Have you ever seen or had a patient that has been doing exercises (maybe even ones that you've prescribed) for some specific muscles, but they continue to test weak, despite weeks or months of doing the exercises? It doesn't make sense. A weak muscle should respond to exercise right? What should you do at this point? There are 3 possible answers that I want to go over, in no specific order.
First, and perhaps most obvious, the patient may not be loading or performing the exercise properly. For example, if the patient is performing a clamshell, but instead of hip ER, they are rotating their spine, the muscle isn't being properly stimulated. That doesn't mean that there isn't still a benefit to the exercise, but it may not develop strength properly. In regards to loading, if a patient can perform an exercise for 20 or 30 repetitions, they may improve muscle endurance or neural activity, but it's unlikely strength changes will occur. One of our first steps with exercise prescription should be ensuring proper technique and appropriate dosage.
Second, the muscle may not be improving in strength due to neural inhibition. If there is insufficient neural input, the muscle will have difficulty fully firing, despite the load that is put on the muscle. For example, if the femoral nerve has decreased nerve conduction due to restricted lumbar mobility, the quadriceps may not improve strength even with hundreds of squats. With these patients, our goal should be to improve the neural mobility at each point of restriction. At that point, the muscle may test completely strong without ever having done one strengthening exercise. An example of this is when a patient with weak L5 myotomes tests completely strong simply with some sideglides or press-ups.
Finally, a patient may not progress in strength due to non-musculoskeletal issues. Issues can include conditions like multiple sclerosis, fracture, tumor, etc. But biopsychosocial factors can absolutely contribute as well. With how powerful the mind is, there may be some individual factors that are blocking any potential strength improvements. More medical conditions obviously warrant further testing and referral to the appropriate practitioners, but the biopsychosocial factors can be addressed by us as physical therapists.
So how do we handle the next patient that comes in with weakness not responding to exercise? I recommend first checking the form for the exercise and how the dosage has been. Should those be correct, assess for any nerve or mobility restrictions that may be causing neurogenic inhibition. Address those restrictions and re-check the strength deficit. You should be able to see some change relatively quickly. If the patient fails to respond to those techniques, do some additional fracture, UMN lesion, cancer, etc. screening and refer out, depending on the results.
-Dr. Chris Fox, PT, DPT, OCS
Do You Struggle Applying the Principles of Pain Science?
Over the past several decades, pain scientists and researchers have made great progress in understanding and explaining pain. Unfortunately, even when the biology of pain appears to be simple, the answer is never straightforward. Each human being has their own set of experiences which impacts how they perceive pain. Science has shown us that using a biopsychosocial approach is integral in addressing these factors. This includes identifying one's biological, psychological, and sociological aspects that may be contributing to their pain. While this sounds great on the surface, it can be hard to apply these principles with each patient.
The Basics of Teaching about the Science of Pain
From my personal experiences, I cannot stress the importance of building a therapeutic alliance with the patient. As health and wellness providers, the ability to understand someone’s needs and tailor one’s language toward these needs will significantly influence the outcome of their situation. Building a strong therapeutic alliance is first and foremost! After a therapeutic alliance has been created, then the multiple factors that impact someone's pain can be explored.
Three main areas I address are mindfulness, nutrition, and sleep (with the primary one being mindfulness). Each of these areas play an important role in the sensitivity of the nervous system. Addressing these factors can reduce the sensitivity in the body’s alarm system to foster an environment of healing.
Strategies I Use to Implement Mindfulness
1) Manual Therapy: During manual therapy, I ask the question, "what do you feel?" This question brings awareness and perception to the patient's body part. It forces them to describe their current environment and take ownership over the symptoms they are experiencing.
2) Keeping a Journal of Symptoms: Journaling allows the patient to describe their situation and environment. It brings context around time, location, and external factors that may be influencing pain. With each journal entry, patterns will be identified that can help alleviate the onset of pain.
3) Meditation as Mindfulness. Identifying strategies to calm down the nervous system is beneficial. While this may seem to foreign for most people, meditation can be great for activating the parasympathetic nervous system- slowing down the heart rate and allowing the body to rest.
It is simply not enough to tell a patient to be more mindful OR watch what they eat! As a profession, we must do a better job providing solutions and offering resources to assist with the multiple factors of pain.
-Jim Heafner PT, DPT, OCS
A couple weeks ago, a video was discussed on some forums about allowing lumbar flexion during deadlifts. While I believe people have always had some lumbar flexion during deadlifts and squats, traditionally, many believe a "neutral spine" is required to safely load the spine during the movement. Recently, there has been an increase in education and awareness of the flexion motion of the lumbar spine during deadlifts and squats in order to help prove the normalcy of the movement pattern. It is in conjunction with the development and understanding of pain science research that we are learning how little abnormal movement patterns may matter. Does this mean we should change our complete philosophy of movements with strength training?
A couple years ago, I wrote a blog about changing scapular positioning during pressing motions. Many recommend performing a bench press with scapulae adducted in order to improve stability and open subacromial space. I proposed that we should consider altering the positions by adding protraction at the end of the bench press and shrug at the end of the military press in order to fully apply the strengthening exercise to the motions of the muscle fibers. The serratus anterior and pectoralis muscles have the function of protraction (SA also upwardly rotates the scapula). Why should we ignore that component of the muscle's function? There was some significant rebuttal from some clinicians out there on the basis of potentially damaging the rotator cuff by decreasing subacromial space. However, with the development of research showing the lack of correlation between pain and pathoanatomical findings, any "damage" that might be done with this movement pattern (if it actually occurs) can be deemed insignificant.
Now, I am not suggesting that you immediately start training these alternative movement patterns with the load you typically use for your usual exercises. A new motion requires a new start. You will likely have to use significantly less weight when doing your first Jefferson curl compared to a typical deadlift. The same applies to the military press when you add a shrug at the top of the motion. Initially you will be weaker with these motions, but by training them, you will improve your strength and stability for positions that some might label as "unsafe" or "faulty."
The real question that should come from these finding is should we decreasing our focus on research that emphasizes the biomechanical approach? If a RTC tear is not correlated with pain or possibly strength, why should we worry about how RTC tears develop? If a herniated disc doesn't correlate with pain or weakness, should we bother looking at studies focused on disc pressure? Personally, I believe we should still consider these concepts to some degree. Some disc herniations are significant enough to cause urinary retention. Arthritis may be significant enough to severely limit motion in a joint, decreasing the function of that joint. I am not saying that we should worry about every pathoanatomical finding either. I believe that there is possibly a middle ground to be met where pathology should still be considered, but shouldn't be the guiding force. I do not have the answer, but hopefully the research WILL continue in the mechanical area.
Dr. Chris Fox, PT, DPT, OCS
Yes, I said it. I train knee valgus. But hear me out before you jump to conclusions. Instead, watch a basketball game. Look at a basketball player grabbing a rebound or taking a shot. If I'm a betting man I say you will see valgus at least 10 times a game. Yes, valgus can be bad, but it doesn't mean it shouldn't be trained to control it.
Let's say you get a referral for a goalie who just had ACL reconstruction. How many of you would say you wouldn't train your goalie for return to sport activities? Well, part of that return to sport is training the goalie to get back to what they do best. Sometimes that means they prefer the "butterfly" position. In case you haven't seen what this looks like, its complete valgus. Yet, this is functional for their position.
So do we train valgus in the basketball athlete and the hockey goalie? In my opinion, we need to help them learn how to control those positions. If the glutes help externally rotate the femur that means it slows down internal rotation. Why not eccentrically train these muscles and also get the athlete into a "safe" position to learn how to control it toward the terminal phase of rehab? if they are going to do it anyway, then we should be helping them control the position to minimize the risk of injury.
Dr. Brian Schwabe, PT, DPT, SCS, COMT, CSCS
Board Certified Sports Physical Therapist
LEARN HOW TO TRAIN SPECIFIC SPORTS & POSITIONS FOR RETURN TO SPORT WITH INSIDER ACCESS
The April 2018 National Physical Therapy Examination is quickly approaching. Since >50% of the examination covers musculoskeletal and neuromuscular content, it is important to spend ample time reviewing Orthopedic evaluation and examination. A portion of the Orthopedic examination is the special tests. While many of these special tests do not demonstrate good reliability individually, the diagnostic accuracy improves when clustered together. In this post, I outline the top 5 most important tests to know for the NPTE.
NPTE Studying Posts
Important Special Tests for NPTE
Importance of Test: The anterior cruciate ligament stabilizes against anterior translation of the tibia on the femur, due to the attachment at the anterior tibial plateau and posteriorly on the medial side of the lateral femoral condyle (Neumann 534). The force applied by the examiner stresses the ligament, and is a better test for assessing the integrity of the ACL in acute injuries compared to the Anterior Drawer Test for various reasons. The position of 20 degrees of knee flexion is a less painful position than the 90 degrees required for the Anterior Drawer Test; thus, there is a lower chance of protective spasms from the hamstrings. Also, in 20 degrees of flexion, the ACL is more maximally stressed and can be assessed more accurately, because other tissues due not limit anterior translation of the tibia ("Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis"). It should be noted that patients with a torn PCL may test positive with a Lachman test. In the starting position of the Lachman test, the tibia will rest further posterior than usual due to the absence of the PCL, leading to increased excursion during the test (Manske, 2006). This means PCL integrity should be assessed prior to looking at ACL integrity. Often with ACL injuries, other tissues and structures can be injured as well. One of the more significant findings recently has been bone contusions with ACL injuries. Look for research on the topic coming out soon!
Similar to the hawkins-kennedy test for impingement, it is again important to cluster this test’s results with other tests and measures when assessing for rotator cuff tears. The cluster for a full thickness rotator cuff tear includes 1. the Drop-arm sign, 2. the painful arc sign, and 3. infraspinatus manual muscle test.
If all three tests are positive, the +LR is 15.6.
(Note is 3/3 are positive and the patient is greater than 60 years old the +LR increases to 28)
If all three tests are negative the -LR is .16
If ⅔ tests are positive the +LR is 3.6
Note: Two of the three tests for this cluster are the same as the impingement syndrome cluster. The differentiating factor between impingement and rotator cuff tear is the drop arm sign for full thickness rotator cuff tears and hawkins-kennedy for subacromial impingement.
Importance of Test: This test's results can be interpreted in multiple ways. Like other neural tension tests, the test may indicate if a patient is experiencing symptoms related to nerves adhering to various tissues while travelling throughout the body. The patient may experience stretching, pain, or other neurological sensation in the area of adhesions. Another use for the test is detecting lumbar disc herniations. With the flexed lumbar spine and hip completed simultaneously with the extended LE, the sciatic nerve and its respective nerve roots are put on tension to detect the potential of a disc herniation. The results of the test should be interpreted based on the patient's pain/symptoms for which they are seeking treatment.
Looking for a more efficient way to incorporate the special tests into your examination? Check out Dr. Heafner's Guide to Efficient PT Examination.
Importance of Test: If a patient tests positive on the Vertebral Artery test, they may have Vertebrobasilar Insufficiency (VBI), but if they test negative on it, you CANNOT rule out Vertebrobasilar Insufficiency. The theory behind this test is to maximally stress the opposite vertebral artery by stretching it to decrease the space in the lumen of the artery. The position of extension with contralateral rotation has been shown to decrease the diameter of the artery, but, again, the diagnostic accuracy of the test is still poor.
Importance of Test: Whenever a you encounter a patient that has neck pain as a result of trauma or cervical instability, you should always inspect the integrity of the transverse ligament before any other exam measures. The transverse ligament is responsible for keeping the anterior facet of the atlas against the dens of the axis. It attaches on the medial side of each large, lateral process of the atlas with the anterior side of the middle part touching the odontoid process. This creates a wide space in the vertebral canal for the spinal cord to pass through, posteriorly. When the transverse ligament is damaged, the atlas can slide forward on the dens, decreasing the size of the vertebral canal for the spinal cord to go through. This can result in neurological symptoms, such as pain, weakness, a lump in the throat, etc. In this compromised position, any movements can impinge upon the spinal cord and cause potentially irreversible damage. The supine transverse ligament stress test works to reproduce symptoms in an instability patient, because the test works to decrease the space of the vertebral canal by pushing the atlas anterior on the axis. This motion is normally blocked by the transverse ligament. The Sharp-Purser test should be performed before the Transverse Ligament Stress Test, because the Sharp-Purser test works to reduce symptoms, while the Transverse Ligament Stress Test works to reproduce symptoms. (“Clinical Testing for the Craniovertebral Hypermobility Syndrome”).
Any Tests We Missed?
Add them to the comment section below and tell us why!
-Jim Heafner PT, DPT, OCS
During one of my recent mentoring sessions for my fellowship, we saw a patient that had plateaued in progress. The patient was being seen for right upper extremity pain. The patient initially presented with pain that was associated primarily with cervical radiculopathy signs, such as bakody's sign, (+) cervical distraction test, (+) ULNT, etc. The patient initially responded great to PT as the radicular signs completely normalized. However, some right anterior shoulder pain remained that presented with signs of symptoms of shoulder dysfunction (anterior glide medial rotation syndrome, weak shoulder ER, restricted IR mobility, etc.). We gave him a few exercises to address these deficits. After a couple weeks, the pain in his shoulder had not changed and we had to decide the next course of action.
The patient's initial reaction was to "give up and live with the pain." We initially talked about the possible benefit of an injection to address the pain, however, that was when our discussion switched to plan of care directly regarding PT. Upon examination, the patient still had restricted inferior GH capsular mobility, shoulder ER strength and scapular strength deficits. While the pain had not improved, the impairments had, but still had dysfunction remaining. When I first came out of school, I may have referred this patient back due to lack of progress, but with the deficits remaining, I would recommend continuing PT. His pain at this point still has impairments associated with it that can be addressed by PT, so we modified his HEP to focus on these strength and mobility deficits.
Don't be so quick to give up on a patient's rehab. It is easy to become concerned when the patient isn't responding as we had hoped, but that is why it is essential to regularly evaluate the patient's progress in strength, mobility, flexibility, etc, instead of simply referring the patient back. It helps us track progress and helps the patient understand how they are responding as well. A change in the treatment plan or perspective may be necessary, or continue along the path the patient is currently on if progress is being shown.
-Dr. Chris Fox, PT, DPT, OCS
How many of you offer annual wellness screenings? How many of you would like too?
As physical therapists, many times we get so stuck on offering reactive services (after injury) that we forget how valuable we really are! Think about it, we study the human body and how to move properly. Yet, as PT's we do a poor job of describing what we do and how much value we bring.
This brings up the idea of offering annual wellness screens. After all, people visit the dentist, their doctor, and their accountant every year but don't get a check up on their bodies and they have to live in them everyday. We must get out of the thinking of PT only as reactive and start thinking about how much more we can help people. How many people say to you they start a fitness program only to get injured and have to stop? Or the desk jockey that says they used to be an athlete but now always feels stiff? These are perfect times to bring up how easy it would be to do an annual screen to prescribe suggested mobility or strengthening exercises to improve their condition and prevent future injuries.
So what do you include in an annual wellness screen? Well, there are many things you could include but remember we are movement specialists so I would make sure you include major movements such as the overhead squat, shoulder functional ER/IR , lumbar ROM, and various breakouts based on the dysfunctions. You also want to tailor the screen to the person's individual activity. If they are a runner include some single leg squatting and hip extension screens. If they are a tennis player look closely at their overhead stability and mobility. This will ensure that the person you are screening feels the value in what you are doing for them.
Remember that as PT's we offer a service and we bring value to people. Start to educate yourself on an elevator pitch and really think about some of the other services you can offer your current patients or future patients. We can do a lot more for people to help them.
Dr. Brian Schwabe, PT, DPT, SCS, COMT, CSCS
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With this past month's JOSPT, an updated Clinical Practice Guideline (CPG) for Knee Meniscus and Articular Cartilage Lesions was released. Meniscus tears and cartilage lesions are commonly seen in the physical therapy setting. Once thought to require surgery, significant research has since revealed that outcomes are similar whether you have had surgery or physical therapy about a year later.
While being able to identify the potentially injured tissue can be beneficial, treating the impairments remains the basis for intervention. However, because of the research that has been accumulated in managing meniscus and articular cartilage injuries, it is still recommended that we identify when these structures may be involved.
Now, some of the research for treating these injuries conservatively is based off of post-surgical management. A lot of the rehab is what you would expect: start with progressive active and passive ROM training and weight-bearing, followed by strength training in open- and closed-kinetic chain and neuromuscular training of lower quarter. Those are generally vague component to rehab but can be highly effective. Of course, not all cases are "text book." Sometimes (or often), the patient's perspective of what the injury is, or what they think it is, is more important than anything. It is extremely beneficial to educate the patient on the current pain science research, the lack of correlation between pathoanatomical injuries, and the success of conservative rehab for meniscus/cartilage injuries.
The importance of progressive loading cannot be overstated. While part of the CPG, using regular and progressive loading can have both mechanical and psychological benefits. There is some research out there that high repetition, low load exercise can be beneficial for cartilage repair. On the biopsychosocial side, progressive loading of the injured area can address some of the fear and apprehension associated with injury. Either way, the main message to take away is that physical therapy can be a possible treatment for meniscus or articular cartilage lesions, based on the recent CPG's, mechanotransduction, and/or psychological benefit.
-Dr. Chris Fox, PT, DPT, OCS
Today's post is from Meredith Castin of The Non-Clinical PT. Thanks Meredith!
You’ve probably heard plenty of grumbling about how the times are a-changin’ in the PT world. Reimbursements are falling and salaries are stagnant at best. Perhaps your loans are looming at epic proportions and you wonder how you’ll ever land a job where you’ll pay them off, much less make a solid living in the process.
Here’s the thing. Lots of PTs are extremely successful in today’s healthcare climate--they’re just changing their approach by seeing themselves as a hot commodity and putting themselves out there as soon as possible.
If you spend any time online (which you must, if you’re following this awesome website and reading this article), you’ll notice that some PTs are just savvy with technology. They’re putting themselves out there and they’re getting noticed. They’re interacting with influencers online and they’re making names for themselves before they’ve even finished PT school.
They’re creating their own online brands for themselves, and you bet your bottom they’ll be the ones getting snatched up for the best jobs when they graduate!
Frankly, I was not that person during school, and I regret it. I waited until I’d been out of school for four years before I even started to make a name for myself online, and I’m writing this article so that you don’t make the same mistake.
Start That Website:
If you’re a PT student or a new grad, you need to start a blog or a website--whatever you want to call it. It’s easy. Just hit up Wix or Squarespace, or Wordpress (that’s my fave and what I use for TheNonClinicalPT.com), and it’s blindingly simple to get things started. But here’s an inexpensive class to de-mystify Wordpress, just in case you like to understand all the bells and whistles, and get an idea of how to maximize your efforts. I do recommend taking a basic course.
In any case, writing about a topic for long enough eventually makes you the expert on that topic. Whether you opt to stay in patient care or leave patient care to leverage your physical degree in a non-clinical career, you need to write about something at least loosely related to physical therapy. Write about what interests you, and what comes naturally. You’ll never find me writing about tibiofibular mobilizations because I don’t find that topic inspiring. I write about non-clinical careers about PTs because that’s what I know.
As for you, you can talk about studying success, the trials and tribulations of being a student, careers, finding good clinicals, technology, networking, ballet, badminton, or whatever else you feel compelled to cover.
Notice how I included ballet and badminton? When I first started writing, it was at the behest of my co-worker (at the time), Brett Kestenbaum, DPT. He wanted to start a website for new physical therapists and I was like, “I don’t really like being a PT. I don’t even know if I want to keep treating patients much longer. Why would I create a website to help new grads? What if I have nothing to offer? WHAT WILL I WRITE ABOUT?”
Well, I figured, at least I knew I liked writing, so I went for it, and I wound up writing about the one thing I did know--how to get the most out of my degree without burning out. I didn’t enjoy treating full-time, so I covered topics about working per diem, preventing burnout, and alternate paths for physical therapists.
Lo and behold, after I started writing about my favorite topics--leaving patient care and leveraging my degree to become a writer, I found that people started seeking me out to do exactly that: write. It was a wonderful feeling to finally build a career around something I love.
And it wound up being my “golden parachute” for when I really did decide I needed to leave patient care behind.
That’s why you need to write. You can’t predict what will happen to you. You might want to leave patient care, or you might want to land a dream job working with professional badminton players. Or dancers. If you write about dancing, even while you’re still in school, you know a hell of a lot more about dancing and PT than 95% of the public. And as you gain experience, that number will climb to 99%. And with your name out there as being the expert about dancing and PT, you’ll land those dream jobs working with ballet companies much more easily than if you were too lazy to start a blog.
What If I Really Suck at Writing?
It’s OK...if you really hate writing, or really suck at it, you have a few options:
The main point is that you’re putting yourself out there. When you’re a student PT or a Fresh PT and you’re competing with all the others to make a name for yourself, you simply have to do something special to stand out. Otherwise, you might find yourself ten years into your profession, wanting something new, and having to start from scratch when you’re already feeling burned out.
I guess I probably should really have called this article “Why Every PT Student Needs to Put Himself or Herself Out There.” But that doesn’t really have the same ring now, does it?
Meredith Castin, PT, DPT (The Non-Clinical PT)
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If you work in a sports medicine environment like I do, then chances are you are getting quite a bit of ACL reconstructions this time of year. With ski season in full swing, unfortunately, many end up with ACL tears. However, a good majority of these patients are recreational skiers that like to dabble in many other sports.
I recently had a few patients who asked about return to running following this surgery. This is always a time when I like to educate the patients on what I want to see from them to get them back to running. By establishing some criteria early on, it allows the patient to get in the mind-frame of what they need to accomplish as well as setting some goals. However, there are many different opinions to what should be established for return to running post ACL.
From my perspective, besides time frame and MD clearance, I like to see a few biomechanical considerations. For example, I like to have a patient single leg squat a minimum of 10-15x under control with good form. What do I consider good form? Well, I often use the single leg stepdown criteria that has been established in some of the literature. Another thing I will look at is core stability. Specifically, I typically like to use a front plank with reciprocal arm drivers. The idea being that this test will look at rotational control when a patient is mimicking the arm swing during running. Again, a general time frame I use is at least one minute. Lastly, I like the reverse lunge for looking at great toe extension and hip extension.
Remember that running is a full body exercise and it requires lots of moving parts. While the above is not completely comprehensive, it gives a good starting point to look at with running. Lastly, if you like this article, check out the post I made for New Grad Physical Therapy on some of the above criteria and more with pictures. Or check out our Insider Access page where I go into very detailed return to sport criteria and exercises for multiple different sports and movements, such as return to lateral agility.
- Dr. Brian Schwabe, PT, DPT, SCS, COMT, CSCS
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