Physical Therapy: A Game of a Few Degrees

Last week, I wrote about the importance of assessing segmental mobility, even with the lack of evidence for our ability to do so. Some of the research says segmental mobility and SIJ assessment have both poor inter- and intra-rater reliability, suggesting we shouldn't waste our time with it. This can be detrimental to the patient as the slight differences may be important for directing our treatment. As I've said before, without these kinds of assessment skills, diagnoses like a fallen cuboid may be missed.

Even if the research hasn't been supportive of our abilities to do segmental assessment, we shouldn't give up on our efforts to find a more effective method. Could the lack of support be due to lack of training in standard physical therapists? Lachman's test requires the therapist to notice a difference of a couple millimeters in order to assess the integrity of the ACL, yet the test has extremely high diagnostic accuracy. Why is it we are presumed to be able to notice these small differences and not others? It is likely due to a lack of training. Physical therapists out of school are used to assessing joints with large amplitude forces that blow through one joints available range and moves into another - negating the findings typically. The smaller differences may play a larger role.

I returned to this topic, yet again, because of a recent discussion I had with some physical therapists in Optim's online mentoring program. Between each course we have several sessions where the participants present a case they have been working on and feedback is given from the mentors and other classmates. One of the issues during the early stages of the COMT program is that there isn't a consistency in assessment between all the therapists. One clinician may list hip and knee ROM as WNL (within normal limits). While this may be true, the therapist may have not been thorough with their exam and missed some subtle differences that may impact treatment. For example, when treating knee pain, often there is a loss of just a couple degrees of knee ext on the involved side that if treated appropriately, may completely eliminate the pain. The same applies to every joint, especially when considering treatments like repeated motions or manipulations. I don't typically use a goniometer in my measurements because I feel like I focus too much on aligning the arms and stop paying attention to the actual motion. The most important finding in my opinion are those small asymmetrical losses of mobility, as it can be the key to your treatment.

-Chris

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