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Where is all the exercise equipment?

Just back from the PPS meeting in Phoenix.  I echo Rob's comments-great meeting organization, great section leadership, and great content.  I had to miss the past few years and I will certainly make the meeting a priority.

I had a conversation this morning with my good friend and noted author/teacher, master clinician, former program Chair, fellow Springsteen enthusiast, and private practioner Carl DeRosa about the noticeable lack of exercise equipment manufacturers in the exhibit hall.  What is up with that?  There were lines of people waiting for the Vitamix and to get their nails done but there was no exhibits featuring models on equipment like there used to be at these shows!  Even, John Iams, the guy who compares himself to Einstein had all kinds of people waiting to get their chin tapped with a therapeutic reflex hammer (according to their booth the "first time in history that a reflex hammer is being use for therapeutic purposes").

I wonder if the lack of exercise folks signifies a bad trend in our industry.  We have a history of giving up significant parts of our profession (e.g. Cardiac rehab and respiratory therapy) and there is some evidence that consumers are seeking out quasi certified personal trainers for all sorts of exercise prescription (an area where EBP is very supportive).  And therapeutic exercise is one of the best reimbursed codes in our limited number of CPT codes!

Does anybody else think we are at risk for losing exercise?

Larry

Graduated……but “Got Goods?”

I had the pleasure of attending my first APTA Private Practice Section meeting this past week….what a great group of people and great professionals (and at a great location to boot!). If you haven’t yet been and are a PPS member, mark it on your calendar for next year (even those who aren’t in private practice could benefit greatly from many of the issues this section deals with on a regular basis). I have always been impressed with private practitioners as they are quick to pick-up the nuances as well as the eye-sores of physical therapist practice that others overlook or often ignore.  Perhaps part of the reason (a BIG part of the reason) is that their financial rear-end is on the line and they are keenly a-tuned to anything that even smacks of being a threat to their survival (or that will impact profitability). As a nascent private practitioner coming out of academia and clinical research who still wears both those hats on a part-time basis, it is interesting to now be a regular  “customer” of the product(s) I have had a hand in producing over the last several years.

Maigne's concept of painless & opposite motion in spinal manipulation

I was Googling (verb?) for a photo of Robert Maigne a few weeks ago, when I came across this interesting article by Robert Maigne (Maigne R. The concept of painlessness and opposite motion in spinal manipulations. Amer. J. Phys. Med. 1964.44:55-69. French Society of Manual Medicine website. The article is now a historical piece that gives us and opportunity to reflect on basic tenets of spinal manipulation and various cultures, and cults, that have evolved around the practice. Maigne promotes manipulation in the opposite direction from the restriction, which is contrary to my own experience of spinal manipulation. However, who amoung us hasn't flipped the patient over to the other side when the manipulative moment appears less than therapeutic.

Indeed, the PTs in the Flynn et al CPR study (Spine, 2002), manipulated the 'side of choice' first 2x, then the opposite side if the manipulation was unsuccessful (I believe a 'cavitation' was the criteria) 2x then the manipulation was attempted on the opposite side. The choice of which side to first manipulate was based on the following algorhythm: positive flexion test, if neither side was positive, then the side of tenderness in the sacral sulcus, if no tenderness, then the side of symptoms and if no particular side was more symptomatic, then a coin-toss. Maigne presents and interesting rationale based on 'experience' (Expert-based practice). Perhaps, direction doesn't matter... so  coin tosses make good sense. Reflection on these issues bring into question the 'expertise' piece or specificity & accuracy of technique, 'handling', and culmulative experience with technique. Any thoughts?

Download maigne. 1964 opposite maip.doc
Britt

Dr. Tony Delitto's Keynote Address AAOMPT 2005

Below is the text from Dr. Tony's Delitto's keynote address for Research Day at the 2005 American Academy of Orthopaedic and Manual Physical Therapist's Meeting on October 16, 2005 in Salt Lake City, Utah. I have also attached a .pdf copy of the text and slides. Enjoy the podcast.

John

Download keynote.pdf

Download aaompt_salt_lake_city_1017.pdf

Beginning of Tony's address:

I would like to thank the meeting organizers for inviting me to deliver this keynote address to the members of the American Academy of Orthopaedic Manipulative Physiotherapists. I presume that you have invited me to deliver a keynote address on the Research Day of this meeting because of previous research that I have accomplished in the area of low back pain. Anyone who has followed this work for the past 5 years quickly realizes, however, that I have taken a "back seat" in many of the ongoing studies and, to be honest, I feel as though I have fallen off the back of the car in most recent cases.

Having said that, beginning an invited talk with such a self-deprecating theme would make for a boring one-sided conversation; so instead, I would like to discuss two major themes: first, a perspective of where we came from and secondly, where I believe we should be heading as a profession. I believe that both looking back and looking forward are appropriate for any keynote address. With regard to the latter, I strongly believe that we have an exciting opportunity in front of us that we would be foolish to let slip by us. I look forward to sharing the details of this opportunity with you a little later in my talk.

The Accountable Practitioner

To follow up on the ownership of manipulation discussion I have posted the October JOSPT editorial, which was written by Julie and John. It specifically deals with advancing the profession and being an accountable for our actions and practice patterns. The point is that clinicians need to become less independent and more accountable to the profession. This of course includes standardization around best practice. A concept that is opposed by some but will eventually lead us toward professional autonomy.

Thoughts??

Josh
Download October2005-Editorial.pdf

When subsequent studies contradict original research in medicine

Medicine, like all disciplines in science, reserves (and preserves) the right to change, however, in this age of instant publicity, Medicine comes off seeming fickled. This article from JAMA is a  review of 45 widely cited articled from 1990-2003: 6 based on non-randomized RCTs and 39 were random sample studies. The author found that 5 of 6 non-randomized studies' findings were either reversed or challenged on their finding (e.g. effect size), whereas, 9 of the 39 RCTs were challenged on their initial finding (mostly strength of effect). These 9 RCTs, which were not replicated on subsequent studies, were found to have small sample sizes. Clearly, a case for the rigors of RCTs vs. non-randomized studies, and an interesting read on scientific process in medicine.

Britt Download ioannidis_j. contradicted & strong effect. JAMA 05.pdf

The Race for Scientific Ownership of Manipulation

With the rapid dissemination via technology, I find it hard to believe that this article was published in April 2005 and that I first came across it this morning browsing around different chiropractic websites. This should be mandatory reading for all physical therapists - not because it references some of our work, but because it expresses why physical therapists have become such a threat to the chiropractic profession.

As much as I support the APTA, PT-PAC, and all the political efforts that go into supporting physical therapist practice (and every physical therapist should be an APTA member and contribute to the PAC!), the primary path to professional autonomy is through clinical research and support of organizations like the Foundation for Physical Therapy and the American Academy of Orthopaedic and Manual Physical Therapists. If you look at the studies referenced in this article, virtually all of them can be traced back to the Foundation. Our profession owes organizations like the Foundation and American Academy of Orthopaedic and Manual Physical Therapists and their supporters a great debt of thanks. If you have not made a donation this year, you should seriously consider doing so now! Our profession’s future hinges on growing physical therapist clinician scientists.

This article also summarizes why the chiropractic profession is in dire need of major reform. The underlying foundation of chiropractic – the vertebral subluxation complex – is a ‘house built of straw’. The problem for the chiropractors is there are not enough credible ones like Bill Meeker who get it. Organizations like the ACA are too busy writing letters to the editor defending their ‘turf’ rather than investing in the resources necessary to grow the science of their profession.

If you are a genuine evidence-based chiropractor, I would suggest you become a physical therapist. You are getting left behind by your profession, while other health care professionals readily understand that evidence is the ‘common currency’ that will drive health care for the foreseeable future. The chiropractic professional associations have invested thousands of your hard earned dollars in fruitless (they have had a few victories) political and legal efforts rather than growing scientists skilled in clinical research. I truly feel bad for those chiropractors out there demanding reform, only to be ignored by their professional associations’ ill informed agendas. This is why I continue to reiterate that our best days as a profession are ahead of us. Make your donation to the Foundation for Physical Therapy today. Combined with a membership in APTA if you are not already a member, it's the best investment you will make all year.

John

Technology and EBP

Pubmed just launched a new service that allows search results to be delivered directly to your desktop via an RSS feed - yet another useful service to facilitate the translation of evidence into practice. Check it out.

John

Download entrez_pubmed.pdf

Patient Satisfaction-Useless Part II

Part II from Oct 2005. Just as relevant today.

My last post attempted to discredit the patient satisfaction survey process that many physical therapy clinics have in place.  My belief is simply that the incremental gains from the analysis of your surveys will not tell you much more than what we know from the published research (some of which I posted) and the effort does not justify such gains.  I have heard from many of you (mostly by email) similar responses-you are appalled by my suggestion not to do them.  You have cited that many regulatory bodies (e.g. hospital systems, networks, insurance products) force you to collect such data and that you have gotten a lot out of them (of note, I did not get any specific and helpful information that you "got out of them").  For many of you the process is so ingrained that "letting go" would be sacreligious!  Although my next post will present a very different concept of patient measurement, I felt it necessary to bring to light two distinct points.

Educating Referral Sources II

Here's one way to do some education to your referral sources. At my hospital based outpatient clinic in the US Army, we have a Fellowship training program in Sports Medicine for physicians. Here is a briefing I gave to them about the use of manipulation and stabilization exercise in the management of low back pain in physical therapy. It covers the manipulation CPR and Lumbar Stabilization training, cites some current literature, and tries to help educate them about our approach. These physicians are quite good at musculoskeletal evaluation, so they were ready to go into detail about some of the issues surrounding the treatments of these patients. We had a very interesting discussion about the use and possible mechanisms of action of both manipulation and stabilization exercise. I had a feeling as I spoke that they did not know PTs were this detailed and knowledgeable in their approach. Of course, this is just the tip of the iceberg for those of us who read and post here, but I think it went a long way toward helping inform them about who they could look to to help them manage and rehabilitate their patients. Maybe you will find the presentation of value, also. As in the previous presentation, the abbreviation DOD/VA LBP CPG or LBP CPG refers to the Department of Defense/Veteran's Affairs Low Back Pain Clinical Practice Guideline.

I hope this is helpful for everyone, please use as you see fit.

Download manip_and_lx_stabil_in_back_rehab_2005.ppt

Jason.