GENERALIST OR SPECIALIST?
When I graduated with my clinical doctorate, I entered the workforce as a general Physical Therapy practitioner. In other words, I knew a little bit of information on a wide array of topics. For example, I could perform an outpatient orthopedic evaluation, but it was relatively sloppy and inefficient. During these early evaluations, I remember performing 20+ special tests and identifying upwards of 50 impairments. Looking back, I probably gathered enough information to give the patient ten different diagnosis. Unfortunately, the diagnosis’ were not clinically significant. Physical Therapy school gave me a general foundation, but I lacked expertise for ranking and prioritizing impairments (plus, the inefficiency added hours to my documentation!)*
EXPERTISE REQUIRES EFFORT
Similar to most physical therapists, I strive for excellence in both my personal and professional life. As a new graduate, I wanted to be a great practitioner, and I wanted to arrive at that gate quickly. The reality of becoming a clinical expert is that it always takes time and effort. You cannot shortcut your efforts because gaining experience is a key part of the process. Clinical expertise happens when research, experience, and intuition flow together. Shortcutting any aspect of this equation changes the final output.
Becoming a clinical specialist in Orthopedics took months of time and preparation. I remember working my full time job as a clinic manager, enjoying a few hours with my wife, and then hitting the books from 10 p.m. to 1 or 2 a.m. They were long days. When looking back, it is natural to ask if the months of preparation were worth the ‘OCS’ credentials. The answer is a resounding, “Yes!” For me, there was no alternative. The idea of showing up to clinic average and not maximizing my results was not an option. The hard work and effort is a rite of passage from generalist to becoming a specialist. It is still the road less travelled, but a worthwhile adventure that will make you a better clinician.
SPECIALIZATION MADE ME A BETTER CLINICIAN
If you have remotely considered taking a specialty examination, it is likely that a colleague has said, “Why waste your time? The examination is a few years outdated and does not apply to real clinical problems.”
Our profession is driven by our most up to date research. Without this research, the physical therapy profession would suffer immensely. Preparing for the Orthopedic specialty examination forced me to truly understand the research. For example, how many people perform eccentric contractions for Achilles tendinopathy? Great! Eccentrics are important. However, if your results are not 100% it is because there is more information behind the eccentric research studies. Some of the best eccentric research assessed ATHLETES with MID-PORTION Achilles tendinopathy. The athletes performed 180 repetitions each day often while working through pain. (1) The clinical practice guidelines for Achilles Pain, Stiffness, and Muscle Power Deficits Achilles Tendinitis mentions that insertional tendinopathy and non-athletes do not respond as positively to eccentric loading. An expert clinician tailors their treatment to the person, current irritability, pathology, and other biopsychosocial factors. The research helps guide the clinician on the best path and allows the expert clinician to intelligently pivot when something does not directly match our current literature.
Specialization does prepare you for the clinical world! Expert practice forces you to critically analyze the decisions you make on a patient-to-patient basis.
TAKE HOME ADVICE
*To clarify- this does not mean Physical Therapy school is not preparing students adequately. We are competent and safe entry-level professionals when we graduate. Physical therapy schools help people pass the NPTE. They do not have the bandwidth nor time to allow for specialization.
1. Alfredson H, Lorentzon R. Chronic Achilles tendinosis: recommendations for treatment and prevention. Sports Med. 2000;29(2):135-146.
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About the Author:
Jim Heafner PT, DPT, OCS is one of the founders of The Student Physical Therapist. He is owner of Heafner Health Physical Therapy in Boulder, Colorado.
Everything you want to know about preparing your athletes for return to sport from a sports clinical specialist (part 1 of 2)
Each year numerous athletes get “re-injured”. What are you doing for your return to sport process?!
Return to sport testing is always an interesting topic discussed within sports medicine. It is an ever-growing subsection of sports physical therapy. While we wait for research to catch up to validate and create reliable tests, what else can we do to put our athletic patients into the best possible situation for a healthy return?
The most important thing with the return to sport process is understanding what components are necessary to consider. For many physical therapists this means ROM, pain, strength, and a few validated tests in the research (think hop tests). Yet this is not nearly enough to consider. In fact, it’s not even close. Let me explain some of the things I look at when treating athletes.
Task Analysis & Sport Biomechanics:
Part 2 will cover specifics on loaded vs unloaded movements, sports specific tests, and return to sport tests! Stay Tuned!
Dr. Brian Schwabe, PT, DPT, SCS, COMT, CSCS
Board Certified Sports Physical Therapist
Recently, my family and I moved to Boise, ID and I started practicing at a new private practice clinic that is one-on-one for 45 minutes with each patient. For those of you unfamiliar with my work history, I had previously worked in both a hospital-based outpatient ortho clinic (for 1 year) and a high-volume private practice ortho clinic (for 3 years). There are many differences between each setting and different pros and cons to each one as well.
Let's start with obvious cons of high-volume clinics: less time with each patient, difficulty with case management and therapeutic alliance, and possibly tech oversight. The worst part of it is that it can be more difficult to develop your clinical skills and clinical reasoning as you are more worried about getting to your next patient or managing your schedule, instead of focusing on the patient in front of you. The pros of a high-volume clinic are that you often are paid better (not always), you may see a more active population, and you get A LOT of exposure to different types of body parts, injuries or surgeries. Having worked in an hospital-based outpatient ortho setting, I would say that 70% of my patient population was chronic low back pain, deconditioning or balance issues. I probably saw 1 case of TMD and 1 or 2 wrist/hand injuries the entire year. Comparatively, I probably had 1 each of TMD or wrist/hand dysfunction throughout most of my time in the high-volume setting. Seeing more patients not only exposes you to more injuries, but also allows you to practice your techniques and skills on more people! You can become a lot more comfortable or proficient treating less common things just via exposure.
I am hoping that my new setting will bring the best of both worlds: one-on-one care, diverse population, good pay, and more. The most important aspect in my opinion is one-on-one care. I cannot wait to get into proper exercise prescription, loading techniques, and, above all else, patient education. Empowering and educating our patients helps to build their independence and restore their function. While I look forward to my new position, I am extremely grateful for my time I spent in a high volume clinic. I feel much more comfortable treating a variety of injuries, managing cases, and using certain manual techniques. The busy clinic can still be a useful part of clinical development, although, I don't recommend it long-term.
-Dr. Chris Fox, PT, DPT, OCS
Last week, I was reading the most recent JOSPT's editorial on chronic pain: "When Chronic Pain is Not 'Chronic Pain': Lessons from 3 Decades of Pain." While an editorial (and the case study presented within it) is not a standard for evidence-based practice, the article does an excellent job of stating that just because we think something is correct today, doesn't mean it will be in 10 years. If you aren't familiar with the article, a case is presented on an individual that had leg pain over 3 decades of his life and was treated with the different "fads" of each decade: McKenzie, core stabilization, and more recently pain science. The individual in the case study showed little change in his symptoms until an exercise-based ABI was performed and revealed circulatory issues in his LE. Once the vascular issue was addressed surgically, the individual was back to his PLOF from 30+ years ago.
Obviously, a case study doesn't hold much weight by itself, but this article does an excellent job of getting us thinking about the state of physical therapy and our overall perception of evidence-based practice. At each point that care was being delivered to the individual, the treatment was perceived as best practice. Today addressing pain science and biopsychosocial aspects is the more evidence-based treatment. If anything, research today should tell us that there is a lot out there that we don't understand, and we are prone to blindly attribute the effects to the nervous system or the mind in general. As the author of the article stated, it will be interesting to see in 10-20 years how the practice of PT changes. While we should absolutely base our treatments in what the evidence suggests while practicing, we shouldn't be so quick to stop researching other techniques that may prove beneficial down the road as we continue to learn more.
-Dr. Chris Fox, PT, DPT, OCS
One of the foundations of physical therapy is exercise prescription. While every PT school is required to teach their students the fundamentals of exercise physiology and prescription, many would agree that what should be an expertise of the profession is often a weakness. More and more research is showing that exercise is likely one of the best interventions we can provide as health care professionals, for both tissue healing and addressing biopsychosocial factors.
A common mistake many are prone to (myself included) is insufficiently challenging the patient. Whether truly focusing on strength, proper tissue loading, or for psychological benefit, it is our duty to properly load our patients. One aspect we should consider is if we are having our patients exercise on a table too much. While there is a time and place for some exercises there, it is not the only place our patients should be challenged. Getting exercises into closed-kinetic chain movements simulates more daily motions that table-based ones. Additionally, we can progress the load our patients are having to move off the table. While those aspects are likely pretty obvious, I believe it can also be motivating to the patient psychologically. I often try and have my patients perform exercises like goblet squats, deadlifts, and others that they may have never thought possible for themselves. It can be extremely exciting! The additional load can also help to desensitize the affected tissue both locally and centrally, meaning the individual isn't overly focused on the area.
While challenging our patients with more advanced exercises has its benefits on improving function and mental health, it is still essential that we recognize the foundations of exercise physiology. If we are truly looking to strengthen a muscle, we must focus our efforts on the proper fuel system and rep scheme. If a patient is performing 20 repetitions of an exercise without any struggle, they aren't strengthening. I'm not saying there isn't a place for an exercise like that or even that there isn't a benefit, but if we are truly wanting to strengthen them, the load must be increased.
-Dr. Chris Fox, PT, DPT, OCS
Below are my TOP 10 Physical Therapy beliefs. These are not meant to be offensive, but merely thought provoking. I hope you can resonate with one or two of them. Please share with a friend!
10. Physical therapists have unique opportunities to change people's lives everyday. Change is not easy, but passion and persistence usually prevail!
9. We do not have all the answers. Twenty years ago we thought ultrasound was good. Ten years ago we believed manipulations worked for biomechanical reasons. Our current research will only be developed and improved upon tomorrow. Look ahead, not behind!
8. In our current society, we have too many under qualified people teaching others how to move (look at our current fitness industry). Physical therapists are the movement and pain experts. We must be active in the community, teaching trainers, coaches, etc... how to move.
7. Orthopedic pains are commonly problems of system overload, not isolated issues. Do not underestimate the value of nutrition, sleep, stress, and lifestyle.
6. Connecting with someone on a human level is enough to get them better. There is plenty of pain and suffering in the world. More low trap or gluteal strength is not always the answer!
5. Shutting down other health professionals is a poor example of our character as a profession. It is an unacceptable way to state an opinion and should never happen.
4. There is a reason massage therapy is a >12 billion dollar industry. While it might not work on paper, people enjoy it and are willing to spend their own cash on it. More importantly, people tell their friends about how great it is. Physical Therapy needs to become a profession that people value and are willing to spend their own money on.
3. We are the only doctoral profession embarrassed to tell people we are doctors! This has got to change. We worked extremely hard for those letters. Embrace them.
2. We search too hard for answers to our client's problems. If we simply slow down to listen, the solution usually presents itself.
1. Physical Therapists should be the provider of choice for all musculoskeletal and movement based problems. We have more than enough intelligence and offer an amazing product. Now, it comes down to our ability to sell- not shamelessly, but with passion and pride! Get out and sell our amazing profession.
Author: Jim Heafner PT, DPT, OCS
Jim is one of the founders of The Student Physical Therapy. He is owner of Heafner Health Physical Therapy in Boulder, Colorado.
Want to learn more from the author:
Check out his Ebook and other online resources:
1) The Guide to Efficient Physical Therapy Examination
2) The Anatomy of Human Movement
(Save $10 on either offering by using the promo code: Top10)
One year ago I entered into the OPTIM Certified Orthopedic Manual Therapy Program. I had been wanting to sink my teeth into something of substance to improve my skills and thought process for some time now and felt a program that was longer than one weekend would be best. I looked into other COMT programs but found them to be unorganized and very lengthy to complete the entire program. Fortunately my colleagues from TSPT and friends Dr. Chris Fox and Dr. Jim Heafner were already instructors for the OPTIM program.
When looking into OPTIM’s program what attracted me the most was the ecletic approach they took. What I mean by that is that one school of thought was not the focus of the year long program. Instead, many different approaches were taught and offered. To me, this was very important. Another thing that stuck out to me was the emphasis on learning more on pain science. This was an area that I felt PT school and residency was lacking. Thus, learning this was important to me. Lastly, I knew from my colleagues Chris and Jim that ample time would be spent teaching and practicing techniques.
So, one year later I am approaching the completion of the program. I can honestly say it was money and time well spent (and significantly cheaper than other COMT programs I might add). The program is really more like a residency as it requires quite a bit of time every month outside of the 7 weekends spent in Phoenix, AZ. There is weekly mentoring sessions online via Zoom call, Medbridge courses, and workbooks to be studied and reviewed. Additionally each weekend class goes over techniques and concepts from previous weekends to ensure constant repetition. After all, manual therapy is really a motor skill that must be practiced over and over again to improve upon.
For those of you interested in seeking quality learning and are dedicated to putting the time in to really make a difference in your skills I would highly recommend this program. And don’t worry, students are also welcome and I think it’s a great adjunct to PT school. Feel free to email me for more information or check out the OPTIM website here: http://www.optimfellowship.com/
Dr. Brian Schwabe, PT, DPT, SCS, CSCS
Recently, a fellow physical therapist and friend came to me for some guidance regarding a case he was having difficulty managing. Below is a synopsis of his initial evaluation. After reading his initial evaluation, please write down a few notes or comments (positives, negatives, things you may have done differently, or further questions). Following his evaluation, I provided my response to certain questions and treatment ideas to provide further insight into his case.
Therapist Initial Evaluation (my friend):
Electric shock from the right low back to distal hamstring with a variety of different movements. Prior injection resolved S1 distribution numbness.
-Spine: normal spine curves
- Hips: narrow, symmetrical hips
- Knee/ankle: genu varum
-Tenderness and tightness into piriformis
Functional movement testing:
-Inline lunge: increased hip flexion, but movement was painfree
-Hurdle step: R lower extremity in WB- poor hip motor control
-Gait: no pelvic innom. rotation
- Squat: inc hip flexion, HS avoidance, R sided lumbar pain "catching"
- SL squat: medial collapse, 'shakiness bilat'
- SL stance: R sided LOB
- SL step down: avoided WB through R via trendelenburg
- Elbow flexion iso #8: paraspinal recruitment thoracic/lumbar, no TA activation
-Bent knee fall out: min TA activation
-Hooklying marches: mod TA activation; limited hip flexion to 105 deg because it will trigger pain
-ASLR: tight HS, no neural symptoms
-PSLR: 50% of WNL with back pain
Muscle length testing:
HS 90/90: R 145, L 155
+ Thomas B, inc sx
L Ely's + at 110 knee flexion, R WNL
+ ITB R, WNL L
Passive range of motion:
Hip 110% WNL with catch during full flexion
Overall Assessment: Pt is a 45-year old male presenting with chronic, insidious onset of low back pain with R sided, electric shock sensation down back of leg and into distal hamstring. Pt has movement impairments with hurdle step (R WB poor hip motor control), gait with minimal pelvic innominate rotation, SL squat with medial knee collapse. Additionally he had frequent R lumbar spasming reported during exam. Pt has functional limitations in running, rowing, and ADLs, sleeping.
Initial HEP prescribed: L thomas test stretch, L hip flexor Stretch, hooklying isometric marching
My Response to Evaluation:
1) From his symptom description and testing, we know he has some level of nerve irritation. I would perform a SLUMP test. If positive, neural glides could be a great treatment for symptom relief.
2) How is his hip mobility, hip IR/ER range of motion and end-feel? Commonly limited hip mobility places stress on the lumbar spine due to improper loading through the hip joints (from his SL squat and other functional movements, he appears to be offloading his right hip).
3) How is his thoracic spine mobility?
4) The patient appears to have increased hip flexion with various movements. Be sure this is not actually early/excessive lumbar flexion. (See link to a post I wrote on hip flexion vs. lumbar flexion
5) The patient appears to have poor coordination between the lumbar spine and hip joints. I would look at more basic movements, such as hand heel rocks (butt to heels in quadruped) to assess lumbopelvic disassociation and general spinal mobility.
6) How is lumbar extension? Many people lack lumbar extension due to prolonged flexion (see point 4 above) and become sensitive to that movement. Retraining lumbar extension throughout repeated loading is often beneficial for range of motion, mobility, and nerve irritation.
My Response Assessment:
Incorporate further mobility exercises for the hip and thoracic spine (likely). Stretching (as he initially prescribed) can further excite nerve symptoms and cause irritation. Additionally, I would incorporate more neural tensioning exercises for symptom management. Since the nerve is irritated, add the recumbent bike or low level total gym for nerve nutrition and proper loading through the hip. From a manual therapy perspective, I have seen good results with lateral hip mobilizations using a mobilization belt. This can improve hip mobility and reduce neural tension. Finally, basic exercises like Cat/Cow are good for emphasizing thoracic extension and are a precursor for lumbopelvic mechanics.
-Jim Heafner PT, DPT, OCS
In the push for advancing evidence-based practice in the orthopaedic setting, the APTA has been working on compiling the research for etiological factors, examination, treatment, outcomes, and more for various pathologies. These collections are known as the Clinical Practice Guidelines (CPG's). There are currently CPG's for these pathologies:
-Low Back Pain
-Hip Pain and Mobility Deficits
-Non-Articular Hip Joint Pain
-Knee Ligament Sprain
-Meniscal and Articular Cartilage Lesions
-Ankle Stability and Movements Coordination Impairments
A couple years ago, the APTA released the CPG's for free viewing to all at this link. A lot of work went into developing these guidelines and they are some of the leading sources of evidence-based practice and preparation for the OCS. While the articles may appear lengthy, there are summary pages at the end of each one as well. Check out the CPG's when you get a chance for a great summary of current best practice!
-Dr. Chris Fox, PT, DPT, OCS
Every year, around this time I start hearing questions about if it is worth pursuing clinical specialization. Recently, I even saw a forum post asking if the specialization warranted a raise. It's a highly debatable topic, but absolutely worth discussing. As you know, the APTA offers clinical specialization in various fields, like pedicatric, orthopaedic, sports, and more. To become a certified specialist, one must past the specialization exam for the respective field which is offered once a year. To qualify for the test, one must either complete a residency in the field or a certain number of hours (1-2 years worth usually) treating the appropriate field and apply for sitting for the test.
Now, whether or not clinical specialization actually changes practice patterns or represents a true expert knowledge is a debate by itself; however, the question that comes more frequently is does it (or should it) translate to a raise. I think what is key to help justify a raise is how does it benefit your clinic. One might initially think improved outcomes, however, I believe that studies have shown little change in outcomes compared to non-specialists. It's not that specialization isn't worth it, but I believe it is not being marketed properly. My current clinic has done very little to market it. It is not labeled on our website, in our office or on my cards. Part of it may be to keep therapists appearing on the same level (to facilitate sharing patients), but it may be due to lack of knowledge of how to market it. I honestly do not know.
While I did get a raise with specialization, I believe there are more benefits to pursuing specialization than just financial incentive. There are definitely aspects of evidence-based practice that are presented in each monograph for the OCS that are beneficial to clinical practice. Also, I think there is definitely something to be said about knowing a standard of orthopaedic knowledge and recognizing that level of knowledge with specialization. It is rewarding and can help identify clinicians with that knowledge. Additionally, it may open up opportunities that may otherwise have been closed. Recently, I interviewed with two companies that were looking to hire a clinical specialist as their staffs are primarily made up of specialists. While I did accept an offer from one of the companies, I cannot for certain say I would have had the opportunity to interview for either or both companies if I weren't a specialist. The potential benefits for clinical specialization lie beyond immediate financial improvements.
-Dr. Chris Fox, PT, DPT, OCS