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Athletic development specialists dedicated to the art and science of excellence in movement

Notes from Physical Therapy Clinic Observation: Day 1

Recently I had the first of my official observation days for PT school applications.  For those that don’t know, PT schools require a certain number of observation hours in various clinical settings.  This requirement serves many purposes, such as screening an applicant’s commitment to the field and exposing applicants to different practice settings.  In this session, I spent a day at a local private outpatient clinic observing a variety of patients.  Below are some notes from the day…

1.       Amazing how young athletes may actually “benefit” from an ACL injury.   Blasphemous?  Hear me out…Rehabbing in the clinic is the first and only opportunity for quality coaching on technique for some kids.  Unlike most high school weight rooms (or sometimes worse, speed camps) where technical precision is a low priority, technique actually matters in the clinic.  Unfortunate to need surgery, but perhaps these kids are better off than those who haven’t had a big blowout.     

2.       Insurance makes life hard for everyone.  However, if patients do homework and have understanding of lifestyle modifications needed, then favorable outcomes with limited visits are possible.  Insurance also leads to absurd practices.  One patient changed insurance (Tricare to medicare), but medicare would not accept testing results done under previous plan.  Rather than send results from one insurance company to another, they had to use a visit on repeating test battery from two weeks before. 

3.       The political balancing act with surgeons.  Some are masterful craftsmen once inside the body yet know very little about rehab.  PT has changed dramatically in last several years, so the surgeons may base their opinions off their experiences of twenty years ago.  However, it does make you roll your eyes when a patient gets referred for a knee and the surgeon demands the PT to focus on the knee, when the real problems may lie in the hip and ankle.  PT’s aren’t tied to the surgeon’s script, but it’s a balancing act to do what is needed versus what is expected (“don’t bit the hand that feeds you.”)

4.       MRIs don’t tell the whole story, though patients have come to expect them for “definitive answers”.  Studies have shown poor correlation between pain and orthopedic pathology.  Some think they (or their family) is not getting appropriate standard of care without imaging. 

5.       Was able to help with a couple of athlete patients who were near discharge.  That’s the way the system should work: teamwork between performance and rehabilitation, working side-by-side.  Also flattering that the clinicians wanted to learn what I could share for performance training.

6.       Car accidents: throw the corrective algorithms out the window.  Very unpredictable due to violence of impact.

7.       Encouraging to see a practice run in a non-assembly line fashion.  Two patients simultaneously in 45 minute time slots, with one PT and one PTA.  Sufficient resources to get done what needs to get done, but most importantly, a relaxed comfortable environment for healing to occur. 

8.       Does fitness help people get better faster?  The literature is fairly unclear.  If fitness was a predictor of recuperation, then why are so many athletes hurt?  However, watching one back pain patient lose endurance mid-session and provoke pain that was not present on arrival makes me think fitness has to play a role, no matter what the literature says or does not say. 

9.       Joint-by-joint approach.  We (performance and rehab) are using the same principles.  One field deals with pain, the other doesn’t. 

10.   Senior citizens who are disappointed to “get better” and released from care.  What does that say about the fitness industry?

11.   Amazing how the mind can affect pain.  Subjectively, almost seemed like certain patients were programmed to hurt.  Just the idea of certain movements seemed to trigger pain (i.e. the knee replacement patient who winced before being touched or before initiating a movement).  Reinforces the reality that pain is output from the brain.

12.   Year round sport specialization…very predictable in injured softball player (HS freshman), who gave up other sports at young age.

13.   Breathing matters, both in performance and in rehab.

14.   Recognizing limitations of your practice.  Just because someone is referred for orthopedic issue, doesn’t mean their main issue is orthopedic.  Fortunately, this particular patient also had referral to see a neurologist. 

15.   How necessary are all the joint replacements?  In the PT’s opinion, most are necessary at some point due to extended lifespans, but they probably happen too early.  What if they had proper exercise in the several YEARS before the replacement, rather than in the several weeks afterward?

16.   Always interesting to hear the “why” for every case (and fortunate to have mentor willing to explain).  In coaching, we can get away with “because I’ve always done it this way and my team wins.”  Less leeway in medicine, where protocols must have basis in evidence.

17.   Scary when surgeons order that knee flexion in rehab not exceed 60 degrees.  How the heck do you get off the floor after a fall, with only 60 degrees of knee flexion?  Fall prevention is important, but perhaps more dangerous to overlook the ability to get up.

Comments

"MRIs don’t tell the whole

"MRIs don’t tell the whole story"

I wonder if there are tools actually "tell the whole story".. or even if they DO "tell the whole story" about a specific body system, does it really matter given that (from a layman's perspective) that no body system TRULY functions in isolation from the other systems?

I have been see this line attached to tools like EMG and FMS.

I don't think that any tools should be excluded just because they don't "tell the whole story" because I don't think anything does. The numbers don't "lie", but people can draw excessively "conclusive" interpretations that are misleading (so the interpretations are the "lie", either in the form of omission or overgeneralization).

"Studies have shown poor correlation between pain and orthopedic pathology. Some think they (or their family) is not getting appropriate standard of care without imaging. "

Similar to how distance swimmers who enter "race pace programs" may be accommodated with practices that don't match the coach's philosophy... wise coach takes into account what their athletes BELIEVES will work as psychology has a HUGE impact on race performance (believing in belief)

Todd Hargrove/Lorimer Mosely put the idea into my head that pain is an output of rather than the input of the brain... that tissue damage doesn't always = pain, and pain doesn't always = tissue damage...

Great post, love and agree

Great post, love and agree with a lot in this post!

MRI's, pain, performance

Good comments Qu1ckbadger

With the MRI there is the cost factor, too.  Should people exhaust their insurance and/or pay substantially out of pocket for something that realistically won't make a difference in the rehab approach?  That said, if there's a belief the MRI may pick up something more serious (i.e. tumor), that's a different story, but the patient (both athletic and general population) has a certain trust in imaging that isn't necessarily aligned with reality of orthopedic rehab.   

You may have seen this before, but here's a very poignant article from last year on that topic:

http://www.nytimes.com/2011/10/29/health/mris-often-overused-often-mislead-doctors-warn.html?pagewanted=all

EMG is a good analogy.  Precision is valuable; we just need to interpret as well.  

FMS is "only" a screen, but let's not forget the power of a screen.  Its a simple concept that many feel the need to oversell, perhaps because of its simplicity!  Ultimately, any screen exists as an early onset triage to guide the next stage of intervention.    

As with anything, it boils down to knowing what the system is used for and applying it accordingly.  

Understanding the neurological basis of pain has a profound impact not only on modern rehab, but also in performance.  Even if someone is not presently in pain, its possible their movements have been shaped by current or previous efforts to avoid pain.  It might not be in our skillset to manage pain, but we should be aware of its power in shaping general and sport specific movement.

Thanks!

@GJohnMullen...Thanks for your comment, Doc!

ACL injuries are a golden opportunity!

So true! After injury kids are educated on their anatomy strengths and weaknesses perhaps they will know their limits!

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