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
Recently, one of my co-workers was treating a patient that had been a couple times over the last couple years for the same injury: groin pain. While it had improved some with PT in the past, it never got 100% better. Typically, with recurrent "strains" we tend to think the nervous system is at fault, which leads to spinal and neural mobility training. However, in this instance, the patient was only having some improvement with dry needling (still never complete improvement in pain).
While I am still far from proficient with my visceral manipulation techniques, my co-worker wanted me to take a look at this patient due to lack of improvement. The visceral manipulation course I took recommended a standard assessment of both general "listening" and local mobility testing. I have only been practicing local mobility testing. While there are more organs that can refer to the groin for pain than I am trained in, I was aware that the cecum can refer to that region, based on the material I was taught. I assessed and treated any mobility restrictions that I found in the 3 planes.
As I've stated previously, the Barral Institute claims that effects for visceral manipulation may occur within 3 weeks of treatment; however, I have experienced the most significant changes occur within 3 days of treatment (not usually same day). When I followed up with this patient the next week, he claimed he was 100% pain-free for 3 days afterwards - something he had not experienced with any other treatment. Now there are too many variables to say that what I did or what I claim to have done was the reason this patient had an improvement. It may have simply been a novel stimulus to the nervous system. It may only be a temporary fix. There are many reasons to be skeptical; however, the fact that the symptoms could be affected by the treatment is intriguing. I look forward to learning more about the potential benefits of this treatment style and will be sure to keep you all updated!
-Dr. Chris Fox, PT, DPT, OCS
One of the difficult aspects of applying current research for treating various pathologies is that not everyone experiences an injury the same. Not only do we have to incorporate injury-based research, but we also should consider aspects of pain science research. Each component of the pillars of evidence-based practice should be incorporated in patient management.
Have you ever wondered why two patients with the exact same diagnosis can present completely differently? While one might retort that the severity of pathology (amount of arthritis or tendon degeneration), imaging studies regarding pain science have found that often presenting with a worse experience can easily present with minimal pathoanatomical findings. Pathology does not equal injury and hurt does not equal harm.
When an individual experiences pain, there are many different factors that go into it. Pain is actually that, an experience. Have you ever noticed how a baby looks to their parents to see how to react when hurt? Or how an individual might describe their pain differently based on the setting? Past experiences (their own or family members), social expectations, individual expectations, fear and much more can influence a patient's injury experience. Because of that, we cannot address every patient with "achilles tendinopathy" the same. We must incorporate their individual expectations, beliefs, and stressors into consideration when managing their care. While it can be upsetting that we aren't able to treat based on pathology alone or even regularly apply pathology-based research to our care, we are fortunate to understand WHY not all people experience an injury the same way. By further developing our understanding of pain science, we will hopefully be better able to treat our patients in the most efficient and successful way.
-Dr. Chris Fox, PT, DPT, OCS
As part Optim Manual Therapy's COMT Program, we have weekly case discussion sessions online. Below is a sample of a recent session on a patient with chronic low back pain. How would you have handled the case differently? While we include the typical didatic material, manual assessment/treatment techniques, OCS prep, online courses, and exercise prescription, regular mentoring is the essential component that sets us apart. It helps to develop clinical reasoning and decision making. Check out www.optimfellowship.com for more information or feel free to reach out to me.
-Dr. Chris Fox, PT, DPT, OCS
It has been long thought that elevated cholesterol served as an increased risk for heart attack or stroke. Frequently, doctors prescribe statins to lower cholesterol, and they have been shown to be effective in doing so. That being said, there are many side effects that must be considered: liver damage, hyperglycemia, neurological side effects, and muscle pain/damage. For this article, I want to highlight its effects on muscles.
About a month ago, I had a patient s/p partial meniscectomy. On one of the follow up sessions, he mentioned he started getting full contractile muscle spasms in his forearms. While I had been familiar with calf pain and spasms as side effects, the violent contractions this patient described was unusual, so I had him call his cardiologist, who had recently changed his statin medication dosage. The patient was instructed to go see his cardiologist and have some tests performed. When the patient returned a week later, he informed me that his doctor had hospitalized him, running many different tests. His symptoms had gotten so bad his entire body when into contractile spasms that would even force his spine into various motions. Eventually, it was determined that the statins were the cause of the muscle spasms and the medication was then adjusted, resulting in reduction in symptoms.
Now I recognize it is difficult to know every single side effect of every drug. The best option is to either know the general side effects of each class of medication and look up each drug as you scan a patient's medication list. Over time, you will become more familiar with each drug's possible interaction, but with how commonly statins can present as "muscle pain," I recommend recognizing when a patient may have related side effects.
-Dr. Chris Fox, PT, DPT, OCS
Lateral ankle sprains are among some of the most common sports medicine injuries each year. We often see this injury with basketball players as we did recently with Kawhi Leonard in the NBA playoffs. However more often than not, unless its a grade III sprain, we can get our athletes back on the court or field pretty quickly. Yet it seems like this is an injury that is often prolonged because of a few critical mistakes early on in rehabilitation. Let's talk about what you can do to quickly get your athletes back in the game.
Critical Points to Consider
There are a few questions you have to ask yourself when an athlete comes in to see you. First, do they have a broken ankle? Refer to the Ottawa Ankle Rules when considering if they need an X-ray. More often than not they don't if they can walk and are not tender to touch over bony areas. Second, do they have a high ankle sprain? While less common, this does occur. Be sure to take a through subjective report to understand the mechanism of injury and previous injury history. The last thing to be sure to consider is what the athlete's practice and game schedule is like. If you can get your athlete in to see you everyday for the first few days you can do a lot of good right away to get things moving in the right direction.
The most important thing is to begin bringing down the swelling. Contrast baths, manual flushing, and elevation of the leg is typically very effective early on. However, one mistake I often see is therapists do not tape or compress the athlete after treatment to continue to improve the swelling. My favorite technique that I learned is a horseshoe technique that is great at improving swelling. Another technique you can use is squid taping with K-tape which is also effective. Lastly, if you don't have access to tape I would suggest having your athlete pick up a compressive sleeve.
The next part of rehabilitation is the ROM and strengthening part. Range of motion should start immediately as the ankle will stiffen up from the pain and swelling. Working on ROM exercises such as ankle circles, ankle pumps, and calf stretches in the beginning are fine but as the pain tolerance improves using half kneeling ankle mobilizations against a wall or manual techniques can make big differences. As far as strengthening goes, I typically like to start manually resisted ankle strengthening quite early as I can control the range of these strengthening exercises. Typically I will start by having my athlete match my pressure so it is more of an isometric contraction but will gradually open up the range. Other exercises include towel scrunches, marbles, ankle theraband, calf raises, and lots of core and glute retraining. Many research studies have shown the importance of strengthening glutes after ankle sprains and quite frankly it just makes sense to keep the body stronger above. In addition, improving work capacity early on can make the transition back to the court/field much easier. I like to get my athletes on the bike as soon as possible. If they cannot tolerate a bike I will get them going on the upper extremity bike. Lastly, working on proprioceptive balance exercises early on is important for furthering rehab. Start with just single leg balance and progress to unstable surfaces and using arm and leg drivers to change planes of motion.
1. Control swelling:
- Contrast Baths, Manual flushing, Elevation of leg, compression sleeve, K-tape, Horseshoe tape technique (favorite)
2. Range of Motion:
- Ankle pumps, Ankle circles, Baps board, Calf stretching (towel stretch, against wall, slantboard), Half kneeling ankle mobilizations against wall, Manual mobilizations, Bike for early movement or upper body bike to keep them in shape
- Ankle/Foot: Manually resisted 4 way ankle strengthening to ankle theraband to calf raises, towel scrunches, marbles. Glute and core retraining.
- Single leg balance, SL balance w/ eyes closed (stay close by), SL balance on airex, SL balance with arm and/or leg drivers to challenge further planes of motion
5. Work Capacity:
- Get them on the bike or upper extremity bike (if you have access to one) ASAP to keep them moving and in shape. AlterG is great for retraining gait and running
- Dr. Brian Schwabe, PT, DPT, SCS, CSCS
*Check out the Insider Access video on my return to sport progression & testing for ankle sprains*
Recently, I was mentoring with Optim Manual Therapy's online case study discussion and a case was presented where there was some confusion diagnosing peripheral neuropathy versus radiculopathy. Due to the similarity in presentation sometimes, I thought it would be good to go over some of the similarities between the two and how we can differentiate as well. I am going to focus on the upper quarter region, but the same concept will apply to the lower quarter as well. Below are a couple pictures of the peripheral nerve layouts and dermatomal patterns that I will reference throughout this post.
For starters, remember that both peripheral nerve lesions and radiculopathy are lower motor neuron lesions, so they can both present with corresponding weakness and hyporeflexia. Additionally, they can sometimes present with pain (or numbness/tingling) in similar regions. Think of the ulnar nerve and C8. Just because a patient has radiculopathy doesn't mean they have to have symptoms centrally/proximally as well. They both can present with symptoms along the ulnar border of the hand. Other regions have more distinct differences, for example, C7 tends to refer down the middle finger and no peripheral nerve typically presents in just that region.
As you can tell, there are a lot of similarities, so how do we differentiate? There are several things to consider. An extremely useful assessment style is assessing muscle strength in muscles that have similar segmental input but different peripheral nerves. We'll go back to our C8 vs ulnar nerve example. Both are heavily innervated by the same segment and can present with symptoms in the same location. A key assessment feature is looking at the strength of Extensor Pollicis Longus. It is innervated by the radial nerve, but it's primary segmental input is C8. Should a patient have weakness here, we would be leaning more towards C8 radiculopathy. If it is strong, we would lean more towards ulnar neuropathy. The same concept can be applied to other areas. Another useful assessment is neural tensioning. Should the patient's exact symptom be reproduced with it, we likely would consider the nerve involvement; however, often radiculopathy does have a neural tension component to it, so it is not as helpful as we would like.
Probably one of the best assessment techniques is using the cervical radiculopathy cluster developed by Wainner, et al:
-Cervical Rotation <60 deg to involved side
-(+) Median ULNT
-(+) Cervical Distraction Test
-(+) Spurling's Test
This cluster has been shown to have high diagnostic accuracy for identifying those with cervical radiculopathy and is probably our best tool (3 positive: +LR = 6.1, 4 positive: +LR = 30.3). While one would think that pain with segmental mobility testing of the spine would be useful if pain is recreated, people can have symptoms in two locations as a result of Double Crush Syndrome or altered neurodynamics. Regardless, the most important thing is that we treat all impairments we are presented with. If the neck is stiff in someone with ulnar neuropathy, I'm still going to work on improving neck mobility. They key is that if there is research for a specific treatment for a specific diagnosis, it is important we try and identify these cases. Also, remember that there are other sources for symptoms other than peripheral nerves and radiculopathy. Patients can also present with symptoms in the exact same region due to trigger point referral patterns, local strains/sprains and more. Hopefully this will at least help with differentiating between two similar presentations. Check out the Insider Access Page for more information on this !
-Dr. Chris Fox, PT, DPT, OCS
Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. "Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy." Spine (Phila Pa 1976) 2003 Jan 1.
A couple months ago, I did a mini-case study on one of my co-workers. As you may recall, he had pain with squatting in his left knee. Apparently, the knee had been bothering him for years, but with his recent running, the symptoms had increased. At the time, I had been able to reduce his symptoms with repeated motions to the lumbar spine and knee. While that worked for awhile, his pain significantly increased after doing a 5K a couple weeks ago. At that point, he came to me regarding to his knee pain not improving with the previously successful repeated motions, hoping for further advice.
Having no longer responded to the quick treatments based off my initial brief evaluation, I recommended my colleague go through a more structured treatment plan. He had gone to a dry needling course with no change in knee pain. I told him to focus on glute strengthening and high repetition/low load training on the shuttle press for thousands of repetitions. While he did have success with reducing his knee swelling and general pain with the shuttle press, he continued to have pain and a contralateral shift with his squat.
Last week, I had some extra time in the clinic, so I though I would mess around with some different equipment. For those of you regular followers, you may recall that about a month ago I took a visceral manipulation course. While I am still practicing the techniques each week, I thought I might try one for my colleague due to the theoretically and potentially odd effects. Being that my colleague's knee pain was on the left side, I thought I would try a stomach manipulation. I first performed a squat assessment of my colleague and he had pain and a contralateral shift. I then performed a couple stomach manipulation techniques and reassessed. During the squat immediately following the techniques, he actually fell posteriorly onto his glutes at the bottom of the squat. It sounds weird, but he actually did and he described his “orientation” being off. We then quickly reassessed and his squat was marginally improved. Having remembered that the primary effects of visceral treatment occur within 48 hours of the treatment, I again checked first thing the next day. It was completely normal and pain-free.
Now I am not saying that the stomach treatment was the needed fix for sure, as it is difficult to identify correlation with such a long time between treatment and results; however, there was definitely an interesting change after so many less successful treatments. If anything, this case makes me more intrigued to practice and begin applying the visceral manipulation techniques, so that I may better learn patterns for which to apply them.
-Dr. Chris Fox, PT, DPT, OCS
There are many jobs to advertise mentoring with few actually failing to live up to expectations. There are also different types of mentoring. Having completed a residency myself and being a residency faculty mentor, my experience has been one on one patient treatment and discussion. We problem solve various cases together and challenge each other on why we are doing what we are doing and possible alternatives. While that version of mentoring is ideal, it is unrealistic for employers to offer that regularly. Mentoring for other employers may mean journal clubs, chart audits, or case discussion with one of your co-workers. The concept of mentoring is understood in such a variety of ways that it is essential that prior to interviewing, you should make sure you understand what YOU want and what the employer is offering.
Now if the job you take doesn't offer what you are looking for, there are other avenues as well. Discussion regularly occurs on social media groups regarding cases or general topics, although, you may have to put up with some preaching occasionally on specific treatment approaches. Additionally, there are services you can pay for where you pay for an expert's time to discuss cases or whatever you want (such as Dr. E at Modern Manual Therapy). If looking for advanced treatment or assessment ideas, you can check out our Insider Access Page. For those looking for a long-term commitment to mentoring and clinical reasoning development in addition to learning advanced techniques, you can look for a program to join, such as Optim Manual Therapy's COMT program or other system based or non-system based programs. These can help to develop your clinical reasoning overall and hands-on skill. Programs like Optim, offer weekly case discussion online as part of the program. The key for you is to know what you want in mentoring, and then to go find it!
-Dr. Chris Fox, PT, DPT, OCS
This past weekend at the Optim COMT course, we were discussing squats as a form of treatment. While the squat is an excellent exercise for a variety of ailments, it is an exercise that is prone to many compensations. Combine that with pain in the knees or elsewhere, and form may be compromised even more. There are several reasons why the pain may impact the ability to squat, but tissue tension may play a role.
One of the common variations that is seen during squats is the "buttwink," otherwise known as posterior pelvic tilt and lumbar flexion. Typically we see this occur as the client nears their bottom depth of the squat. There are many possibilities as to why this may occur: lack of hip flexion, poor motor control, decreased spinal mobility/strength and more. Another possible explanation for lumbar flexion is poor quadriceps strength. As an individual with poor quad strength descends into a squat, they typically either stop early in the depth or display a compensation like lumbar flexion and forward trunk lean. To try and control the movement that the quads are insufficient to support, the body tries to rely on the passive tissue tension of the posterior chain and a shift in center of gravity anteriorly. As the "buttwink" occurs and the trunk shifts forward, the muscles, tendons, and ligaments become taut and provide a form of passive support to control the body during the motion. Over time, this may lead to injury.
So how do we fix this? There are many avenues to address this client, but strengthening the lower quarter should absolutely be considered. There are many ways to strengthen the quadriceps, and it may be tempting to avoid squats due to the client's poor form; however, the exercise can be modified to the appropriate level. Using an assistive device like a TRX or leg press can simulate the motion at less than body weight to allow proper form. There are some cases where adding a load to the individual actually improves form! Regardless, improving an individuals functional squat may be as simple as improving their strength.
-Dr. Chris Fox, PT, DPT, OCS