As 2014 approaches, I thought it would be appropriate to highlight some of the headway we have made over the past year, and the direction our profession is heading. Here is a list of the top 10 things I have learned about my practice of Physical Therapy over the past year.
10. The healthcare delivery model is changing in the United States. In an open letter I wrote to Dr. Paul Rockar, CEO of CRS and President of the APTA, I asked for assistance in getting in-network with UPMC insurance (a predominate payer in Pittsburgh). This appeared to spawn a local newspaper article which then spawned a reaction from Dr. Rockar and the APTA. His initial response highlighted an evolving delivery system, in which IDFS and ACO systems are becoming the norm (ie. The healthcare delivery system, provider and payer are becoming integrated). This is not just happening in Pittsburgh, but nationwide. As this is occuring, it is our responsibility as providers to show insurance companies the quality of care we deliver (on individual and group basis). We must hold each of our colleagues responsible for high quality care and we must demonstrate this quality to our payers. Lets bombard them with all of the good data we are collecting. Lets challenge ourselves achieve better outcomes than our competition. Ultimately, it is each of our individual responsibilities.
9. Our current understanding of the Neuromatrix and Pain may have originated in 1872. I woke up on September 3rd, to a text message from a colleague, who was presented with a Physiology text book from 1872. In this book, the following passage described the human pain experience,
“Strictly speaking, pain is not in any organ, but in the mind, since only that can feel. When any nerve brings news to the brain of an injury, the mind refers the pain to the end of a nerve.” – Dr. J. Dorman Steele
8. Motivation is likely the primary determinant in predicting outcomes-regardless of practice setting. Over the past 2 years, I have been working on an algorithm (M.I.P) for motor control which is built upon three primary variables which influence an output of action programming. These are motivation, input and plan. When we move within our external environment, we do so with a goal in mind. We move instinctively and as a whole, to achieve this goal; we do not move as individual segments. For example, when I wake up in the morning, I instinctively sit up, put my feet on the floor and stand. I do not consciously think about what to contract. This is important. As therapists, we often get caught up in the process of teaching individuals to contract muscles individually because we think it will correlate to function. We are able to view this concept by looking at human movement vs. robot movement. Until one can incorporate mirror neurons, a basal ganglia and dopamine into a robots algorithm, they will continue to dance like this (watch the video at the bottom).
7. We still have a lot to learn about red flags. Back in April, the co-writer for ForwardThinkingPT, Adam Rufa, presented a great piece on red flags. I suspect the quote below is quite important for us (when attempting to rule out the risk of cancer in someone with spinal pain):
“Limited evidence available suggests that only one “red flag” when used in isolation, a previous history of cancer, meaningfully increases the likelihood of cancer. “Red flags” such as insidious onset, age > 50, and failure to improve after one month have high false positive rates suggesting that uncritical use of these “red flags” as a trigger to order further investigations will lead to unnecessary investigations that are themselves harmful, through unnecessary radiation and the consequences of these investigations themselves producing false-positive results. While the lack of evidence to support or refute the use of “red flags” is recognized, a more pragmatic solution is to consider the possibility of spinal malignancy (in light of its low prevalence in primary care) when a combination of recommended “red flags” are found to be positive.”
6. Mirror neurons, mirror neurons, mirror neurons. These were a “buzz” word in the neurophysiology circles in 2013, and there is still some vagueness regarding their role and influence over motor control, pain and empathy (Mark Powers, a fellow-in-training at Sports Medicine of Atlanta, and myself, recently completed a narrative review investigating our understanding. Look for this sometime in 2014). We were all able to appreciate the role of these little guys in March 2013, when Kevin Ware, broke his leg in the Louisville/Duke basketball game.
5. The real reason for the brain…movement. In his TED lecture, Dr. Daniel Wolpert gave a very convincing argument that the real reason we have brains is to ultimately compute the intricacies of movement, which are essential for living. This lecture really hit home and helped support some recent thoughts I was having.
4. Side-to-side differences exist in healthy individuals. When I went through school, I was taught to compare the effected side to the non-effected side. What I wasn’t taught is that the non-effected side was likely different from the effected side, before the effected side, was effected (try saying that really fast). An article in Manual Therapy highlighted this concept for scapular kinematics and reinforced the concept that comparing side-to-side differences, may not tell us as much as we thought (think).
3. Osteoarthritis and the brain. To what degree do we utilize information gathered on two dimensional imaging of bone? When we spot OA, does that give us much insight into that individuals living condition? Dr. Tasha Stanton, one of Lorimer’s crew down-under, gave this phenomenal presentation which highlights the connection between OA and the brain. What will be our understanding of OA moving forward?
2. Ultrasound, Tiger Balm and Bumpy Balls. I have come to a point of acceptance that while many of us try really, really, really hard to promote key concepts in understanding pain, others will continue to promote, well, not-so-up-to-date ideas. We must attempt to promote our evolving understanding of key concepts, especially when we are on a national platform (even in Oz). In 2014, you will probably be seeing less of me on ForwardThinkingPT, because I have accepted a position as an editorial board member with the APTA and will be updating “consumer-driven content” through venues such as MoveForwardPT.com . My first project: Creating a consumers guide to pain. I ensure you: this will not contain the words ultrasound, tiger balm or bumpy balls.
1. An input is simply an input. As I completed my fellowship through Sports Medicine of Atlanta, I came to the realization, that an input is simply an input. We can argue all day about what is more effective: mobilization vs. manipulation; dry needling vs. tools; etc. but I suspect all of our outcome driven data will continue to regress towards the mean over time, because all of our interventions likely work through the same neural pathways. In this concept, we must understand all of the “noise” that is present within a clinical interaction (even when studied in an RCT). For example, have you ever read an RCT and thought, “I wonder what his prosody of speech was like when approaching one group vs. another”? Or “I wonder what the lighting was like in the room which they were treated”. There are many confounding variables which influence our clinical interaction, and accounting for these will help us better understand useful approaches to patient-care.
What do you think we will learn in 2014???