Category: PTs

centralization and the correlation to discogenic pain

Critical Appraisal for a Reference-Standard Validity Study

 

P: For patients with chronic low back pain, with varying levels of distress,

I: can the centralization phenomenon

C: as compared to discography results

O: provide diagnostic power for discogenic pain

 

Reviewer:

Vincent Gutierrez, PT, MPT, cert. MDT

 

Search:

Ovidsp with keyword terms “low back pain and centralization and specificity and sensitivity”.   44 citations were found between the years 2004 and 2014.

 

Date of Search: January 21,2014

Re-evaluation date: January 25, 2014

 

Citation:

Laslett M, Oberg B, Aprill C, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine Journal 2005;5:370-380.

 

Summary:

This validation study has two purposes. The first is to investigate the predictive value of the centralization phenomenon (CP) in relation to provocation discography, which is the only reference standard available for discogenic pain. The second is to investigate the role of distress and disability with regards to the predictive value of the centralization phenomenon in relation to provocation discography.

 

The inclusion criteria were patients with persistent low back pain (LBP), with or without lower extremity (LE) symptoms, whom were referred to a private radiology practice. Patients were excluded for the following reasons: a normal magnetic resonance imaging (MRI) assessment, severe degeneration associated with spondylolisthesis, and if the discography was contraindicated or a referral ruled out discography. The patients that were included were assessed consecutively.

 

Prior to the evaluation by a physical therapist, the patient completed a visual analog scale (VAS) for pain and the Roland-Morris Disability Questionnaire (RMDQ). The Zung Depression Index (ZDI), Modified Somatic Perception Questionnaire (MSPQ) and the Distress Risk Assessment Method (DRAM) were also completed prior to the physical therapy (PT) evaluation. The evaluation was performed prior to the discography and the physician performing the discography was blinded to the therapist’s results. The therapist was blinded to the results of the subjective outcome measures.

 

The physical evaluation consisted of a McKenzie evaluation. The exam required 30-60 minutes and also included sacro-iliac joint (SIJ) provocation tests. Centralization or peripheralization was noted and at this point the examination was terminated.

 

Discography was performed using standard technique and the patient was required to report pain in at least one disc, without pain at an adjacent disc in order to receive a positive test result.

 

One hundred eighteen patients participated in the PT evaluation and discography. One hundred seven patients were included in the initial analysis. Of the 107 patients, 69 received a full PT evaluation, 21 received a partial evaluation and 17 did not receive an evaluation. Of the above, the physical therapist offered an opinion regarding CP for 83 patients.

 

Appraisal:

The authors utilized the only reference standard studied, provocation discography, in order to determine if CP is predictive of discogenic pain. The physician was blinded to the physical therapists’ evaluation and the physical therapist was blinded to the patients subjective outcome measures. Not all patients received both the PT evaluation and discography.

 

The confidence interval was 95%. For non-distressed patients, the following statistical measures were calculated: sensitivity of 37%, specificity of 100%, positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were incalculable due to a specificity of 100%. For distressed patients, the following statistical measures were calculated: sensitivity of 45%, specificity of 89%, LR+ of 4.1, and LR- of 0.61. For not severely disabled patients, the following statistical measures were calculated: sensitivity of 35%, specificity of 100%, LR+ and LR- are incalculable due to 100% specificity. For severely disabled persons, the following statistical measures were calculated: sensitivity of 46%, specificity of 80%, LR+ of 3.2 and LR- of 0.63

 

Conclusion:

Performing a McKenzie evaluation in order to determine the presence of CP is a good test for determining a positive discography, especially in patients without severe disability or distress. The presence of CP improves the pre-test probability to post-test probability of positive discography from 39% to greater than 75% in patients with severe disability or distress. CP is a strong predictor of positive discography in patients without severe distress or disability.

Why be a mentor?

I have some passions in the profession of physical therapy and the first is to provide the best care to my patients.  The second is to create therapists that will provide the best care to patients, as they indirectly represent me.  I do my best to ensure that PT students that go through me develop the reasoning ability to understand ethical and unethical environments that will challenge their ability to provide that best care to patients.  This profession is very much driven by the almighty dollar and I understand why some students make specific decisions as to which job to take, but as long as that student has weighted the “pro’s” and “cons” of taking a job, I know that I did what was right in teaching my students.  Some students unfortunately never develop that ability to reason past the $$$.  

 

The Oxford dictionary defines mentor as “an experienced and trusted advisor” and “an experienced person in a company, college, or school who trains and counsels new employees or students.” 1 There are published studies that oppose this definition, which will be discussed in detail further in the paper. Other professionals have specific definitions of mentor as follows: “ Mentor is an individual with noted experience and position within the Military Nurse Corps who possesses a genuine interest in guiding the professional and personal development of a less experienced Nurse Corps officer.”2 As a physical therapist, mentoring is a topic of importance for the author.   I started my career as a teacher of biology, secondary education, with the intent to mold current students into future leaders. Because of circumstances, that dream was never to become a reality and I chose a different career path. My first year of clinical practice, I was asked by GSU to be a clinical instructor because of personal characteristics. Holmes3 states that novice clinicians placed in a mentoring role may have difficulty with individual personal development. My boss/mentor at the time believed that I possessed the qualities to overcome this added adversity and after serving as a clinical instructor for the first student, I found that my initial dream could become a reality in this new field. The stresses of mentoring during the initial years

Christiansen et al5 notes that there are two processes for mentor selection: assignment by an institution or selection by the protégé. Others disagree with this statement, in that preceptors are assigned, but mentors are chosen8. It is advised to choose a team of mentors in order to advise on multiple issues, with each mentor having a specialty6. In the end, one should choose a mentor “who exemplifies traits and skills that you want to adopt”6.

As a mentor, it is rewarding to observe students and clinicians that choose me as a mentor when these individuals apply the information garnered from the relationship in order to treat a patient whom previously the clinician would not have the knowledge or experience to treat. This is consistent with Wainwright et al4, in which the following is stated: 1. clinical decision-making is advanced through clinical education, 2. positive mentoring enhances clinical practice skills, 3. Experienced clinicians inevitably become mentors to novice clinicians. Christiansen et al5 and Holmes et al3 also relate mentoring to the advancement of clinical skills.

Attributes and roles of a mentor are widely published in the research as demonstrated in the following table:

Characteristics Roles
Experienced4,8 Coach6,10
Content knowledge5,6 Advisor1,6,9
Communication skills5,8,9 Counselor1,6,10
Personal integrity5,6 Confidant6
Self-reflection5  
Systems-based learning5  
Willingness to teach5  
Intellectual humility5  
Internal locus of control5  
Empathy8  
Caring8  
Unbiased6,9  
Committed6  
Maintains confidentiality6  
Patience6  

 

As stated previously, a mentor is an advisor…who counsels new employees or students1. Christiansen et al5 states, “Mentoring is not supervising, advising, career counseling, shadowing or coaching. Mentoring is workplace learning and must occur within that environment.” Although the previous statement relays that a mentor must work in the same environment as the mentee, Liu and Ansbacher6 state that long-distance mentoring can be successful through e-mail, phone conferencing or meeting at annual conferences. Based on the aforementioned articles, the act of mentoring appears subjective in nature, as varying authors have different opinions on both the definition and act of mentoring.

“Mentoring requires dedication to the process, which includes substantial investments of time, energy, and resources-physical, emotional and intellectual.”3

As a clinical instructor and mentor to other Mechanical Diagnosis and Therapy (MDT) trained therapists, this statement is accurate. When I was a new professional (< 5 years of experience), I was consistently studying the concepts of MDT, hierarchy of knowledge principles and coursework for clinical instructors. This studying was not without cost. I sacrificed time from family, friends and life experiences in order to work towards that initial dream. Being a mentor also poses a challenge of finding a mentor4. The mentors that I chose are from around the country, and I am only able to meet with them at large spine conferences. As a clinical instructor, I am aware of the bias that is inherent when a relationship is created and established with a mentee and try not to provide preferential treatment for my students7.

The American Physical Therapy Association (APTA) does not define a mentor, but establishes the roles for the mentor and protégé as follows11:

MENTOR

  1. Acclimate the early-career protégé into the culture and the value of PT12
  2. Help the ECP understand the core values of PT and the role of each PT and PTA to support the practice mission of PT
  3. Be open to working as a mentor
  4. Create a collegial atmosphere that provides responsiveness and respect for the ECP
  5. Seek training and education to further skills in mentoring

PROTÉGÉ

  1. Identify knowledge and skill gaps
  2. Establish career goals for life-long learning, both short and long term.
  3. Identify specific experiential opportunities
  4. Identify potential mentors, both junior and senior, who have compatible interests.

During the literature review for this paper, there was only one article that formalized a mentor program. Burritt et al13 studied the outcomes of removing experienced nurses from clinical practice in order to work as a mentor for novice nurses. “The prevalence of stage 2 or greater nosocomial pressure ulcers improved by 38%, which was significantly lower in the post implementation phase. A 47% reduction in the number of adverse events that comprise the composite measure of failure to rescue was also noted to be significant.” Tactics such as this may also influence retention rates of nurses8.

CONCLUSION

To conclude, Holmes et al3 sums it up in a concise statement, “Rejoice in the successes of your mentee, these triumphs can only enhance your own standing.” The author personally chooses to be a mentor for those with less experience, in order to assist those with the characteristics needed to become a successful mentor. My dream of creating future leaders is now reality as my protégés are now becoming mentors.

Bibliography

  1. Mentor. In Oxford dictionary online. Retrieved from http://www.oxforddictionaries.com/us/definition/american_english/mentor.
  2. Blankenbaker SE. Mentor Training in a Military Nurse Corps. Journal for Nurses in Staff Development. 2005;21(3):120-125.
  3. Holmes DR, Hodgson PK, Simari RD, Nishimura RA. Mentoring: Making the Transition from Mentee to Mentor. Circulation. 2010;121:336-34.
  4. Wainwright SF, Shehpard F, Harman LB, Stephens J. Factors That Influence the Clinical Decidion Making of Novice and Experienced Physical Therapists. PTJ. 2011;91:87-101.
  5. Christensen N, Gerber P, Jensen G, et al. (2014). American Board of Physical Therapy Residency and Fellowship Education: Mentoring Resource Manual. Accessed from: www.abptrfe.org
  6. Liu JR, Ansbacher R. Assembling the Optimal Mentor Team. Obstetrical and Gynecological Survey. 2008;63(4)

7.Coulson CC, Kunselman AR, Cain J, Legro RS. Graduate Education: The Mentor Effect in Student Evaluation. Obstet Gynecol. 2000;95:619-622.

  1. Martin CA. Across the Generations: It takes a village to raise a nurse. Nursing Critical Care. 2007;2(3):45-49.
  2. Ansbacher R. A Guest Editorial: The Mentor-Mentee Relationship. Obstetrical and Gynecological Survey. 2003;58(8):505-506.
  3. Hurst SM, Kplin-Baucum S. Innovative Solution Mentor Program: Evaluation, Change and Challenges. Dimens Crit Care Nurs. 2005;24(6):273-274.
  4. American Physical Therapy Association. (2012). Best Practice for Mentoring Early-Career Proteges: HOD P06-12-16-05. Retrieved from: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Professional_Development/BestPracticesMentoringEarlyCareerProteges.pdf.
  5. Gardner EA, Schmidt CK. Implementing a Leadership Course and Mentor Model for Students in the National Student Nurses’ Association. Nurse Educator. 2007;32(4):178-182.
  6. Burritt J, Wallace P, Steckel C, Hunter A. Achieving Quality and Fiscal Outcomes in Patient Care: The Clinical Mentor Care Delivery Model. JONA. 207;37(12):558-563.

Not all back pain has a definitive cause

“Findings such as disk height loss and disc bulges are coming in individuals without low back pain.”

Disc bulges, degenerative joint disease, spinal stenosis, do you all a result of living in this world. We have gravity acting a force on us almost 16 hours a day. Anytime that there is a problem, we want to blame something or somebody. Low back pain is an enigma at times. we can draw correlations, we can come up with risk factors, we can even tell you how to treat it sometimes, but what we can’t do is tell you exactly what causes your back pain.

“Surprisingly, disc protrusions were associated with a lower risk of subsequent back pain. Nerve root contact and central stenosis had the largest hazard ratios on baseline imaging findings, and they were associated with incident back pain in the expected direction but not statistically significant. Self identified Depression was the strongest predictor of subsequent back pain, with a greeter hazard ratio than any imaging findings.”

What should be taken from the above statistics is that mental health plays a role in pain. There are a lot of new studies that are associating catastrophizing and external locus of control with increased pain levels. Work by Nadine Foster demonstrates screen for patients who will have a difficult time improving with therapy alone. New were books, such as the one by Annie O’Connor and Melissa Kolski (two people with whom I’ve studied at our RIC), goes into great detail regarding pain science. Big picture, we can not neglect the patient’s emotional well-being when attempting to treat the patients physical complaints.

“Our results indicate that depression is a strong predictor of who will subsequently reports low back pain then baseline imaging findings.Subjects with self reported depression at baseline were 2.3 times is likely to have back pain compared with those who do not report depression.”

There is obviously a psycho social component to low back pain. The question is… Chicken or the egg. Is a person more likely to be depressed because they have back pain that is not improving? Or is that person more likely to have back pain because they are depressed? I don’t think that there are cause and affect articles in the literature at this point, but there is definitely a high correlation between patients who are depressed and patient who continue to report low back pain.

“In our analysis of baseline data, we concluded that central stenosis, nerve root contact, and disc extrusion were the most important imaging findings related to prior low back pain. Our current analysis indicates that central stenosis, disc extrusion, and route contact may also be risk factors for future low back pain.”

In other words, if you have a major deformity you will probably have pain. This doesn’t mean that you will definitely have pain, it just increases your risk of experiencing symptoms.

The moral of the story is that we cannot deny the brain. The brain has the ability to see pain, and some patients are more susceptible to seeing this pain. Don’t get me wrong, a thorough mechanical evaluation should be performed when a patient has pain, but when this patient is not inclined to respond to mechanical therapy, the patient should be referred to someone that can better handle this patient’s pain.Sometimes, that person will be a behavioral therapist, a psychotherapist, or a clinical psychologist. Physical therapists are not always the go to in order to treat a patient’s pain.
Excerpts from:

Jarvik JG, Haegerty PJ, Boyko EJ. Three-Year Incidence of Low Back Pain in an Initially Asymptomatic Cohort. Spine. 2005;30(13):1541-1548.

Lead from the front

“When an organization or an individual experiences success in any manner, it may be difficult to alter the path we have been following.”
I could see this being true, but only for people who have that one success as the end goal. Some people aspire for more, some people aspire for better.
“Successful leadership is not just about the leader; it is about the team. Leaders must constantly find new solutions to the problems.”
This sounds like a quote from Phil Jackson. The team is the number one priority and the star athlete has to figure out how to fit into the team. The leader’s job is to ensure that the team can play together, and play at a high-level together. In order for leaders to constantly find new solutions to the problems, the leaders have to have an open point of view in order to see the problems. I have seen many who simply stick their head in the sand and ignore that the problem exists. In order to fix problems though, things will have to change. It’s obvious that should there be no change there will be no solution to the problem. This change will cause stress to the dynamics of the team, and the team must be able to handle that stress effectively and efficiently in order to maintain that high level of productivity.
“But leaders should not be afraid to erase the chalkboard sometimes and start from scratch”
Every system has flaws. Every system can be improved. Sometimes the flaws in the system are fatal. When this occurs the entire system needs to be scratched. I don’t know if a leader though can see this. These types of issues need the 20,000 foot view in order to see the big picture. When one is so close to the problem that they are in the problem, I do not believe that that person can actually see the problem.
Excerpts taken from:

Gregersen H. Leadership: When was the last time you asked, “Why are we doing it this way?”. IMPACT. June 2016:57.

Lean Management Theory

Lean Management Theory

 

  1. “The concept of 5S is just one of several key elements of the lean principle, which is designed to improve efficiency in the workplace while promoting organization and cleanliness.”

 

I can remember my teenage years. I started working at the age of 12 as a ranch hand and continued to work through this day. During those years, I worked as much as I was needed, because $20 was more attractive than anything else that I was doing with my time. My room was a disaster. I had trails in order to go from the door to the bed and another trail to get to the dresser. Fast forward 7 years, I was working at Sam’s Club 8298 during the overnight shift. I was nicknamed “The Tornado”. I could stock off a pallet faster than anyone else in the club. At times, they had to have someone come behind me to clean up after me, because it was faster to let me do all of the heavy work and pay someone else to do the “easy” stuff”. Continue to fast forward to one year ago, I was the most productive therapist in the clinic, priding myself in how many patients I could treat in a day, and still get good results of course. Fast forward to today, I realize that none of that matters. If I can teach people to do what I do, then I can help to create systems, which is now more interesting to me than simply stocking shelves, feeding horses, or treating patients. Don’t get me wrong, I enjoy treating patients, but I can only effect one person at a time. That is not as productive as creating systems to treat 10’s of patients at once, with the same treatment philosophy and outcomes. I now realize the importance of cleaning up my room, 36 years later.

 

  1. “The 5 “S’s” in Japanese are Seiri (tininess), Seiton (orderliness), Seiso (cleanliness), Seiketsu (standardization), and Shitsuke (discipline)”

 

Am I the only one imagining Myagi-son saying these words with emphasis? It sounds do formal and warrior-like.

 

  1. “In its simplest form it is designed to keep the workplace safe and organized without regard to size or pace”

 

When I worked at Sam’s, I could do aisles per night without ever tiring. Now, I left all of the cleaning until the end of the night (unless of course they had someone come over and clean up after me). What was the problem with waiting until the end of the shift to clean? I made everyone else’s jobs harder by taking up so much space that it was hard to get a forklift down my aisle during the shift. It was very productive for me, but I slowed down the entire team. It took years to figure this out, but my zealousness of productivity may be a detriment to the team.

 

  1. “The goal of the 5S is to remove waste, both actual and conceptual, by eliminating excess inventory and out-of-stock supplies, and reducing wasted time searching for, getting to , and waiting for supplies”

 

This is but one example. Think of the 20,000 foot view of eliminating waste (both in terms of stuff not used, and time spent on stuff not needed). I try to listen to multiple podcasts per day, and this concept is spoken of in many shows such as EntreLeadership, Barbell business, Tim Ferriss, and The School of Greatness.

 

  1. “Keep only what is necessary”

 

This is hard to do, especially when thinking of “what if”. I have like 8 pairs of jeans, but will only wear the jeans that don’t restrict my squat, namely 2 pairs. This means that at the end of my closet, I have 6 pairs of jeans that haven’t been worn in a long time, just in case I need to wear a third pair of jeans. The clutter in the closet would be removed if I just donated or sold the other pairs of jeans. Parting with any thing that we “own” is hard because we can always create scenarios in which those “things” are needed. Unfortunately, that same scenario never plays out in real life.

 

  1. “…identify, organize, and arrange everything in the work area, so that items can be efficiently and effectively retrieved…Everything should have a place and a purpose”

 

I suck at this step. Good story. I am on a team that is very close in terms of trust and partnership at work. There is a long running joke that I am Oscar and my supervisor is Felix. Hang out with us enough and it becomes obvious to those that understand the metaphor. I am learning that I need to become more like Felix in order to improve professionally. (For those that don’t understand the metaphor, go look up the Odd Couple…and nothing that was produced after 1990).

 

  1. “Once you have everything sorted and set, it is important to keep it that way…requires regular cleaning”

 

Because I suck at the previous step, this is also not a strong point for me. I know where I want to keep things, but for some unknown reason my way is not always the best way for everyone else. I struggle with the regular cleaning step. When I worked at PT and Spine, Bill was a stickler for standard operating procedures (SOPs). It wasn’t written, but he had a way that he like the clinic cleaned every night before locking the door. There was a proper way to open and close the clinic. Because I don’t have that type of standard at the place I work now, it makes it difficult to put everything in its place. I know that it sounds corny to think that there should be a standard operating procedure for the little things, but go back and listen to barbell business’ SOPs episode and it will all make sense.

 

  1. “Develop written structures and standards that will support the new practices and turn them into habits”

 

I am hard headed at some things. When it comes to organization, I have the ability to learn it, but I am a slow learner. I can spout off statistics on back pain, I can assess/treat darn near anything coming into the door, but performing organizations skills and all of a sudden…DUH? In Bill’s clinic, I was there for 2 years and by the time I left, I was able to leave the clinic in the exact way that I found it.

 

Funny story though: My dad is a Vietnam Vet (101st Airborne medic) and he could tell if something in his room moved while he was at work. Needless to say, if I wanted to be discreet, I could be. Unfortunately, this same discreetness doesn’t carry over to other situations.

 

  1. “Standardize is one of the harder steps in 5s as it calls for changing habits”

 

If I were a clinic owner, I would only hire new graduates that performed a clinical with me. It just seems much easier to teach what I find works best than to unteach stuff that I don’t like or research doesn’t support and then teach what I do prefer. This being said, being in a clinic with people who have much “experience” makes creating new standards difficult. Clinicians can be set in their ways and change can be scary. It is less scary for those that don’t know any better.

 

Excerpts taken from:

Spradling SC. Practice Management Systems: Add value to your practice by “5S’ing”. Impact. June 2016:31-32.

Is therapy worth it?

“Value is defined as cost divided by benefits”

 

This is very elementary in definition, but many of us in healthcare don’t do enough to sway this equation to make the benefits match the costs. When patients come to see me they receive multiple benefits during the session: educate, educate and over educate, personal care as much as possible staying within the realm of the evidence, and entertainment during the whole process. When I teach students, I make them tell me if they believe that they are worth $100/hour. Although we don’t get paid this much, that is the average payment to the clinic. We may have an excellent front desk staff and only have to provide the same amount of value as the cost of our salary, but I believe that we should be conveying the cost of the session, which may be up to 3 x the amount we actually receive in payment.

 

“What are the costs associated with the care we deliver? Co-pays, coinsurance, and deductibles question? ”

 

These are the basics to consider when treating patients. Patients sacrifice their times to come see us. Patients sacrifice time away from family to come see us. Are we providing the value, beyond the monetary value, to the patient? Human connection has value. I provide value to my patients not just through treatment, but also through that human connection.

 

“Now look at the benefits: what are the benefits we offer our clients through physical therapy?”

 

It’s easy for me to say functional outcomes. Patients at this point in time, do not know what that means. My job is to take the patient’s wants and needs and turn those into results. I have my own functional needs, but it would be wrong of me to impose my functional needs onto the patient. Some patients are quite content to sit in a wheelchair all day long instead of putting the work in to stand up. The best I can do is to educate the patient. If after education, I can’t motivate, then I can’t help that patient. We make the assumption that patients coming to therapy are ready to get better. This is not always the case. I see patients frequently that are only coming to therapy because their doctor told them to go to therapy. There was no indication as to what therapy would actually do to help the patient. If they are not ready to change, then it is very difficult to help that patient.

 

“patient’s assume they will get better when they see us”

 

Malarkey! At no point in time am I providing divine intervention. No one gets better simply by breathing the air I breathe (although this is one of the jokes in my repertoire). I am sure that my patient understands they will only get better when they take ownership over their problems.

 

If you are that patient, and you are ready to change, then there is help. When patients understand the problem and takes ownership of the problem and then performed the treatments in order to treat the problem, there very few patients that will not improve. Some physical therapist, such as myself, believe that we hold the answers to fix our patients. Robin McKenzie many, many years ago stated that the patient has the answer, our job is to bring that answer out. I would be arrogant of me to think that I am that answer.

 

Again, I went off on a tangent, but I did not believe that the rest of this article held any additional information that would be benefit to you.

 

Excerpts taken from

Quatre T. WHY THEY BUY: Because They Can Calculate Your Value. Impact. July 2016: 11.

Does taping in addition to PT provide increased benefits?

 

This is a look at a popular form of taping using in the PT profession. This was popularized in the Summer Olympics years ago and has increased in usage in the PT profession, regardless of what the evidence states.

 

  1. “Low back pain is a significant public health problem that affects approximately 39% of individuals worldwide at some point in their lifetime”

 

This is like beating a drum. If you follow the blog, I have written many times over the year regarding how expensive back pain is in the developed countries. One aspect that surprises me is how low this number actually is. In other articles, it talks about the lifetime prevalence rate between 70-80%. I would have to surmise that “worldwide” changes this number. I don’t have the reason why, but I have my guesses. I would guess that those “undeveloped” countries are spending less time on their kiester and more time either in a deep squat or standing position.

 

  1. “Several interventions commonly used by physical therapists, such as manual therapy techniques and exercises, are endorsed in most guidelines as effective treatments for patients with low back pain…”

 

Moving is better than not moving (in most cases). It’s funny because when I was a personal trainer (many, many years ago) I used to think of Physical Therapists as overpaid personal trainers. I completely disagree…sometimes. Don’t get me wrong, there are some PT’s that only prescribe 3 sets of 10 repetitions because it is traditional and for those PT’s I would agree that they are overpaid personal trainers. When prescribing exercise, we always have to think; “what’s the goal”. If the goal is pain reduction, than 3 sets of 10 may not be appropriate. If the goal is absolute strength or power or endurance, then 3 sets of 10 may not be appropriate. If the goal is hypertrophy…you got me…it may be appropriate for some patients for some muscle groups. In the end, 3 sets of 10 for everyone is no better than 3 sets of 5.

 

This isn’t meant to blast the PT profession, but if you are being treated in PT…Look around! If you are doing the same exercises as everyone else, then you have to question whether you are exactly like everyone else?

 

  1. “Kinesio Taping method was introduced at the Olympic Games in Athens and has since gained in popularity”

 

We have seen these tapes for the most part. The colorful tape worn on shoulders or backs of athletes. In the summer games, especially for women’s volleyball (I’m sure other sports have them, I just seem to watch more of this than anything else except for weightlifting), these colorful tapes are apparent. I use the tape, not for the reason indicated, but it makes for a great thumb wrap when using the hook grip in weightlifting.

 

  1. “The evidence of the benefits that Kinesio Taping can provide for patients with chronic low back pain is still scarce”

 

I could sell a cup of water to a drowning person in the ocean. I could easily sell Kinesio taping to my patients and others in the athletic arena, but I have yet to read a well-performed study that shows it is better than not using Kinesio tape. It’s the modern day ultrasound…It works until it doesn’t.

 

  1. “There is no current evidence to support the use of this method.”

 

This is not to say that it doesn’t work…yet, but of the studies performed thus far…it doesn’t work. One of two things will happen over time: 1. The company(ies) that sell the tape will continue to publish their own case studies to show the efficacy and/or 2. The peer reviewed journals will stop publishing all of the negative studies because academia will stop performing studies that consistently give the same results.

 

  1. “…the objective of this randomized controlled trial was to compare the effectiveness of adding Kinesio Taping to a physical therapy program in patients with chronic nonspecific low back pain.”

 

This is a well-performed study. Randomized doesn’t mean that the study is done randomly or half-assed, but the people in the study (guinea pigs) are separated in a scientific manner.

 

6a. Misc: There is a bunch of instructions for how the study was actually performed in the Methods. This is boring to the non-medical reader, and sometimes boring for those of us that read research. I will spare you the details. Just know that the study is well-performed.

 

  1. “The group that received physical therapy plus Kinesio Taping had the elastic tape applied to the lower back at the end of the sessions”

 

Essentially, if the tape is to provide greater benefit than exercise alone, this group should outperform the exercise-alone group in the data measured.

 

  1. “The corresponding author is certified by the Kinesio Taping Association International and provided training to the therapists on how to apply the Kinesio Tape”

 

This is important. If there is a method to perform on a patient, but the participating therapists are not certified in the method, then it could be that the practitioner doesn’t know the method well enough to perform the method. Since at least one of the authors is certified, it would make this a moot point.

 

  1. “After 5 weeks of treatment, the between-group comparisons showed no advantage of using Kinesio Taping in these patients for all primary outcomes…the addition of Kinesio Taping to physical therapy did not enhance treatment outcomes at any point in time.”

 

Crickets chirping………….Enough said.

  1. “Our data corroborate the results of 3 previous randomized controlled trials that do not support the application of Kinesio Taping in patients with chronic nonspecific low back pain.”

 

This means that if you want to tape your thumbs in order to lift weights, then go ahead, but using this type of tape (there are many different manufacturers of this type of tape) for back pain may not be ideal.

 

QUOTES TAKEN FROM: (Also, the initials of the first author is actually MAN, that’s awesome)

 

Added MAN, Costa LOP, De Freitas DG, et al. Kinesio Taping Does Not Provide Additional Benefits in Patients With Chronic Low Back Pain Who Receive Exercise and Manual Therapy: A Randomized Controlled Trial. J Orthop Sports Phys Ther. 2016;46(7):506-513.

Unleashed upon the world

I work in a small community hospital. At this hospital, I have been blessed to work with people that are really good at what they do. We all expect excellence with our specific niches, and it’s great to call them colleagues.

In this location, I also get many students (physical therapy students) and volunteers (hopeful to get into PT school). There are some students that I wonder how they got into the program and they force me to worry about the direction that our profession is going. This has nothing to do with knowledge, but with passion, excitement, initiative, confidence, and people skills.

Every once in a while I come across students that make me sit back and enjoy. It’s like watching a Picasso at work. They have people skills mixed with passion, integrity, knowledge and time spent in the books.

It’s disheartening to hear of some student’s clinical internships. For instance, a recent student’s experience was nothing more than that of a PT mill. The student reports doing the same intervention to all patients with a similar diagnoses. There was no classification, there was no critical thinking and the student then passed the patient off to an aide once the manual therapy portion of the session was over.

This is why I am an CI. Students deserve to learn the craft of Physical Therapy. There are many short-cuts. There are ways to maximize profit, but the ways to maximize profit, by performing said short-cuts, doesn’t typically translate into proper patient care.

We all have what’s called the sniff test. If it smells bad…it probably is. I take mine a couple of steps further and call it the “I’m disappointed in you” test. I’m 36 years old and can remember the one and only time that I heard these words from my Dad. It hurt enough that I don’t want to hear those words again. When I am practicing and treating patients, I think to myself; “Does this pass the sniff test? Would my Dad be disappointed with how I treated a patient?” It doesn’t take much people.

We recently were required to take 3 hours of ethics courses per renewal period (every 2 years). I know…it doesn’t sound like much, and it isn’t, but these 3 hours that I spend “learning” ethics are 3 hours that could be spent learning the latest/greatest interventions to treat problems. You know why we have to take ethics courses? Because there are some in our profession that are not practicing in an ethical manner. Mr. Pelligrini from Providence (my high school), on day one, wrote a big dollar sign on the chalkboard (do they even use these anymore?) and he proceeded to walk up to the $ and bow to it. This was day one. In high school, he was probably the hardest teacher that I had, but having grown a little older and more mature, that guy was so full of knowledge that is coming true during these times. I won’t go into it, because I am trying to avoid political blogging, but just know that he was wise beyond his years.

Unfortunately, many in our profession are bowing down to the almighty $. Why? When I poll students, they are graduating with over $150,000 of cumulative student loan debt. These students have a house payment…without the house. Therefore, these students will be forced to make decisions that take salary and bonuses into account. I have listened to over years of Dave Ramsey on the Podcast and unfortunately most students don’t live by his principles. Hard at first, but allows for ethical decision making professionally. When students don’t have to worry about how they are going to pay back their student loans, they can make more altruistic and personally satisfying decisions in his/her career, instead of chasing the $.

If you are applying to PT school, do your research! How much is that school going to cost you in total? Are there scholarships? How much is that school going to cost you per month when you graduate? Can you graduate without taking on any debt? How much will your starting salary be? What type of lifestyle do you want to lead and will this profession allow for that type of lifestyle?

Having lectured to many students prior to getting into the profession, many students have never even considered these questions. It’s sad, but it becomes easier for companies to play the puppetmaster because it is known that the students have to pay that loan monthly and they can’t do it without a high paying job.

Schools need to hear this and start offering financial planning courses. It’s sad that we take a student and have them rack up $150,000 in debt, but never prepare them for how to start paying that money back, saving for retirement, choosing an ethical job position, etc.

I went on a rant, but it’s on my mind this morning.

CAT of the Oswestry and Roland Morris

A Critical Appraisal of the responsiveness of a patient specific outcome measure compared with the Oswestry Disability Index v2.1 and Roland and Morris Disability Questionnaire

 

P: For patients with at least a six week history of back and/or leg pain

I: is the patient specific outcome measure

C: as compared to the Oswestry Disability Index and Roland and Morris Disability Questionnaire

O: as responsive

 

Reviewer:

Vincent Gutierrez, PT, MPT, cert. MDT

 

Search:

Ovidsp with title term of “Oswestry”. The results were limited to full text.   73 citations were found with no limit to year published.

 

Date of Search: February 22,2014

 

Citation:

Frost H, Lamb S, Stewart-Brown S. Responsiveness of a Patient Specific Outcome Measure Compared With the Oswestry Disability Index v2.1 and Roland and Morris Disability Questionnaire for Patients With Subacute and Chronic Low Back Pain. Spine 2008;33(22):2450-2457.

 

Summary:

 

The purpose of this study is to assess the responsiveness of the Patient Specific Activity Questionnaire compared to the Oswestry Disability Index v2.1 and the Roland and Morris Disability Questionnaire.

 

The inclusion criteria were subjects at least 18 years old, with at least a 6-week history of low back pain. Subjects with or without leg pain and/or neurological signs were also included. Subjects were excluded for the following: serious pathologies, gynecological problems, ankylosing spondylitis, tumors, infection, past spinal operations, pregnancy, serious spinal pathology, unable or unwilling to complete questionnaires independently, received physical therapy in the previous month or were referred for intensive functional restoration.

 

The subjects were randomized to either a physiotherapy advice group or an advice with additional physiotherapy intervention group, which was not described. The subjects completed the following measures both prior to intervention and after 12 months: the Patient Specific Activity Questionnaire (PSAQ), the Oswestry Disability Index v2.1 (ODI), the Roland and Morris Disability Questionnaire (RMDQ), and the Global Transition Rating Scale (GTRS).

 

Subjects were divided into three groups, based on the GTRS, after 12 months: better, same or worse. The change score was calculated by subtracting the baseline scores from the follow-up scores for the ODI, RMDQ and the PSAQ. A relationship was established between the GTRS and each of the latter three outcome measures using 1 way analysis of variance (ANOVA).

 

Of the 286 subjects randomized initially, 201 completed the follow-up questionnaire. The PSAQ is responsive among subjects noting improvement, but is less sensitive to those reporting no improvement, when compared to the ODI and RMDQ.

 

Appraisal:

The validity of the study is questionable, as there are flaws in the design. The authors do not account for the patient’s lost to follow-up, which may alter the results of the study. The authors fail to note the differences between the two groups at baseline, with regards to demographics. The authors note that a P value of <0.01 was utilized to differentiate among the outcome measures, which provides for a more limited confidence interval to detect true change.

 

The authors note the area under an operating receiver operator curve as follows: ODI as 0.752, PSAQ as 0.751 and RMDQ as 0.689. This indicates the order of responsiveness to change respectively.

 

Because the study results indicate that the tested outcome measure (PSAQ) is less sensitive to those patient’s with little change in status pre-post intervention, it would be prudent to utilize an outcome measure than can assess both small and large changes in status, such as the ODI and RMDQ.

 

Conclusion:

With patients presenting to the clinic with complaints of at least a six week history of low back pain, with or without leg symptoms, the ODI would be the most effective to assess change.

 

 

Good Ole Days…Gone!

  1. “When I graduated from physical therapy school, therapists expected to work for someone and had abundant choices in location and specialties. The expectation was for a good paying job with ample opportunity to learn from mentors and a patient load that would allow for generous one-to-one patient time. It was also expected that the salary would afford an improved lifestyle and cover the payment of their low-interest student loans”

 

Wow! This was a mouth full! Let me start by saying…those were the days (in the Edith Bunker voice). If you don’t know Edith, go get some culture!

 

Prior to the balance budget of 1997, jobs were a plenty and the salary was good. Unfortunately this is also one of the situations responsible for the need of a balanced budget. People were seeing patients for such a long time and Medicare, and other insurance companies, continued to pay for any and all treatment issued. This was regardless of need. Can you imagine that in today’s day and age? We shot our own foot by over treating and creating the spa-type environment in which everyone got ultrasound, hot packs, electrical stimulation, and massage. That’s not very physical for being physical therapy. Those days are long gone and welcome to modern times. Students are taking out between 100-200K in order to earn the right to make 65K to start. Doesn’t sound like living the dream to me.

 

  1. “The emphasis on cost containment and required documentation has created an atmosphere that does not support the very reason that most of us went into this field in the first place: ‘patient care’….Student loan debts compared to starting salary make a potential physical therapy student consider other options that have better financial outcomes.”

 

I have this discussion with prospective students often. If you think that being a Doctor of Therapy sounds lucrative, think again. Depending on school choice and loan terms, the school could cost in excess of 500K (when interest over time is accumulated). We make good money, but retirement will have to be sacrificed in order to pay off student loans. Once ours are paid off, then we have to worry about providing an education for our children. Good luck in this profession! It has treated me well, but I don’t live an extravagant life either.

 

Quotes taken from:

 

Brown TC. From the President: Come Together Right now. IMPACT. July 2016:5.