NSC was this past weekend and for those of you who may have missed it, here is the link to an interview with John Dewitt speaking on the topic of residencies/fellowships.  Here he discusses what the difference is between the two, when you should consider participating in a residency, the financial concerns, and more.  

One of the best things about USC's sports residency program is the ability to be flexible with schedules.  These past few days, I had the opportunity to cover AVP's Professional Beach Volleyball tournament in Huntington Beach, CA.  Now I'm not gonna lie, working on the beach was pretty awesome.  However, it was the full experience that made it such an unbelievable learning environment.  

The event was being covered by full team of healthcare professionals: PT's, ATCs, DCs, MDs, MT's, and EMT's.  WIth the diversity of the group, each athlete was ensured to get whatever treatment they needed.  I covered the Thursday qualifying round and the Friday rounds.  My duties included stretching, assessing, treating, and taping athletes.  It had the luxury to have different professionals right next to me when I needed to refer out to them.  What I really loved about this event was each sports medicine professional was there to teach each other something new.  I learned different kinesio tape methods which was very helpful for me.  Also, I was able to see how different healthcare professionals approached their treatment with the athletes.    

In addition to working the event, when there was down time in the medical tent we were allowed to cover the games and watch the games.  It's amazing to see these athletes cover so much ground in a short amount of time.  Many of these athletes are in amazing shape and would come in regularly before and following games to get soft tissue work even if they didn't have an injury.    

The one thing I took away from working this event, besides how much fun it was to work on professional athletes, was the amount of collaboration between all of the sports medicine professionals.  We all were able to work efficiently and effectively together to help each athlete the best we could.  It goes to show that a team of different sports medicine professionals can work together for the best treatments.  

A few of the faculty members at the Harris Health System Orthopedic Residency started a Manual Therapy Fellowship program, OPTIM PT, last year. Part of their fellowship is devoted to pain management and how to incorporate manual therapy in the treatment of chronic pain. To introduce the topic of pain management, they brought in Rod Henderson, physical therapist and specialist in pain management. As a bonus, they let the Orthopedic residents attend the course as well. During the course, we covered the physiology of pain, pain theories, how to educate, and select appropriate interventions. Let me be clear now, we are not just talking about chronic low back pain. Chronic pain is present in a significant number of musculoskeletal problems. Consider the knee replacement patient who has had pain and decreased quality of life for the past few years; or consider any type of tendinopathy patient. Both of these patients are in a chronic state of pain.

Before we begin talking about pain, it is important to accurately define the word. Pain can be defined as a sensory and emotional experience in response to actual or potential tissue damage. The pain response has both protective and adaptive abilities, and is a necessary and important part of our lives. While it is necessary, the transformation from acute to chronic pain is where it can become a problem.    
 
The dominating theory of pain science today is the Pain Neuromatrix, a theory that has not fully made it into physical therapy schools yet. In this theory, there is no true "Center of Pain." The Neuromatrix theory suggests that there are several factors (inputs) that determine a person's reaction to pain (output). Inputs include sensory, cognitive, and affective components that all interact with each other to determine how the person will perceive a stimuli, what actions need to be taken, and the appropriate stress regulations. The inputs are heavily determined by past experiences and the person's expectation to a certain situation. When you have chronic pain, there is an expansion of the receptive fields that send input to the brain. Certain stimuli will begin to have heightened states of sensitivity. This can manifest as pain with light touch, an increased heart rate, or sending the patient into tears. For example, a stimulus that previously went unnoticed, like putting on a pair of socks, can become immensely painful if your nerves are sending mass amounts of improper triggers to your brain. It is our task to rewire these inputs, using graded exercise, desensitization, and proper education. 

A few take home points to remember when treating any chronic pain patient:
-All pain originates in the brain. I would suggest finding a tactful method to tell the patient that news. They probably will not come back if you simply say the pain is just in their head. 
-The amount they hurt does not equal the amount of tissue damage that is present. Think about a paper cut on your index finger. It is rather small, but it can hurt a whole lot. Many people with chronic pain have completely healed "paper cuts", but their brain is responding as if the event just happened.
-Patients with chronic pain have maladaptive thoughts and beliefs. Many of these thoughts and beliefs go beyond their physical appearance. Most have additional stresses at work and home, complicating their musculoskeletal pains. Address these issues in your plan of care. 
-Chronic pain implies that the issue has been present for a long time. Do not expect to heal these people in 1 or 2 treatments.
 
I know you did not go to PT school to become a psychotherapist, but other than psychologists we spend more time with our patients than any other healthcare provider. This is an unique advantage. Chronic pain is everywhere. If you are not learning how to incorporate the biopsychosocial model into your clinical practice now, you need to start. Understanding this will take your outcomes from good to great. 

-Jim 

Well, I am about 2 months into my orthopaedic residency here at Scottsdale Healthcare and it has been quite an experience. Not only am I learning an incredible amount, but the area is beautiful as well. Starting off my first couple weeks, I was eased into the practice with a lighter caseload as I learned the ropes to documenting here. We started off our first day after orientation going through the EMR, so that we could find our way through the system. As helpful as it was, the best way to learn that sort of thing is to actually do it over and over again. The lower patient number each day initially was definitely beneficial while I was trying to become more efficient documenting. Once I had adapted to the EMR, my caseload was increased to that of the other physical therapists. We typically treat 1-on-1 with about 8 patients a day (depending on how many hours you work). I enjoy this individualized care so I can continually assess my patients and adjust any faults with their mechanics when performing exercises. It also allows more time for manual therapy if appropriate for that particular patient. As with any clinic, there can be fluctuating patient populations which may lead to "down time." Whenever I have no patient or paperwork to do, I'm able to observe one of the other clinicians. The benefit of being able to observe different PTs cannot be overstated. Everyone has their own "style" of care, so I can continuously become a little more rounded with my clinical reasoning.

Probably the thing that stood out to me the most thus far has been the mentoring. Each week, I get 4 - 8 hours of 1-on-1 mentoring with a clinician that has both OCS and FAAOMPT credentialing, along with dry needling certification. We work side by side when treating or evaluating patients and in our breaks discuss other patient cases. During PT school, I rarely had any patients that I found too difficult. Here, it seems like every other patient is extremely challenging or with atypical presentations. The ability to schedule these patients for my mentoring hours allows me to build upon my reasoning after working with my mentor and is definitely one of the highlights of residencies in my opinion.

Another component of residencies is class work. Thus far, we have had 4 classes: residency overview/subjective interview, clinical reasoning/evidence-based practice, medical screening, and sacroiliac joint. The sacroiliac joint lecture was just this past week and is the first of all our lectures on the joints (we have lectures every other week). We have initial readings to do for each topic: the APTA monographs. These include readings on both non-surgical and surgical coverage of each joint based on the most recent evidence. The lectures then are created by our faculty and are followed up by lab, where we go over examination techniques, exercises, and extensive manual techniques. I feel like my PT school did a very good job covering the SIJ joint, but my confidence in treating and assessing the SIJ after that lecture and lab increased dramatically. The individual focus and conversational discussion of the material likely played a significant role. I am looking forward to covering the rest of the body.

Some additional components of the residency that have begun include additional course work and case study presentation. Throughout the year I am required to present 3 interesting cases or cases where I implemented interesting techniques to my co-workers, along with the current evidence on the subject. Something that I have enjoyed particularly with this residency has been their appreciation of continuing education. As the hospital hosts some courses, we have the opportunity to attend for free. They are paying for my attendance at the AzPTA fall conference next weekend and have been extremely accommodating with allowing me to design my schedule so that I may attend other courses as well. I can't believe 2 months are already gone, but it should be a fun remaining 10 months! If you have any questions about the residency, feel free to ask.

-Chris