Clinical Integration - Part 1: Strategies to get familiar with new information more quickly

Use your existing skills - Don't stop them

The sub-classification model we use is designed to help you with clinical reasoning to better apply your existing skills

Background

The SMARTERehab sub-classification model is the most comprehensive model in musculoskeletal medicine. It provides a rehabilitation directive for almost all patients. Despite the completeness, the sub-grouping is very easy. After the patient is sub-classified, we have specific courses which detail appropriate treatment for individual subgroups.  If you don't have that skill set, or it is not within your scope of practice, you know where to refer on.

Each course presents cases and does demonstrations which highlight how you can use various manual and passive techniques. Clinicians are by nature very helpful and frequently want to use their hands. One of the biggest challenges is to know when not to do this (HINT: it isn't always with behavioral presentations).  We present very clear indications when this should not occur, but also give you other skills you can use to help manage the presentation using other strategies.

Some techniques are "semi-passive" in that although they are passive, they either directly facilitate better movement (e.g. taping) or involve active participation from the patient (e.g. sensory discrimination training).  This is how we encourage the use of traditional manual therapy. In mechanical pain presentations, they should be used to help improve movement and other aspects of motor control to allow the patient to better use their active strategies.

The point being, regardless of your background or current skills, the model provides enhanced clinical reasoning to allow you to better utilize your current skills. The "trial and error" methods that are generally used are now almost obsolete when you apply the model.

Reduced Stress and Burnout

What a time to be a new graduate (or someone in the midst of a career crisis)! You no longer have to struggle with not knowing what to do or people blaming you for their problems. You can confidently give patients clear rehabilitation options. You don't have to (or no longer have to) go through the painstaking trial and error methods that countless clinicians have done. IT'S NOW MUCH EASIER.

Obviously it is up to the patient to take this information and they are not always able to do that (Note: I will post the use of the transtheoretical model of behavior change in the near future). This involves a complex interactions of beliefs, expectations and other psychology.

Getting Familiar with Course Material

The information I am going to mention below applies to all courses, not just SMARTERehab courses.  You do weekend course and you show up to work - what to do? You'll likely remember some things from the course, but unlikely everything. It takes a bit of work to get familiar with the whole course manual. Below are some things I started doing as a student and new graduate. If you think of others, please let us know so that we can tell others.

• Favorite Patient

·        We have all had friendly patients. They tend to show up early, talk to staff and want to know everything about you. They would be more than willing to act as a model for you to try new things. Book off a little extra time (if possible) and bring your manual into the treatment room with you. Practice the relevant tests, techniques and rehab.

• Anything Can Happen Thursdays (or some other day during the week)

·        Read the manual the night before or morning before work. Pick a group of tests, techniques or rehab exercises to focus on. As much or as little as you can handle. Practice them on all relevant patients that come in on that day. The reading was meant to be so that you don't have to bring in the manual with you.

• What Happens in Vegas Stays in Vegas

·   For those of you that are not familiar with this, it means a "Non Judgmental Environment"

·         Not everyone like being assessed by our peers. For the next three strategies to work, there needs to be open dialogue with your co-workers where there is a commitment to learning rather than judging. Workplaces that have this, have workers that are much happier (which results in less turnover, more productivity) and facilitates a better therapeutic environment.

·       If there is a mistake, or if something could be done better, more than one set of eyes / ears is better than one so feedback can help self reflection.

• Case Study Presentation

·      This will encourage you to read your manual, and check your notes prior to presenting. Along with dialogue from your co-workers or peers, this facilitates self refection of the case and the material.

• Inservice Training

·       Pick a common patient presentation and look up the relevant tests, techniques and rehab related to this to perform an inservice for your coworkers. Along with the above, this facilitates self refection of the case and the material.

•  Mentoring Program

·        We have had several requests over the last couple of years about mentorship. This mostly by patients in remote areas or who work on their own. We are currently looking at the best way facilitate this and will have some options soon.

• Clinical Visit

·      We do offer clinic visits to see complex patients. Here, you can sit in on the assessment, treatment and plan making for a patient. There are a variety of formats this can be done in depending on what you, your staff and the patient want to get from it. Note: This is normally done as an end stage learning process rather than early in the learning process, but it can be done early.

What are some useful skills for a clinician?

We would hope that your school would have taught you how to screen for red flags and do a basic assessment of function. Good communications skills and the development of a healthy therapeutic relationship are needed and can be learned over time. Some people are naturally good at this, while others need more practice. We give you the skills to know about what to ask, how to ask it and how to relay answers back to the patient while considering their individual factors (see previous post on the sub-classification model). There are some very important common skills that can enhance the therapeutic relationship, which are enhanced or limited by the personality, presentation, beliefs and expectations of the clinician (e.g. clinician's individual and environmental factors).

After that it is useful for clinicians to be able to

• Address articular, myofascial and neurodynamic restrictions (in mechanical pain presentations). There are different schools of thought and techniques for these.
• Prescribe a functional and / or graded exercise program
• Teach pacing, and pain control strategies as well as how to deal with a flare up of symptoms
• Use taping, splinting etc as indicated
• Provide education to patients as indicated. There are many different forms of this (e.g. pain physiology education).
• Offer counseling skills and various behavioral interventions (e.g. Cognitive behavioral therapy), however these are frequently outside the scope of practice for many
• Refer on to another professional when they are unable to help. Ideally this would be done very quickly in the assessment - rehab process.

Once again, I need to stress the importance of not applying passive techniques inappropriately and out of context as well as giving information, or other passive supports (including rest) to patients which could negatively influence the outcome (e.g. instill fear or the need for inactivity).

We do demonstrate many of techniques and strategies on our courses to help show how you can integrate your skill set into your clinical practice, but what we do should not substitute for other full length continuing education courses. You should endeavor to continue to learn throughout your career. The SMARTERehab Concept can be used a template for clinical reasoning to help you apply your new learning more appropriately.

Sean GT Gibbons BSc (Hons) PT, MSc Ergonomics, PhD (c), MCPA

The Movement Project - Part 3: Outcome Prediction Based on Specific Motor Control Exercise

Give the patient the responsibility for their recovery

Improve compliance

Accurate prediction

Background

Patients, third party payers, coaches and others frequently want to know how long recovery will take. This is a very challenging situation for the therapist because there is very little evidence to draw upon.

"Normal Time Frames for Recovery"

The magic 80% in 4-6 weeks rule is at best a mild rule of thumb. This is very limited since the statistics apply to first time incidents of the injury and do not include any co-morbidities. The statistics also do not include the well known high number of recurrences that occur.

"Normal Time Frames for Return to Work"

Along with the above comments, this type of prediction is further complicated by social issues related to income and work psychosocial factors.

"Normal Time Frames for Healing"

These link closely with the normal time frames for recovery noted above and are also very limited. They do provide some guidance for progressing rehab.

Behavioral Factors

These are moderately useful in giving the clinician guidance if there is a risk of a prolonged outcome. The accuracy is still limited (Note: In the Behavioral Project we developed a new screening tool that combines numerous ultra brief screens. This allows the screening of a variety of conditions from the DSM V. It also provides a novel  strategy for predicting outcome).

Experience

This is obviously critical, but is difficult to quantify.

Specific Motor Control

As we have already mentioned in previous articles, when Behavioral Factors, Neurological Factors, Non Mechanical Pain and Medical Co-Morbidities are ruled out, the response to Specific Motor Control Exercise (specific movement pattern control, translation control) is highly favorable.

From considerable clinical, prospective cohort and clinical trial, we have been able to identify various short and / or long term outcomes from specific motor control exercise ability from all regions of the body. Depending on the original sub-classification, this is based upon having achieved mile stones in controlling movement and / or muscle imbalance and / or having a level of efficiency of translation control. 

This has proven very beneficial clinically. It is great to be able to say to a patient something like: "when you can do this (insert specific motor control exercise) you have a 95% chance of being significantly better". This improves compliance, reduces uncertainly about outcome and reduces the stress of the clinician. Further, it facilitates the "ownership and responsibility" of the condition and recovery process to the patient and not the therapist.

A note of caution: to make these statements to a patient, the clinician needs to be highly competent at sub-classifying movement patterns, prescribing specific motor control exercises and appropriately progressing the rehabilitation. Further, as noted above, Behavioral Factors, Neurological Factors, Non Mechanical Pain and Medical Co-Morbidities must be ruled out for the patient to have a favorable response to specific motor control exercise.

Sean GT Gibbons BSc (Hons) PT, MSc Ergonomics, PhD (c), MCPA

Sub-classification by SMARTERehab: Mission accomplished!

The most comprehensive sub-classification model

Background

Sub-classification identifies subgroups based on clinical presentation criteria, physical assessment, specific  questionnaires or other diagnostic investigations. These subgroups then have targeted treatments associated with them. Interventions that use sub-classification are better than ones that do not.   

The goal was to have a reliable and valid sub-classification model that could accurately address all patients that presented to clinicians and provide a rehabilitation directive that would provide significant benefit. The aim of this model (reliability and validity) was to allow it to facilitate a change in the profession and it was designed with that goal. For it to be useful, it needed to be n evidence based model that could be used in the same manner by all therapists.

Mission Accomplished

There are many sub-classification models out there. We have showed quite clearly from our literature review model "what is different between normal subjects and (insert condition)" that all other models fail to adequately address the complexity that patients present with. The completion of The Movement Project, The Learning project, The Body Image Project, The Pain Project and The NISE Syndrome Project has provided the most comprehensive sub-classification model in musculoskeletal medicine. We can now accurately sub-classify and provide a rehabilitation directive to nearly all (>97%) patients with musculoskeletal pain. 

Figure 1: The SMARTErehab Sub-classification Model

·    

           Sub-classification Categories in Brief:

      NISE Regulation (Neuro-immune-sympathetic-endocrine)

o   assesses symptoms in 18 bodily systems

·         Behavioral Factors

o   using a combined battery of ultra short screens, 14 psychological domains are assessed

·         Pain Mechanisms

o   Nociceptive

o   Central Body Image Pain

o   Central Sensitization spectrum (including neuropathic pain)

·         Neurological Factors & Central Nervous System Coordination (ability to learn)

o   Neurocognitive function

o   Sensory motor deficits

o   Neurological soft signs including Primitive & Postural Reflexes

o   Midline Awareness

·         Movement & Motor Function

o   Movement pattern control

o   Translation control

o   Respiratory function

o   Strength and endurance

o   Directional preference

·         Patho-anatomical

o   Articular

o   Myofascial

o   Neurodynamic

o   Connective tissue

Functional Mechanisms

It is necessary to understand the underlying causes of each sub-classification. Although genetics play a role, rehab can only address those mechanisms that are modifiable therefore the focus is on "functional (modifiable) mechanisms". There are many therapies that are logical and useful, but fail because they do not consider the true underlying functional mechanism. We have organized our sub-classification and interventions to address this.

Reliability & Diagnostic Accuracy

There are many great models out there to address aspects of movement, motor control and chronic pain. Unfortunately many of the assessment strategies have poor reliability or would highly unlikely be found reliable if tested because they do not lend themselves to having reliability if assessed. The mandate of SMARTERehab was to have a reliable sub-classification. In order to change practice and facilitate wide implementation, there is a need to have a reliable sub-classification model. Therefore, questionnaires were chosen as a key component as the assessment since they are much more likely to be reliable than a physical assessment alone. Further, the goal was to have tools with high diagnostic accuracy. It is great of a questionnaire identified two-thirds of a group with a poor outcome for example, but that may be fine for an academic who wants a publication in a peer reviewed journal, but it not helpful for the clinician to miss one - third. We would not accept that for serious medical conditions, so why would we accept it for musculoskeletal pain. The goal of the SMARTERehab model was to get upwards of 90% accuracy (averaging specificity and sensitivity). We have achieved this goal. With an experienced clinician taking a subjective history and utilizing aspects of a physical assessment it even gets higher than this, but even the novice can achieve upwards of 90% accuracy utilizing the existing tools.

Professional issue

I do appreciate that a complex model requires extensive training and adds a financial aspect to learning. A simpler model will likely have more uptake, however do we want to settle for something basic that only sub-classifies psychology and everything else?

A basic model (but albeit slightly better than current practice) will have basic results. It's that simple. If the profession wants to do better, it needs a more comprehensive model.

Given the wide spectrum of deficits that people with chronic pain present with and without addressing the underlying functional mechanisms, a basic model will be have mediocre results.

Some issues

• There is no accepted standard therapy for musculoskeletal pain
• There is no consistent international learning in physiotherapy schools.
• Physiotherapists as new graduates can start practicing without any structured supervision
• Continuing education is not mandatory in many countries. Where it is, the structure or quality of the learning is not addressed. There are only certificates of attendance given, not certificates of competency.

In its current form, it is up to the individual therapist  to better themselves mostly at their own cost. We have a model to facilitate individual learning which can integrate existing knowledge to help significantly improve outcomes. Doing this has secondary benefits of reducing job stress and improving quality of life for the clinician.

A Great Time to Learn - Eliminate Burnout

This is an exciting time for all therapists. Certainly for the newer graduates who have not yet been exposed to the excessive poor outcomes, futility of many therapies, they have a model and learning structure they can follow to have a strategy to provide a rehabilitation directive for almost all patients. They can avoid the frustration, disappointment, and burnout of many others. Extensive research by many individuals has finally come to fruition - MISSION ACCOMPLISHED!