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The Façade of Patient Safety Advocacy

  • “Physical therapists shouldn’t see patients without a referral from a physician.  Your back might hurt because you have cancer.  Physical therapists don’t treat cancer.”
  • “Physical therapists shouldn’t be permitted to do dry needling.  They aren’t trained as acupuncturists.  An acupuncture needle can be dangerous in the wrong hands.”
  • “Physical therapists shouldn’t perform high velocity low amplitude thrust manipulation to the spine.  Spinal manipulation is an advanced procedure.”

Health care providers will inevitably compete for potential patients and certain interventions since the legal and practical boundaries that separate medical professions can be blurry.  The divisions that do exist are often more political than pragmatic.  The easiest way to discredit another political party is to portray it as soft on national defense and formulate a doomsday scenario whereby terrorists will rule the earth if said group assumes power.  Similarly, the best way to vilify another medical profession is to allude to all the undiagnosed malignant tumors, punctured lungs, and severed spines that would ensue if a particular group of providers expanded its scope of practice and professional autonomy.  In other words, shared interventions can be to medicine what terrorism is to politics.  The difference in medicine, however, is that the villains are professions with a weaker political lobby and lesser resources, not every potential competitor.  In medicine, we only pick the fights that we can win.  Consequently, many of the dialogues that occur between medical professions are just as mindless and futile as those that occur between politicians.  Lots of words are exchanged but nothing is actually said.

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Case Study: Femoral Acetabular Impingement

Mike is a 32-year-old male law enforcement officer presenting with chief complaint of left hip pain upon transition in and out of his work vehicle and exercises involving hip flexion like squatting (loaded and unloaded). Patient was diagnosed with left Femoral Acetabular Impingement (FAI) with bony growths and a torn hip labrum. Mike was recommended to have surgery to fix his abnormal orthopedic findings after failed attempts at out-patient physical therapy. Patient’s goals are to return to a consistent and non-painful training program for health as well as preparation for occupational demands and selection testing for a specialized law enforcement team next year.

Examination Findings

  • Toe Touch = 2 inches from toes
  • Functional Squat (feet shoulder width, knees tracking over toes) = exacerbated painful symptoms one quarter of the way into decent
  • Hip Internal Rotation = 0° bilaterally – bony end feel – exacerbated painful symptoms
  • Ober’s or “Adduction Drop” Test = (+) bilaterally – bony end feel – 2 inches from table
  • Hip Flexion = 100° bilaterally exacerbates painful symptoms

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What Is The Language Of Physical Therapy?

Whether physical therapists want to admit it or not, the profession is suffering an identity crisis at a very critical time.  Direct access (with stipulations in many states) notwithstanding, the level of professional autonomy and earning potential for in and outpatient PTs is not commensurate with cost and duration of entry-level education.  To be fair, achieving legitimate doctoral status will take time, which is all the more reason PTs need to develop a unified message consistent with a professional identity that resonates with the public.  Physical therapy is struggling to incorporate evidenced based medicine while also establishing itself as marketable and relevant.

It is not uncommon to see the self-anointed physical therapy intellectual elite criticize commercially successful colleagues who, in an effort to speak to the public in a language that it can understand, simplify complex phenomenon like pain.  Should private practice PTs be directing their message to other clinicians or directly to the public?  How much deviation from scientific dialect and randomized control trials is acceptable if it helps distinguish physical therapists from health care providers and even non-clinicians who provide similar services?  I don’t have definitive answers but without asking the right questions, the profession will never achieve its full potential.

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Resilient’s View of CrossFit

Greg, Trevor, and I are fortunate to practice at Solace New York, a model Crossfit facility for performance minded physical therapists.  Prior to working out of Solace, I had not spent any appreciable time in a Crossfit facility.  Everything I knew about Crossfit came from the Internet, watching the games on ESPN, and treating a few Crossfitters.  Our experience thus far has been overwhelmingly positive, mainly because the sense of community at Solace is unlike anything I’ve experienced in fitness.  The people at Solace are truly passionate about their own training and more importantly, about creating an atmosphere that motivates their peers.  Even when people are attempting to break their own personal records, the team-first mentality remains pervasive.  The community here has embraced Greg, Trevor, and I with open arms and taken a legitimate interest in what we do.

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Advice For Aspiring Performance Oriented Physical Therapists

The educational constraints influencing physical preparation and physical therapy have led many professionals to question the delineation between the two disciplines.  As mentioned previously on this blog, the boundary between these fields is often more political than practical.  Outside of very specialized situations like high-level track and field and competitive strength sports, physical therapists need to delve into the performance realm to adequately prepare patients for discharge.  Similarly, inpatient and acute postoperative circumstances notwithstanding, performance specialists are often unable to avoid navigating in clinical waters.  Pain is typically regarded as the line that differentiates the performance and the clinical worlds.  However, it is simply unrealistic to expect every hard-training athlete to see a clinician whenever the pain threshold is crossed.  What that line should be is beyond the scope of this post but the point is that the unavoidable overlap between professions had led to the emergence of the performance-based clinician concept.

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