasound imaging.. Journal of Orthopaedic and Sports Physical Therapy, 37(8), 472-479.
It’s the holiday season and the time is ripe for a holiday-related post! Thanksgiving is a time to give thanks, so what do physical therapists have to give thanks for this year? How about:
1. Bountiful clinical research productivity
2. The DPT transition in educational programs and rapid adoption of the tDPT degree
3. The APTA’s new CEO
4. Growing numbers of Residency and Fellowship programs
5. Podcasts, videos, and re-designs offered by our journals; and blog readership and writing, as more PT’s exchange information via the collaborative web.
Whatever your celebratory affiliation is, gifts such as these corporate hampers are somehow involved in December; and the season is upon us. What are some things that might fall on physical therapists’ wish list? Here is mine:
1. Not just autonomous practice, but true ownership of our profession through phasing out of referral-for-profit arrangements.
2. License to utilize radiological imaging in clinical practice.
3. A profession-wide, rapid shift to a clinical education model that more closely resembles the medical model.
4. Abolition of the CAP.
5. Freedom from legislative assault
Leave some comments about what you might be thankful for…or are hoping for as the new year approaches!
Happy Holidays!
image by Robert Lynn
For those of you who are not power blog readers, I may first need to introduce you to the Respectful Insolence blog, written by Orac. It’s one of the best, so subscribe.
Orac has made mention again of over-zealous chiropractors, characterizing them as "physical therapists with delusions of grandeur who don’t know their limitations." He, along with Panda Bear, MD, is quick to point out the gaping holes in the science behind the whole subluxation concept. Yes, that’s the concept which forms the core of chiropractic medical care. In this case, Panda Bear, MD is concerned about the new pediatric focus in chiropractic care:
"Would you take your child to a Physical Therapist for routine health maintenance, well child checks, or even something as serious as asthma? Of course not. And no Physical Therapist would touch your child in this capacity for the same reason I don’t perform abdominal surgery, namely that it is well outside of my training and my legitimate scope of practice."
Limitation, problems with subluxation science…seems like something I’ve heard before. Indeed I have. Please reference Peter Huijbregts’ Journal of Manual and Manipulative Therapy editorial manifesto:
Also check out the continuation of this conversation in the subsequent responses to the editorial (one of which was penned by yours truly).
Agreed, Orac and Panda Bear, MD. Stealth medicine at its best here. But perhaps the world does not realize how truly vulnerable the physical therapy profession is to these attacks. It’s a simple case of "my lobby is bigger than yours."
For those non-physical therapists reading this, it may be timely to point out that what IS in our scope of practice is all sorts of manipulative therapy. That’s right, the specialization area of Orthopaedic Manual Physical Therapy is one where the physical therapist is equipped with both the tools to manipulate the spine or peripheral joints AND develop a comprehensive, integrated program of neuromuscular modalities for orthopaedic conditions. Check out the AAOMPT for more info on this area of physical therapist practice.
ERIC
I posted a while back on Stephania Bell’s ESPN Fantasy Blogging gig. Well, she’s going strong and recently wrote up a winner in her breakdown of the LCL injury to Viking’s running back Adrian Peterson. If you’re into fantasy sports or if you want to learn some "fun with biology" regarding your lateral collateral ligament, this column should be a regular read.
The broad and ever-growing appeal that Stephania is creating, not to mention Physical Therapy branding, is simply priceless for the profession. Often, it only takes one door to open before the masses push through. What does that mean? Well, I could imagine several well-written physical therapists leveraging Stephania’s role at ESPN to quickly become the medical translators of choice in popular media outlets.
ERIC