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Concussion Across The Spectrum of Injury Debrief

I recently attended the “Concussion Across The Spectrum of Injury” conference at New York University.  The conference featured talks by concussion thought leaders from specialties including neurology, pediatrics, orthopedic surgery, physical medicine and rehabilitation, optometry, athletic training, and physical therapy.  The key takeaway from the conference was that concussion management requires multidisciplinary care because so many subsystems are affected by brain injury.

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Random Thoughts: Instrument Assisted Soft Tissue Mobilization (IASTM)

I recently encountered a Twitter post featuring a link to a systematic review that concluded “evidence does not support the use of IASTM”.  A thread ensued between snarky people who derided the use of IASTM and defenders who cited favorable clinical outcomes with IASTM.  I don’t personally utilize IASTM. I can’t exactly articulate why though I suspect it has less to do with what randomized controlled trials and systematic reviews say and more to do with the fact that time and resources are finite and I prefer to prioritize other things, some of which may not be “evidenced based” either.  I am not personally offended by IASTM, however, as some of the people on that thread appeared to be. Regardless of what the “evidence” may say, I trust that most providers aren’t using things like IASTM in isolation. Since I’m not privy to other clinicians’ complete treatment plans, I try to not judge them based on one thing they may do even if I don’t find that particular thing very influential.

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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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