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In Defense of Primary Care

I recently spoke to a group of medical students at Hofstra University about the continuum between physical therapy, physiatry, and orthopedic sports medicine.  I was also invited by a primary care physician there to listen to the multidisciplinary team she manages discuss difficult patient cases, most of whom were on Medicaid (health insurance for low income families), to help her determine which patients might be candidates for physical therapy.  This experience reinforced for me how underappreciated primary care providers are in the medical system. In fact, they are often unfairly criticized. Primary care providers are frequently responsible for managing complex disease processes that are both poorly understood and influenced by so many individual, systemic and cultural variables.  

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Case Study: In Season Hockey Player

The reason for sharing case studies is to start a collective conversation, not to suggest that there’s anything particularly sound or exemplary about the methodology. Many people agree in the abstract and pay homage to things like progressive overload, periodization, graded exposure, and desensitization but rehabilitation and coaching ultimately require actionable decision making and the application of theoretical concepts. We share these examples to demonstrate what we do when we have real skin in the game- when we’re professionally responsible for someone’s preparation. Population based studies can be informative but individual cases promote greater clinical transparency. We welcome the scrutiny that accompanies this transparency even if it comes at the expense of our mistakes.

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A Case For Earlier Access To Advanced Imaging

There is a prevailing sentiment in the pain medicine community that advanced imaging techniques like MRIs are overutilized. While I tend to agree that given the current set of constraints dictated by the health care system that MRIs are overprescribed, this acknowledgement need not justify the demonization of anatomical/structural considerations that is beginning to pervade pain management as a field. I’ve been very critical of the manner in which painful conditions are reduced in medicine to single anatomical sites. That said, an MRI just provides information and with the right diagnostic and conceptual framework, more information is generally helpful, especially something that visually depicts the site of one’s pain.

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Performance Teams and “Lanes”

“Stay in your lane,” said nobody any of us would like to work with.  When it comes to medical and performance teams in sport, it is not always clear where the lanes are.  First, who decides where to draw the lanes? In medicine, the lanes are often guided by political and economic incentives, not necessarily by clinically meaningful criteria.  The “lane lines” are typically drawn by the party with the more powerful political lobby in anticipation of, or in response to, competition for market share.

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Movement Realism: Why Sports Medicine Can’t Be Reduced To A Hashtag

It is hopefully uncontroversial to say that there is no such thing as perfect posture or ideal movement.  That perfect posture or ideal movement is, at best, a theoretical fantasy does not justify a prevailing sentiment in the rehabilitation and training world that any movement pattern that emerges under particular environmental constraints is beyond reproach.  The thinking here is that the body is a highly adaptable system that organically “finds” the optimal solution to environmental challenges. From a training or rehab standpoint, therefore, one need not do anything but regressively or progressively load the pattern that emerges in the absence of coaching or cuing.

Ideal movement isn’t supposed to exist but some commentators suggest that any motor pattern that allows for task completion is effectively ideal because emergent movement is always “best” even if they don’t use that word.  It’s “best” to them because they never consider that changing that pattern may help improve performance or mitigate the potential for injury. Instead, every training and rehabilitation situation is purely a load management issue.  Emergent movement can’t be “best” though if optimal doesn’t exist in the first place. The real question is whether the emergent movement is “good enough” or if a movement-related intervention is warranted. While errors of commission (doing too much) tend to pervade medicine, errors of omission (doing too little), to include ignoring alternative movement-related solutions, can also be quite consequential.

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