At least once a year I make an attempt to argue for the benefit of reaching beyond the current clinical standards. There are many who live and die by a single pillar of evidence-based practice: research. While it is an essential component to improve our practice patterns, it has limitations. Some of the crazier techniques out there are currently impossible to standardize and accurately assess. Should this alone make them useless? The other pillars include patient beliefs and clinical experience. With the power the mind plays in pain and dysfunction, it is essential we do whatever it takes to help our patient, even if the higher level research doesn't support it.
Am I saying we should abandon what decades of research have taught us? Absolutely not. This evidence should absolutely guide our decision-making, just not rule it. For example, should a patient come in with patellafemoral pain syndrome, the evidence says we should incorporate quadriceps and gluteus strengthening. However, if tibial IR mobility is limited, we may possibly significantly improve the patient's function and pain through simply addressing that. There is no research to support this concept but has been seen clinically by many clinicians who implement repeated motions.
Even repeated motions has some sort of foundation of research. There are other techniques and schools of practice out there that are laughed at and have shown significant clinical success, such as visceral treatment, craniosacral, dry needling and more. I'm not sure these techniques can be categorized the same way much of the EBP followers are used to, but success can be shown with implementation of asterisk signs (even if we don't know the mechanism). Without some individuals attempting to go outside the current boundaries of evidence-based practice, we would fail to learn not only what techniques or treatment styles work, but also what doesn't work.
-Dr. Chris Fox, PT, DPT, OCS
Regional interdependence is a concept regularly being taught currently, that describes how a limitation in one region can affect the movement and pain in another region. For example, limited thoracic rotation may limit overall shoulder elevation mobility and result in excessive wear/pain. With a standardized mobility examination (like the Selective Functional Movement Assessment - SFMA), we are better able to pick up some of these deficiencies.
While a system like the SFMA is built more on musculoskeletal limitations, it can be useful for other systems as well. Some of you may have seen my post a couple weeks ago on my experience with visceral therapy. It is said that there is a visceral component in 80% of musculoskeletal injuries. Some of my thoracic extension mobility restrictions were secondary to visceral issues. The concept makes sense generally speaking if you think about how any tissue can theoretically resist motion. With referral patterns for pain as well, they can present with a sort of pattern. That doesn't mean visceral restrictions cannot improve without visceral treatment. However, it does mean we need to be extremely thorough with our examination. If cervical mobility is limited due to a restriction in the liver, there will unlikely be much improvement if only the neck and upper quarter observed. A system like the SFMA forces you to look at the entire body and possibly have some success through treatment. In being forced to be thorough, you will be much less likely to miss significant findings, that at first glance, appear minimal.
Be sure to check out my post on my experience with visceral therapy from a couple weeks ago. I'm excited to be signed up or the level 1 course in April! Check out www.barralinstitute.com for more details on their methods of treatment/evaluation.
-Dr. Chris Fox, PT, DPT, OCS
Whether a physical therapist is performing a cervical evaluation or ankle evaluation, analyzing a patient's gait pattern should be a standard aspect of every examination. The information gathered during this functional assessment will allow the clinician to quickly make educated decisions regarding the patient's overall presentation. For example, if the patient has a compensated Trendelenburg during the stance phase of gait, one can assume the strength or motor control of the Gluteus Medius is insufficient. One's ability to recognize these patterns will ultimately differentiate a novice clinician from an expert.
Gait Analysis Considerations
If you are looking to improve upon your clinical skills, orthopaedic knowledge and clinical decision making, consider joining OPTIM's COMT program. With OPTIM, you can expect a residency-like learning experience without breaking the bank, all while learning from highly skilled physical therapists. Check out optimfellowship.com for more information!