Continuing Education Bits for PTs & PTAs

Posts tagged ‘Physical Therapy Continuing Education’

What led YOU to become a PT or PTA?

It is PT Month and let’s focus on YOU as we open a 3-part series focus around the career ofmarilyn-pink-profile physical therapy.

As a PT myself, this month is the time I use for professional reflection: where I have been, where I am, where do I want to go, and how am I going to get there. Am I leveraging my past to be the best PT that I can be today? What have I given, what am I giving, what do I still want to give to our profession?

Given this is a ‘professional reflection’ month, let’s start by remembering your interview for school. Please take this short poll (below), and let’s engage into a conversation about this wonderful path we have taken. I look forward to what you have to say! 

Marilyn Pink, PT, Ph.D

PLEASE TELL US…

PT-month-1

 

There are no right or wrong answers — you’ve chosen a noble career and we salute you as we look forward to what you have to say.

And keep your eyes peeled for stories, reflections and tools that we will be publishing, which we hope will be useful in your professional life.

Comment at will!

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Farewell and Thank You, Dr. Jobe!

by Marilyn Pink, PT, Ph.D., MBA

Jobe banner

A patient sitting in his/her pre-op exam with Dr. Frank Jobe would hear about the surgery, and then they’d hear “—and that is only Jobe in scrubsthe first half of the job, the second half is your physical therapy”. On March 6, 2014, physical therapy lost a great friend and a firm believer in the profession with the passing of Dr. Jobe.

Given the great therapists he worked with, it is easy to see how he came to appreciate the benefits of PT. So, before going on with remembrances of Dr. Jobe, I, as a PT, would like to thank all of you PTs who affirmed Dr. Jobe’s belief in us: Haideh, Judy, Clive, Kevin, Pat, Brian, Matt, Stewart and many, many more. For those PTs who have not had the privilege to work with Dr. Jobe: we are making his EDUCATA course The Process of Progress (a collaboration between myself and Dr. Jobe) available for free this month of March 2014 in his honor. Click here and enter coupon code JOBE2014 at checkout if you’d like to hear and learn directly from this great clinician, surgeon, educator.

Like Hippocrates, Galen and Pare, Dr. Jobe went to war to learn about surgery. He joined the Army out of high school during World War II and served in the 101st Airborne Division during the Battle of the Bulge. One day, out of the blue, he told me a story about how his group was about to move to a new location the next day. As the medical supply sergeant, he stayed up all night packing supplies. The next day, once they’d arrived at their new destination and he had unpacked, he decided to take a nap.  So, he went into the forest and fell asleep – until he heard yelling, screaming and gunfire. He looked out from the dense forest, and saw the Germans had overtaken his camp. As a young man not knowing what exactly to do, he went deeper into the forest and became quite lost. Multiple days in the cold without food went by. Then he heard trucks. He decided it didn’t matter if those trucks were American or German, he was going to flag them down.

Lucky for him, and us, they were American trucks. Dr. Jobe became a medic and the Army doctors whom he saw performing surgery, keeping calm and focused with gunfire overhead, became his inspiration.

Indeed focus and keeping calm became landmarks of his personality.

The first lecture I did for Dr. Jobe was at a Baseball conference. After speaking and on stage, Dr. Jobe came up to shake my hand and leaned in, for what the audience probably assumed was a gentlemanly kiss on the check.  But, here’s the truth – he was whispering in my ear that I’d forgotten to distinguish between the upper and lower subscapularis!! So, Dr. Jobe: in the lecture on shoulder biomechanics that is currently in production at EDUCATA, I make a big deal out of the difference of those two RADICALLY DIFFERENT parts of the muscle.

Dodgers Fantasy Camp fixed

Baseball Fantasy Camp for MD’s and PTs. Dr. Jobe flanks one end and Marilyn Pink the other

Much has been said this past week about his breakthrough surgical procedures and the famous people he treated – mostly athletes. But I’d like to put in my two cents for his generosity to humanity. Here was a busy man who loved his work and the people around him. He helped us define our strengths and then gave us an opportunity to push a bit more. He knew what and when something was taking our minds off of work, he’d gently inquire about it and turn the focus to what we did well. He helped us believe in ourselves.

Jobe Manuel Bunelos

I’m at a lack of words for the greatness of this human being, but I’d like to close with this remembrance: frequently, at the end of a lecture, Dr. Jobe would turn to the audience and say “We aren’t done.  It isn’t over yet.  It is for you, the next generation, to take this knowledge to the next level.  I want YOU to do the research to make my words outdated.”

I take that to heart.  This past year we saw Dr. Perry pass away, as did Dr. McKenzie and now Dr. Jobe.  Who among us are the next leaders in clinical advancement?  What questions are we asking?  What do we look for and how can we consistently optimize treatment with our patients?  Equally pertinent is how do we deftly communicate our findings and promote learning in all of us?

So, thank you Dr. Jobe, Dr. Perry, Dr. McKenzie and many other leaders who have shown us not just the facts of medicine, but also the process of thinking through problems, deriving solutions and communicating results. Thank you too, for making it clear that we each have a responsibility to enjoy our work as we push it forward.   Thank you for being our inspiration.

Marilyn

Dr. Jobe and Marilyn

“A great surgeon but a better person” – Tommy John, retired Dodger’s pitcher.

Dr. Frank Jobe with Tommy John.

ASSESSMENT: zeroing in on the problem with our runner

 By guest blogger Susan Bamberger

Thank you all for your detailed and well thought comments on the first installment of this case study! At the end of the history, we should have some idea of what might be going on. Performing a detailed interview will help to create hypotheses that we can test in the physical examination.

Giving some thought to pathoanatomical causes, it is possible the he may have a tendonosis of the psoas. It is also possible that he has a mechanical impingement of the hip joint. He may also have a structural defect such as a labral tear. The symptoms could be coming from the lumbar spine or the hip, SIJ, knee or foot. It is also possible that he has a stress fracture. Each of these pathoanatomical possibilities are managed in different ways. How do you discern which to treat?

While the pathoanatomical possibilities are there, we do not have the ability to look inside and determine the exact cause. The most accurate information we have in front of us in this visit is the patient’s pain presentation and its behavior of symptoms. We can look at the behavior of symptoms and assess for change in these symptoms through the course of testing. This will become the most effective guide in developing a plan of care.

My assessment utilizes Mechanical Diagnosis and Therapy (MDT) which is used to target the problem based on symptom presentation and behavior. More common in the spine, MDT has proven to be reliable, valid and prognostic in multiple studies conducted over the last 40 years. However, the principles of assessment can easily be utilized in any joint of the body, including the hip.

As I begin to plan the physical exam I must consider all of the factors contributing to his recovery:

  • The pain is a 5/10 on a 0-10 scale, 0 being no pain and 10 being the worst pain ever imagined.
  • It comes on as soon as he begins running and it ramps up immediately. However, it goes away within a few minutes after stopping his run.
  • He does not notice the pain otherwise- he sleeps well, and does not feel the pain when going up and down stairs.

He has been trying to run every few days, without any noticeable change. Any objective baselines I find must be related to the exact pain he experiences when running. However, he was not prepared to run on this visit, so another baseline will need to be used.

To get a solid baseline, I may need to be pretty aggressive in my examination on day one. However, in order for trust to be established, I decided not to try and provoke his symptoms, but rather to educate him in the assessment process and the need for him to participate in the analysis.

The location of symptoms indicates the pain could be coming from the hip or the lumbar spine. The behavior of symptoms does not exclude the hip or lumbar spine. So a screen of the lumbar spine was necessary before exploring the hip in detail.

The physical exam reveals an athletic man in no apparent distress. Left hip passive range of motion into flexion, abduction internal and extension rotation were tested in supine. IR and ER were tested supine in 90 degrees flexion. Extension was tested in side lying. Flexion ROM is approx 100 degrees and painful. Abduction is approx 25 degrees and painful. There is a minimal loss of internal and external rotation, with pain greater into external than internal rotation. Extension lacks approximately 5 degrees to end range.

Resisted motions are strong and painless in all directions except flexion and adduction, which are weak and painful. These tests were performed in supine. Resisted flexion in supine, in particular, produced his primary pain. This was the baseline to refer back to when I perform my mechanical testing later.

While special tests ( Hip scour, compression) could be performed, none were performed on visit one. The patient had been referred from his orthopedist, who was confident there was not an operable structural issue, and there was nothing yet in the history that indicated surgical referral. At this time, special tests did not have a practical use. If there was not a consistent response to the repeated motions, at that time special tests may be indicated for further clarification.

Screening for the lumbar spine did not reveal any significant lumbar component. This was done by first checking for lumbar range of motion in standing, flexion, extension and side gliding were  within normal limits. To determine if the lumbar spine was involved, 15 progressively loaded lumbar extension mobilizations were performed in prone, and then his primary baseline ( resisted hip flexion in supine) was retested for change. There was no change, indicating it was necessary to move to the hip for further testing.

The next step is the repeated movement examination, a key component of the MDT assessment process. Responses to symptomatic, mechanical and functional baselines give us the information needed to classify his condition and devise a directed and effective treatment plan. Repeated movements can be performed dynamically, with sustained positions or with resistance. If the baselines demonstrate an immediate and lasting change, the classification is derangement and the prognosis is excellent.

Repeated hip extension in half kneeling was the first movement chosen. Given the irritability of the symptoms, half kneeling would provide a great deal of force, and is a good start to providing movement that will provide immediate and lasting results. The direction of extension was chosen as this is often the direction most frequently seen for patients with hip derangements. The position of half kneeling was chosen as a relatively aggressive position, knowing that since an aggressive force was needed to produce the symptoms, that an aggressive force would be needed to reduce the symptoms.

The patient had 0/10 pain at the start of the repeated motions exam. There was some pain at the end of the range of the first repetition, in the same location as his primary pain. This pain progressively improved with subsequent movement, as did his ability to move further.

In retesting his primary baseline (5/10 pain with resisted hip flexion in supine), 10 repetitions of dynamic hip extension in half kneeling reduced his pain to 4/10, and 10 more reduced it further to a 2/10. His ROM in all planes were restored to symmetrical and within functional limits.

runner flexing

With an immediate and lasting change in range of motion and pain, the repeated motions exam confirmed a classification of derangement, indicating an excellent prognosis. As his pain decreased, his strength also improved, indicating the weakness with resisted hip flexion was more likely related to pain inhibition than true strength loss.

Since we have not actually tested running, we cannot conclude that this movement alone will resolve his primary pain. However, since we were able to find a baseline that reproduced his primary pain, and it changed with the repeated motions exam we have something to start his treatment plan.

The patient was sent home with instructions to assess the effects of this test over the next few days. He was instructed to discontinue any other stretches he was performing, and to perform just this one exercise until he came into the clinic again. This would help to determine the effect of this one stretch alone. Specifically, he was instructed to do hip extension in half kneeling, 10-15 times, 4-5 times throughout the day. In a few days, he was instructed to test running, to see if a few days of the repeated hip extension in half kneeling produced any positive results for running. Pt understood the mechanical issue, and experienced the immediate results during our assessment. He was eager to take a role in the analysis of his symptoms.

Visit two

Four days later, the patient presented to the clinic with a journal describing his pain behavior and exercises. There was a consistent effect with the exercise: immediate discomfort, then a loosening of the range of motion and a lessening of pain with each subsequent repetition.

He had tried running two days, and was encouraged as he could now run 10 minutes before experiencing pain. In addition, the pain was not as intense- it was a 2/10 instead of a 5/10 as before. He ran to the clinic for this visit, and was experiencing a 2/10 pain towards the end of his run to the clinic. He demonstrated the exercises, and was performing them correctly.

The patient is better, but is it enough to continue with the current plan of care?

What would you like to add to his home program at this time?

What would you do on this visit?

What other treatments would you want to apply, and why?

How would you help this runner?

Introduction by Marilyn Pink: from time to time EDUCATA has the privilege of hosting guest bloggers on this platform. This series is written and moderated by Susan Banberger, a PT since 1999. Susan is a Diplomate in Mechanical Diagnosis and Therapy and works at Advance Sports and Spine Therapy in Wilsonville, OR. She has contributed to several publications, including the International Journal for Mechanical Diagnosis and Therapy. 

The case study examines the experience of a runner who has recently dared long distances and comes to the PT with severe hip pain.Please feel free to participate and comment at the end of the article, as much is learned by all in the process of exchanging ideas.

A runner with hip pain – getting him back in the race

By guest blogger Susan Bamberger

When a runner comes to physical therapy with debilitating hip pain, there are a multitude of treatment options. The accessibility of information from the internet leaves patients confused as to which shoes they should wear, if they should wear shoes at all, if they should stretch, and if so, should they stretch before or after their run, or both? They come to us to help sort out this information and to determine what is best suited for them.

Physical Therapists have the responsibility to create an effective plan for each patient in a reasonable amount of time. Not every treatment works for every patient. Anyone can research stretches, strengthening and shoes on the internet. Our challenge is in proving that we hold unique knowledge and skills to deal with individual problems in this information age. This case study is an example of how skilled physical therapy provided excellent results and gave this runner the knowledge and treatment he needed to return to running, pain free.

physical therapy runner with hip pain

The patient is a 38 year old male plant manager and new long distance runner presenting with complaints of left anterolateral hip and thigh pain. He was referred to physical therapy from his orthopedist, who diagnosed him with greater trochanteric bursitis.

His onset of symptoms was 6 weeks prior to the initial evaluation, after running a marathon (26.2 miles). By the end of the race, he was in intense, constant pain, rated at a 5/10 that remained constant for 3 days after. His symptoms became intermittent, and have not changed much since that time. His plan was to run 4 marathons in the next year, but he has stopped running completely, as every time he runs the pain comes back to the same intensity it was immediately after the race.

Since becoming symptomatic he has tried many stretches and strengthening exercises he researched on the internet. He has also received advice from his massage therapist. However, the same pain comes back when he runs. He has good shoes, and changes them every 250-300 miles, per industry recommendations. Because of all of his research, he is concerned that this is an issue that is going to keep him from running altogether.

When asked if the patient had any imaging, he replied “only an xray”. Then he said, “Why, do you think I need an MRI?” Sensing fear of life-altering structural damage, the patient was assured that one of the goals of physical therapy is to determine the right place for them. With a careful assessment over 2-3 visits, we should know if further testing is necessary.

Given the history, which structures are you going to examine?

How can we establish functional baselines and how vigorous can we be in our examination?

What examination tests would you use, and why would you use them?

We look forward to your comments!

Your aging patient

Without exercise, aging is accompanied by a slippery slope of decreased vigor and well being. As PTs, there is much we can do to halt this decline and to help ourselves and our patients.

In this blog entry, we’d like to take the pulse of our community with a series of quick questions — for fun and for learning. Check them out and participate! We’ll share the responses (and correct answers!) in a follow up soon.

How much do you know about aging and exercise? Quiz yourself!


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How did you do? We will publish the combined responses in the next few days. In the meantime, if you are treating older patients, you owe it to yourself to check out EDUCATA’s Functional Assessment and Exercise for the Aging Adult course by Drs. Avers & VanBeveren. They cover this topic with great expertise in a series of engaging lectures.

During February, we are offering this course at 25% off its regular price. That means that the cost of the 7-hour course is now only $157.41. The lectures include:

This offer will be good until February 28, 2013. To take advantage of the offer, click here and enroll. The discount will be automatically applied.

In the meantime, stay tuned for next week’s post with the results of the above quizzes. And, as always, we’d love to hear your questions and comments, so feel free!

Warmly,

Marilyn Pink, PT, Ph.D.

Workplace Consulting: poll results

Last week we posted some information about consulting to businesses on injury prevention and a short, three-question survey to gauge your general familiarity with this subject. The results were very interesting, as always. Around 400 PTs participated and the graphs below show the responses in percentages, so it’s quick and easy to see how many had the correct answer, represented by the green bar.

The first question, “Who pays the fee for providing an on-site injury prevention program, such as a Back School?” seems to have been a cinch, since a majority hit the nail on the head:

Lauren q A

On the second question, only 19% got it right (how did YOU do?). Here are the results:

Lauren q B

The third and final question had to do with NIOSH lifting techniques, and it seems that many of you picked “twisting” and “grip mechanics” as being excepted from the set. Good deductive logic, but the correct answer was… “body mechanics/lifting technique”! Take a look:

Lauren q C

We hope you enjoyed this quick poll! You are always free to comment or ask questions on our blog posts. And remember, if you want physical therapy continuing education credits while you learn how to develop a workplace consulting practice, check out Dr. Hebert’s audiovisual online course at EDUCATA. This is a 4-lecture course. Each lecture can be taken independently, in smaller bites, or the course (10 hours) can be taken as a whole. Earn every penny that you are worth!

Hebert 25 off

When Orthopedic and Vestibular Physical Therapy Meet Neck Pain, Headaches and Dizziness

INTRODUCTION, by Marilyn Pink, PT, Ph.D: I have known and admired Dr. Landel for many years as a top orthopedic clinician, researcher and educator, recognized with numerous awards. Just this year, Dr. Landel was named a Catherine Worthingham APTA Fellow, the highest honor among APTA membership categories. So, we are particularly pleased to bring you the first on a series of posts by Rob and encourage you to comment & pose questions. This is an opportunity to interact with a real luminary in PT!

An evolving patient presentation: what else is going on here?

Rob Landelby guest blogger, Rob Landel, PT, DPT, OCS, CSCS, FAPTA

You are a physical therapist treating a 67-year-old female accounts payable administrator for the past 2 weeks for neck pain and headaches (HA).

Her neck pain is bilateral, localized to the suboccipital region, without radiation into either upper or lower extremitiy. Her headaches are mainly in her bilateral forehead region. Both her neck pain and HA began after a motor vehicle accident (MVA) 4 weeks ago but both are improving since starting PT with you.

Radiographs taken the day of the MVA were negative and the MD referred her to PT for a diagnosis of “muscle strain.” Your plan of care has been to address the impairments associated with soft tissue damage in the cervical spine following her whiplash injury: early immobilization and inflammation-reducing modalities followed by progressive AROM as tolerated, gradually introducing gentle PROM including manual therapy, and postural re-education. You have just recently started working on improving her muscle function through exercise.

Today as you begin her treatment when she goes to lie down she grabs the plinth for several seconds, shutting her eyes and swaying slightly, before gradually relaxing and proceeding to assume a supine position. She opens her eyes, notes you looking at her, smiles grimly and sheepishly apologizes. When you question what just happened, she says she’s been getting dizzy spells for the past several days. She hadn’t mentioned it to you since you were treating her for her neck pain, not for dizziness.

How did you vote?  

In our next blog post I will provide our own input, but for now I invite you to not only vote, but type in your comments to expand on WHY you picked that particular answer.

I look forward to hearing from you!

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