Monday, November 7, 2016

Challenging the Status Quo - A Clinical Commentary

Over the course of the last 2 years, I have tried to provide you a weekly blog that is based on the most current peer reviewed literature and evidence.  I am going to veer off that trend for this blog and hope you don't mind.  Please let me explain.  I hope you have enjoyed this blog and the various series within it that we have done.  If you have learned one thing, walked away with one clinical pearl at all during the course of this time, it was all worth it to me.  I am honored to have you as a follower of this blog and appreciate you sharing the passion for injury prevention with me.  This is not a blog that I am paid to do, it takes a lot of time and research but it is something that I take very seriously and am very passionate about.  To me, this was a calling that God called me to.  He called me to be a physical therapist and He called me to take on this challenge.  I don't know why me but I have accepted it and devoted my entire career to it. With His direction and will, we have accomplished some amazing things.  Why do I feel this was a calling?

Back in 1998, in my own practice in Phoenix, Arizona, I had 22 young athletes come into my clinic over a 2 week period of time with ACLR.  During the course of their rehab, I was providing the most current standard of practice to these young athletes.  However, in doing their discharge evaluations and seeing them move, seeing them walk and seeing them run, I could see movement patterns that I knew instinctively that put stress on their ACL and put them at risk for re-injury.  This is prior to all the great literature that we have now so this started me on a mission of discovery.  I felt a deep, deep desire to do something for these kids.  After going back to get my doctorate and spending countless years in reviewing of the literature, clinical research and over a decade in development, it led me to some clear conclusions:

  1. Movement is very complex and very hard for the majority of people to see and assess
  2. The standard of practice is often 5-10 years behind the literature and clinical advancements
  3. There is a strong correlation to improvements in movement efficiency and to mitigating risk of injury and improving athletic performance
  4. We need to recognize where the flaws are in the current ways we assess movement are so that we can become better at what we do
  5. Sometimes movement is just movement and we try to over complicate it
  6. The standard of practice or care, in my opinion, tends to be the standard of the lazy and status quo. 
This is why this is a clinical commentary.  This is based on one person's perception after years of literature review, clinical practice, educating clinicians and assessing 4000+ athletes.  That said, I am Joe Blow PT, I am nobody and have an opinion based on the above.   But it is only my opinion.  Take it or leave it but it will provide insight of why I do what I do and why I do this blog.  This particular blog is a blog to question the status quo.  Whether you are a clinician, a coach and athlete, question what you get from your health care provider.  Sometimes the experts aren't necessarily the experts even though they are very good at convincing you they are.  Laziness bothers me.  Especially if those that the public sees as the leaders are truly taking the easy road out and doing things half ..... (let you fill that in).

Movement is very complex.  Of the 2000+ clinicians (PT, ATC, MDs) that I have taught over the last 15 years, only about 1% can assess movement to the degree that I would consider proficient and accurate.  Is that a training flaw or is it that movement is that complex?  If consider the fact that the medical profession still struggles with development of a comprehensive return to play assessment or even a movement assessment, then I would suggest that it might be that complex.  There is over 15 years of biomechanical literature on movement and yet we STILL don't have it figured out.  Simply stated, when you look at an athlete (like the one pictured here), you have to look at the entire kinetic chain instantaneously.  You have to see what their foot/ankle are doing, the knee, hip and pelvis, and where the core is in relation to the center of gravity.  You have to see where all these same joints and segments are in relation to one another.  You have to see which one falls first in relation to the rest.  And you have to assess all this in an instant.  The human eye and brain are just not equipped to take all that in and interpret it at the speed at which movement occurs.  So, many have resorted to technologies to aid them in assisting in that.

With the advent of some of the 2D technologies, this has done a lot to advance what we know about movement.  It is a great tool and better than the eyeball alone.  Yet, at the same time, many fail to question the true validity and reliability of what they are doing.  Too many believe it is technology and therefore it must be accurate.  All too often, I sit in lectures at professional conferences where a clinician will present a running assessment or movement assessment done with 2D technology where they show improvements in the angle of ankle pronation or knee valgus by 5-10 degrees based on a treatment they did.  So, you are telling me that your treatment improved their movement by 10 degrees?  Or is it that your placement of your starting and ending points of your angular measurements on 2D video was off by 5-10 degrees?  Do they know that studies indicate that there is a 10-15 degree variance in measurements taken from 2D video versus when you measure using palpation and a goniometer or a Viacom system?   Unless they are using markers on the body to palpate the bony landmarks and making measurements from that then you have to question the validity of this measurement.  Do they know that the orientation of the camera to the horizontal and vertical can dramatically change the angular measurement taken from 2D video?   Unless they are using a plumb and level on the camera to ensure this is level to the horizontal and vertical, then you have to question the validity of this measurement.  My point, less than 1% take it to that step and if they aren't then how valid is the information you are getting?  It is fine if you are using that for documenting progress but when you try to apply that to determining an athlete's ability to return to play safely, that is really where we need to proceed with caution.

The standard of practice is often 5-10 years behind the literature.  Case in point.  Recently, I was asked to review an athlete's case that was seeing a local PT.  A PT that is considered to be "the sports medicine guru", treats all the high level athletes and local pros.   This athlete, high level semi pro MMA athlete, chronic knee condition was treated for over a month and being sent for evaluation for return to training camp.  Movement assessment clearly shows where there are some gross deficits and yet review of the chart shows none of those being addressed in a closed kinetic chain training or in the aggressive nature that would an athlete of this nature would need.  Sadly, this athlete even stated where he felt weak and yet this was not even being addressed.  Why is that?  I can't answer that specifically in this case, but what I will say is that had this person been reviewing any of the literature in the last 5-10 years, there would have been a significantly different intervention.  In most cases, most don't review the literature.  Most will rely on what they learn in a course which is sometimes not even most current evidence based.  As a health care professional, it should be our professional obligation to keep up on the literature and use that to develop our evidence based interventions. 

Next week, we will continue this discussion and look at challenging the status quo.  I hope what you take away from this section is:

  1. If you are doing assessments with 2D video, take it to the next level.  Always question the validity of your data.  If you do that, you will ALWAYS look for ways to improve it.
  2. Keep up on the literature.  Don't rely on courses or someone else's interpretation.  Pull the literature, evaluate it and see how this can impact your clinical treatment TODAY!

Dr. Nessler is a practicing physical therapist with over 17 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >4000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training. 

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