Rainy Days = Continuing Education

Steve Allen assesses the Lumbar Spine

The rains are upon us here in Seattle. Gross!  If you've never been here during the doom and gloom season, what you've heard is true.  It's grey, dark, cold, wet, and everyone is a bit more cranky.  (Or maybe that's just me?) But the leaves are beautiful to look at and the candles are lit and ALL the blankets are ready to get cozy and it's hot chocolate season... so that's all exciting.  And what better way to hide from the weather than to take some continuing education courses?

This past weekend, I completed my fourth NAIOMT (North American Institute of  Orthopedic Manual Therapy) course.  I've previously written about my experience with these courses on the blog here following the last one I took way back in 2017.  Since I started working at Seattle Children's Hospital in 2017 I've used considerably less manual therapy so these classes have fallen lower on my learning priority list.  The kids don't tend to need it so much and I've learned so much about the impact manual therapy sometimes has on patients psychologically that even when I'm in the adult clinic, I'd prefer to use it less.  As I continue to grow in my career, I keep learning what I like and what I don't which changes how I interact with patients. In general, I try to avoid "doing things to patients" and prefer to help them learn how to do things for themselves.  That's not to say I don't use manual therapy at all... it just isn't my first step most of the time. I do occasionally work with adults and they typically have expectations of receiving this sort of treatment, particularly because of the way the clinics I work at organize their schedules.  Sometimes they really do need it - but for sure not always.  And in the State of Washington, physical therapists who manipulate the spine need a special certification with specific continuing education, so to maintain my certificate, I took this class.

Amanda Scharen teaching lumbar instability tests

To be fair, these NAIOMT courses aren't just about manual therapy, either.  Sure, the photos I've included are of a manual technique performed by Steve Allen, NAIOMT faculty member and a Physical Therapy Historian who exudes love for the profession along with my friend and Director of Therapeutic Associates - Queen Anne - Amanda Scharen. I'll even quote Steve from this weekend, "Manual therapy is a small ut vital part of our practice.  Combine it with exercise for the best outcomes." But these classes also include advanced review of anatomy and biomechanics, which is important when you haven't studied it specifically since PT School.  There are many cases presented during the weekend which challenge clinical reasoning.  The partiipants of NAIOMT courses are all physical therapists so there are really interesting discussions about evidence supporting different topics, sometimes even debates, and some of the scientific literature is included for participants to read ahead of time.

SI Joint - from Wikipedia

For example, this course included this paper "Evidence-Based Diagnosis and Treatment of the Sacroiliac Joint" from 2008.  I had not previously read it, but did learn this in PT School.  It describes the different tests you can use to try to identify if the joint between the sacrum at the base of the spine and the ilium (pelvic bones) is contributing to a person's pain presentation. During class this weekend, we had a discussion on whether or not this joint moves at all - as many believe that it is fused and therefore immobile. I personally believe that the SIJ does move for three reasons: 1) I have seen too many patients with pain that improves with changes in their pelvic positioning or with exercises training stability for this region 2) When I have a specific pain pattern, treatment to my own SIJ resolves my symptoms almost immediately, and 3) I don't think women would be able to give birth if this was an immobile structure.  Doesn't really explain why it would be as mobile in males - but I don't usually see this as a problem region in men as much. If you're a PT who hasn't been exposed to the tests that may help identify the SIJ as a contributor to pain, the article outlines each one and presents pretty good psychometric properties when using them as a cluster.  Interestingly, the author describes the tests and then admits that he no longer uses SIJ manipulation as a treatment because it tends to be unsuccessful.  He recommends stabilization exercises and, if that is unsucessful, injection into the joint.

What I've come to understand more and more is that the healthcare you receive from any provider is biased to the beliefs of that provider.  For example - if you came to see me and I determined that you had tight hamstrings, I tend to guide you to strengthen the hamstrings in an effort to relieve some of that tension.  Some of my coworkers, however, would teach you how to stretch your hamstrings. There are articles supporting both methods. There are groups of people who support both sides. As a patient, if you don't have any prior knowledge on the topic, you're probably just going to take your therapist's word for it that they know what they're talking about.  As another example - I've been experiencing some really annoying abdominal pain for the past several months.  My GI doctor sent me for tests like an endoscopy and colonoscopy and is treating me for acid reflux.  Yes, the medication made me feel better, but I didn't think that was the underlying problem, so I sought out another opinion.  She's treating me for something entirely different.  Her beliefs about my symptoms match more with my own beliefs of my symptoms and I'm far more optimistic that I'll have a good outcome with this method.  As long as the patient gets better, does the method used to get there even matter? Regardless - the evidence is strong that for low back pain, physical therapy should be your number one choice for care.  Not medications.  Not injections.  Not surgery.  Not imaging.  PHYSICAL THERAPY.  Get PT First.

These are the things I think about during these dark Seattle fall-winters.

I have another continuing education class coming in two weekends.  I'd imagine it will still be raining then... so a blog post about it is likely.  It's very different from this one, so that will be a fun juxtaposition.

AASPT Traveling Fellowship

Fellows @ Cincinnati Football

Long before sunrise on the morning of Thursday, September 12, 2019, I boarded a sleepy airplane lightly coated in the typical Pacific Northwest mist heading towards a career-enhancing expedition.  After a brief pit stop in Denver, I continued on to Cincinnati airport, weirdly located across the Ohio River in Northern Kentucky.  Upon arrival at the CVG baggage claim I met two physical therapists who I would spend the next eleven days learning and observing various topics related to sports physical therapy. Rebecca Troulliet from North Oaks Health System in Louisiana and Patrick Barber from University of Rochester in New York joined me for the American Academy of Sports Physical Therapy (AASPT, formerly known as the Sports Section) Traveling Fellowship.  Sponsored by Kevin Wilk, LightForce and DJO Global/DonJoy. We spent about three days each at University of Cincinnati, Mayo Clinic locations in Minneapolis and Rochester, Minnesota, and The Ohio State University. 

What does it mean to be a Fellow?  According to Wikipedia, "a fellowship is a group of people who work together to pursue mutual knowledge or practice."  Though each of us had individual purposes for participation, we are all physical therapists working with athletes and we were all looking for growth in our careers.  Through observation and lecture attendance with more seasoned clinicians, we had exposure to different techniques and clinical approaches than our usual day-to-day experiences.  Now that I've returned to my usual swing of things and seeing my patients at Seattle Children's Hospital, I'm taking this opportunity to reflect on the experience and share why I chose to pursue this Fellowship along with some highlights from our trip. 

First: Why did I want to complete a Fellowship?
In May 2014, when I was completing PT School at the University of Connecticut, my career aspirations were to serve as a team physical therapist in the WNBA.  I had previously worked in a non-medical capacity for the Connecticut Sun for four seasons, but elevating to this new type of position as a new grad PT didn't seem remotely feasible.  Beyond the fact that I was a new clinician,  WNBA teams didn't have physical therapists, then, so this goal seemed unrealistic. (Most teams still don't, which I wrote about here)  I thought my fastest route to working with professional female athletes was to advance my education from PT School through a Sports PT Residency Program. In 2014 there were about twenty of those programs nation-wide, mostly offering one or two slots. I applied to three, including Ohio State, but was not successful in securing a position.  Now there are almost fifty SCS Residency programs with so many more opportunities nationwide! To search Residency programs in any PT Specialty area, click here.

Fortunately, physical therapists have an alternative route to obtaining board certification and specialization in sports physical therapy that does not require participation in a residency program.  You can find the requirements to do so here. As I pursued the alternative route, I also landed a role with the Seattle Storm, and in March 2019 completed my Board Certification Exam.  In our cohort, Pat also took his exam in March following completion of the University of Rochester Residency program and Becca is currently working through the alternative route requirements to specialize in the future.  So because I did not complete a residency program but did pursue specialization, I felt like I lacked some of the mentorship and on-field hours that a residency would have provided, and this fellowship filled some of that gap.  

Second: What was the Fellowship like? 
Each location was very different from the others which helped us gain a broad spectrum of the possible roles and responsibilities for a sports physical therapist.  

Fellows and PT staff @Cincinnati

At the University of Cincinnati, we were hosted by Bob Mangine and Tim Machan and primarily spent our time in their athletic training room with them and on the sideline.  We had the chance to watch game-time coverage, led by Head Athletic Trainer Aaron Himmler and had a sit-down discussion with their concussion program and vision training expert, neuroscientist Dr. Joe Clark. We attended lectures on a variety of topics by members of their staff including wearable technology, use of the ACL-Return to Sport Index Outcome Measure, Neuroplasticity, Prevention of Catastrophic Injuries, and and we each presented our own lectures. My presentation examined the Impact of Fear Avoidance on Return to Sport, Becca discussed Sudden Cardiac Death and Pat outlined Upper Extremity Return to Sport Tests.  

With Timberwolves Robby Sikka and Matt Duhamel

After exploring Cincinnati, the three of us packed our bags to head to Minneapolis for the first half of our visit to the Mayo Clinic.  Our host in Minnesota was Corey Kunzer who is the coordinator of the Mayo Residency program.  The clinic in Minneapolis serves the community as well as having partnerships with the Minnesota Lynx (WNBA), Minnesota Timberwolves (NBA),  and Minnesota Twins (MLB).  Only days before our arrival, the Seattle Storm had knocked the Lynx out of the WNBA playoffs so I felt a little like I was in enemy territory, but I was glad to finally meet Emily Beyer, Lynx Team Physical Therapist as well as Matt Duhamel, Team Physical Therapist/Director of Athletic Therapy for the Timberwolves and Jeff Lahti, PT for the Twins.  We also met Robby Sikka, Timberwolves VP of Basketball Performance and Technology who uses wearable technology with the basketball players to improve their on-court performance.  Their basketball facilities are fantastic and, according to their staff is considered to be the best training site in the NBA. They have practice basketball courts with athletic training rooms and locker rooms for the teams right next to the medical clinics where they have physical therapists, orthopedic surgeons, physicians, athletic trainers, and other specialties who can thoroughly care for the athletes alongside the general public.  Can you imagine being at your PT session and rehabbing alongside (Lynx superstar) Sylvia Fowles or  (Timberwolf and UConn great) Shabazz Napier?! The Mayo providers collaborate with the team providers in their biomechanics lab which includes force plates and multiple angles of cameras for jump-testing and movement assessment as well as for recommendations for optimal care.  It was a really interesting arrangement for sports medicine for all levels of athlete.

Diagnostic Imaging with Dr. Jay Smith @ Mayo

Then we drove down to Rochester, MN, home of the original Mayo Clinic.  Founded in 1889, the Mayo Clinic is basically the entire town of Rochester and the area is spotted with old historical buildings that contain the most beautiful old libraries and intricate marble ceilings that tell the history of medicine in the US along with more contemporary constructions housing the huge variety of specialties that the Mayo Clinic houses.   We learned about Diagnostic Ultrasound from expert Dr. Jay Smith were taken to the Mayo Clinic Biomechanics lab which houses the machine used by Dr. Tim Hewett to extensively study ACL injury, and participated in a golf biomechanics lab.

Coach Tamika (Williams) Jeter @ OSU

After Minnesota we headed to Columbus, Ohio, home of The Ohio State University Buckeyes.  Our host, John Dewitt took us on a tour of their athletics and training facilities where I ran into former UConn and Connecticut Sun basketball player Tamika Williams for a quick reunion.  We attended a discussion on articular cartilage surgical procedures presented by Caroline Brunst and a lecture presented by Dr. Ken Yeager on Building Resiliency observed the nationally recognized Ohio State Marching Band rehearse, attended the marching band Skull Session pep rally and another football game.  We had the chance to meet many of the Ohio State Physical Therapy Residents studying in a wide variety of specialties including performing arts, oncology, sports, orthopedics, women's health, and neurology.  And I got to see some of my Ohio family living nearby, which was the cherry on top of a really awesome collection of learning experiences.

Fellows with John DeWitt @The Ohio State University

I can't recommend this Fellowship highly enough, and would be happy to connect with anyone considering application for future participation.  I'm sure that if you asked Pat and Becca, they would select different portions of our trip as their highlights or what was most impactful based on the differences between our patient populations and professional goals, but I'm so glad I was able to share this impactful experience with them.  Thank you so much, American Academy of Sports Physical Therapy for this opportunity!

Physical Therapist Board Certification

On a dreary morning in March 2019, shortly after we lost an hour for daylight savings and my internal clock was thrown for a disastrous loop like it does every half-year, I turned off my three alarm clocks which were completely unnecessary because I hadn't slept a wink, crawled out of bed, and drove over to a ProMetrics testing center near my house to complete the Sports Certified Specialist Physical Therapist exam.  I had my photo identification, my registration paperwork, and a list of test day reminders: make sure you remove all jewelry before going through the metal detector, be prepared to pull up your shirt and pants sleeves and have your ears checked, bring water and snacks because your exam is seven hours long but you can have a break in the middle, and a bathroom will be available.

Now, here we are almost the end of June 2019, more than four months later, and today I received the results - I passed my test!  I was walking out of basketball practice with the Storm when I glanced at my phone and saw the email with this report.  Without the Storm, I would not have met the criteria to even take this exam, because you need sideline coverage hours in a contact sport, and lots of them.  I'm so grateful for them.  Per the rules of the examination and ProMetrics, I won't go into any details on the actual content of this test, but I wanted to discuss the preparations I used and what advanced certification as a physical therapist even means.  Fortunately, I wrote many of these thoughts in March, because there's no way I would have remembered them now!  But I couldn't get myself to share it, in case I hadn't actually passed the test!

What does it mean to be a Board Certified Physical Therapist?  Right now, if you go to PT school in the USA, you're going to graduate as a DPT - Doctor of Physical Therapy - but you are a generalist.  You've learned the basics of physical therapy for all the areas of specialty that a physical therapist can work in and you took a big, terrible test that shows you are competent to practice physical therapy.  That test would cover all the different areas of practice and is very broad, covering a lot of topics.  After graduation, a new grad physical therapist will get a job and, with or without intention - begin to specialize.  To some extent, your job may dictate your specialty because that's the area of practice you're going to focus learning about moving forward.   The beauty of this is that you're able to change the area of specialty by working in different settings and pursuing alternative continuing education, but it also means that when we first come out of school - or if we change work settings - we're not very experienced in that care area early on.

When I first graduated, I worked at an adult orthopedic clinic while picking up shifts in a skilled nursing facility.  I focused my learning on orthopedics because it was my interest, but I had to learn the basics of the rehabilitation center because the needs of those patients were different.  Another example - if you came into the rehab gym at Seattle Children's where I work, you would see physical therapists working with children who have developmental conditions, which looks entirely different from what the sports physical therapists, like me are doing.  We're working side by side, all physical therapists, doing entirely different things from the same generalist education. I'm in awe of their work every day... and it's so different!

In some ways, the pathway of a physical therapist mirrors how a physician (MD) completes their schooling.  Any doctor you have seen - your primary care or specialist - went to medical school and graduated as a generalist.  However they can't practice medicine that way.  They are required to continue on their education pathway into a residency, determined by an intense matching program that I'm incredibly thankful I did not have to endure. They will be matched into the field they will pursue and specialize in, like emergency medicine, cardiology, orthopedics, family medicine... that list is super long.  And then, after another several years of working in their specialty while learning on the job, they become a specialized physician and can practice in their field.  But they don't have the wiggle room to wake up in the morning and say - I don't like being a heart doctor anymore, so I'm going to study diabetes and be a doctor for that.  They're a bit more restricted in their careers.

I have read articles recommending that physical therapy transition into the medical school model, requiring residencies to specialize.  This is an option now, but it is not required.  A physical therapist currently has the option to specialize in nine different areas, and this can be done by either completing a residency program and taking a big test, or by meeting a list of requirements and taking the same big test.  This is the test I took earlier this year and have been tortured into waiting four months to get my results. The residency program is meant to give you the hands-on experience and focused training needed to pass the test, but you're able to test without the residency and achieve the same end-goal if you meet specified criteria.

In early 2014 I had applied for residencies in Sports Physical Therapy.  I wanted to work in sports and having had years of experience working with women's basketball and a shortage of physical therapists working with the WNBA, I felt this was the direction I needed to go in.  At the time, I think there were fifteen programs, but only three had options that were not soccer (none had options specific to women's sports) - and those were the programs I decided to apply to.  (No offense soccer, but I'm a fair weather sports girl.  I'll support the USWNT all day long and cheer and attend games when the sun is shining, but a year of sideline coverage in the rain was NOT on my To-Do list.)  And so - I applied to University of Southern California, Ohio State University, and Duke University.  (It would have killed my Husky Heart to be a Blue Devil a little bit, though the education would have been superb at all three institutions).  Needless to say, I was not selected for one of the few slots available, a very sad failure, but a few months later I managed to secure a spot in the WNBA without it, so I took the alternative route. 

The options for physical therapist specialist certification right now are: Cardiovascular/Pulmonary, Clinical Electrophysiology, Geriatrics, Neurology, Oncology, Orthopaedics, Pediatrics, Sports, Wound Management, and Women's Health.  The list of accredited residency programs is here for all the specialties.  A recent presentation I watched discussed focus on making a new specialty for Pain, which has not yet been established, but that seems like an interesting approach to try to advance the use of physical therapists in treating people with persisting pain. Since I've previously written about pain on many occasions, and I work with the Seattle Children's Chronic Pain Team, I'm excited to see if that will be specialty number ten.

A little about preparing for the exam:

The application deadline for the Sports specialty was July 31, 2018 to test in March 2019.  These dates have been consistent annually with all the specialties having application deadlines sometime in July the previous year for a March test date.  That means that if you want to take the test in 2020, you have 1 month to apply - or even less! The application process is pretty complicated for some of the specialties if you haven't completed a residency, so I advise you check it out soon.  All the information you could ever need is right here.

So, once you've applied, the American Board of Physical Therapy Specialties (ABPTS) reviews your qualifications to determine if you're eligible to take the test in your requested area.  That takes about 6 weeks.  I started studying when I applied, but I know others waited to make sure they could even take their exam.  Here's a look at how I prepared.

First, I gathered a bunch of materials to help me determine what content I needed to study.

The materials I used were:
1) The SCS Prep Course from MedBridge Education which has a nice table of contents covering all the content areas on the exam.  They have prep programs specific to many of the specialty areas.
2) I googled "SCS Residency Program Curriculum" on Google.  There are many, but I used this one which outlined a lot of the content topics.
3) I purchased "PT Sports Questions" by Matthew P. Brancaleone PT, DPT, SCS AT, CSCS" a question/answer book off Amazon for $35.
4) I already have my CSCS (Certified Strength and Conditioning Specialist) and the book "Essentials of Strength Training and Conditioning" and the study guide I made when preparing for that test.
5) I borrowed "The Fundamentals of Athletic Training" book from my boss
6) I found my course materials from the Emergency Management Course I took at REI which was a required pre-requisite to take the exam.
7) I borrowed the Manual of Structural Kinesiology from the Seattle Children's Inter Library Loan System for a review of anatomy and biomechanics basics, particularly with regard to the mechanics of the shoulder, and review of throwing motions and gait cycle.  My test was two weeks before giving this presentation at Seattle Children's so I was preparing for both at the same time.
8) Per the recommendations of the curriculum in #2, I secured copies of the National Athletic Training Association Position Statements, all of which are free here as well as many of their consensus statements and several of the APTA Clinical Practice Guidelines here.  The highlight of reading those was seeing how many of my UConn mentors were authors of them, including Lindsay DiStefano, Doug Casa, and Robert Huggins.  Man UConn puts out some amazing stuff!
9) Lastly, and probably most importantly, the Description of Specialty Practice (DSP) for my exam.  The APTA has a breakdown for each exam listing the material that would be covered on it. If you're approved to take the test, they send it to you as part of your application fee.  Or you can buy it before you apply.

Second, I took a practice test.  Right from the start.  The MedBridge Prep Course offered several practice exams that were shorter in duration than the actual test and covered a wide variety of topics.  Based on the results of my first practice test, where some of my outcomes were abysmal, I knew how to prioritize things.

Third, with my current skills clearly identified, and more importantly, my biggest weaknesses, I looked at this ginormous pile of stuff to read and the ~80 hours of online MedBridge videos available, and, I made a study schedule.  This is the same approach I took when studying for the PT licensing exam, so I was optimistic it could be successful again. I tried to cluster things together in a sensible way.  For example, when I read the chapter in the Athletic Training book about weather-related injuries like heat stroke or how to deal with lightning, I also read the NATA position statements related to the chapter, and then watched the Medbridge Video on that same topic.While I was studying the weather-related injuries, two quotes stuck out to me that I had saved for this post  With regard to cold-related illness: "Nobody is dead until they are warm and dead."  So, if you find someone buried in the snow, they're not dead until their body has been warmed up.  And with regard to lightning injuries, "In the contest between people and lightning, lightning always wins." So I got the repetitions for a topics and kept notes on things that I was unfamiliar with or wanted to come back to after I had gone through everything once.  Repetition is helpful for me, but also sometimes felt like I was beating a dead horse by the end of some of the longer (or less interesting) topics.

And then I took my test.  I'll be honest - I was behind on my schedule pretty much from the second week, but I just kept plugging along.  I had an excellent student in the clinic, who I wrote about here and here, and who was treating about half of my case load for several weeks leading up to the test, allowing me more time to devote to reading papers and studying.  I read A LOT of the materials listed above, but found some of it to be too inapplicable to the patient care I typically do, that I decided it was worth leaving out some chapters despite the risk of doing so.  I watched almost every single Medbridge course that was listed in their prep program, several just listening while I was driving, including most of the optional ones.  I was stuck on the Brooklyn Bridge for over an hour in traffic and watched an entire course on nutrition in that time.  And I was certain that I did not pass.  Today's news that I passed was super exciting.  Hopefully writing up my preparations will help someone else on their road to board certification.

What Do Physical Therapists Do? Installment #5: Emergency Response

REI Seattle Outdoor Space

Welcome back to the recurring segment on the blog: "What do Physical Therapists Do?"  I've previously written four other posts on this topic, all tagged with #WhatDoPTsDo so you can search the blog for those previous posts if you're interested.  I spent the last two days getting my certificate in Wilderness Emergency Response and First Aid hosted by the REI flagship store in Seattle.  (Beautiful fall weather and somehow managed to get out of there without buying anything!)

Before you get too far into this, you should know that in general, many physical therapists are not trained for emergency response care.  As trained healthcare providers who usually have training in CPR and First Aid, I would think that a physical therapist would be better in an emergency than someone without any training - but in general we're not trained for emergency response.  But we can be!  This is a key difference between physical therapists and athletic trainers where, generally, physical therapists are not present when an injury occurs and help rehabilitate the injury days or weeks (or sometimes much more time) later.  Athletic trainers are specifically trained to respond at the time of an injury or to an onset of illness to the athletes they work with. There are many ways in which PTs and Athletic Trainers With regard to urgent response, athletic trainers and educated physical therapists also differ from EMTs in many ways.  In the case of an emergency, 911 is still your best bet, but since I just attended the course, I thought I'd share why I would learn about emergency response and some of the tips and tricks I learned.

The class was structured with didactic learning intertwined with case scenarios.  We'd learn how to assess a patient and then practice in groups. Then we'd learn about various signs and symptoms of different conditions and then assess patients again.  There were numerous repetitions and they even used makeup to make bleeding/bruising so that you were looking for injuries to treat.  Conditions we discussed included musculoskeletal injuries - like I'm used to treating - and special focus on injuries to the spine, plus wounds, burns, weather-related conditions, abdominal pain, chest pain, allergic reactions.  We learned basic treatment techniques to help determine needs for evacuation/emergency care as well as splinting and wound care.

Fake Makeup Hand Injury

Why would a physical therapist get trained in emergency response?  Many physical therapists are also athletic trainers and, as such, need to keep their education current to best treat urgent cases.  There are, however, PTs who are not athletic trainers who also provide sideline coverage for sporting events (like myself with the Seattle Storm) and who can take these advanced courses in order to work towards board certification as a Sports Certified Specialist Physical Therapist.  For me, personally, I was also an EMT in my previous life and have always loved learning about urgent response.  I like knowing that I can be a helpful resource in an emergency situation.  The courses are also great reviews of basic anatomy and common illness or injury situations.

Key tips and tricks I learned in this course:

1) If you ever come across a person or group of people who are in need of emergency response, you must first make sure that the area is safe.  Otherwise you risk becoming an additional victim!  A person who fell off their bike in the middle of the street or someone who experienced a snake bite are both scenarios in which you could be putting yourself in danger and need to consider the surroundings before you can really provide adequate care.

2) Once the surroundings are determined to be safe, start with the key life threatening findings which are remembered by ABC.  Airway.  Breathing.  Circulation.  If a person is sitting up and talking to you after an injury - their airway is open and they are breathing and have a pulse - but you should still look for major bleeding that can impact circulation.  Nothing else matters if the person does not have an adequate airway, respiration, or circulatory system because those are life threatening situations.

3)  Medicine happens at the skin level.  This is something that was discussed a lot in PT school and I appreciated this reminder.  If someone says their shoulder hurts - LOOK AT THEIR SHOULDER! I remember a case we discussed in school where a patient came to PT complaining of back pain.  He went to the doctor first, was given pain medications (that weren't helping) and was sent to PT.  The physical therapist started their examination by lifting up the shirt to look at the back and see if there was any bruising - only to find a large rash.  PT wasn't going to help that condition.  Once life threatening conditions are ruled out, an injured person should be assessed from head to toe and any pain region should be exposed.

4) Failing to prepare is preparing to fail.  Take a first aid kit with you when you go hiking or backpacking in the woods.  At the very least, have the ability to splint an injury, protect injured skin, and stay hydrated and energized with enough water and food.  And always tell someone where you're going and when you should be back.  If you don't return by a certain time, they should send for help because if you're stuck in the wilderness with a major injury, you're going to need help.

5) Injuries may be easy to see, but illness may not be.  Things like heat exhaustion, altitude sickness, hypothermia, allergic reaction, diabetic emergency, or a heart attack are hard to identify if you don't know what to look for.  If you're concerned about someone feeling poorly but you can't see anything - you're better off calling for help!

I hope this is helpful if you ever find yourself in a situation where someone needs emergency care - but know that this was a 5 minute overview of a 2 day course, and that my EMT training was weeks long with ambulance calls and real life response training.  Again, you should always call 911 in an emergency situation, and only help a person in ways that you have been trained to do so.  If you're an adventurer, you should probably take a course in emergency response and/or first aid, whether or not it's specific to the wilderness, because many of the principles are similar.  I hope you go learn all this information and never need to use it!

NAIOMT Course

So many continuing education opportunities the last few weeks!  I'm starting to realize that the summer time is for kayaking and WNBA basketball and the rainy winter season of Seattle is for reading and continuing education.

About 3 weeks ago I took the North American Institute of Orthopedic Manual Therapy Cervical I course taught by Steve Allen. Prior to this, I've taken their Lumbar I and Thoracic Courses.  NAIOMT offers courses in manual therapy so you can work towards different levels of certifications. The first certification, CMPT- Certified Manual Physical Therapist- requires completion of seven courses: cervical I and II, lumbar I and II, thoracic, upper extremity, lower extremity and then a practical exam. They focus on safety first, differential diagnosis considerations, identifying pathology broken down between contractile and noncontractile tissues, and courses loaded with hands-on learning along with online didactic portions that are evidence-based and actually quite entertaining.  For example, they used videos of an owl's excessive cervical range of motion to compare to the human.  

What I like about these classes:

1) Anatomy reviews are so beneficial as I move through my career. I notice a lot more of the smaller details and am reminded of smaller accessory muscles that contribute to the idiosyncrasies of the human body. When I read articles and watch social media posts for continued learning, it is rarely a review of anatomy except, for example, the occasional Eric Cressey reminder about the importance of the latissimus dorsi. I often feel I should go attend a cadaver examination now to see how much more I would get out of it than I did in 2011.  

2) I have a spine manipulation certification- and these courses are an easy way for me to maintain that status. Washington State allows physical therapists to manipulate the spine (think chiropractics) as well as the rest of the body with a specific protocol outlined to get that certification. As a manual therapy course, these give attention to precautions and contraindications for spine manipulation which are important reminders. I personally don't manipulate the neck almost ever- but the cervical/thoracic junction down to the lumbar and sacro-iliac joints along with the extremities I mobilize all the time and manipulate as needed.  These classes teach me techniques to use that I like and they prioritize safety. 

3) The courses focus on examination and assessment heavily with the notion that if you take a detailed enough history and listen to your patients, they'll tell you everything you need to know to identify the likely pathology pattern they fit into.  And they use a movement screen that is consistent throughout the spine so if you take a neck class and then a low back class- you get the repetition of process and ideas. It's different than the exam I learned in school- which for the most part is what I continue to use with pieces of their exam included. 

What I don't like about them?  Well like all continuing education they're a bit expensive- this one was about $600. They are not frequently offered nearby so I've had to travel pretty far for two of the three I've taken.  Additionally, a lot of the techniques in the level I courses I had learned at school, but many I had not used enough so they were a review and I definitely integrate at least a few of them into my practice each time.

Overall- if you're looking for a class to take (especially if you need all 20 of your annual hours in a crunch- these are 21 hour courses) and are interested in manual therapy- I would definitely recommend NAIOMT. There are lots of other companies who also focus on manual therapy- they're probably also great, just not where my path has taken me.

Let's not debate the research on whether or not manual therapy is a useful tool... I use it in the adult population and primarily the post-op kids I treat and think it's a useful component to my sessions.  That's not what this is about.  This is about what NAIOMT offers and my opinions on their courses.

Any recommendations of courses I should take next year?