Monday Memo 6/18/18

The Monday Memo

June 18, 2018                                                                           PITT DPT STUDENTS

 

Clicker Training and Task Analysis

 

A few weeks ago, 2nd-year president Jim Tersak wrote about learning a new skill and the ways in which we can break down practice to learn that skill. Not long after reading Jim’s memo, I heard an interesting podcast discussing the ways in which we learn. I highly recommend checking it out. The episode focused on the importance of the learning environment during the cognitive stage of motor learning, and the effect of an instructor’s feedback upon the learner. First, let’s talk about some basic principles of skill acquisition.

 

Table 1 outlines the principles of experience-dependent plasticity as taught in Neuromuscular PT. As clinicians, we help our patients acquire new skills and refine their movement patterns. It is imperative for us to carefully design the environment in which our patients learn, and control as many aspects of that environment as possible to avoid interference. Whether caused by environment, the student, or the instructor, interference can occur in response to a single experience during skill acquisition and negatively impact future training. In the podcast, Dr. Martin Levy discusses the role that feedback plays when training surgical residents. He explains how external feedback may be misconstrued by students early in the learning process, and that this negative emotional association can impede the ability to learn that skill in the future.

 

To remedy this issue, Dr. Levy has adopted a style of teaching which has long been used by animal trainers: a clicker. He uses a clicker to provide objective, external feedback when instructing orthopedic residents in various skills required for surgery. He prefers the technique because it removes the learner’s desire to be rewarded by the instructor. Instead, the students are rewarded by perfecting the movement. As soon as they perform the task correctly, Levy simply clicks and they move on to the next step. The system is binary: either the learner correctly performed the task or they did not. This allows the student to focus on intrinsic feedback (aka the information received from visual, motor, and somatosensory systems) when completing the training, which is then verified by the external feedback of Levy’s click. This emphasis on intrinsic feedback enables the students to correctly perform surgical tasks under a variety of conditions.

 

The key to appropriately utilizing this technique is to first perform an extensive task analysis on the skill being taught; the clinician must be able to break down the whole task into its smallest components, just like Jim discussed in his memo. Levy teaches each component until it becomes highly skilled, then manipulates his students’ environment to prepare them for real OR scenarios. We must be able to do the same for our patients and for ourselves as we learn. For example, when learning to perform joint mobilizations, our body mechanics are absolutely critical. We can effectively master this technique by breaking down the task into steps:

  1. Patient positioning
  2. Table height
  3. Clinician foot placement
  4. Clinician hand placement
  5. Direction of mobilization, force of mobilization, etc.

 

If we are able to effectively analyze a task to promote our own learning, then we can apply similar logic to educating our patients. By coaching a patient through the foot placement, then ankle, knee, hip, and trunk movement, we can effectively help them master a lateral step-down task.

 

Clickers may not be ideal in a physical therapy setting, and some patients could potentially be offended at the thought of using one. However, we can utilize the key principle that the clicker provides by simplifying our feedback and optimizing our patient’s environment. This allows our patients to focus more fully on the task at hand, so that you can make the environment increasingly more functional after they’ve mastered the basics. A simple ‘yes’ or ‘no’, or even a click, can go a long way.

 

-Joe Dietrich, SPT, ATC

 

References:

https://www.ncbi.nlm.nih.gov/pubmed/26369658

https://www-ncbi-nlm-nih-gov.pitt.idm.oclc.org/pubmed/18230848

https://www.npr.org/2018/06/04/616127481/when-everything-clicks-the-power-of-judgment-free-learning

June 18, 2018 |

Monday Memo 6/11/18

The Monday Memo

June 11, 2018                                                                           PITT DPT STUDENTS

Play Ball!

 

Summer is upon us, and that means it is time for outdoor activities such as baseball, softball, and volleyball. A lot of us have been cooped up all winter and are ready to get out there and start playing. Today we will go over the mechanics that contribute to throwing and provide tips on how to make sure you stay safe while performing these activities.

 

As we know, the stability of the shoulder is due to both active and passive structures such as muscle and bone, respectively. All structures that make up what we consider the shoulder joint contribute to both the stability and mobility of the shoulder. During throwing activities, both are needed. Without proper mobility, one will have trouble initiating and generating enough power for an effective throw. However, with too much mobility, one will not be able to control the motion available. Overhead athletes are known to be more susceptible to instability. Examples of instability include tears of the labrum, rotator cuff, or capsular injuries. Many labral tears that overhead athletes (swimmers, throwers, volleyball players) are susceptible to are due to overuse and can be recurrent.

 

Lesions can be treated non-surgically and have good results. However, the best way to ensure that it does not impact one’s athletic performance is to prevent these injuries. Whether it is a major league baseball player or a grandfather playing catch, throwing is an activity that involves the entire kinetic chain from the feet to the fingertips. Below is a chart describing abnormalities that may take place in the kinetic chain and the visible effect they may have on the throwing pattern.

Seroyer, ST et al. “The Kinetic Chain in Overhead Pitching: Its Potential Role for Performance Enhancement and Injury Prevention. Sports Health. 2010;2(2):135-146

 

Below are some tips on how to prevent common throwing injuries to ensure that you stay active all summer long:

 

  • Single leg stability: An effective throw starts at the feet, ensuring that the thrower has a stable base of support is critical. Working on single leg balance as well as hip abductors, quadriceps, and hamstring strength can ensure that you maintain a stable base during the initial phases of throwing.
  • Core stability: A lot of power involved in throwing comes from the core. The quick rotation that occurs during the stride/ late cocking phase of throwing is critical to generating adequate momentum. Working on abdominal and oblique strength can improve this.
  • Rotator cuff strengthening: The rotator cuff muscles contribute a great deal to stabilizing the shoulder during throwing. Performing internal and external rotation exercises are highly beneficial. However, making sure that you are doing them at 90 degrees of shoulder abduction will translate the best to an overhead throwing activity.

 

References:

 

Seroyer, ST et al. “The Kinetic Chain in Overhead Pitching: Its Potential Role for Performance Enhancement and Injury Prevention. Sports Health. 2010;2(2):135-146

 

Baker CL, Uribe JW, Whitman C. Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med 1990;18(1):25–8.

 

Bernstein N. The coordination and regulation of movement. London: Pergamon;1967

 

Special thanks to Adam Popchak, PT, PhD, SCS, whose lectures provided a great deal of information that contributed to this piece. 

 

-Layne Gable, SPT

June 11, 2018 |

Monday Memo 6/4/18

The Monday Memo

June 4, 2018                                                                           PITT DPT STUDENTS

Let’s Learn a Skill

 

Learning a new skill can be difficult and perfecting a skill can seem near impossible. Whether that skill is opening a jar or shooting a slapshot from just inside the blue line, moving through the ranks from beginner to expert can be a long and challenging process. One skill involves fine sensorimotor and upper extremity control, the other involves the ability to balance and transfer weight on the ice, with great force, while aiming a 3-inch puck at a 4-inch opening greater than 60 feet away. Interestingly enough, learning these different tasks can be approached the same way. Correctly identifying the type of skill and the level of experience of the patient or client can offer a clear guide to creating a useful and challenging exercise.

 

First, categorize the task at hand as discrete, serial, or continuous. Each is described differently, and when learning can be approached differently as well:

  • Discrete – a skill that has a clear and definite beginning and end.
    • Cartwheel, swinging a baseball bat, kicking a ball
  • Serial – a series of separate discrete skills completed in a specific sequence, ultimately creating one larger activity
    • Ex. – a place kick in football (including components of the run-up and the kick)
  • Continuous – have no distinct beginning or end, and are repeated continuously
    • Ex. – Swimming, walking, jogging

 

Then, using the information we have already, we can design an exercise by deciding how we want to break down the task if we want to break it down at all. Here we can decide if we want to do part vs. whole training, and blocked, variable, or random training.

 

Whole vs. Part training:

  • Whole – The whole technique is practiced without a break
  • Part – Separating a complex skill into its base parts

Blocked vs. Variable vs. Random

  • Blocked – Practice that involves repeating the same movement or task under the same conditions
  • Variable – Practice that involves repeating the same task or movement, but where one component of the action is changed after each repetition
  • Random – Practice that involves completing various discrete or serial tasks necessary for the overall skill, but completed in a random order unknown to the performer

 

Here is a good example of how exercises can be prescribed based on these principles. An example of a few levels of exercise are described, and it is discussed when each is appropriate or not appropriate to be used. Although these ideas may seem simple, if used correctly, they can help maximize the effectiveness of your training.

 

References:

 

-Jim Tersak, SPT, CSCS

June 4, 2018 |

Monday Memo 5/28/18

The Monday Memo

May 28, 2018                                                                           PITT DPT STUDENTS

A Sample of Pediatrics 

I am currently in the pediatric setting for the first time for my first 6-month clinical rotation. Over the past month, each day has been vastly different. Not only are the patients and their diagnoses different from session to session, but the patients’ behaviors vary each session, and sometimes even within session, as one can imagine with ages 0-18. I certainly have not been bored!

 

I believe physical therapists are naturally adaptable humans; we have to be in this health care environment, no matter the setting. As I’ve observed so far in the last month is that in pediatrics, especially, adaptability is vital. You have to be on your toes, and I mean the very tips of your toes, at all times. It certainly has made every day exciting and has allowed me to quickly develop my skills in a new setting.

 

With a new setting and experience, comes new diagnoses. One in particular that we learned about in the classroom is Reflex Neurovascular Dystrophy, or RND. In short, it is a condition that leads to pain in the musculoskeletal system in children, females typically affected more often than males. In this short month I have seen a large number of children that are being treated for this condition. Each presents differently, with varying locations of pain and wide ranges of pain. Despite medical tests showing normal results, the pain that these children are experiencing is absolutely real, and cannot be helped with pain medication. The pain can be so intense that these patients are limited from their previous activities such as sport, ADLs and even school.

 

Physical therapy and aerobic exercise is effective, but to treat RND, a psychological approach in combination with PT needs to be taken. While they are referred to psychology, everyone on the medical team needs to be on the same page and take the biopsychosocial approach to treatment. Pain is not discussed during PT except for initial evaluation and recurring reevaluations. These patients are educated on pain management and stress reduction strategies to “power through the pain”. As a PT, it is important to establish a comprehensive program of aerobic and general strengthening and conditioning exercises, but perhaps most importantly, to educate the patient and family to tackle this condition together. It is more common that one may expect, and is something that can recur throughout the lifetime. Even if you are not working in pediatrics, being aware of this diagnosis is helpful, because inevitably, the child is going to grow up to be the adult we see in all settings. It is vital to establish a program and psychologically informed PT strategies so that this chronic pain can be dealt with throughout the lifetime and won’t hinder the patient from living a full, active life.

 

So far the experience has been unique and I’m excited to continue to learn so much more.

May 28, 2018 |

Monday Memo 5/21/18

The Monday Memo

May 21, 2018                                                                           PITT DPT STUDENTS

PTs as Leaders

Leadership dons many colors. There is no singular quality that defines it, and no distinct formula that produces the individuals who exhibit it. The act of leading is a multifaceted endeavor imbued with nuance and shaped by instinct. As budding leaders in the field of physical therapy, these are ideas that should not be readily forgotten – especially in the ever-evolving landscape of healthcare – and as such, particular attention should be given to the foundational traits that allow us to have the greatest impact among our colleagues and those we rehabilitate. As we look to “transform society by optimizing movement to improve the human experience”, it is essential that we commit ourselves to visionary thinking and refining the skills required to communicate those thoughts.

 

Leadership is many times firmly associated with the qualities most representative of delegation. While unfortunate, this is not without merit as leading requires the ability to coordinate many individuals and unify an effort in the direction of one common goal. In physical therapy we see this most commonly in the collaboration between therapists, assistants, rehab aides, and administrative staff. However, to see leadership solely in this capacity is both an incomplete and one-dimensional assessment. The act of delegation is simply a conduit for the communication of a greater vision, and without vision the operation ceases to exist. Whether it be for a single patient or an entire cohort, a leader in physical therapy cannot affect change in absence of innovative thought. Patient care is a dynamic process because the patients are inherently dynamic themselves. They are fluid in both their internal and external environment, and the only way we can accommodate this is if we are fluid as well. We cannot afford to be static and we most certainly cannot expect to apply cookie-cutter methodology to every patient of the same ailment. We must be malleable and adaptable so that we can best execute the overarching goals of our care and meet the needs of the individual.

 

Equally important to the formation of this vision is how we choose to communicate it. Patient care is a complex network of various healthcare professionals and the community in which the patient exists. The success of our care is ultimately dependent upon how we articulate our course of action and the interventions we utilize. How we construct that communication comes first from the insight we glean from the patient profile. From here we can begin to devise how we conduct our patient interview and collect the information necessary for formulation of a plan of care. Further synthesizing that information is entirely dependent upon our ability to listen to not only the patient’s story, but also its subtext. To put it simply, our insight only goes as far as our willingness to listen, and its quality only as strong as our empathy. We may guide the patient through their rehabilitation, but they ultimately guide our treatment decisions. Through this marriage of insight, active listening, and empathy we can develop the clearest picture of our patients and a much more linear, streamlined approach to communicating their care.

 

Though a leader in physical therapy is not limited these skills in practice, they are essential foundational pieces on which to build our influence. By situating these elements within our scope of care, we will not only initiate a transformation, we will also pioneer progress.

-Holden Sakala, SPT

May 21, 2018 |