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The NPTE, Graduation, and Professional Identity

Physical therapy students in the United States are unable to practice unconditionally until they graduate from an accredited program and pass the National Physical Therapy Exam (NPTE).  Many states permit students to sit for the NPTE within 90 days of graduation.  Even in these states, however, program directors at the university level must authorize these students to take the exam.  In Ohio, for example, program directors must certify that pre-graduation NPTE applicants are “bono fide candidates”.  In other words, program directors, not state and federal adjudicators, ultimately control when a physical therapy student is eligible to take the NPTE.  Any physical therapy student within 90 days of graduation, however, is effectively a “bona fide candidate”.  A program director’s written endorsement of a candidate should therefore be more of an administrative formality than a permission slip.

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Should Coaches Do Character Building?

Last week, three University of Oregon football players were hospitalized following a workout supervised by the strength and conditioning coach.  The suggestion from many media outlets is that the workload was sufficiently excessive that it posed a danger to the participating athletes.  Whether the ultimate suspension of the strength coach for one month without pay is a reflection of his complicity or a capitulation to political pressure (e.g. scapegoating) is something we may never know.  Hopefully, the university conducts a thorough internal investigation and addresses whatever issues, systemic and personal, contributed to this unfortunate outcome.  Regardless of the strength coach’s culpability here, the popular narrative that certain coaching practices build character warrants further scrutiny.

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What Evidence Based Practice Is Not

The following post is inspired by Stu McMillan’s “Evidenced Based Coaching” piece on Brett Bartholomew’s site.  McMillan’s article is intellectually honest, nuanced, and refreshingly uncontroversial.  His thesis is that practical experience and science are complimentary, not dichotomous, because neither paradigm is comprehensive in itself.  In full disclosure, Stu and Brett have greatly influenced my clinical thought process and I am grateful for their transparency.  They actually demonstrate what they do with their athletes, which leaves them open to criticism when somebody’s lumbar spine visibly budges while performing a maximal effort lift in one of their Instagram videos.  McMillan’s article was primarily directed at the coaching profession but is equally applicable to physiotherapy.

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Case Study: Anterior Hip Pain During Pregnancy

Background
Patient is a 29 year-old female (34 weeks pregnant) complaining of bilateral hip and pubic pain, both of which were more pronounced on the left side.  Pain was present during activities of daily living and while sleeping.  Patient reported being unable to sleep throughout the night for several weeks secondary to the discomfort.  Patient is a devout Crossfit athlete and, with certain modifications, has remained extremely active throughout the pregnancy, her first.  Patient’s medical history is otherwise unremarkable.

Key Findings

  • Hip extension within normal limits bilaterally
  • Limited hip adduction: positive Ober’s test bilaterally, soft end feel, resistance from posterolateral hip
  • 20 degrees hip internal rotation (left), 40 degrees hip internal rotation (right)

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Case Study: Multi-Directional Shoulder Instability

Background
Patient is a 31 year-old male tactical athlete with a history of multiple traumatic right shoulder dislocations currently presenting with anterior shoulder pain and apprehension during overhead activities.  Athlete must routinely perform overhead activities to include climbing caving ladders and controlling a parachute canopy during his workday.  Patient is likely a surgical candidate but cannot have surgery at this time for a variety of reasons.

Key Findings

  • Pain at end range passive right shoulder flexion (170 degrees)
  • 50 degrees of passive right shoulder external rotation, soft end feel (guarded)
  • Symptom exacerbation and perception of instability with passive right shoulder external rotation >50 degrees
  • Limited right external rotation appears to be protecting a pathological joint.  Attempting to passively increase external rotation not indicated despite patient’s ability to achieve greater range of motion with various mobilization techniques.
  • Assessment also included gross movement analysis with specific orthopedic testing where indicated

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