Career Advice Article Archives

Check out all my career advice articles. There’s something for everyone, from students, to new grads, to the more experienced.  Explore the archives below or click the button to subscribe and never miss another post.

Subscribe Now


5 Things I Learned in 2009

image As 2009 comes to a close in the next few weeks, I would like to reflect back on a few things that I learned, or at least strengthened my understanding on, this year.  It is a practice that I try to perform each year and recommend you do as well.  I feel that it helps me focus my energy and prepare for the upcoming year.  Please comment on this and share with me what you learned this year.

1. Posture plays a significant role in upper extremity function.

Its been well documented that posture plays a role in function.  As an example, now that i have you sitting in front of your computer, slouch as much as you can (as if you weren’t already!) and try to elevate your arm.  How high do you go?  Now sit up straight and elevate your arm again, goes up all the way doesn’t it?  I get that, there is research to support changes in subacromial space, increased impingement etc.

image What I am talking about is function – how a simple thing like tightness of the pec can tilt the scapula, which inhibits the lower trap.  But let’s not stop there, try this one.  Sit in your chair and slouch again.  Now anteriorly tilt your pelvis.  Isn’t it amazing how you can not slouch when you pelvis is tilted?  Looking at the body as a whole is an amazing approach.  learn, understand, and apply the concepts of the upper and lower body cross syndromes into your patient care.   Read more about these concepts from Vladimir Janda in this nice article from Phil Page.

image               image

 Figures from Chaitow: Muscle Energy Techniques, 3rd edition, with permission

image Another interesting note, I recently tried out this cushion that helps you sit more upright.  It’s called the Tush Cush, hilarious!  It helps you site with an anterior pelvic tilt.  It really works, you sit better and you back feels better.  A great product for those that drive or sit a lot that experience any spine or shoulder pain.  I am actually using it as I type this!

2. Trigger points are real and can be managed.

I am going to take some heat for this and I have already heard from people that disagree.  I have witnessed many soft tissue structural issues that occur from acute and chronic postural adaptations that respond well to trigger point therapy.  Haven’t you had a knot in your upper trapezius / levator that felt better and improved your neck and shoulder motion after you self-massaged the area?  I have.

There isn’t a lot of science behind the theories just yet, but there is more every year.  The Journal of Bodywork and Movement Therapies is working towards improving this as well.  I’ve mentioned it in my post on the Essential Reading List, but you really need to check out some of the work of Leon Chaitow.  He is not the only person with this thought process, there are many, many more.  But Leon does a great job putting the info together in a practical way in his books.  He also summarizes the available efficacy well.  Here is a good video of one of his technique:

3. There are a lot of great resources on the internet to learn new techniques and share ideas.

As I grew this website over the last year, I found many more great resources on the web.  The majority appear to be from strength and conditioning specialists, but there are a some by athletic trainers and physical therapists as well.  Some have a small cost (but are worth it) but most are free resources.

Take advantage of these resources, they are only getting better every day.

I try to share what I find each week in my Stuff You Should Read articles.  Be sure to fill out the form below to sign up for my newsletter.

4. Online continuing education is effective and a great way to further our skills.

image If you remember back to earlier posts here, I have been saying that I think online continuing education is the wave of the future.  Don’t get me wrong, the live seminar/lab structure will never be replaced, but more and more people will begin to explore online education.  There are many pros – study at your own pace, go back and forth as you see fit, combination of video, reading, and interaction, and the fact that you don’t loose a whole weekend!

I have started some webinars this (and will do more, I know it’s been awhile).  These are live presentations that I perform from a distance.  I have my past webinars recorded and available at AdvancedCEU.

I also just finished my first 7-week online continuing education program on the Recent Advances in Evidence-Based Evaluation and Treatment of the Shoulder.  I didn’t know what to expect but the response was huge.  This was a great experience and I will continue to grow this program, will likely start another one in either January or March (Let me know what you would prefer).  UPDATE: You can now start this program anytime at ShoulderSeminar.com.

See some of the responses from participants around the world:

  • “I’ve been a PT for 18 years and have grown confident in my treatment of all shoulder injuries. I have a strong reputation in the Cape Cod community as the shoulder PT. This course was humbling. I have never been as excited to treat shoulder patients then I have been during the past 6 weeks due to this course. Mike’s video presentations, assigned research reading, and knowledge on the discussion board made me think differently about how and why I treat shoulders the way I do. His knowledge has challenged me and opened my eyes to things I need to consider for evaluation and treatment and what I need to do better. He has fine tuned all my treatments. I’m a better PT now, and my patients will get better results. It’s amazing that I’m most excited about shoulder treatment now than at any other point in my 18 years experience. Thanks Mike.” – Jim Hawley, PT Hyannis, MA
  • “The course was FANTASTIC!!!!! I learned a lot and i hope there are more courses like this one! Great experience!” – Eduardo Corrêa – Salvador/Brazil
  • “Mike Reinold’s Online Shoulder Course is not one to miss. The information from this 7 week course is a great clinical foundation for all clinicians that see patient’s with various shoulder pathologies. You will definitely walk away a better clinician and provide better care for your patients after taking this course.” – Megan Eorio, DPT Danville, CA
  • “Mike’s course does a brilliant job of integrating the most recent evidence based practice with current surgical techniques and rehab of the surgical and non-surgical shoulder patient. He brings together a very organized learning experience that offers the participant the flexibility to move at their own pace and access to open discussion with a diverse, very knowledgeable cross-section of therapists. This course organized the approach I will take with my shoulder patients in the future.” –  Christine Panagos. Portland, Oregon.
  • “This online course was a great learning experience for me. It definitely expanded my knowledge on shoulder pathology and treatment techniques. I was able to interact with some of the best clinicians in the country without leaving my home. I highly recommend this course and look forward to future online courses taught by Mike Reinold.” – Christie Gaston, PT, DPT Homewood, IL
  • “This course provided an unbelievable amount of content, focused on recent research, regarding the shoulder joint. If you complete this course, with all presentations and readings, you will have a very thorough understanding of the shoulder joint. It was great to have the ability to review the material at any time, from anywhere, via the internet format. Also, the ability to interact with a leader in our field for over 6 weeks is incredible!!” – Carlyle Schomberg, Waynesville, NC

5. It is easy to get consumed by work, there are more important things in life.

You can thank my now 1 year old daughter for this one.  I am guilty of being consumed easily, not just in work but really anything I set myself to do.  My motto was always, “I’ll work hard now so that I can afford to slow down when I need to in the future.”  Well, that time is now.  My goal of 2010 is being consumed with the important things in life.  A friend of mine once told me, when our careers are all said and done, the only people that will truly remember you accomplishments are your family.

Have a great holiday season and an even better 2010!

Photos by bigpresh and thomasbrightbill

Michael Boyle’s 25 Mistakes in 25 Years

imageIt is with great pleasure that Strength and Conditioning Guru Michael Boyle has allowed me to reprint his magnificent article “25 Mistakes in 25 Years.”  I remember reading this when it was first published and being blown away.  I recently stumbled upon it again when I was browsing through Michael’s website StrengthCoach.com (which, if you haven’t checked out yet could possible be one of the best websites available on imageStrength and Conditioning).

This is probably a timely reprint of the post as Michael has just release a DVD of a presentation of the material in this article, called “Evolution of a Strength Coach,” available through Perform Better.

Thank you Michael for allowing me to share this with my readers, I know that this will be a valuable benefit for us all and if you’ve been living under a rock for the last 25 years, be sure to follow the links to learn more from Michael.  Strength and conditioning concepts are extremely valuable for rehabilitation specialists.

25 Mistakes in 25 Years – The Evolution of a Strength Coach

Michael Boyle, MS, ATC

Michael BoyleThis year I’ll enter my twenty-fifth year as a strength and conditioning coach. Last month I watched Barbara Walters celebrate her thirtieth year with a special called “30 Mistakes in 30 Years.” I’m going to celebrate my twenty-fifth anniversary by telling you my top twenty-five mistakes. Hopefully I’ll save you some time, pain, and injury. Experience is a wonderful but impatient teacher. And unfortunately, our experiences in strength and conditioning sometimes hurt people besides us.

Mistake #1: Knowing it all

I love Oscar Wilde’s quote, “I’m much too old to know everything.” Omniscience is reserved for the young. As the old saying goes, you have one mouth and two ears for a reason. I’d take it a step further and say the ratio is four to one: two eyes, two ears, and one mouth.

To continue down the cliché road, how about this one: “It’s what you learn after you know it all that counts.” When I was young I had many answers and few questions. I knew the best way to do everything. Now that I’m older I’m not sure if I even know a good way to do anything.

Mistake #2: Not taking interns sooner

I was so smart that no one was smart enough to help me. (See mistake number one.) My productivity increased drastically when I began to take interns.

Note: Interns aren’t janitors, laundry workers, or slaves. They’re generally young people who look up to you and expect to learn. Take your responsibility seriously. Remember the golden rule.

Mistake #3: Not visiting other coaches

God, it seems everything goes back to number one! I was too busy running the perfect program to attempt to go learn from someone else. Plus, when you know it all, how much can you learn?

Find the good coaches or trainers in your area (or in any area you visit) and arrange to meet them or just watch them work. I often will just sit with a notebook and try to see what they do better than I do.

I can remember current San Francisco 49’ers strength and conditioning coach Johnny Parker allowing us to visit when he was with the New England Patriots and then asking us questions about what we saw and what we thought he could do better. Coach Parker is a humble man who always provided a great example of the type of coach and person I wanted to be.

Mistake #4: Putting square pegs in round holes

The bottom line is that not everyone is made to squat or to clean. I rarely squatted with my basketball players as many found squatting uncomfortable for their backs and knees.

It killed me to stop because the squat is a lift I fundamentally believed in, but athletes with long femurs will be poor squatters. It’s physics. It took me a while to realize that a good lift isn’t good for everybody.

Mistake #5: Not attending the United States Weightlifting Championships sooner

My only visit as a spectator to an Olympic lifting meet made me realize that Olympic lifts produced great athletes. I know this will piss off the powerlifters, but those Olympic lifters looked so much more athletic.

I remember being at the Senior’s when they were held in Massachusetts in the early eighties and walking away thinking, “This is what I want my athletes to look like.” Understand, at that time I was a competitive powerlifter and my programs reflected that.

Mistake #6: Being a strength coach

How can that be a mistake? Let’s look at the evolution of the job. When I started, I was often referred to as the “weight coach.” As the profession evolved, we became strength coaches, then strength and conditioning coaches, and today many refer to themselves as “performance enhancement specialists.”

All these names reflect the changes in our job. For too many years, I was a strength coach. Eventually I realized that I knew more about conditioning than the sport coaches did, so we took on that responsibility. Later, I realized that I often knew more about movement than the sport coaches too, so we began to teach movement skills. This process took close to eighteen of my twenty-five years. I wish it had been faster.

Mistake #7: Adding without subtracting

Over the years we’ve continued to add more and more CNS intensive training techniques to our arsenal. Squatting, Olympic lifting, sprinting, pulling sleds, and jumping all are (or can be) CNS intensive.

I think I do too much CNS intensive work, and intend to change that. My thanks go out to Jason Ferrugia for pointing out this one.

Mistake #8: Listening to track coaches

Please don’t get me wrong. Some of the people who were most influential in my professional development were track coaches. I learned volumes from guys like Don Chu, Vern Gambetta, Charlie Francis, and Brent McFarland.

However, it took me too long to realize that they coached people who ran upright almost all the time and never had to stop or to change direction. The old joke in track coaching is that it really comes down to “run fast and lean left.”

Mistake #9: Not meeting Mark Verstegen sooner

Mark may be the most misunderstood guy in our field. He’s a great coach and a better friend. About ten years ago a friend brought me a magazine article about Mark Verstegen. The article demonstrated some interesting drills that I’d never seen. I decided my next vacation would be to Florida’s Gulf Coast as Mark was then in Bradenton, Florida.

I was lucky enough to know Darryl Eto, a genius in his own right, who was a co-worker of Mark’s. In the small world category, Darryl’s college coach was the legendary Don Chu.

Darryl arranged for me to observe some training sessions in Bradenton. I sat fascinated for hours as I watched great young coaches work. Mark was one of the first to break out of the track mold we were all stuck in and teach lateral and multi-directional movement with the same skill that the track coaches taught linear movement. This process was a quantum leap for me and became a quantum leap for my athletes.

This was my step from strength and conditioning coach to performance enhancement specialist (although I never refer to myself as the latter). The key to this process was accepting the fact that Mark and his co-workers were far ahead of me in this critical area.

Mistake #10: Copying plyometric programs

This goes back to the track coach thing. I believe I injured a few athletes in my career by simply taking what I was told and attempting to do it with my athletes. I’ve since learned to filter information better, but the way I learned was through trial and error… and the error probably resulted in sore knees or sore backs for my athletes.

Track jumpers are unique and clearly are involved in track and field because they’re suited for it. What’s good for a long jumper is probably not good for a football lineman. It took me too long to realize this.

Mistake #11: Copying any programs

Luckily for me, I rarely copied strength programs when training my athletes. This mistake might be beyond the statute of limitations as it was more than twenty-five years ago.

I think copying the training programs of great powerlifters like George Frenn and Roger Estep left me with the sore back and bad shoulders I’ve carried around for the last twenty-five years. What works for the genetically gifted probably won’t work for the genetically average.

Mistake #12: Not teaching my athletes to snatch sooner

We’ve done snatches for probably the last seven or eight years. The snatch is a great lift that’s easier to learn than the clean and has greater athletic carryover. Take the time to try it and study it. You’ll thank me.

Mistake #13: Starting to teach snatches with a snatch grip

When I realized that snatches would be a great lift for my athletes I began to implement them into my programs. Within a week some athletes complained of shoulder pain. In two weeks, so many complained that I took snatches out of the program. It wasn’t until I revisited the snatch with a clean grip that I truly began to see the benefits.

Just remember, the only reason Olympic lifters use a wide snatch grip is so that they can reduce the distance the bar travels and as a result lift more weight. Close-grip snatches markedly decrease the external rotation component and also increase the distance traveled. The result is a better lift, but less weight.

Mistake #14: Confusing disagree with dislike

I think it’s great to disagree. The field would be boring if we all agreed. What I realize now is that I’ve met very few people in this field I don’t like and many I disagree with. I probably enjoy life more now that I don’t feel compelled to ignore those who don’t agree with me.

Mistake #15: Confusing reading with believing

This concept came to me by way of strength coach Martin Rooney. It’s great to read. We just need to remember that in spite of the best efforts of editors, what we read may not always be true.

If the book is more than two years old, there’s a good chance even the author no longer agrees with all the information in it. Read often, but read analytically.

Mistake #16: Listening to paid experts

Early on, many of us were duped by the people from companies like Cybex or Nautilus. Their experts proclaimed their systems to be the future, but now the cam and isokinetics are the past. Just as in any other field, people will say things for money.

Mistake #17: Not attending one seminar per year just as a participant

I speak approximately twenty times a year. Most times I stay and listen to the other speakers. If you don’t do continuing education, start. If you work in the continuing education field, go to at least one seminar given by an expert in your field as a participant.

(Note: Mistakes 18-25 are more personal than professional, but keep reading!)

Mistake #18: Not taking enough vacation time

When I first worked at Boston University we were allowed two weeks paid vacation. For the first ten years I never took more than one.

Usually I took off the week between Christmas and New Years. This is an expensive week to vacation, but it meant that I’d miss the least number of workouts since most of my athletes were home at this time. I think the first time I took a week off in the summer was about four years ago. My rationale? Summer is peak training time. Can’t miss one of those weeks.

I think there’s a thin line between dedication and stupidity, and I often crossed it. I think in my early years I was more disappointed that the whole program hadn’t collapsed during any of my brief absences. I felt less valuable when I returned from a seminar and realized that everything had gone great.

Stephen Covey refers to it as “sharpening the saw.” Take the time to vacation. You’ll be better for it.

Mistake #19: Neglecting your own health

This is an embarrassing story, but this article is all about helping others to not repeat my errors. Every year in February I’d find myself in the doctor’s office with a different complaint: gastro-intestinal problems, headaches, flu-type illnesses, etc. I had a wonderful general practitioner who took a great interest in his patients. His response year after year was the same: slow down. You can’t work 60-80 hours a week and be healthy.

Like a fool I yessed him to death and went back to my schedule. After about the fifth year of this process my doctor said, “I need to refer you to a specialist who can help you with this problem” and he handed me a card. I was expecting an allergist or perhaps some type of holistic stress expert. Instead I found myself holding a card for a psychiatrist.

My doctor’s response was simple. I can’t help you. You need to figure out why you continue to do this to yourself year in and year out. I went outside and called my wife. I told her it was a “good news-bad news” scenario. I wasn’t seriously ill, but I might be crazy. Unfortunately, she already knew this.

Mistake #20: Not recognizing stress

Again I remember talking to a nurse who was treating me for a gastrointestinal problem. I seemed to have chronic heartburn. Her first question was, “Are you under any stress?” My response was the usual. Me? Stress? I have the greatest job in the world. I love going to work every day!

Do you know what her response was? She said, “Remember, stress isn’t always negative.” It was the first time I’d really thought about that. My job was stressful. Long days, weekend travel, too many late nights celebrating victories or drowning sorrows. A part-time job to make extra money meant working at a bar on Friday and Saturday until 2 AM, and that was often followed by drinks until 4 AM.

Sounds like fun, but it added up to stress. The lesson: stress doesn’t have to be negative. Stress can just be from volume.

Mistake #21: Not having kids sooner

As a typical type-A asshole know-it-all, I was way too busy to be bothered with kids. They would simply be little people who got in the way of my plans to change the world of strength and conditioning. I regret that I probably won’t live to 100. If I did I’d get to spend another 53 years with my kids.

Mistake #22: Neglecting my wife

See above. It wasn’t until I had children that I truly realized how my obsession with work caused me to neglect my wife. I have often apologized to her, but probably not often enough.

Mistake #23: Not taking naps

Do you see the pattern here? Whether we’re personal trainers or strength and conditioning coaches, the badge of honor is often lack of sleep. How often have you heard someone say, “I only need five hours a night!”

In the last few years I’ve tried to take a nap every day I’m able. As we age we sleep less at night and get up earlier. I’m not sure if this is a good thing. I know when I’m well-rested I’m a better husband and father than when I’m exhausted at the end of a day that might have begun at 4:45 AM.

There’s no shame in sleep, although I think many would try to make us believe there is.

Mistake #24: Not giving enough to charity

Most of us are lucky. Try to think of those who have less than you. I’m not a religious person, but I’ve been blessed with a great life. I try every day to “pay it forward.” If you haven’t seen the movie, rent it. The more you give, the more you get.

Mistake #25: Reading an article like this and thinking it doesn’t apply to you

Trust me, denial is our biggest problem.

imageFor more information, please visit the below sites:

5 Tips for Landing a Sports Medicine Job in Professional Sports

Four Leaf Clover There are a lot of students that I have worked with and that read this website that ask me one recurring questions – “My dream is to work for [insert your favorite sports team here]. How do I get a job in professional sports?”

I like your dream!  I too had the dream of being the PT/ATC of the professional team in the town I grew up in, Boston.  I was also a big fan of baseball, and obviously the Red Sox.  I was lucky enough to achieve my dream, here is what I would say to help you:

“Luck is when preparation meets opportunity” – Seneca, Roman Philosopher, 5 BC – 65 AD

1.  Determine what exactly you would call a “dream job.”.  I know when I started college, I really had no idea what my career would be like or what exactly I wanted to focus on.  I applied to some colleges as an athletic training major and others as a physical therapy major.  I often reflect and think that it is so difficult for a 16-17 year old to make a decision as to what they want to do for the rest of their lives.  I had so many classmates drop out or switch majors because they realized that physical therapy was not for them.  To be successful, you need to love what you do.

I would recommend you spend some time in your potential field in high school or early in college to see what a day-in-the-life is for people in the field you want to go into.  Many people don’t realize how challenging sports medicine is as a profession.  You need to be energetic, compassionate, patient, and love to interact with people.  People also don’t often realize what a normal work day is like.  I work 12-hour days, 7-days a week, for 9 straight months.  I am not kidding or exaggerating, check out a baseball schedule, there are no days off.  Even on our off-days we have treatments and have to prepare for upcoming games.  It is amazing that I have a supportive family.  As a physical therapist in a clinic, you are performing a service and your fate is determined by your patients.  If they come late, you miss lunch.

2.  Associate yourself with the best.  My next tip may be one of the most important.  You need to seek out the best people in your field and learn, work, and grow with them.  With hard work, time, and a lot of effort you will become one of them.  That is what I did, I searched out the best sports medicine people in baseball and discovered Dr. Andrews and ASMI in Birmingham, AL.  Over the course of almost 8 years, I progressed from a student research position, then did a year long sports medicine fellowship, 5 years later I was the Director of Rehabilitation.  I put myself in a position where I was desirable to baseball teams.

This also goes for networking.  Unfortunately, it is all about politics and who you know.  The more you can network and join associations or attend conferences with people that are in a position that you want to be in one day, the better.  Look for mentors, look for friends, and look for opportunities.

Out of the tunnel3.  Work your way up.  It is near impossible to reach the level of professional sports without spending time in the trenches.  High school and collegiate athletics is a step in the right direction.  Internships are very popular in professional sports and essential to getting your foot in the door.  Seek out the professional sports medicine association of the sport you are interested in (we are PBATS in baseball, not sure about other sports) and look into doing an internship or volunteering, even if it is just for training camp.  Nothing beats experience, so the more specific your experience can be the better.

4. Set yourself apart from your peers.  This one is important and difficult.  I was lucky and figured out what I wanted to do with my career early on in college.  When I was taking my neurological and pediatrics classes, I would spend my book money on buying new orthopedic and sports medicine books and just obtain my neuro and pedi required reading from the library.  OK, so this may not be good advice, but it shows and example of how I used my time and energy to set myself apart.  I read everything I could on my topic of interest, baseball sports medicine.

The easiest way to set yourself apart from your peers early on is to show an extreme desire to learn and achieve.  I really do feel that hard work will beat out intelligence every time when the race is close.  As your career advances, try to set yourself apart.  How can you do this?  Maybe conduct some research, submit manuscripts to journals and newsletters, take charge and organize journal club, work extra hours, take on extra projects, and volunteer your time.  Remember, this isn’t going to be easy, if you want a top level job, there will be sacrifices.

5.  Be patient.  I don’t think there are many new grads working in professional sports, probably wont be any time soon either.  Use the above thoughts to make yourself standout from the crowd.  Using baseball as an example, you are trying to get a job with only 30 positions in the entire world.   For my dream job, there was only one position.  I am lucky to say that I obtained my dream job and I am grateful for this. Realize that it will take a little luck and timing, make sure you do everything you can do to be sure you are ready when an opportunity presents itself.

Good luck and best wishes!

Photos by Kaibara87 and exquisitur

Using the QUADAS Tool to Assess the Quality of Research

Have you been feeling lately that the quality of research reports are not always the same across journals?  Or that some articles you read do not appear to have the best methodology?  With all the emphasis on evidence based medicine, it is more valuable now than ever to assure that research reports are of superior quality to assure that we are conveying accurate information to our colleagues.  Harrison Vaughan

Today’s guest post is written by Harrison Vaughan, PT, DPT.  Harrison is a physical  therapy practicing in South Hill, VA at In Touch Therapy.  His professional interests include clinical diagnostic tests and treatment consisting of orthopedic manual therapy, predominantly spinal manipulation.

Using the QUADAS Tool to Assess the Quality of Diagnostic Accuracy Research Studies

The research community has fortunately developed a tool to critique studies and aid in clinician’s decisions to choose the correct physical examination tests, called QUADAS.  QUADAS stands for:

  • Q – Quality
  • A – Assessment of
  • D – Diagnostic
  • A – Accuracy
  • S – Studies

Many of you may have never heard of it and from speaking with others, this appears to be the norm.

What is QUADAS?

QUADAS is an evidence based tool to be used for the quality assessment of diagnostic accuracy studies.  It consists of 14 items phrased as questions, each of which should be scored a “yes”, “no” or “unclear” that examine bias in the study.

How do clinicians determine which study is most appropriate based on QUADAS score?

Past studies have shown a score of 7 of 14 or greater of “yes’s” to be of high-quality and scores below 7 to be of low-quality.  However, some authors have recommend articles with 10 or higher “yes’s” as cut-off for a high-quality diagnostic accuracy study.

How do I use this tool in my clinical assessment?

Below is an example of comparing two studies using the QUADAS score to clinically diagnose SLAP lesion.  These studies were mentioned in a previous post on the clinical examination of SLAP lesions.

O’Brien’s test: Sensitivity: 100, Specificity: 99, LR+: NA, LR-:NA, QUADAS Score: 3

Biceps Load Test II: Sensitivity: 90, Specificity: 97, LR+: 26.38, LR-: .11, QUADAS Score (0-14): 10

clinical examination of SLAP lesions

From the data above, it appears from first glance that the O’Brien’s test is superior showing great statistical numbers compared to the latter test (even though both show promising figures). However, if you look at the QUADAS score, you can see the significant differences between the two showing O’Brien’s test has much more bias. The Biceps Load Test II is on the lower end of a high quality score (10/14) but much greater study that O’Brien’s (3/14). I am not specifically picking on O’Brien but this makes a good example of similar diagnostic values but very different QUADAS score. In other words, if you obtained a (+) O’Brien’s test, you shouldn’t be so optimistic of a positive SLAP lesion due to poor study design.

I recommend the book Orthopedic Physical Examination Tests-An Evidence Based Approach by Cook & Hegedus to obtain recent QUADAS scores (as well as sensitivity, specificity, etc) for most, if not all clinical diagnostic tests; both new and old. It will surprise you that most of the “classic” special tests that many have been using for years have poor diagnostic value.

Download the QUADAS tool.

It may be difficult for many to change their evaluation regimen, but I do hope this data changes your outlook on the best special test to choose and strengthen your examination.  I hope this information adds to your realm of knowledge and help you become more objective in clinical diagnostics.  Have you used the QUADAS tool before?  What popular study do you know of that everyone references but has a very low QUADAS score?  Thanks Harrison, great post.

Penny Whiting, Anne WS Rutjes, Johannes B Reitsma, Patrick MM Bossuyt, Jos Kleijnen (2003). The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews BMC Medical Research Methodology, 3 (1) DOI: 10.1186/1471-2288-3-25

Predicting Which Patients Will Not Respond to Physical Therapy

downing

We are lucky to feature a guest post from Christie Downing, PT, DPT, cert MDT, ICLM.  Christie works at Alexian Brothers Rehabilitation Hospital in Elk Grove Village,  IL.  She specialize in musculoskeletal care as well as lymphedema management.  She is a MDT credentialed provider and student in the Diploma level of MDT, focusing primarily in MDT in both spine and extremity problems.

Predicting Which Patients Will Not Respond to Physical Therapy

Now, I love my profession as much as the next PT, but I think I am realistic when I say that PT cannot fix everyone’s problems. I’ve come to realize that predicting positive outcomes of intervention is only one side of the coin, and that we must also be able to predict who will not respond to physical therapy. Often times, the medical community is not privy to such predictors and focus their attention simply on an imaging study or other medical test.

If you have been followed this blog, you will find my previous post about Mechanical Diagnosis and Therapy (MDT) and its ability to predict annular competence in the lumbar intervertebral disc. In MDT, we often focus on the predictive abilities of centralization in those with a derangement syndrome to indicate GOOD outcomes.  This has been shown in several articles, include some of my favorites listed in the below references.1,2,3,4,5

However, a truly great therapist must also recognize when improvement by physical therapy just “isn’t in the cards.”

For those who practice MDT, this includes those with “irreducible derangement” which has specific diagnostic criteria for inclusion in this category. The predictive ability of failure to centralize in the irreducible derangement has exceptionally high predictors of chronic disability.3,6

Werneke and Hart showed this well in a study of 223 subjects with acute low back pain.  The authors assessed 23 different psychosocial, clinical, and demographic factors in an attempt to determine predictive values of chronic disability.  Of the 23 different variables, the strongest predictive variable to chronic low back pain and disability was noncentralization of pain.  This has been shown by Skytte et al as well.

Rapidly Reversible Low Back Pain

I’d like to pause for a moment and briefly discuss Rapidly Reversible Low Back Pain by Ronald Donelson, MD, MS. This was also Mike’s Book of the Week in the past.  In this book, Dr. Donelson critically examines our current state of diagnostic triage of those with low back pain. He takes a painfully realistic look at current practices and investigations among both the medical and allied health professions and highlights their shortcomings. Dr. Donelson has invested much time in investigating conservative care of low back pain and has taken a particular interest in MDT. So why does an orthopedic spine surgeon want anything to do with conservative care of low back pain? Well, you’ll have to read his book to understand the story about how he became acquainted with Greg Silva, PT, Dip. MDT. In my opinion, Dr. Donelson, in both his book and research,7 eludes to the notion that MDT clinicians have been able to help HIM better select patients for surgical intervention.

Imagine that, WE, as PTs, having valuable input as to the need for further intervention!

Very little frustrates me more than when I feel that a patient will not benefit from further PT only to have the physician continually refer a patient back to physical therapy for the same pointless interventions. Surely, not everyone can be a Dr. Donelson. However, how ready is the medical community to hear our messages?

Does this happen to you and what resistance have you faced when you predict a poor outcome?  Furthermore, what other pieces of evidence do we have that demonstrate strong predictive abilities for poor outcomes?  If anyone has predictors for poor outcomes of meniscal derangement and any other pathology, I would be particularly interested.

Note from Mike Reinold: Rapidly Reversible Low Back Pain is a great book that is highly recommended for those interested treating low back pain.  I was amazed at how simple, yet highly effective, the concepts are that are outlined in the book.  Definitely one of the best reads for treating low back pain for under $20!  Click here for more information or to purchase from Amazon.com.  Thanks Christie, great post!  If you are interested in guest writing for this website, please contact me.

References:

  1. Aina A, May S, Clare H; The centralization phenomenon of spinal symptoms – a systematic review Man Ther; Aug;9(3):134-143, 2004.
  2. Donelson R, Silva G, Murphy K.; Centralization phenomenon. Its usefulness in evaluating and treating referred pain. Spine; Mar;15(3):211-3, 1990.
  3. Skytte L, May S, Petersen P; Centralization: Its prognostic value in patients with referred symptoms and sciatica Spine; 30:E293-E299, 2005.
  4. Werneke M, Hart DL, Cook D; A descriptive study of the centralization phenomenon. A prospective analysis. Spine; Apr 1;24(7):676-83, 1999.
  5. Werneke M, Hart DL, Resnik L, Stratford PW, Reyes A; Centralization: prevalence and effect on treatment outcomes using a standardized operational definition and measurement method. J Orthop Sports Phys Ther; 38:116-125, 2008.
  6. Werneke M, Hart DL.; Centralization phenomenon as a prognostic factor for chronic low back pain and disability. Spine; Apr 1;26(7):758-65 , 2001.
  7. Wetzel T, Donelson R, : The role of repeated end-range/pain response assessment in the management of symptomatic lumbar discs. The Spine Journal; (3): 146-54, 2003.

Werneke M, Hart DL (2001). Centralization Phenomenon as a Prognostic Factor for Chronic Low Back Pain and Disability Spine, 26 (7), 758-764