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.

Conflicted

Hey everyone.  This past week I've been conflicted with something I use in my patient care.  Conflicted enough that I've brought up this conversation with my coworkers and a close PT friend and it's still weighing heavily on my mind. So now it's here for others to read and comment on. Please send your thoughts, fellow PTs.

There is a physiotherapist out of the UK named Adam Meakins who posts regularly about various physical therapy topics including issues with the profession, our techniques, and our shortcomings. He goes by "The Sports Physio" and has a very respectable social media following: 54.4K twitter followers and 76,000 followers on his blog... compared to my 270 twitter followers and 9 blog followers (plus my mom).  I present these numbers for the sole purpose of demonstrating that he's a well-known PT.  I have followed him and read his materials for about a year and have come to find that he challenges my thought processes, which is essential for my growth, though sometimes is hard to swallow.

ID 2530204

© Chrisharvey

| Dreamstime.com

In the past week, two physical therapists who I respect - but also occasionally differ in opinion with - have mentioned Adam Meakins. One of them linked to a video Adam posted on Facebook which he further discussed in this recent blog post and he was also interviewed on this podcast about a different subject - so he's just come up a lot more this week than usual and his messages have been on my mind.

This post is not meant to be an attack on Adam.  He works hard to improve healthcare and physical therapy practices - noble efforts with messages I often agree with.  He expresses his perspectives confidently in an unapologetic abrasive manner that has a certain appeal for getting his message across.  (AKA - there's no bullshit.  He tells it like he sees it.  I love this about him.) He's a physio and he's trying to help people live healthier lives doing the things they love to do... so I respect him. I have never met him in person (yet), but I do pay attention to what he's posting because I think his perspective is really valuable, even if mine differs, like it does right now.  I wonder what it would be like to shadow him treating patients for a day.

The blog (and video) he posted discuss the use of palpation (evaluative touch) and how we present our findings to patients.  

Adam listed multiple studies as his references, many of which I have now read, which report that either more research is needed or that palpation techniques are not reliable. To my knowledge, there are not many papers that say the opposite, and my skills of critically appraising research are certainly inferior to Adam's, but this paper contradicts the research presented in Adam's blog post.  I had to search to find that one.  I searched because I have found multiple occasions where someone has told me to do something with patients because they read an article about it - and I was able to find multiple publications that stated the opposite information.  So when I read his post and immediately felt like it didn't sit right with me, I had to do some searching. Maybe I don't understand his message properly.  Maybe I'm too biased to see through my own thought processes.  Regardless, I am conflicted.

Adam points out that physical therapists are not good at palpating things like "knots" or "trigger points" or "tight bands" or "joint play at the spine" and that we are not consistent between providers or even consistent with our own practices.  In non-medical terms - if you smell pizza in the morning and identify that it is, in fact, pizza - but in the afternoon smell the same exact thing and identify it as a cheeseburger, you're not being consistent with your own findings.  And to tell someone that you have a cheeseburger when it's actually a pizza could be confusing or problematic.  Scientific research says that physical therapists touch patients to evaluate them but report different findings. The research also says that we cannot identify if parts of the spine moves abnormally or identify which level of the spine we're touching with consistent results.

Now... when I palpate a patient and feel like a segment of their lumbar spine feels hypomobile, I agree with Adam that it makes no sense for me to state the specific level of the spine to the patient, because I don't have XRAY vision to know I'm 100% accurate and, working with kids, it probably doesn't have much meaning to them anyways.  I worked with a patient with neck pain today and, as I've previously mentioned, I currently have a student.  So when I palpated a segment that I thought was hypomobile (and reproduced the patient's symptoms), I relayed to my student that she should look around where C3 would likely be because I can't actually be certain that it is C3.  I think it is, I'll document it as such, but the reality is - I don't actually care exactly what level it is.  I feel something, it reproduces my patient's symptoms, it's where I want to treat.  I don't know how I could have better directed my student to what I found for her to feel it herself, but the patient felt relief with mobilizations at this region.  Adam's post suggests that this confirms my bias to this being a useful technique.

Maybe it's more about the way the care is interpreted and explained to the patient than the actual identification of specific structures and the interventions that are applied that Adam has a problem with.  I agree with him that we really need to STOP TELLING PEOPLE their L5 is rotated or their back is out. What does it mean for you to throw your back out?  That is not medical terminology.  Can your back ever be in?

But... when I palpate, particularly at the spine, I do feel "something." Of course I'm biased on my opinion of my own patient care...it would be wrong of me to use interventions that I did not believe were helpful and, since I also manipulate the spine on occasion, I feel it is essential for me to use palpation to identify hypomobile segments of the spine.  I feel hypomobility in some regions compared to other regions in the same person.  While I don't generally compare spinal mobility person to person because I don't find that useful, I do correlate certain patient responses with what I'm feeling in soft tissues in my hands and compare that to what I've felt with others.  If a person laying on the table in front of me presents with a neck that is tender to palpation and their cervical and thoracic spine feel stiff compared to their lumbar spine, I want to treat this issue.  Maybe with manual therapy.  Maybe with exercise.  Maybe with both.

I used to do things very differently.  I no longer say to my patients, "Wow your neck is really stiff," or "Your 1st rib is stuck"- though I do sometimes feel a stiff neck and a hypomobile first rib... which I treat.  I don't say these things any more because it freaked out the patients.  They'd worry about their rib being a problem.

I used to look at the pelvis and tell patients that they had one leg longer than the other. All the time.  Guilty. I didn't know better, then! I used long axis distraction of a leg to distract the hip while simultaneously re-aligning the SI Joint.  That's what I truly believed.  I'm telling you that I used to regularly yank on people's legs. Maybe as often as daily. Wanna know why I did it so much?  Because sometimes IT ACTUALLY WORKED.  And they felt better.  And that's a bit of what Adam Meakins is saying... that we can be convinced that the care we're providing is beneficial, even when it is not supported by research. I eventually learned that it didn't work as much as I thought it did.  It didn't help enough people.  It could have been harmful to the patients and I constantly felt like I was doing something to patients to try to fix them rather than guiding them towards ways to fix themselves.

Humans can't be symmetrical if we have hand dominance and we move to get in and out of a car in the same way all the time but less frequently on the other side of the car. Our heart is not centered in our chest cavity.  There is only one spleen and one liver and they're not in the middle perfectly symmetrical....  So while Adam Meakins is practically pleading with physical therapists (and hopefully chiropractors and physicians) to STOP telling our patients that they have anatomical problems that are probably not actually problems, and I agree with that message... I still feel "something" when I palpate the spine.

If patients ask, I now use an explanation about the nervous system having a reason to try to protect that particular region of the body and that by using load management strategies, it may calm down. I explain that "hurt does not equal harm"... that the tissues of the body may hurt even though damage is not occurring.  The body uses pain to protect itself.  And then I give a home exercise program to guide them on restoring motion, strength, or function based on what I determine the patient needs... which I did by using palpation.

I remember sitting in PT school and being taught how to palpate the multifius and the transverse abdominus musculature to assess if they're contracting.  I could never feel the multifidi.  Never.  And then the PTs at my first job out of PT school encouraged me to focus on assessing the multifidi in various positions and using abdominal bracing and using electric stimulation in conjunction with abdominal bracing on my patients.  I tried to use that.  But I could not feel it.  This is what Adam seems to be describing but relevant to palpating the spine.  Is it possible that we have different skills with regard to palpation?  Is it possible that while I cannot feel the multifidi, I could feel hypomobility at the spine?  Is it possible that the issue is not about what we identify, but more in how we express it to our patients?  We are definitely impacting the beliefs of the patients we see.

The podcast interview goes a bit more into the discussion of the narratives that physical therapists (and healthcare providers) present to their patients and how this can negatively impact them.  I like that Adam states in the podcast that removal of pain is the wrong way for PT to be going as a profession.  We need to be empowering patients, give them realistic expectations, and help them operate within the constraints that their individual bodies allow.  The goal should be developing resilience and tolerance - not elimination of pain.  I agree with Adam on all these points.

I also agree that we are over-treating patients.  Too many visits.  Too many referrals from person to person rather than really understanding what's going on.
I also agree that the medical system doesn't operate in an ideal fashion.  Insurance companies limiting treatment influence the care that patients get.  This is wrong.
I also agree that sometimes the best treatment for a patient is NO TREATMENT.  I recently was working with a patient who was seeing so many different providers that I just sat her down and told her - I think you're trying to find too many solutions to a small number of problems and can't follow a single path to your recovery.  I recommended that she sit down and write a list of all the people she had been seeking answers from, and pick the one that she wanted to commit to.  Who do you believe is helping you?  Follow that person.  Get rid of the rest of us.  Everyone telling you different things is confusing and ineffective.   I don't actually care if physical therapy is her solution.  The best solution for every patient is the one they buy into and helps them find a way to get back to their function.  Period.

Even as I write this, I'm feeling my thought processes shift about what I say, but I"m not ready to throw away palpation yet.  I like that I'm trained to provide spine manipulations and have had some really great results using it. I use it selectively and in conjunction with movement.  And so, I'm unwilling to throw away a tool from my toolbox that I sometimes find essential.  At least for now.

Take Home Message: There are lots of really good physical therapists out there, many of which are creating content that is easily accessible and easy to apply.  The messages differ between them.  But patient populations differ and you have to believe in what you're selling to your patients.  I believe in a little Mike Reinold and a little Lenny Macrina and a little Lorimer Moseley and a little Adam Meakins and then I add some strength and conditioning with Eric Cressey and a little breathing from yoga practices and a little mental health... and I'm my own unique clinical provider because of all those influences... which is why I keep writing about all of them!  So use a variety of backgrounds and consider opposing opinions, try out different techniques, challenge your own beliefs and welcome growth along with failure.  Feel free to tell me if I'm wrong... I may not like that, but I'd like to think I'll be respectful and consider the alternatives.

Above all else - Do No Harm.

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?