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.   

1) Weight bearing equally through both legs
2) Equal and adequate hip extension bilaterally
If the patient does not demonstrate adequate hip extension while ambulating, it is important to assess the strength of the gluteals and/or length of the hip flexors. Clinically, strong/dominant hip flexors will limit a patient's full hip extension.  
3) Trunk control during single limb loading
While watching a patient walk, does the torso remain relatively neutral? A common fault often seen in patient's with low back pain is excessive pelvic motion or rotation through the spine. This impairment may indicate poor motor control of the core muscles or poor lumbopelvic rhythm. If this is noted, further motor control testing should be performed.  
4) Lacking ankle and knee motion
If a patient lacks ankle dorsiflexion, they may compensate by out-toeing their foot or going into an early heel rise. In either situation, the gastroc muscle is not being utilized throughout the full range of motion. The compensation at the ankle can create achilles issues, knee pain due to the added stress on the quadriceps muscle, or low back pain.  
5) Trendelenburg or compensated Trendelenburg
The ability to remain upright through the hips will demonstrate the strength or motor control of the outer hip muscles. When either a Trendelenburg or compensated Trendelenburg is observed, it is important to assess gluteus medius strength. Additionally, this sign can be an indication to assess lumbar mobility, specifically lumbar side bending. The poor gluteal performance will often cause the low back to load asymmetrically with each step. 
6) Knee valgus during single limb stance
Observing knee valgus during the gait assessment is another indication for assessing gluteal strength. Knee valgus is typically accompanied by femoral internal rotation and adduction, both signs of inadequate gluteal muscle or hip external rotation activation. Additionally, knee valgus is common in people who over pronate. 
7) Excessive pronation or supination
Since I mentioned pronation above,  it is important to monitor for excessive supination as well. When supination is noted throughout the gait pattern, it may indicate joint mobility restrictions in great toe extension, subtalar eversion and/or restrictions in hip internal and external range of motion.  

Whenever analyzing one's gait pattern, be sure to be systematic. Either perform the assessment from top-down or vice versa. Look for common substitutions first, then verify these impairments during your joint-by-joint examination! Identifying these common movement substitutions will make you a more efficient clinician. Repeated clinical efficiency will create excellence! 

Jim Heafner PT, DPT, OCS

Want to learn more about efficiency? Check out Jim's ebook, "The Guide to Efficient Physical Therapy Examination." This book breaks down concepts similar to the gait analysis post above to help clinicians with pattern recognition.  Speed up your evaluation and give yourself more time to treat! 
Use code: TSPT50 to save >$20 on the book. 

OPTIM Manual Therapy is now enrolling the Dallas, TX cohort for the COMT program. OPTIM's unique curriculum provides participants a well-rounded, “Monday morning applicable” experience. OPTIM was started with one singular goal in mind. We want to improve the practice of physical therapy. We promote excellence in psychomotor skills, exercise prescription, differential diagnosis, and pain science. Please contact OPTIM if you are interested! 

Last week, I was treating another PT's patient with the diagnosis of patellafemoral pain syndrome (PFPS). On this day she was complaining of L lateral foot pain after having to wear heels a couple times during the week. With the location of pain, we should immediately develop multiple hypotheses. The patient's asterisk sign was lateral foot pain/tightness with lumbar flexion while in a half lateral split position.

Initial hypotheses based on pain position could suggest cuboid dysfunction, S1 radiculopathy, Intermediate Dorsal Cutaneous neural tension, peroneal strain, lateral ankle sprain, or more. I immediately found no local pain with palpation or muscle testing (making these diagnoses less likely), so my mind went to the spine. I did have some mild pain recreation with common peroneal neural tensioning, but it wasn't a significant amount. While the patient did have some lumbar mobility restrictions, mobilizing the lumbar spine and performing repeated motions had limited improvement in the asterisk sign. Even though I typically like to start at the spine with treatment, some cases are more peripherally based.  At this point I addressed the proximal tib-fib joint restriction due to the proximity of the common peroneal nerve, which has a distal branch known as the Intermediate Dorsal Cutaneous nerve. Still no significant change in the asterisk sign occurred.

Fortunately, earlier this year I took a course on dry needling. One of the things I found most beneficial in the course was learning about trigger point referral patterns. A commonly involved muscle, and the culprit in this case, is the gluteus minimus. While the muscle frequently presents with local pain and a "sciatica-like" distribution, it can also present with lateral foot pain (based on the trigger point charts in our dry needling workbooks). After needling this muscle, the patient's asterisk sign significantly improved and the patient returned this week with no more pain in that foot. The lesson from a case like this is that we should not become overly focused on one body region. While many injuries will respond to treatment through different methods, there are certain injuries that require specific treatment.

-Dr. Chris Fox, PT, DPT, OCS

We are frequently taught that we should be able to get about 80% of the information we need to figure what is wrong with a patient, simply through our subjective evaluation. What is frequently missed, however, is what we are telling patients (verbally and non-verbally) and the impact it has. Mike Reinold recently wrote an article on 6 things we shouldn't do as physical therapists. It is definitely worth a read. There are things we do as therapists that we may not realize the impact. With the development of pain science research, we are learning that the things we say and how we act impact patients significantly. This includes the diagnostic process. It is best to avoid using pathoanatomical wording, as it creates a fearful and potentially hopeless attitude in the patient. Focus more on what we can do as physical therapists, i.e. “get your hip moving,” “strengthen these muscles,” and “teach you how to move.” Find out what the patient wants out of therapy and work to align your goals with theirs. It is essential that we establish a two-way relationship with our patients so that trust can be the foundation for improvement.

-Dr. Chris Fox, PT, DPT, OCS

For October's Insider Access Post, I wanted to make the video available to all due to the little known importance of the topic. As many of you saw in my post a couple weeks ago, I had an incredible response to visceral treatment for an odd symptom of throat tightness. According to the therapists that treated me, there can be visceral involvement in orthopaedic injuries up to 80% of the time. Many of the patients that don't respond to our treatment, may benefit from seeing a visceral therapist. Below is a video on how to help screen for these patients. Visceral pain referral patterns are helpful for this, but insufficient.

-Chris Fox, PT, DPT, OCS