Welcome to the fourth installment of "What Do Physical Therapists Do?" I chose to use this as a recurring segment because there are several common misconceptions about what we actually do, probably because we do so many different things! This 2006 paper noted that over 1/3rd of participants surveyed (college-aged potential physical therapy students) were unaware of PTs' ability to help decrease pain and promote health. That same paper mentions the lack of knowledge of the general public regarding the amount of education required to be a physical therapist and what that training would include.
Overall, the key underlying action of a physical therapist is guiding our patients or clients back to their optimal function - whatever that function may be. I often feel like people think our primary purpose is to help people get out of pain, despite the report from the previously mentioned 2006 paper. While pain relief is a consideration, it's really more about the activities. So this recurring segment looks at various ways we help people get back to their chosen functional activities. In the past, I've discussed that we strength train (#3) here, we listen to the needs of our patients (#2) here, and we examine body mechanics with different movement patterns (#1) here.
One of the most common questions I'm asked by patients and their family members is "When can I get back to X activity?" In this scenario, X can be anything. Some are obvious functions or activities that aren't surprising... when can I run or exercise, when can I lift my toddler, when can I go back to work, when can I walk without crutches, when will I be able to reach the top shelf of my closet... an endless list. Some activities have been less obvious (or less sensible)... when can I get back to head-banging at concerts was a surprising question I've been asked by a gentleman recovering from neck pain after a car accident. It surprised me - but that's what he wanted to do. And why a teenager who had a severe injury on a trampoline would ever want to get back onto a trampoline shocked me... but they ask! (Side note - if I ever have my own children, I hope to find a way to ban them from trampolines. SO MANY injuries.)
The activities are frequently sports-related so it is a responsibility of a physical therapist to clear athletes to return to sports. This week, I was fortunate enough to present the new Upper Extremity Return To Sports Assessment that will be implemented at Seattle Children's Hospital to the Sports Medicine Team of Physical Therapists and Athletic Trainers. The program we developed has not yet been thoroughly tested despite being based on published research, so it's still a work in progress. It includes a group of tests to assess athletes who have had upper body injuries and/or surgeries as criteria to get back on the field/court.
Seattle Children's Hospital already has protocols for returning kids to sports after ankle and knee injuries, so we had a template to use of what has been helpful in the past. I like using the lower extremity assessments because they make it easy for a kid and their family to understand that they can go back to their sports when they pass all their tests. There are benchmark goals that help them progress in activity as you go along so having a series of tests at the end fits into the way things progress along the way. Using tests and goals motivates patients. For example, with consideration for surgical protocols and healing timelines, I tell kids that they can stop walking with crutches when they can stand on their injured leg for 30 seconds with steady balance and when they can complete 10 straight leg raises without any bend in their knee. Those are usually components of their home exercise programs and they often know if they're getting better and coming closer to meeting the goal. The goals help motivate them to work on their home exercises and they're measurable.
Did you know that if you are a healthcare provider - of any kind - and you clear an athlete to return to sports prematurely, you can be held liable if they get re-injured? You can. Did you know that a physician who clears an athlete back to their sports usually bases this on a tissue healing timeline whereas a physical therapist who clears an athlete back to their sports bases the decision on movement mechanics and other test criteria - such as the tests in this protocol - to make the decision? Something I find interesting about myself as a healthcare provider is that I rarely tell a patient to stop participating in an activity if they're tolerating it enough - but when it becomes my responsibility to allow them to return to a sport that a physician has discontinued their activity from, I'm much more confident in my decision if they have to complete tests showing they're ready in a controlled environment.
A basic summary of the categories of tests included in the protocol for upper extremity injured athletes returning to sport are as follows:
1) Range of motion comparison between shoulders with consideration for the total arc of motion for internal and external rotation.
2) Strength testing comparison for shoulder internal and external rotation as well as for grip.
3) Endurance testing observing how many push ups can be done with proper form. There are published normal values for this test by age and gender and, in the USA, this is part of the physical fitness testing conducted.
4) Upper body stability testing including the upper quarter Y Balance Test and the Closed Kinetic Chain Upper Extremity Stability Test
5) Power assessment using a seated shotput test.
6) Biodex testing as available.
Using numerous published papers on each of these tests, criteria were developed and the sports medicine crew at Seattle Children's will start to use the tests to determine if kids are ready to go back to their activities. There is still not enough published evidence for returning athletes to sport from any injury, so developing a protocol like this is not only challenging, but needs to be supported by clinical judgment. If you or someone you know is being treated by a physical therapist to get back to playing sports, you should ask them what criteria they use to determine if you are ready. Feeling good and being pain-free isn't enough and we want to prevent future injury as much as possible.
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