To me, the most important aspect of patient care is knowing who you can and cannot treat. Stratifying your patients based on who needs to be referred out, and who you can help is essential to providing the best care.
Quite simply, there are few better resources out there that outline how to do this than Scott’s ebook.
In it, he delves into what relevant questions to ask, tests to perform, and establishing a relevant diagnosis. Often underlooked, yet exceptionally important components of the clinical examination.
Again, I cannot recommend Scott’s ebook and site enough. It’s a great resource for many things PT, including many of his eclectic and unique manual therapy techniques. Definitely check this guy out.
Rehabbing a 5th Metatarsal Fracture to High Level Basketball
In this podcast, I outline a case I worked on back when I was in the NBA D League.
This kid suffered a distal 5th metatarsal fracture with only a couple minutes to spare in a game. It was a brutal injury after one of the worst games in my life that I experienced, namely because we had three guys go down in one game.
Talk about awful.
I outline my entire process and every detail of what I did to get this kid back to high level basketball. A process that started with a fracture and ended with him establishing a franchise rebounding record the last game of the season. Pretty spectacular to say the least.
I feel very fortunate to have worked with such a driven and hardworking guy, and ultimately that was what his success hinged upon. Though minor, it was an honor to be this guy’s guide back to high level performance.
In this podcast, we dive into the following topics:
You shed that mindset with the game on the line. You must do all in your power to get that player back on the court tonight, expediting the return process to the nth degree.
I had a problem.
Figuring out the most efficient way to treat an ankle sprain was needed to help our team succeed. I searched the literature, therapeutic outskirts, and tinkered in order to devise an effective protocol.
The result? We had 12 ankle sprains this past season. After performing the protocol, eight were able to return and finish out the game. Out of the remaining four, three returned to full play in two days. The last guy? He was released two days after his last game.
It’s a tough business.
The best part was we had no re-sprains. An impressive feat considering the 80% recurrence rate¹. Caveats aside, treating acute injuries with an aggressive mindset can be immensely effective.
Research has demonstrated that often evidenced-based medicine is low on the list for why clinicians choose a particular treatment. From an ethical standpoint, it is important to consider evidence. This chapter is very short so I will just provide the highlights that I got from it.
Appraising a New Theory or Approach
There are six criteria that a new theory should be evaluated by:
1) Support from anatomical and physiological evidence.
2) Designed for a specific population.
3) Studies from peer-reviewed journals.
4) Include a well-designed randomized controlled trial or single experiment.
5) Present potential side effects.
6) Proponents discuss and are open to limitations.
Here are some definitions of different ways research measures agreement.
– Cohen’s Kappa: Measures nominal data reliability.
>0.75 is excellent agreement.
0.40-0.75 is fair to good.
<0.40 is poor.
– Pearson product movement correlation: Measures interval/ratio data.
– ICC: Measures continuous data.
The closer to 1, the better.
There are also many different validity types defined throughout this chapter. The first two are proven through logic and have the least evidence support.
– Construct Validity: Valid relative to a theoretical foundation.
– Content Validity: Can I use this measure to make an inference?
The next two are higher up on the evidence support hierarchy.
– Convergent Validity: The test shows a correlation between two variables.
– Discriminant Validity: The test shows a low correlation between two variables.
Lastly, these are criterion-based tests that infer similar results compared to an established test.
– Concurrent Validity: the compared tests are performed at the same time.
– Predictive Validity: The tests are compared at different dates.
All approaches (Maitland, Mckenzie, Mulligan) have myths. The common bond between them all is pain. Today we will look at building a clinical framework with pain as the cornerstone.
Evidence-Based Medicine (EBM)
EBM is defined as a conscientious, explicit, and judicious use of current best evidence in making patient care decisions. This concept is not merely reading researches articles, but it combines scientific evidence and clinical expertise. You have to know when to apply what.
2) Evidence suggests manual therapy improvements are more psychosocial than physical.
3) A disconnect between researcher and clinician.
The researcher thinks: “What does this work contribute to the literature?”
The clinician thinks: “What does this work do for my patient?”
The movement towards outcome-based therapy per EBM is also problematic for several reasons.
1) Clinicians begin to think statistical analysis becomes greater than any other form of knowledge rather than complimentary.
2) Research doesn’t take into account the inherent uncertainty and subjectivity in a clinical encounter.
3) Good evidence can lead to bad practice if applied in uncaring and unappealing environments.
4) Outcomes may be coming out too quickly, leading to research development stopping in certain areas.
Butler’s thoughts are summed up very nicely when he states it would be a sad day if meta-analyses have the final say instead of exposing clinical errors. However, the self-scrutiny and analysis is a good thing as long as it stops short of reducing clinician self-confidence. For confidence is what allows us to practice in uncertainty and maximize the placebo effect, our most powerful pain reliever. The uncertain conditions which we practice in are what Butler terms the Grey Zone. These typify most syndromes in which underlying pathoanatomy and physiology is unknown.
Clinical Reasoning Science
Clinical reasoning involves the merging of three areas: science, current therapies, and the clinician-patient relationship.
Butler also suggests that we need to shy away from thinking damaged structures and move towards movement dysfunction. We must realize that movement sensitivity does not involve the tissues only, but is a process that involves changes at a chemical and cellular level. When a movement becomes sensitive, changes occur in the ion channel, neurotransmitters, and nervous system. These changes are driven biopsychosocially.
Following this process, central processes are very much active in all types of pain. For example, acute pain depends on peripherally activated central processes. We must also look at recurrent pain, which is actually a chronic, central process as opposed frequent acute injuries.
Does that mean we need to be psychologists?
We must treat faulty movement patterns, but that does not mean we cannot take aspects from psychology, namely…
Output: Sympathetic, immune, and endocrine systems, potentially consciousness as well.
Step 4: Classify in terms of dysfunction.
General physical function/dysfunction: The patient’s main problems.
Specific physical function/dysfunction: Problems found by clinician that are related to patient’s problems.
Mental/psychological function/dysfunction: What the patient thinks/feels about his/her injury, the clinician, the treatment, and society’s approach to his/her disability. Distress fits in here.
Step 5: Make sense of dysfunction
One needs to determine if the dysfunction is maladaptive or adaptive. For example, limping after a sprained ankle would be an adaptive response to allow for tissue healing. Limping for the same sprained ankle 25 years later would be considered maladaptive. Often too we must realize that we accumulate dysfunction over time, and minor findings may not be relevant to a person’s complaints.
Step 6: Find your sources
In terms of dysfunction and mechanisms. You need to know where you would fire a magic bullet if you have it. This could be a particular manual therapy or even explaining pain to reduce the fear of movement.
Step 7: Know your contributing factors
This can include any factor related to the predisposition, development, and maintenance of a problem. These factors can include psychosocial, genetics, anthropometrics, and ergonomics.
Do no harm is first and foremost. When thinking manual therapy, use the least amount of force for maximum gain.
Step 10: Management
Realize and be comfortable knowing that chronic pain is something we may never cure, but it is something we can manage.
The Reasoning Process: Key Points
Reasoning is an evolving process throughout the treatment course that starts broad and moves toward refinement. This path occurs via the information gained from the patient assessment coupled with the clinician’s knowledge, understanding, and previous experience.
Most important, we must keep the patient as part of the reasoning process. Their hypothesis of their problem affects all reasoning categories and will alter as assessment and management proceed.
The intervention provided will affect the evolving concept of the problem, and the placebo effect can occur anywhere in the process. With that in mind, be mindful of any errors made during.