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.

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?