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Posts Tagged ‘ebp’

Rec Fem Causes Hip…


But that isn’t what this post is about…  Our models for understanding pathology are too primitive to be meaningful.  The background of what I’m thinking:

This article is a perfect example of how remarkably complex human motion really is.  And all I can help taking from it is that after explaining the mechanism to 3 people now, all have fired back with “So, how is that functional?”  Without even giving a minute or two to try to think about a circumstance when something like that might actually be functional.

“This is what I’ve observed.”  “It has to be this way because of the origin and insertion.”

Besides the actual function and clinical relevance discussed in the article, I like to think more about how many other parts of everything I’ve learned act as functional oversimplifications.

These over-simplifications are the basis, for instance, for much of how we model and explain very complex evaluative tools.  I wrote this post a couple weeks ago, and have been thinking about it since then, with a little feedback from a mentor.  At the same time, not too soon after, a friend of mine (@RGWooderson) forwards a blogpost to me called “A Few Tests To Toss”.  It is a great post that actually offered ANSWERS to some of the questions and things I’ve been thinking about.  A recommended read, for sure.

Now my purpose: 

The Low Back.  We try to model the mechanics of it, in all the spine’s complexities.  And evaluate the “motion” people perform by merely touching and observing.  I’m not bashing touching and observing.  I think touch and observation are our greatest tools – just extremely inaccurate, or inconsistent at best.  And seem to fail to achieve proposed/described biomechanical influences. And in the end we are frustrated or confused – as a freaking profession! – about why we can’t cure back pain.  Or why our outcomes for certain sub-populations aren’t better than surgery. 

I’m not satisfied.  Not with the methods of evaluation I was taught in school – like SI movement, low back quadrant testing, and evaluating based on assumptions of biomechanics that don’t hold true.  When I was learning it in school, and disagreed, I felt like I was out of the loop.  Like there was another lecture that I didn’t get to hear. So WTF? Am I an idiot?  Arrogant?  Hopeless? 

Pain I understand – and trying to create a more meaningful picture with provocation testing (see “A Few Tests to Toss”) makes sense to me, especially if it can be linked to treatments that are effective at reducing pain (are they?).  BUT trying to explain the mechanism of pain by assessing 1 – 2 mm of movement through centimeters of soft tissue doesn’t just seem useless, it seems irresponsible.

One answer, as I was hoping to hear (homework: revisit hindsight bias) was outcomes.  We have got to critically analyze our treatments and their outcomes as a GROUP, and hastily discontinue treatments that don’t yeild meaningful results – or as a practice we should be left behind.  Stop trying to explain the mechanism because it is very poorly understood.  Focus on what works, and be certain you are truly quantifying it. 

I started reading Doctors: A Biography of Medicine.  I haven’t finished (thanks, self, for sucking at modalities and cardio/pulm).  There were two main schools of thought regarding medicine.  Both wanted to help patients.  One school of thought was Hippocrates, who, as the father of medicine, and, as I understand it from the book, discusses change in patient condition and patients getting better as the focus of his practice.  The other school of thought in Pergamon focused on pathology, and, ultimately, did not produce a father of medicine.  Galen was more like an uncle of medicine.  Brilliant, to be certain, but wrong frequently about anatomy and physiology.  Understanding of pathology, cell models, etc… was too primitive to be meaningful then, and in many cases today, too primitive to be meaningful now.   I like the clinical prediction rules as a starting point for treatment because, while ignoring the ever elusive question of “why are you in pain?”  it still offers solutions which have documented improvements compared to older methods of treatment. 

Rant over.

Jumping back on the cardiovascular/pulmonary and modalities studying for the NPTE bandwagon.  Thanks for reading. 


Accuracy of a Paradigm

The importance of am accurate paradigm. “Truth emerges more readily from error than from confusion.” – Francis Bacon

No, I’m NOT Reading Journal Articles on My Last Academic Xmas Break. . .

We don’t necessarily need new evidence to support abandoning outdated standards. There is a need for more reflective practicing clinicians who don’t accept the notion of having”arrived” in their clinical expertise. ONGOING and purposeful reflection of skills and outcomes is why I choose a DPT. I think the abstract hints at this. I’m adding the rest of the scooter to my kindle reading list.

Chondrocyte Implantation Procedure Presentation

Additional Resources and Research (*.rar format) and My PPT Presentation

I just presented a case study presentation on a patient I saw in my last clinical rotation.  The purpose of the presentation was to explore 3rd Generation Autologous Chondrocyte Implantation (ACI) indications and contraindications for therapy.

To briefly summarize, rehab protocols and movement restriction post-op depends GREATLY on the site and size of the site grafted with chondrocytes.   The patient in the case presented had chondrocytes grafted to the articular surface of his patella.  Compression of the grafting site can decrease chondrocyte proliferation by more than half of un-compressed controls.  This compression is not immediately reversible, either, as chondrocyte proliferation begins to plateau at 7 days post op (in animal studies).

Different portions of the patella articulate with the femur depending on the angle of knee bend. The portion of the patella which was grafted with juvenile chondrocytes would have articulated with the femur between 30 and 60-70 degrees.  Tension through the quadricep inside that range would compress the patella and grafting site directly into the femur and hurt chondrocyte proliferation.

In order to effectively decide on a protocol, we, as autonomous practitioners of PT, have a foundation in sciences (such as biomechanics, kindesiology, cell biology, research) to keep up to date with novel surgical procedures.  We have the skills, abilities, and informational background to make clinical decisions for patients as technology continues to advance in the medical field.  Don’t get left behind.

1.Buckwalter JA.  Articular Cartilage: injuries and potential for healing.  J of Ortho Spo
2.Hettrich C, Crawford D, Rodeo, Scott.  Cartilage Repair: Third-Generation Cell-based Technologies – Basic Science, Surgical Techniques, and Clinical Outcomes.  Sports Med Arthrosc Rev. 16:4; 2008.
3.Kon E, Gobb A, Filardo G, et al. Arthroscopic Second Generation Autologous Chondrocyte Implantion Compared with Microfracture for Chondral Lesions of the Knee. Am J Sports Med. 37:33; 2009.
4.Li K, Falcovitz YH, Nagrampa JP, Chen AC, et al. Mechanical Compression Modulates Proliferation of Transplanted Chondrocytes. J Orthop Res. 18:3; 2000
5.Levangie PK, Norkin CC.  Joint Structure And Function: A Comprehensive Analysis Fourth (4th) Edition. 4th Edition; 2005.