A Book Recommendation

Posted: May 3, 2015 in DAT Life

I just wanted to take minute to share a new book. While I have not read the entirety of the book yet, the book warrants a recommendation. The book is Evidence-Guided Practice: A Framework for Clinical Decision Making in Athletic Training by Bonnie Van Lunen, Dorice Hankemeier, and Cailee Welch.  The book was advertised in an NATA email not long ago, and I purchased the book.

This Saturday I will be presenting an EBP presentation to the Ohio Athletic Trainers’ Association. The focus of my presentation is creating evidence in your own practice through the implementation of EBP. I received the book in the mail as I was making my final tweaks to the presentation. I was sold on the book after a very quick skim through the pages. In fact, chapters 15-18 directly reflected much of the information I was already including in my presentation. So, I was able to use some of their graphs and ideas to more succinctly convey my thoughts.

Since then, I have read chapters 1-3, and 15-18. The beauty of the book is that it presents essential EBP and PBE ideas in a very conversational and easy to understand manner. The authors present the information in a way that foments a desire to improve your clinical patient care, and then the authors outline ways to achieve this change. In total, the authors broadly outline a development of knowledge and clinical practice transition with which many in the DAT can relate.

I also enjoyed that the authors continually utilized patient-rated outcomes that we routinely use in the DAT. The authors present the Disablement in the Physically Active (DPA) Scale, the Global Rating of Change (GRC), the Numeric Pain Rating Scale (NPRS), and the Patient-Specific Functional Scale (PSFS). The authors noted several important characteristics of these measures as related to the patient-athlete populations athletic trainers typically treat (i.e. DPA developed specifically for physically active populations).

I will continue to develop my opinion of the book as I read more. So far, I definitely recommend it as an entry text to evidence-guided practice and as a more advanced guide-book for those interested in disseminating their clinical findings. I have already discussed using the book in our Athletic Training Program at the college with our faculty. I also think that I’m going to gift a copy of the book (relatively cheap $56, who am I kidding I’ll just get desk copies from SLACK) to my clinical colleagues at the college.

I hope this review was informational. Below is a copy of the table of contents and the citation. If you have any questions, please feel free to ask in the comments below.

Table of Contents

  • Chapter 1: Construction of Clinical Questions
  • Chapter 2: Types of Research Design
  • Chapter 3: Searching the Literature for Evidence
  • Chapter 4: Foundations of Research and Statistics
  • Chapter 5: Introduction to Critical Appraisal
  • Chapter 6: Selection and Assignment of Participants
  • Chapter 7: Concepts of Validity
  • Chapter 8: Measures of Reliability
  • Chapter 9: Diagnostic Accuracy
  • Chapter 10: Levels of Evidence and Grades of Recommendation
  • Chapter 11: Scales and Checklists for Critical Appraisal
  • Chapter 12: Application of Critical Appraisal
  • Chapter 13: Clinical Prediction Rules
  • Chapter 14: Epidemiological Measures
  • Chapter 15: Disablement Models
  • Chapter 16: Patient-Oriented Outcomes Assessment
  • Chapter 17: Considerations for Selecting Patient-Rated Outcomes Measures
  • Chapter 18: Health Care Informatics

Van Lunen, Bonnie, Hankemeier, Dorice A., & Welch, Cailee E. (2015). Evidence-guided practice : a framework for clinical decision making in athletic training. Thorofare, NJ: SLACK Incorporated.

I covered a baseball double-header this Monday. During the game I did things that I would/could never have done before the DAT. I had three patients present with three diverse injuries in the middle of a double header. I was able to quickly provide relief to all of them. Before the DAT all of these patients probably would have been sat for the remainder of the day and given ice.

Patient #1

20 yo centerfielder. Slipped and took an awkward step when twisting to make a play on the ball in the outfield. He limped jogging back into the dugout at the end of the inning. His chief complaint was pain over his left adductors. He was point tender over the belly of the adductor longus muscle and tested 4/5 on adduction. He was fourth up to bat in the inning, so I went for the treatment that I thought would give me the most return in the shortest amount of time. So I did PRRT by taking the leg into adduction and then asking him to fire against resistance into abduction while I tapped the abductors. Two quick rounds took his pain from a 5 to a 0. He completed his at bat, which ended the game. I evaluated him during the break between the first and second game. There were no complaints, no functional loss, and full strength. No complaints since.

Patient #2

19 yo catcher. After the end of the first game he presented in the dugout with a chief complaint of anterior knee pain while squatting 6/10. He was point tender over the midline of the patellar tendon about 2cm distal to the patella. Again hoping to get the quickest return on investment in the dugout, I performed a MWM into a squat while using the tibial IR glide. Two sets of 15 reduced the pain to 0. So I taped him using the MC tape for the glide. He remained pain free for the rest of the day. He later presented in the clinic as a follow-up. The squat was still 0/10 but there was some point tenderness, 2/10, in the tendon 2cm distal to the patella. Further evaluation revealed a beneficial effect from the application of neural sliders. Two sets of two minutes of sliders reduced the palpation pain to 0. After the success with the knee, the patient inquired about “fixing my movement.” So we are no addressing his restrictions using TMR.

Patient #3

While I was treating patient #2, patient #3 presented with a “sore hamstring.” So I talked him through the modified mulligan TMR hamstring treatment seen in this video while I continued to treat patient #2. Patient #3 tested multiple torso directions (twists, bends, etc) until he found the movement that provided the most improvement. Then he performed several sets to improve himself to about 90%.

As the second game started I was reflecting on the treatments I had just provided. I was trying to decide what had guided my clinical decision making in those very quick evaluations and treatments. Due to the time crunch of returning the patient back to the field I had followed my intuition and used treatment-based evaluations to quickly select treatment strategies that worked. Now I may have gotten lucky, but I would like to think that it was my advanced practice development that provided me with enough background information to quickly make successful judgements. Either way, I provided treatments in the dugout to correct dysfunctions that I would have previously thought not fixable immediately in the dugout. My coach, my patients, and I are incredibly thankful to the DAT for this new standard.

Opportunities

Posted: April 2, 2015 in DAT Life

Over the last two weeks I have spent a lot of time traveling covering baseball and softball games (nine games in six days in three states), which has meant ample time to reflect about a lot. During this time I read several blogs (JNash’s Blog and Janet’s Blog) about personal and professional development. I am forever indebted to the DAT for my professional clinical and scholarly development. More so, and this is what I have been contemplating the most, I am indebted for the personal change. For me, the articles published in in the first issue of the 2015 ATEJ (LINK) really made me reflect and say, “what am I doing?”

Now let me explain. When I started the DAT I was just beginning a new clinical position at a new institution. I was familiar with my new institution and the athletic trainers working there. When I started, there was an excitement about the new techniques that I was using. The ATs I worked with were all about having me show them new techniques with their patients. They even took interest in reading new research and learning the new techniques. Eventually, the honeymoon period wore off. I became just the AT that did things differently. They stuck with RICE and stim. I had challenged them, but never followed through.

So how does that apply to the ATEJ articles? I work at a DIII institution that has an ATP. An ATP I graduated from several years ago. I have never really had any quality discussions with the ATP faculty about clinical care or athletic training education. I had a short conversation with the program director a while back about the appropriate degree for athletic training, but It was more of me answering his question about whether I thought we should transition to the masters level. I answered with a “yes,” but not much more than that. So as you can see, clinically, didactically, professionally I was missing my opportunities. Better said, I wasn’t being mindful of my opportunities.

So when I read the ATEJ issue I thought, “the faculty and our VP need to read these.” Quickly following that initial thought, I thought to myself, “my guess is they won’t, that’s too bad.” I was about to not be mindful of another opportunity. This is when I really just wanted to kick myself because I became mindful of how I was sabotaging myself yet again. I was doing well at having these discussions with students and colleagues outside of my institution, but I was not cultivating home base, my co-workers. Talk about a humbling realization.

So, the action plan. I shared these articles with the faculty to generate more professional discourse. Further, I plan to approach my interaction with my staff co-workers more mindfully. Currently my co-workers are not roadblocks, but they aren’t helping build a path forward either. As Janet mentioned in her blog, we need torch bearers moving forward. Building a new direction of clinical care at my institution will have to involve all of us. I really am disappointed with how little I have been able to influence change in my co-workers practice, but now I am energized as ever to be mindful of the opportunities for stewardship.

Just wanted to openly share my reflection to encourage others who may be having trouble being mindful of these opportunities.

FIFA11+ & TMR: A Good Match?

Posted: March 5, 2015 in DAT Life

I have had several people ask about the warm-up/injury prevention program I am doing with the baseball team here at Wilmington College. So here it is…

I started the journey to get to this point when I read the article by Grooms et al. about the integration of the FIFA11+ warm-up into practice with a DIII male soccer program that is actually just down the road from where I work. So at the next state convention I approach the lead author and discussed the program with him because I was looking for something to implement with the women’s soccer team I had recently began covering. The team had a long history of ACL and hamstring injuries. Grooms shared all of his information for the FIFA11+ program with me through a file sharing system. I implemented the program, and we saw a significant reduction in time loss due to injury. We also did not have an ACL tear for the first time in years (program or coincidence?).

So, I began to get very interested in the effectiveness of the program in other sports. If you do a literature search for the FIFA11+ program, you will find articles reporting effectiveness of the program in several sports.

Then serendipitously the baseball coach approached me. He said that he felt like the current “warm-up” for the baseball team needed to change. He had heard from the soccer coach that I had introduced the FIFA11+ program with successful outcomes. This lead to a long conversation about the current state of athletics and sports medicine and some of my ideas about how we might be able to provide better preventative care to our patient-athletes. Lots of things came out of the conversation, including that we are now an iceless baseball team, but let’s focus on the warm-up.

So, I set out to plan a warm-up/prevention program. I knew that the FIFA11+ program was going to be the core of the program. Also, working under the ideas of regional interdependence and the role of imbalances in injury, I wanted to implement a part that targeted these ideas. This is where the Gamma et al. article came into play. Instead of just doing the arm raise and trunk twists, I taught the team the FAB6, one movement a day for six days. After having a conversation with Tom Dalonzo-Baker, I began to implement 1D, 2D, and alternate positions. As a player reached a point where a TMR level was not identifying imbalances, they were moved to the next level.

So here is what the program looks like:

Part of Warm-Up Activity
FIFA11+ Movement

Jog x2

Hip out x2

Hip in x2

Shuffle around partner x2

Shoulder bump x2

Jog/backpedal (2 up-1 back)

Core/Balance/Strengthening

Forward plank x2

Side plank x2 (bilaterally)

Eccentric hamstring curls

Single leg stand x2

Squat to heel raise x2

Squat jumps x2

Movement

Sprint 75% x2

Bounding x2

Cutting x2

TMR Test FAB6 (or 1D, 2D, alternate position)

Treat greatest imbalance (usually get two to three movements treated)

We are able to complete the whole program in 25 minutes. I know I am a little fortunate here. My coach has decided that the first 30 minutes of practice are mine to do whatever injury prevention I want to do. I think this stems from our lengthy conversations about preventative care that I mentioned early. His theory is he would rather spend thirty minutes of practice every day to try to prevent losing one of his best players for the season. This is great. In addition to the regular program I will sometimes add information about breathing, rolling, etc.

Additionally, we screened the whole team using the FMS. This helped identify some gross motor movement dysfunctions. After highlighting players that might be at risk of injury, I sat down and had a conversation with the coaching staff to identify priority players on which to specifically focus on correcting movement dysfunction. Mostly the list ended up being populated by pitchers and catchers. So I now use my time during practice working with these players to restore quality functional movement. I plan to re-FMS the players at the end of the season to see general changes.

So far, the coach loves the program. We have less time loss so far this pre-season than last. This could be from the warm-up, my improved skill as a clinician, or chance. Many of the players have reported to me and the coaching staff that they feel better than they ever have at this point in a baseball season.

Now it is your turn to help me. Anecdotally the program has been very beneficial so far. I am using this season as a pilot to develop a research plan for next season. As a clinician-researcher, what information would you want to see me produce when I report this as an action research project in the future? FMS scores? ROMs? Injury numbers? Stakeholder comments? I appreciate the feedback and comments.

I encourage you to investigate the FIFA11+ website below and to do a quick literature search. It may not be a perfect program, but it is definitely something worth examining.

http://f-marc.com/11plus/11plus/

Grooms DR, Palmer T, Onate JA, Myer GD, Grindstaff T. Soccer-Specific Warm-Up and Lower Extremity Injury Rates in Collegiate Male Soccer Players. JAT. 2013;48(6):782-789

Gamma SC, Baker RT, Iorio S, Nasypany A, Seegmiller JG. A Total Motion Release Warm-up Improves Dominant Arm Shoulder Internal and External Rotation in Baseball Players. IJSPT. 2014;9(4):509-517

Mulligan and the Meniscus

Posted: February 16, 2015 in DAT Life

There have been some intriguing conversations about the Mulligan Concept (MC) in some of the blogs. The first years have definitely had some interesting comments about MC theory and clinical use. So, here is another patient to add to the conversation.

2/9/15

The patient was a 20-yo female soccer player presenting with a c/c of joint line knee p! that began during lifting the day before. In the clinic she complained of an inability to extend the knee and pain. As compared bilaterally, she was lacking 20 degrees of extension (R: 0, L:-20) and 40 degrees of flexion (R: 132, L: 92) actively NWB. Flexion and extension were 4/5 on the affected side and 5/5 on the unaffected side. There was moderate swelling in the joint line and tenderness to palpation at the medial (5/10) and  lateral (4/10) joint line. She was positive for pain with Thessaly’s, McMurray’s and joint line compression. The working diagnosis was a lateral meniscal tear.

PROs (beginning of eval): NRS 7, 3, 4 (worst, best, now); NRS with lunge 6/10 and with squat 4/10; PSFS-See table, DPAs- 46; LEFS 56.25%

With the working diagnosis of a meniscal tear in mind, I attempted the MC squeeze technique. There was no improvement in motion or pain. So I attempted another MC technique. I attempted a NWB tibial IR with knee flexion. This MWM reduced the pain and increased ROM immediately. So 3×10 NWB tibial IR MWMs into flexion were used. Then the patient was able to move to a WB tibial IR MWM in a kneeling lunge position on the plinth for 3×10. Finally, a WB DF MWM was added to the other WB MWM for 3×10. Each progression of the MC alleviated more and more pain. At the end of the session her joint line tenderness had decreased (med: 2/10, lat: 0/10), and the patient had gained 10 degrees of extension and 13 degrees of flexion. She was taped with the tibial IR Mulligan tape. She was instructed to limit lifting activity

PROs (end of eval): NRS 2/10 at rest, 3/10 with lunge, and 1/10 squat. GRC for the day +6. She also noted decrease pain with the special tests.

2/4/15

NRS was 5,2,3 with no pain with a squat, but still had pain with a lunge. The ROM improvements from the previous session were maintained. There were signs of swelling in the joint line, and the patient stated that she had been up on her feet working all day. She stated that she felt limited in ROM not due to pain but stiffness or fluid in the knee. She was treated with NWB tibial IR MWM 1×10 and WB lunge tibial IR 2×10. Squat NRS 0/10, lunge 4/10;  GRC: +6 overall, +5 today.

2/9/15

PROs (start of session): LEFS 80%, DPA 31.

NRS at the start was 3,0,1 with no pain during a squat and a 1/10 with a lunge. The swelling from the previous session was no longer present. She also now had full ROM in flexion (135°) and extension (0°). Her chief complaint was pain (4/10) when walking up steps and when kneeling. So I did lateral tibial glide MWMs 2×10 while walked up stairs. This reduced her pain to a 1/10. Adding tibial internal rotation to the lateral glide for 2×10 reduced the pain to a 0.5/10. Finally, the MC squeeze technique was used walking up the steps for 2×10 to reduce the pain to a 0/10. NRS scores at the end of the session were 0/10 at rest, 0.5/10 with a lunge, and 0/10 with a squat. GRC was +6 overall and +7 for the day.

2/12/15

The patient reported an NRS of 1.5, 0, 1 at the start of the session. She stated that she was feeling great and had lifted doing a light leg session earlier in the day. Her only complaint was a NRS 1/10 with a lunge. The MC squeeze technique was used during a lunge 2×10 to reduce the pain to a 0.5. Then 3×10 MWMs using a medial tibial glide during a lunge was used to completely reduce the pain.

The patient was feeling great after the session and was interested in not returning for more treatment. Since the MWMs had held so well, I agreed to discharge her as long as she followed-up with me in a week, or sooner if any issues arose. She had equal ROM and MMT bilaterally and no longer had any positive tests with the ST used during evaluation. PROs: GRC +7, DPA 0, LEFS 100%, NRS 0.

I haven’t seen her since, so I am assuming that everything is going well. I will see her again on 2/19/15, and I hope I can report the good outcomes held.

Every time I have such robust results using the MC I just have to smile and say ‘of course.’ This patient definitely added more strength to the MC in my clinical practice. She was released pain free and functional nine days after suffering an apparent meniscal injury. The patient also reminded me to try multiple MWMs before giving up. The squeeze technique didn’t work right away, but another MWM did. Later on the squeeze technique was what her knee needed. I also think I did a really good job of listening to this patient’s body. As you can see the MWMs were continually adjusted as needed to best fit the moment.

I just wanted to share another positive MC outcome with everyone and encourage everyone to keep improving. The sky is the limit…

 

PSFS Scores 2/3/15

(pre-tx)

2/4/15

(pre-tx)

2/9/15

(pre-tx)

2/12/15 (pre-tx)
Lunges 4 5 8 8
Walking up and down stairs 3 4 6 8
Standing from seated position 4 4 7 9
Fully extending leg 5 6 10 10

As many of you might remember, Mike had some interesting AC joint patients last spring that he treated using Mulligan. Those cases can be found here and here. I had similar experience with a patient recently, and as McKeon, McKeon, and King (2014) encouraged in their article Case Studies: The Alpha and Omega of Evidence-Based Practice, I am presenting it to you as further discovery and validation of Mike’s treatments.

The patient is a 21 yo left-handed baseball pitcher. He is about 6’2” 230lbs. Over the break he was out snowboarding on New Year’s Eve, and while going down the hill he fell and landed on his right shoulder. He felt instant pain and could not move his arm. Due to the amount of pain and loss of function, his friends took him to the ED. There he was diagnosed as having an AC sprain. On 1/2/15 he reported to our athletic training clinic and spoke to another AT since I was at home with the flu. That AT sent him to our team orthopedic physician who took weighted x-rays and diagnosed the patient as having a grade III AC sprain.

I first evaluated and treated the patient on 1/8/15. The patient was not in a sling, but exhibited great apprehension to movement and struggled to remove his shirt. He reported his pain in the last 24 hours to be 7 at worst, 5 at best, and a 5 currently. His DPA was a 32. Patient specific functional scale scores are listed in Table. 1.   He was TTP over the AC (7/10).  He had a positive piano key sign and a positive sheer test. Seated ROM measures were taken for shoulder flexion and shoulder abduction (the limited ROMs). Forward flexion, abduction, and IR all tested as 4/5 with increased pain for IR. External rotation was 5/5. As a part of the evaluation, I used an MWM for shoulder flexion. The use of the MWM produced a PILL response. So 3×10 MWMs for shoulder flexion were performed.

Following the MWMs the patient reported an alleviation of pain at rest (5-> 0) and during shoulder flexion AROM (6-> 0). There was also an increase in AROM for shoulder flexion (143° -> 180°) and abduction (93° ->103°).  Following the treatment the patient reported a general neck musculature pain on his right side. A tender point was found in the anterior scalene (5/10). I used PRT to reduce the tender point to a 2/10. The patient was taped using leukotape to sustain the MWM glide.  The patient left reporting a +5 on a fifteen point (-7 to +7) GRC.

The next day, the patient reported NRS 5,2,2 (worst, best, now) and improved PSFS scores. Again the MWMs produced a PILL effect, and 3×10 MWMs for shoulder flexion were done. Additionally, following a complaint of movement pain, horizontal abduction movements at 90° were done using MWMs. Similar to Mike’s patients, my patient complained of a general posterior shoulder pain. Tender points were found in the rhomboid major. This is different than Mike’s patients which had tender points in the traps. Using PRT the rhomboid points were reduced from a 6/10 to a 2/10. The patient reported a +4 for the day and +6 overall on the GRC.

On 1/15/15 the patient reported an NRS of 1, 0, 0 and a DPA of 9.  He threw a light bullpen workout off the mound, and he reported feeling great during the bullpen. He did note feeling a little restriction, no pain, with a D1 type flexion pattern. So, 4×10 MWMs were performed using that motion, which alleviated the complaint.  He left the treatment session reporting +5 for the day and +7 overall on the GRC.

He was discharged on 1/20/15 with full ROM and MMT. His DPA was 3 and his NRS was 0. On his one week follow-up he reported an increase on the NRS (3, 0, 0) and the DPA (7). He stated that most of his issues were related to “tightness” and pain in his back musculature. I was on my way out to travel with the basketball team so I quickly showed him TMR movements and told him to check back in when I returned. I have yet to see him since, but I will update when I do.

After reflecting on this case I reinforced a few things. 1. The case can be used to support the outcomes Mike presented last year. 2. I failed to take a good whole body look at the patient before discharging him. I got caught up in the improved AC and failed to look elsewhere, even though his body had screamed it the whole time (tender points). 3. His return to activity was dramatically faster using MWMs and PRT than the 6-8 week prognosis given by the physician.

This is definitely not an outcome I would have expected pre-DAT.

 

Table 1. PSFS Scores

Action 1/8 1/9 1/12 1/15 1/20 1/28
Put shirt on without pain 6 8 10 10 10 10
Put socks on without pain 4 10 8 10 10 10
Carry book bag 2 6 10 10 10 10
Throw off mound 0 0 0 7 10 9
Hit off tee 0 0 0 6 9 10
Live hitting 7

 

Mokha 2015 Functional movement training in snapping hip

I just wanted to take a minute to share an article from the IJATT with everyone that I enjoyed. The article attached above from Mokha looked at a clinical case involving a runner with external snapping hip syndrome who was evaluated and treated using the FMS and SFMA. The article does a great job of describing the theory behind evaluating and treating functional movement patterns instead of initial focus on activity-specific movement training (e.g. training running gait) or strength training. The authors demonstrated that changes on functional movement evaluations, which are used as comparable signs, were possible by addressing functional movement pattern training. In this case, the changes coincided with a correction in gait mechanics and an alleviation of symptoms. While their treatment protocol may have some room for acceleration using some more robust treatment techniques, their foundational theories are strong.

The aspect I enjoyed the most from was that the article reminded me that others are successfully using movement assessment to evaluate and correct patient complaints. Working with other athletic trainers around my conference and reading the literature, it sometimes feels like we (the DAT) are the only ones pushing these ideas. Every once in a while it is great to be reminded that similar minded clinicians are out there as well pushing professional knowledge forward. This reminder usually comes from the IJATT. Regularly reading the IJATT has definitely become one of my favorite professional practices. It has also been the catalyst for conversations with colleagues…Just wanted to share the article with all of you.

 

Good luck to everyone as we start a new semester. All our hard work will pay off.