Clinical PT Talks

Psychological factors are always and irrevocably present in any clinician interaction with patients. They can be a help or a hinderance. When problematic, they can negatively interfere with intended treatment effects. However, they can also be present in clinicians as well. This can lead to distortions of thinking that alter our ability to properly interpret what we are doing, why, and what our results are like. Recognizing such issues is helpful in deciding what to do about them. Join me in this first part of a 2-part podcast as I discuss these aspects of psychologically informed practice and more.     REFERENCES Ballengee LA, Zullig LL, George SZ. Implementation of Psychologically Informed Physical Therapy for Low Back Pain: Where Do We Stand, Where Do We Go?. J Pain Res. 2021;14:3747-3757. Published 2021 Dec 7. doi:10.2147/JPR.S311973 Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378 (9802):1560–1571. doi:10.1016/S0140-6736(11)60937-9 [Study design flaws lead to overestimation of beneficial result.] Rogers JS, Witt PL, Gross MT, Hacke JD, Genova PA. Simultaneous palpation of the craniosacral rate at the head and feet: intrarater and interrater reliability and rate comparisons. Phys Ther. 1998;78(11):1175-1185. doi:10.1093/ptj/78.11.1175 Rosa L, Rosa E, Sarner L, Barrett S. A close look at therapeutic touch. JAMA. 1998;279(13):1005-1010. doi:10.1001/jama.279.13.1005 [9 year-old girl’s science fair project debunks therapeutic touch.]

Not everyone lies, but patients lie more than we might expect. And we’re not good at detecting it. So, what is one to do, as a healthcare provider, when faced with this reality? Afterall, lies and failure to disclose vital health information can dramatically and disastrously impact our ability to provide quality care. Join me in this podcast as I discuss these issues and provide a perspective on what’s known from the published scientific literature blended with the pragmatism of clinical practice. NOTE: Patient examples in this podcast episode are representative. They are drawn from composites of multiple clinical cases modified to protect identities and protected health information.    REFERENCES Embattled Harvard honesty professor accused of plagiarism | Science | AAAS https://www.science.org/content/article/embattled-harvard-honesty-professor-accused-plagiarism Levy AG, Scherer AM, Zikmund-Fisher BJ, Larkin K, Barnes GD, Fagerlin A. Prevalence of and Factors Associated With Patient Nondisclosure of Medically Relevant Information to Clinicians. JAMA Netw Open. 2018;1(7):e185293. Published 2018 Nov 2. doi:10.1001/jamanetworkopen.2018.5293 Palmieri JJ, Stern TA. Lies in the doctor-patient relationship. Prim Care Companion J Clin Psychiatry. 2009;11(4):163-168. doi:10.4088/PCC.09r00780

Patients come to us for a variety of reasons, not all of which are centered on a musculoskeletal complaint, or even necessarily centered on regaining full function. This confounds some healthcare providers, and it can lead to confusion, distractions, and misdirected effort. Much in the patient complaint and presentation needs to be unpacked and contextualized to make sense of what a particular patient’s complaint is really about, what they really need, and to distinguish needs from wants. Join me in this podcast as I discuss ideas and perspectives that aid our efforts to deal with these issues to better help our patients.

What we know in practice is built upon our formal education, what we read of the scientific literature, what we glean from continuing education and professional development resources, and our participation in residencies and fellowships, but it also can be built upon experience. However, experience can be misleading if knowledge developed from our own clinical practices is not subject to some type of systematic examination. Join me in this podcast as I discuss methods and ideas I have found helpful, and how we can learn from clinical practice.

An enduring and hard question in the world of physical therapy is: How long should beneficial therapeutic treatment effects last? This is a deceptively simple question. With many different patient presentations, treatment techniques, schools of thought, and approaches to patient management, however, results may vary. Join me in this podcast as I discuss 3 levels of intervention where we have the opportunity to observe changes in our patients with chronic musculoskeletal problems, and how we interpret our findings.

Orienting oneself to the early career demands of treatment design in clinical practice can be an uncertain and daunting task for new graduates. This is made more challenging by lack of appropriate guidance during academic and clinical training. Thus, self-assessment is critically important for new graduates so that they can understand if they are progressing toward independence. Join me for today’s podcast as I discuss a simple rule that can be used to determine where you are at in your journey across the landscape of professional development.   

As professionals, how do we know what to do for any given patient problem? We of course are educated in physical therapy schools, experience increasing responsibility as interns, pass many tests, including licensure exams, and then are released into the world to ply our skills as best we can. We know to survey the literature to help answer our questions, including use of the PICO template to aid this process. And we know to expect to have many questions. But what do we do when the scientific literature does not provide answers? Join me in this podcast episode as I discuss this issue in context to what I observed when teaching students and the surprising reactions their efforts produced.

Do you measure your patient's ability to produce or manage forces? Why or why not? Ours is a profession of movement-oriented focus, and yet it often lacks investigation of basic concepts vital to movement, i.e. the forces involved. This is true regarding the ability to produce and control movement, and the decision-making processes regarding how much to prescribe and why. These issues are fundamentally relevant to rehabilitation activities, and daily life. So, why do we do the things that we do? And, why do we not do other things that make sense? Join me as I discuss these and other ideas that will help sharpen our focus on issues related to dosing, modifying, and monitoring our work to improve the care we provide to our patients and, over time, improve our outcomes.    REFERENCES Dominguez-Romero JG, Jiménez-Rejano JJ, Ridao-Fernández C, Chamorro-Moriana G. Exercise-Based Muscle Development Programmes and Their Effectiveness in the Functional Recovery of Rotator Cuff Tendinopathy: a Systematic Review. Diagnostics. 2021;11:529. Souza LA, Martins JC, Moura JB, Teixeira-Salmela LF, De Paula FV, Faria CD. Assessment of muscular strength with the modified sphygmomanometer test: what is the best method and source of outcome values?. Braz J Phys Ther. 2014;18(2):191-200.  Mueller MJ, Maluf KS. Tissue adaptation to physical stress: a proposed "Physical Stress Theory" to guide physical therapist practice, education, and research. Phys Ther. 2002;82(4):383-403. White JM. Mechanobiologically Oriented Rehabilitation of a Complex, Comminuted, Displaced Acetabular Fracture in a 70-Year-Old Medically Complicated Patient: a Case Report. JOSPT Cases. 2021;1(3):185-196. doi:10.2519/josptcases.2021.10266  

A man with over 2-decades of complaints related to an old traumatic ankle injury as a consequence of a motorcycle crash now faces a critical decision: surgery or no surgery to fix his problem? Except that it might not work. The uncertainty is backed by a history of a multitude of past incomplete or failed treatments and the reality of a worsening problem that includes increasing pain, loss of balance, and change of lifestyle. Join me in this podcast as I discuss how preconceived obstacles to recovery realized in a hypothetico-deductive reasoning model can be eliminated or reduced with a varied problem-solving tool set.    This is our sixth story in an ongoing series. It illustrates lessons learned from a transformative moment in a PT's career. Like all of our stories, it is drawn from real-world experience. 

Patients with chronic musculoskeletal conditions are often thought of as resistant to treatment. This is true for both conservative and non-conservative treatments, including pharmacological interventions. In settings where this is not the prevailing thought, then the amount of change expected as a result of conservative interventions is often small and seemingly insignificant, especially if improvements are not durable. In my practice, approximately two thirds of patients I work with have chronic musculoskeletal conditions. Join me as I discuss the why and how of a simple rule we use that helps signal significant improvement has occurred, the kind that often signals greater potential for recovery. 

Many patients with chronic neuromusculoskeletal problems, including pain and disability, have been through the healthcare system and reached the dreaded impasse where 6 discouraging words tell them all they need to know about the path they are on: "We've done all we can do...." By this time, they have utilized more healthcare dollars and visits than other patients. The amount of improvement they experience when they are helped is often small and short-lived despite the time and effort and dollars. Still, some small improvement is better than no improvement. And, very likely, it signals that more can be achieved. Despite these experiences, it is possible in many cases to create dramatic improvements. The kind that exceeds expectations. Join me in this podcast short as I discuss what is possible.     

Pressure pain tolerance algometry can help with phenotyping pain, identifying responder patients likely to improve with a given intervention, aid tracking and monitoring changes in patients, and much more. Join me in this podcast short as I discuss what is perhaps the most underutilized, yet useful, tool in the neuromusculoskeletal toolbox. 

Musculoskeletal residuals. What are they? Join me in this podcast as I provide an introductory discussion of what they are, and provide some important ways to think about them which helps frame our understanding of their role in a rehabilitation science and clinical context. This is especially critical with regard to unrealized recovery. Know the right questions to ask, and what do with the information you acquire. Knowing how to look for and interpret the presence of residuals can provide guidance for what to do next.  

Sometimes the origin of a problem can be unexpected, and sometimes treatments don't go according to plan. It's easy to get flustered, frustrated, and lost. But paying attention to important clues along the way, such as responses to special tests, and detailed symptom behavior, can help anchor our understanding of what is actually happening. Sometimes, it even offers us a glimpse of the bigger picture, one that ties the rehab process together in new or unexpected ways. When this happens, it can reveal deeper connections that lead to useful revelations. Part of the process to gain such insight is understanding what normal recovery should look like, even when we are confronted with novel circumstances. Join me in this podcast short as I discuss these issues in context to an unusual case.    This is our fifth story in an ongoing series. It illustrates lessons learned from a transformative moment in a PT's career. Like all of our stories, it is drawn from real-world experience. 

Treatment design is a complex problem facing every clinician. But how well do we understand this issue? What does the science have to say? How much can we rely on what is in the research literature? As it turns out, the answer is: it depends. Join me in this podcast short as I discuss some recent research findings regarding the completeness of treatment descriptions and what this means for treatment design. 

Biomarkers can provide much needed information that is critically important to our work with patients. One you need to know about, the Load Tolerance Test (LTT), may be among the most broadly useful tools at our disposal. It may also be among the least well-known. Join me in this podcast short as I discuss today's topic in more detail, and why you need to know more about this. 

What is mechanotoxicity? This term relates to mechanisms of injury. We recognize that mechanical insults to the musculoskeletal system occur in many different ways. Join me in this podcast short as I define, explain, and provide examples linked to the meaning behind some of the terminology we use within the framework of mechanobiologically oriented rehabilitation.

In orthopedic physical therapy, we have many options when it comes to measurements we might choose to acquire when we examine our patients. But what should we measure? And why? What is clinically relevant? Join me in this Podcast Short as I discuss these ideas and more as I provide an overview from a pragmatic perspective.  

Today's topic is about an emerging area of science and practice that may be new to many. It is one of special interest for me, and a domain within which I have been working, thinking about, writing about, teaching, and applying to patients since day 1 in the clinic. So, here a few questions to consider: Do you know what mechanobiology is? Do you know what mechanobiologically oriented rehabilitation is? Do you know how to dose treatment for management of neuromusculoskeletal pathology in order to optimize a likely desired treatment effect?  Have you heard of or thought about these or similar issues? Join me in this Podcast Short as I discuss the topic of mechanobiology and share insights about what it means in context to the world of physical therapy. 

Shoulder pain is common, and it can originate from a variety of sources. Join me in this Podcast Short as I discuss a quick differentiation technique that aids dichotomization of pain originating from one of two common musculoskeletal sources, i.e. those associated with shoulder structures themselves vs. another anatomical region.