The Primacy of Reasoning

I always have considered myself to be a fortunate man.  Well good fortune must be a weighted average as I missed my freaking flight out of Lubbock this morning. 

On the flip side of this rather un-fortunate coin, I had the pleasure of sitting and talking with a few of my colleagues from this weekend’s contact session on radiological anatomy.  It was a conversation (along with several others this weekend) I don’t think I’ll ever forget.  If this weekend has taught me anything, it is that we have some incredible human beings in this profession.  My mind keeps turning to a recurring conversational theme over the last two days: reasoning.

The Primacy of Reasoning

In a thoughtful editorial recently published in the Journal of Manual Therapy, Gwendolen Jull  outlines one of the most important issues facing our profession.  The history of our profession is characterized by amazing advances in the understanding of human movement.  Progress in the fields of biomechanics, neuroscience, and even immunology have contributed to these advances.  Yet what are we to do with all this information?  How can the volumes of useful data being generated be filtered into meaningful clinical practice?

The filter is our own brain along with our willingness to use it.

Jull makes a compelling plea to clinicians not to be passive recipients of evidence.  In fact, in other editorials the very term “evidence-based” has been scrutinized as an overstatement of research’s potential to guide clinical behavior.  A more appropriate term may indeed be “evidence-informed”.  Jull goes on to argue for the primacy of reasoning in mediating the best outcome for each patient.

It is the practitioner’s clinical reasoning, assessment and clinical practice skills that are a crucial nexus between the patient, the research evidence and successful clinical outcomes.  It might not be too incorrect to assert that the evidence will lose its impact for enhanced patient care in the absence of high level clinical reasoning and practical skills in the practitioner

Jull G.  The primacy of reasoning in clinical practice skills.  Manual Therapy. 2009(14):353-354.

Let’s be very clear about what is happening in our profession.  We are learning (almost daily) that many of our interventions are effective at managing movement disorders and improving human performance.  This despite working with a heterogeneous population and using wildly varying techniques and methodologies.  A patient with low back pain can receive anything from advice to spinal manipulative care.  A football player can be trained with power cleans or more “functional” activities.  There simply must be a way to reconcile this apparent mess!

Beyond Outcomes

The observation that the patient got better or the athlete played better is no longer sufficient to justify our methodology.   Justifying our treatments retrospectively based solely on our outcome will not move our profession forward.  In fact, there seems to be compelling observational evidence that it leads to further fragmentation of thought and halts our professional development.   On the other hand, prospectively identifying the rationale for a treatment or training methodology will not only improve outcomes, it will strengthen our profession along a unified front: science-based practice.

My Challenge

I have a three-part challenge for my colleagues out there.  Firstly, read at least one article from a related but unfamiliar peer-reviewed journal.  A great start might be the Journal of Human Movement Science or Medicine and Science in Sports and Exercise.  Secondly, ask yourself why this information may or may not be useful for you in the clinic or gym.  Thirdly (and this one is tough), ask yourself why you think the information is or is not useful?  I know this exercise may seem excessive, but this form of thinking known as metacognition is a great mental exercise that can yield tremendous benefits for your patient care.  Think of it as mental jogging!

Also, if you are one of those therapists feeling overwhelmed by the amount of knowledge being produced in peer-reviewed journals these days, join the club.  To keep all this information organized, I strongly suggest signing on to a free journal aggregator such as Google Reader.  It is a great tool that brings all your favorite journals to you without having to perpetually flip through them all.  I’m not a fan of engineering all the movement out of your day, but this does make the process of sifting through articles a bit less daunting!

Until next time! I better go catch my flight…

Lubbock Calling…

Not sure if anyone will pick up on The Clash reference, but it’s the best I title I could conjure sitting here across the street from campus.

Yet another contact session for my Sc.D. program at Texas Tech University brings be back to the land of cattle and transiently competitive college football teams.  My colleagues always give me a wary look when I tell them how excited I am to return to Lubbock, but each trip brings more knowledge and closer to reaching another milestone in my career.

The past six months have left precious little time for blogging or podcasting.  I’ve been taking full caseloads, teaching in the classroom and clinic, and managing two nearly busy outpatient clinics.  Doing all these things and keeping a contented balance between my professional and family life is a persistent challenge.  Fortunately, I find myself perpetually energized by it all.  I have my family, friends, and colleagues to thank for this and I am eternally grateful for their support.

In addition to completing the second half of my doctoral study, I hope to continue blogging and podcasting the latest research and clinical peer-reviewed insight in the fields movement science.   While the fields of biomechanics and orthopedics continue to produce amazing work, you will be amazed at how much neuroscience, immunology, and even endocrinology is telling us about how we can help our patients and clients move with greater ease and virtuosity.

I am looking forward to my return to the blogosphere and thank you for joining me!  As always feel free to drop me a line at movementscience@gmail.com.

Movement Science Podcast #3: Interview with Barrett Dorko, PT.

As I mentioned in an earlier post, it has been too long between podcasts.  Fortunately, getting into the swing of things was made possible by an interview with physical therapist Barrett Dorko. 

Barrett is not only an experienced manual physical therapist, but is also an accomplished speaker. He has been invited to speak at ten national conventions of the American Physical Therapy Association and has conducted workshops at state chapter meetings and private institutions throughout North America. He currently teaches a workshop titled Simple Contact, and has appeared in over 200 cities since 2004. Barrett’s writings are designed to influence the teaching of manual care and his work is commonly used to emphasize the nature of gentle handling and sound scientific reasoning in the clinic. In 2004 Barrett served as the Prestige Day Speaker for the physical therapy program at Cleveland State University, which is one of the highest honors given in his profession.

This podcast gave me an opportunity to discuss numerous topics with Barrett including:

• The concept and utility of the ideomotor effect in pain management and rehabilitation
• The emergence of evidence supporting the ideomotor effect in rehabilitation
• Barrett’s essays which have provided thought-provoking insights into clinical reasoning.

If you trudge through some of the threads on SomaSimple.com, you will quickly find that Barrett and the gang on that forum have both strong and informed opinions about various issues within the fields of movment.

I will freely admit I have come into a few heated discussions and even anticipate a few more down the road.  However, what simply cannot be argued or disputed in any format is the relentless pursuit Barrett and his moderators have in trying to make our professions better.  It is this passion Barrett has that drove me to have our conversation today.

I hope you will visit Barrett’s website as well as SomaSimple.com.  However I would also encourage your participation in other arenas of ideas including the forums on RehabEdge.com and EvidenceinMotion.com.  These are all emerging as powerful and inexpensive ways for us to share ideas and truly move our professions forward.

To listen to this thought-provoking interview, please feel free to download it at the home page for the Movement Science Podcast.  Remember you can stream the audio below or download it directly.  You can also directly subscribe to the podcast on iTunes.

Once again, I’d like to thank Barrett for appearing on the podcast.  As always, if you have questions or comments, feel free to post them here or contact me via movementscience@gmail.com.

References:

McCarthy S, Rickards L, Lucas N. Using the concept of ideomotor therapy in the treatment of a patient with chronic neck pain: A single system research design Int J of Osteopathic Medicine. 2007;10:104-112

Getting a bit Wii-diculous…

I’m sorry folks but I’m not sure I can hold this in any more. I just don’t get the what all the fuss is about. The Wii-nomenon has come and settled in and I have yet to find a reason to be impressed with this device.

I get it…Like the good folks at Nintendo, I also want people to be active and adopt a healthy behaviors. I’ve even gone through great lengths to make exercise more appealing and enjoyable to the point of acting a bit silly at times. However I think I’ve reached a saturation point with the Wii.

Fortunately, thanks to the people at sarcasticgamer.com, I’m not the only one who finds the Wii-fit to be a Wii-bit much. I hope you enjoy this video half as much as I did. Please to enjoy…

On a more serious note, I wonder if our approach to making fitness “fun and exciting” may be missing the mark? After all, do we require other basically healthy activities to provide us with non-stop entertainment? Will there be a time where a video game will introduce us to the wondrous excitement of flossing? This is an issue which I would like to address on another day, but in the meantime I hope you enjoy the video nonetheless!

Onward and Upward!

Well folks. I really have enjoyed the Blogger format to this point and it has served me very well over the past year. In fact, I’m enjoying the process so much I started the Movement Science Podcast hosted by Podbean, and have even joined forces with Eric Robertson at the PT Think Tank.

With this said, I have found a new home for the blog on WordPress. The next evolution of “Orthopedic Physical Therapy” will be the Movement Science Blog and Podcast. At this time WordPress seems to have a really nice format that offers me some additional flexibility for integrating both the blog and podcast together in one website. It also has a very user friendly interface I believe you will enjoy once it is fully up and running.

The format will be essentially the same as it has been for the past year on this website. I will be discussing issues such as:

• Rehabilitation Science
• Exercise Science
• Orthopedic Medicine
• Neuroscience and Motor Control
• Current events relevant to the fields of movement science

I am officially knee-deep in my doctoral studies at Texas Tech and with the IAOM, so I hope you will continue to join me on my journey to better understand the amazing processes that govern human movement. As time goes on, I hope to integrate more research, more interviews, and hopefully challenge you to never stop learning.

I am still getting acquainted with the format over at WordPress, but I hope you will visit me there and continue to follow this blog in its new format. I will continue to put my posts here on Blogger until the official turnaround at the end of April. In the meantime, I will have all my new and old posts and podcasts on both sites.

So to wrap this up: I’m moving but will take it slow and post regular updates until the final transition to Movement Science at the end of April 2009. Also don’t forget to visit the PT Think Tank and interact with me there as well. In the meantime, take care and I hope to talk with you soon!

Good stuff from the APTA on manipulation

This is a quick-hitter post I thought some of you out there might find interesting. I recently a pleasant but slightly contentious discussion with a local chiropractor that wandered off into the topic of manipulation and scope of practice.

“I find it curious that PTs are so eager to criticize chiropractic, yet are equally eager to manipulate.”

- Unnamed Chiropractor

First of all let me please go ahead and thank God for the ability to guide my emotional and physical restraint. Were I a younger man this is something that would have put me over the edge. Fortunately I was able to sit on my hands and restrain my tongue long enough to calmly discuss the issue with him. My talking points included:

• The physiology of manipulation (i.e. its role as a self-perpetuating “adjustment”versus a means to normalize function).
• The messages of self-restoration in physical therapy compared to chiropractic (I know – this is the supposed mantra of the chiropractic profession. I guess you only need a lifetime of adjustment before realizing this self-correction…)
• Unsubstantiated claims regarding risk of a manipulation performed by a physical therapist

The conversation was brief, but I felt amazingly well prepared for the conversation. Best of all…I carried it off with a sense of satisfaction that I did the right thing for our profession in sending a message to the chiro that we are well trained to perform thrust-mobilization (manipulation) and have a better model of care to support its use.

Right on the heels of this conversation, I received an email from the APTA which I strongly suggest you review if you are close to this situation. The email was from our Advocacy section and outlines some great presentations and handouts regarding PTs and manipulation. I’m a vocal critic of my organization on some issues, but man they do some great things with our dues. It is a tough check to write each year, but I feel more strongly it is the right thing to do everytime I get one of these emails. This will be a great resource for us for some time to come.

P.S.

Thank you all for the great responses to my first podcast! They were greatly appreciated. Stay tuned and I’ve got some really good topics on the way. Also, I may be updating the format of my blog to be more user friendly and offer easier access to archived posts and my podcasts. Hang in there and we’ll continue to grow!

Movement Science Podcast: On the Air!

Ok folks here we are – my first podcast. This episode explores the relationship between motor learning, motor control deficits, and low back pain. I hope you enjoy my rookie effort and will hang in there as I continue to improve this new feature of my blog. Please let me know if you are having difficulty dowloading the podcast and I will get the bugs worked out asap! I hope to be up on iTunes soon so this should add an additional level of functionality to the show.

Powered by Podbean.com

Topics include:

• Recent editorials in the BJSM on the role of lumbar stabilization in low back pain
• Basic motor control theory and the process of motor recovery following an injury including a reduction in cognitive regulation, decrease in visual dependency, and improvements in sensorimotor adaptability
• How pain influences motor behavior including local and affective influences on muscle activity
• An overview of what we know and don’t know regarding motor control interventions
• How this information has influenced my approach in the management of low back pain

Articles cited:

Allison, G., & Morris, S. (2008). Transversus abdominis and core stability: has the pendulum swung? British Journal of Sports Medicine, 42 (11), 630-631 DOI: 10.1136/bjsm.2008.048637

Hodges, P. (2007). Transversus abdominis: a different view of the elephant British Journal of Sports Medicine, 42 (12), 941-944 DOI: 10.1136/bjsm.2008.051037

Cook, J. (2008). Jumping on bandwagons: taking the right clinical message from research British Journal of Sports Medicine, 42 (11), 563-563 DOI: 10.1136/bjsm.2008.048629

Mulder T, Neinhuis B, & Pauwels J (1996). The Assessment of Motor Recovery: A New Look at an Old Problem J Electromyogr Kinisiol, 6 (2), 137-145

Hodges, P. (2003). Pain and motor control of the lumbopelvic region: effect and possible mechanisms Journal of Electromyography and Kinesiology, 13 (4), 361-370 DOI: 10.1016/S1050-6411(03)00042-7

Young Guns

I just wanted to say congratulations to a few former students of mine who recently earned their licenses. They graduated from UTMB back in December and are all gainfully employed! I was very fortunate to have them as students and am now privileged to call them colleagues. Congratulations and best of luck to Anne, Andrew, and Ryan. I’m very proud of you all and wish you all the best.

Rod

Put down the barbell and slowly back away…

This may get me in a bit of trouble but here I go. Many colleagues have taken issue with my stance on the role of physical therapists in the realm of exercise as well as strength and conditioning.

My stance is simple and begins with a simple observation: Physical therapists are the undisputed experts of rehabilitation science. Rehabilitation is a sub field within the broader category of movement science and is accompanied by other sub fields such as biomechanics, exercise physiology, neuroscience, motor control, and the like…

As sole title holders of “World Champions” of rehabilitation, exercise physiologists and biomechanists cannot and should not declare themselves rehabilitation experts. This observation is plainly obvious to most physical therapists (just ask one). We are happy to share this with anyone who is willing to listen as well as some who aren’t.

So why then do we in physical therapy get so befuddled when those specializing in exercise science question our role in prescribing exercise programs for athletes and otherwise healthy individuals?

A recent discussion on the RehabEdge forum took place in which we debated the merits of athletic trainers in treating a nonathletic population. Without getting into the specifics of the debate, it was generally agreed that physical therapists can’t hold a trainer’s jock (so to speak) in the assessment and management of an acute athletic injury. At the same time we argued that trainers can’t hang with a PT in the majority of rehabilitation settings. To put it succinctly, while there is some overlap in skill set, there is clearly only one professional best suited for the job. Of course, many therapists and trainers are duly credentialed in both fields….all bets are off for you!

We aren’t bad…but there is better.

Physical therapists, like doctors and other health care professions, should feel a natural pull toward providing general activity guidelines for patients. In this regard our role in healthy movement should not be underestimated. However it will be difficult to press on and be great in rehabilitation if we are trying to be all things to all people. There is a professional best suited to provide exercise advice and leadership, and it is not us.

Now would be a good time for a wary reader to point out my arrogance in claiming to be both. This would be a fair criticism, but for better or worse, I have graduate degrees and extensive training in human performance and physical therapy. Like those credentialed in both athletic training and physical therapy, I hold titles in both sub fields. With that said, it is tough for me to be good at both. I’m probably a much better physical therapist right now than I am strength and conditioning specialist. That’s OK though…my patients probably would want it that way!

Want to be an expert? Here’s how to earn it…

So here’s my official position and recommendations for physical therapists wanting to become exercise professionals:

· Physical therapists are not exercise specialists and should lay limited claim to human performance training unless specific criteria are met.

· The first criterion is achievement of an advanced certification from either the American College of Sports Medicine or the National Strength and Conditioning Association. Sorry to the pretendors that I carefully excluded from this list. These two organizations represent the highest standards of the profession and offer numerous opportunities for increasing knowledge of exercise science.

· The second criterion is a graduate (preferred) or undergraduate degree in exercise physiology or related curriculum. This will provide a solid and specific academic background in exercise science. You can attempt to tell me a physical therapy curriculum is sufficient to achieve this knowledge, but you would also be wrong.

· In the absence of meeting either of the above criteria, the physical therapist should spend at least 2-3 years working in a fitness and human performance setting with a seasoned conditioning specialist. I have a tough time with this one, but realize that it isn’t easy to achieve both of the above criteria. Trying to give a little here…

Bottom Line

If you believe my recommendations to be unreasonable I would challenge you to have a discussion on a specific issue pertaining to exercise science with someone who has met the above criteria. You may think you have sufficient knowledge and understanding of exercise physiology and human performance, but the conversation may cause you to think twice. I strongly encourage those in the rehabilitation profession to do what you do best. If you want to be considered an expert in physical therapy, you know where to go. If you goal is to hold expertise in exercise as well, please apply the same rigor to your standards as we expect from other professions.

P.S.

The first podcast is currently “in production” and I hope to have it up and running soon faster than I expected. Thanks for visiting and I’m looking forward to talking to you soon. If you have a question or comment, please don’t hesitate to contact me and I’ll try to address it on the podcast. Take care.

Class Dismissed…

Just got back from Lubbock and feel like a charged capacitor…

There are so many thoughts and ideas running through my brain that it will be a true test for me to sit still long enough to articulate them. Fortunately my wife, blog, colleagues, and my upcoming podcasts will give me a nice steady discharge of this energy as opposed to blowing all at once!

The origin of my excitement is my experience at a recent contact session for my Sc.D. program at Texas Tech. The title of the course is “Motor Control in Orthopedics” and is basically part two of last semester’s “Neuroscience in Orthopedics” course. The weekend began with a review of the motor control principles we independently studied over the last eight weeks. Information processing, attention and memory, peripheral and central contributions to movement, motor learning and practice…these were all reviewed and discussed with our course (and program) director Phil Sizer.

The second component of the course jumped over into practical application where we discussed issues pertaining to motor control and syndromes of the cervical and lumbar spines, shoulder, knee, and ankle. The vast majority of slides and resultant discussion stemmed from the peer-reviewed works of people like Hodges, O’Sullivan, Powers, Hewett, Falla, Jull, Flynn, Childs, and many MANY others. From this standpoint, the information presented was a good representation of the state of motor control as it pertains to our profession.

This information was juxtaposed with Phil’s infectious passion for the material and synthesis. The result was the generation of great (raw…but great) ideas regarding management from my fellow classmates. I have to say from this perspective it was very inspirational. I will admit my threshold to excitation is a bit on the low end at times, so take that for what it’s worth…

NOW. There were a few occasions on day two where I seemed to scratch my head. As positive as I am about the course, I have some questions/concerns about our integration of these topics. Predictably my concerns pertain to things like the relevance of feedforward TrA activation, hip weakness in anterior knee pain, etc…

• What is the relationship between lumbar muscle dysfunction and LBP? We know the relationships are there, but identification is not sufficient to place them in proper perspective. Despite our eagerness to dive into and “treat” these areas with various activity programs such as “core training”, a stricter adherence to principles of motor control may cause us to rethink our current approaches. (more on this soon!)
• What are the relationships between hip muscle strength and anterior knee pain? We often see measurable decreases in hip capability in the presence of knee dysfunction. However this observational statement is only the beginning. Is this relationship causal or simply correlative? If it is causal, are we confident which came first? The answers have not been clearly defined and have profound implications for evaluation and management.

I believe the answers will become clearer as we begin to integrate clinical observations (weak hip abductors, functional instability, etc…) with our emerging understanding of neuroscience and motor control. Over the next several weeks, I hope to present examples and arguments in favor of integrating these fields of movement science and the evolution of understanding that they can bring. I am excited to share this with you and look forward to your questions and comments!