Knowing what path to take following graduation can be very difficult. If you are like us, you have many unanswered questions: What continuing education courses should I take? How can I maximize my success with patients? What common professional mistakes can I avoid making and how? We recently reached out to some of the top professionals to find out what steps they took to become successful. The answers below are brought to you by Dr. E (The Manual Therapist). 1. What advice do you have for physical therapists in their first years of professional practice? My advice is to get a system of assessment and treatment. Most schools still teach the tired and not so true history, AROM, PROM, palpation, special tests up the wazoo, come up with a diagnosis, and now what? I know we have to learn basics in school, but this ends up leaving most novice clinicians with too much info! Any clinician needs a system of assessment which leads to treatment. Classification has been shown in the research to improve outcomes versus treatment of patho-anatomical models. This leads me to my next answer! 2. What is one continuing education course you would recommend every physical therapist attend? Please provide a brief explanation. Years ago, I would have told any new grad to take a series of manual therapy courses like Paris, Maitland, Grimsby, NAOIMPT, etc... While these courses will enhance your clinical decision making eventually, you will be overwhelmed with options. Your first day back with live patients, you will be left with dozens of ways to passively assess movement and often hundreds of new treatment techniques. Is complex better? Often not... it's also less reliable. That is why I tell all my students to take McKenzie Courses A-D. Certification is not necessary, but helps solidify your knowledge by getting you to really study the system and then have your knowledge practically and didactically tested. It's one of the most proven methods of assessment for reliability, and has been shown to have superior long term outcomes versus traditional OMPT in the lumbar spine. 3. What are some important components a new graduate should look for in their search for a first job? If possible, you should look for freedom to assess and treat, plus quality time with your patients. I realize beggars cannot be choosers and I worked two jobs for the first two years of my career seeing 4-6 patients an hour and having 30 minutes for evals. Do not be discouraged or complacent. I have seen too many students settle on clinics that see way too many people and cannot possibly provide quality care. The clinics that do provide 1:1 are out there, and sometimes you have to form your own. I did not think that was possible 7-8 years ago, but decided to take a risk 10 years in and finally have a practice of my own. Your future employer should be open to how you want to evaluate and treat, not dictate pathways per diagnosis. A recent fellow mentee finished his hours, graduated from the program only to be employed by someone who wanted everyone to get a "fru-fru" type of massage and have the patients dictate the Tx a la carte, not the clinician. She took also took away IASTM and spinal manipulation even though on the interview, she said these treatments would be fine. Lastly, you want to have an employer that pays for a decent amount of con-ed. One to two courses per year are enough to keep up with your learning. 4. What is one thing you would have done differently early in your career? And why? I wish I would've learned to be lighter with my hands a long time ago. Telling patients to suck it up, and I have to plastically deform their fascia and joint capsules left a lot of people sore and occasionally bruised. That's not cool. If going lighter and lighter all the time with my forces and getting patients better faster is not an indication that interaction, education, and then manual therapy are the way to go, I don't know what is! 5. Any other words of advice for the new graduate? Yes, you're always a student! Keep up with the learning, the more you learn the less you know and that is how it should be! As a know it all, I thought after taking Paris' courses that I was a bullet proof clinician. Yet, somehow 12 years ago, it was taking me 15-20 visits to make patients better. There are so many resources available to you online from twitter to facebook and of course blogs! You are practicing in a very exciting time! I find myself changing assessment, treatment, educational and interaction models with patients every 2 years or so. If you haven't had a paradigm shift in 2-3 years, you're not learning enough! One last piece of advice. I thrive as a mentor. Feel free to post in the forum or contact me via the link in the sidebar. I try to get back to everyone within one business day! Good luck out there! About Dr. E: Dr. Erson Religioso III, DPT, MS, MTC, CertMDT, CFC, CSCS, FMS, FMT, FAAOMPT, graduated from D'Youville College in 1998 with a dual Bachelor's of Science and Master's of Science in Physical Therapy. His interests in Orthopaedics and Manual Therapy lead him to pursue a Doctor of Physical Therapy degree from the University of St. Augustine. Studying under StanleyParis, Ph.D, PT, internationally known for his manual skills and knowledge of the spine as well as his distinguished faculty, Dr.Religioso earned his DPT and Manual Therapy Certification in 2000. He later became credentialed in Mechanical Diagnosis and Treatment of the Spine in 2000, and in 2008 became one of four mentors in the country who can train orthopaedic manual therapy to MDT Diplomats, of which there are only several hundred in the world. Thanks to extensive training and certification from Dr. Mariano Rocabado, PT, of Chile, one of the world’s foremost experts in treatment of temporomandibular joint dysfunction, Dr. Religioso became certified in evaluation and treatment of oromaxillary, craniofacial, and temporomandibular pain in 2005. Later in 2005, he obtained Fellow status in the American Academy of Orthopaedic Manual Physical Therapists and serves as a mentor for future Fellows through Daemen College’s Fellowship in OMPT program. He recently became certified in FMS level 1 in December 2011 and expects certification in level 1 of the Selective Functional Movement Assessment soon. In January 2013, Dr. Religioso became an official FMT level 2 certified Rock Doc, a start of the art method of kinesiotaping. In mid to late 2013, Dr. Religioso is pursuing courses leading to the completion of the Postural Restoration Institute's PRC Certification. Dr. Religioso is adjunct faculty of D’Youville College, Daemen College, and SUNY at Buffalo, where he teaches orthopaedic manual physical therapy in the DPT programs. He founded themanualtherapist.com to help mentor and teach professionals around the world and physioanswers.com to help educate consumers and the general public on the profession of physical/physiotherapy. He also is the creator of the EDGE Tool, a high quality stainless steel tool for assisted soft tissue manipulation, the EDGEility Tool, a lower cost, high quality plastic tool for IASTM, the CupEDGE, silicone cups for cupping massage and assisted tissue manipulation, the EDGE Mobility Bands, for enhancing mobility with compression wrapping and self mobilization from neck to foot, and the Stop Thought Viruses Challenge, for individuals in chronic/persistent pain states. He also is an importer of high quality Mirror Boxes for pain, arthritis, stroke rehab, and neuroorthopaedic problems. In 2013, courses in the continental US, Canada, and Chile will be available on the Eclectic Approach to TMD and Facial Pain, Neurodynamics, Soft Tissue Manipulation feat. the EDGE, Spinal Thrust Manipulation, and Assessment and Treatment of the Upper and Lower Quarter (2 separate courses).
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As some of you may have noticed, we have a strong interest in evidence-based practice. In fact, one of the missions of this website is to increase awareness of the latest literature. However, to what point should we rely on evidence? Having read more than a few studies that showed little support for modalities in general (Yes, there are some pathologies that respond extremely well), you can imagine we would be hesitant to administer things like ultrasound, hot packs, etc. in the clinic. Coming across patients who request these modalities during treatment can be frustrating as we know they often have little effect physiologically. We have all had the experience of a patient saying, "last time I had therapy, the TENS Machine was really what got me through the day." On one hand you know you do not want to spend valuable treatment time performing these interventions, but on the other you feel it may benefit the patient psychologically. So, where do we go from here? Having recently listened to David Butler's and others' audio recordings from IFOMPT, the importance of the biopsychosocial role really stood out to us. We cannot underestimate the impact of the mind. The neuroplastic changes associated with chronic pain often are as big a part of a patient's complaints as a mechanical component. Patients have been suffering with pain or have had dysfunctional movement for so long that the nervous system has adapted to the new "norm," and it is the true normal movement that feels abnormal. Butler, in fact, states that the biggest predictor of low back pain is depression and that we must explain to patients that the source of there pain is not necessarily mechanical (if a patient is grouped here). So how does this tie in with evidence-based practice? Knowing how the nervous system can affect the patient's perception of pain, there may indeed be a role for interventions with low evidence, such as certain modalities, if a patient believes the treatment will help them return to function. We are not saying that these interventions should consume a significant portion of our treatment time (or that we should go to them at all), but it is something to consider for a trial to calm the patient's fears and give us time for them to "buy into" our methodology, especially if they made a request for that treatment. That being said, we cannot stress enough the importance of educating our patients. Perhaps spend some time explaining to the patient how physiologically, there is little evidence of changes occurring at the cellular level with that specific intervention and then continue to educate the patient on what the literature shows as having the best outcomes. Obviously, education on proper movement patterns and posture must be included as well. You might be surprised at how literal some of our comments are taken. Consider the idea that you teach your patient to lift with a slight lordotic posture, so as to minimalize the stress on the back. Some patients might incorporate this posture into all aspects of their life, thinking that they should never bend their back if they want to avoid pain. Think of all the compensations that might result! We must evaluate all faulty movement patterns a patient presents with and educate them clearly on better strategies. Of course, we should still utilize our clusters, clinical prediction rules, and clinical practice guidelines when treating patients, but we must be aware that not everyone falls into those groupings. Some people have a larger biopsychosocial role than others, and it is these patients that we must spend even more time on education. Yes, maybe we should consider the use of interventions with lower quality evidence early in our treatment plans, but in it, we must include education and interventions with higher quality evidence as well so that we can move toward the desired outcomes. If you feel like we having been referencing The Gait Guys a lot recently... it is because we have! They have put out a few great segments recently including this 2 part series on the Power of Observation. As clinical novices, we often do not have enough opportunities to see pathological gait patterns and conditions. As former students, almost of our lab "patients" were healthy classmates. While those experiences were rewarding, they were far from a real situation. In this series, Shawn and Ivo dissect a triathlete's gait pattern. The patient presents with chronic low back pain, but has impairments throughout the entire lower chain. One interesting impairment they discuss is a "clenched fist on the L," which they attribute to flexor dominance and related to decreased arm swing and proprioceptive deficits. Their explanation: the proprioceptive system feeds the cerebellum. The cerebellum helps fire axial extensors. Because proprioception is limited in this athlete, the patient is naturally drawn into a flexor dominant position. Check out the entire post to gain more gems like this one! Because the gait guys use a Tumblr format, you may have to scroll down to June 25 and June 26. Enjoy! As evidence-based practice is becoming a staple in physical therapy education, it is important we properly assess each piece of research before choosing whether or not to incorporate its findings into our practice. Given the breadth of science courses that consume most of our schooling, non-clinical classes like evidence-based practice often get set aside as less important. Unfortunately, we often fail to realize the significance of search strategies, article assessments, and more when we are in the didactic portion of school. Instead, this material should really be one of the largest emphases in our programs, due to the need to stay up to date with best practice methods. With the NPTE and clinical work coming up soon, we thought it would be a great time to review some of the core components of EBP. This review is by no means exhaustive, but instead is intended to give you a foundation for further review. CONTINUE READING.... Studying for the NPTE can seem overwhelming and expensive. We ran across this website the other day that provides good content and sample examination questions to help make this process a easier: www.physicaltherapyexamprep.com. Check it out!
So how do we address these differences? Shirley Sahrmann discussed this topic in a lecture that we highly recommend listening to. Instead of focusing on the side with increased stiffness, we should address the side with decreased stiffness. Strength training has been found to increase muscle stiffness (Magnusson, 1998). By bringing both sides of the body to symmetry (equal stiffness), an equal distribution of forces prevents any abnormal stresses on the body. Stretching still has its place, of course, but we must be sure to distinguish between muscle stiffness and adaptive shortening when choosing to apply the intervention. Next time you're measuring muscle length, check for stiffness and muscle length! References:
Magnusson SP. (1998). Passive properties of human skeletal muscle during stretch maneuvers. A review. Scand J Med Sci Sports. 1998 Apr;8(2):65-77. Web. 10 June 2013. Mizuno T, Matsumoto M, Umemura Y. (2013). Decrements in Stiffness are Restored within 10 min. Int J Sports Med. 2013 Jun;34(6):484-90. Web. 10 June 2013. Mizuno T, Matsumoto M, Umemura Y. (2013). Viscoelasticity of the muscle-tendon unit is returned more rapidly than range of motion after stretching. Scand J Med Sci Sports. 2013 Feb;23(1):23-30. Web. 10 June 2013. Check out this recent post on the AAOMPT Student Special Interest Group. In it you hear from several experienced clinicians, regarding the development of their clinical reasoning. As new grads or students, this is usually something we only gain through experience or any mentoring chance that happens to fall into our laps. Take the opportunity to hear the advice of these practitioners! As of May 18th, we, along with the rest of the Saint Louis University PT Class of 2013, received our DPTs. Congratulations to the recent graduates from other PT schools as well! We thought we'd take some time to discuss the upcoming plans for ourselves and the site, as we do plan to continue the development of the website with some exciting upcoming features. First, an update for where each of us will be heading off to now that we've finished PT school. Jim accepted a position in Harris Health System's Orthopaedic Residency in Houston, TX that begins in late August. Chris accepted a position in Scottsdale Healthcare's Orthopaedic Residency in Scottsdale, AZ that begins at the end of July. Brian accepted a position in University of Southern California's Sports Residency in Los Angeles, CA that begins in August. With all that we expect to learn from our residencies, we hope to bring some of that to you all through one of our additions to the website. Now that we have graduated, we tossed around the idea of changing the name of the website for awhile but decided to keep the current name. A lot of our information does cater to students, but we hope that clinicians with various levels of experience find benefit in it as well. In reality, with the push for evidence-based practice and continuing education, we should be "students" of physical therapy for our entire careers. Now check out some upcoming additions to the website: Resident's Corner: As the profession continues to advance, there is an increasing push for the pursuit of residencies from various directions. With this section of the website, we will be bringing you updates on the content/curriculum of our residencies, along with some interesting techniques and information that we learn. Since the three of us will be attending different residencies, we hope to bring you three different perspectives of what residencies can offer. Hopefully, this will give you some more insight as to whether or not a residency is right for you! Interesting Cases: We have found that one of the most useful aspects of physical therapy blogs is a section like Case of the Week by The Manual Therapist, in our opinion. The step-by-step process that displays the clinical reasoning in managing each patient's case is extremely useful for developing the understanding of the transition from subjective history to objective exam to evaluation to plan of care and so on. Hopefully we can transition some of the guidance we will be getting through our mentors to you all, so that you can gain a new perspective on care. Guest Posts: We have received multiple requests from some of you on becoming involved with our website. We love to see the excitement and passion for physical therapy! Well, with our upcoming additions, you will have the chance to contribute. In general, we will be looking for a post on the Guest page every 2-4 weeks. The author would review some material they found interesting and write up a post, along with a short bio and picture. They would then submit it to us, where we will edit grammar and such (in case that's an issue!). We will not alter the content as we recognize there is benefit to discussion of controversial material. We might attach a reflection of the post in order to help facilitate some of that discussion, but the post submitted to us will remain unchanged (apart from any grammatical/spelling errors). If you would like to contribute, shoot us an email! This is a good, quick 7-minute TED Talk given by the orthopaedic surgeon, Dr. Kevin Stone. He presents several interesting concepts and innovative strategies about the future of joint replacements. This might not be something you see in your clinical practice today, but as science continues to improve Dr. Stone's biological approach to joint replacements could be something you see on a more regular basis. Check it out! As physical therapy students, much emphasis is placed on screening for Red Flags to help determine if a patient is appropriate for our services. Generally speaking, a Red Flag can be defined as a sign or symptom indicating the presence of a serious pathology. In a 2011 article, Davenport and Sebelski defined Red Flags as "abnormalities within the systems review...which may suggest the need for referral to another healthcare practitioner (Davenport 2011)." In this same article, these authors are quick to point out that Red Flags have a low predictive value for forms of pathology. A list of Red Flags commonly seen in the clinic are as follows:
With the profession of physical therapy on the brink of direct access and autonomous care, our ability to correctly determine a patient's appropriateness for therapy is crucial. A recent post from the ForwardThinkingPT outlines a 2013 Cochrane Review regarding the effectiveness of using red flags to screen for malignancy in the low-back pain population. The review assessed 8 cohort studies that specifically addressed 11 Red Flags in the patient's subjective interviews and physical examinations.* Of these 8 studies, which looked at >6000 patients, the symptom of low back pain presented as a more serious pathology <1% of the time. The review found that Red Flags associated with low back pain have high false positive ratings and that the "indication of spinal malignancy should not be based on the results of one single red flag question (Henschke 2013)." Despite the overall low probability of Red Flags, a few studies did find a meaningful increase in probability if the patient had a previous history of cancer. So where does this leave us as practitioners? It is important to consider that the Cochrane review only assessed the impact of 1 Red Flag in its relationship to increasing the chance of malignancy. In the clinic it is important to document Red Flags and use proper judgement if several of them are positive. Because of the high false positive occurrence, Davenport and Sebelski recommend utilizing a diagnostic process to help guide your clinical reasoning. This diagnostic process involves using a symptom based approach for diagnosis. With each patient you should ask yourself, "Among all possible health conditions, what is causing my patient's symptoms (Davenport 2011)?" Obviously this is a loaded question, but the question does stress the importance of having strong differential diagnosis skills. In conclusion, assessing for Red Flags can be a difficult process. Always remember to utilize good communication and practice forward-inductive reasoning to recognize patterns during your examinations. *It should be noted that all 11 Red Flag questions were not indicated in every chart and a possible limitation to the study is inadequate therapist documentation. References:
Davenport & Sebelski. (2011). The Physical Therapist as a Diagnostician: How do we, Should we, and Could we use Information about Pathology in our Practice? Physical Therapy. 2011;91.11. Web. 3 April 2013. Henschke N, Maher CG, Ostelo RWJG, de Vet HCW, Macaskill P, Irwig L. Red flags to screen for malig- nancy in patients with low-back pain. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD008686. DOI: 10.1002/14651858.CD008686.pub2. Web. 3 April 2013. |
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