Tuesday, October 21, 2014

Deliberate Practice & Clinical Reasoning

I have had the privilege of studying from some of the “greats” in musculoskeletal medicine e.g  Professors Sahrmann, Janda, Lewit, Kolar to name a few.  In the years of clinical practice and teaching, many clinicians that I meet ask for “short cuts” and “clinical patterns.”  It’s not wrong to give folks short cuts and clinical patterns, as long as they also understand the reasoning behind the why-how-when-where to apply particular tests or treatment techniques. 

It is my bias that wrestling to understand the fundamentals is an exercise NOT to be short-circuited. It helps one appreciate the approach fully, at the same time acknowledging its strengths and limitations, and how that  particular approach can be integrated with other approaches. 

It can be beneficial for backward reasoning when the treatment outcome is not as expected or optimal.  The discipline and lessons learned from my days of competitive badminton have proven invaluable and have shaped how I approach clinical reasoning.  This  quote by Pablo Picasso strikes a cord with me and I will illustrate its clinical relevance with a short personal story. 

I started playing badminton at a young age, and began competing at age 10.  By age 14, I won the state U-15 singles title championship, and went on to win several more championships under the tutelage of Master & Mrs Ng Boon Bee & Mr Khong Shu Ming.  At age 17, I had a change in coaches after completing high school.  This particular coach-teacher, Master Aw  believed that I had the talent and drive but lacked the foundational footwork & stroke play to take meA to the national level.  So began the long arduous journey of motor re-programming for efficient footwork that would lay the foundation for polished and stronger stroke play.  I was already a state champion at that time, but I was going back to the basics. Needless to say, my ego took a beating as he drilled me on the fundamentals. Those deliberate hours of practice on and off the court seemed mundane & endless but I was motivated by an inner drive to make it to the national squad.  When we were not practicing on the court, he would make me analyze my strokes and footwork as well as those of my opponents.  After each match, while others celebrated their victories, we went over plays or strategies that worked or failed. 

During one particular match, I defeated my opponent to win a tournament. To my surprise and dismay, Master Aw chewed me out as he saw that I had returned to my old patterns of scrappy footwork and un-strategized powerful smashes solely for the purpose of winning. So it was back to more deliberate practice. A couple months later in another championship match, I lost to a junior player. I was humiliated and embarrassed. As I hung my head in shame after the game, Master Aw surprised me by congratulating on a job well done and proceeded to explain that he "saw "or rather detected that my brain was processing in choosing the new over the old pattern. There was hesitation in my strokes and footwork which made me a split micro-second slower but nevertheless I chose the newer pattern.  That experience will always be etched in my memory as that was the beginning of a lesson well learned.  A motor engram was formed from that new foundation and my coach was able to build upon it to teach me variations and finessing of the strokes (ART) to make them more polished, powerful,or deceptive depending on my opponent’s play.  To make a long story short, that was the beginning of my rise as a polished badminton player and in the next 4 months after that humiliating defeat, I won the National U-18 singles championship and  soon after that, was selected to join the national team and represented Malaysia in the Uber Cup championship (equivalent to Davis Cup in tennis) in Japan.  

What has this story to do with the clinical world of physiotherapy? Below are some of my thoughts.

  1. Good coaching (education, mentoring) is of great value and significance. I got pretty far merely from some talent, sheer grit and drive (NATURE) to succeed. But my coach in his wisdom and foresight showed me that appreciating the fundamentals, discipline of deliberate practice and self-reflection made me a superior player(NURTURE).   I have carried these lessons to my clinical career and I owe much to my family, coaches and teachers who patiently guided and nudged me to better myself.  Thank you for believing in me. I will always be grateful for your influence in my life.
  2. It is my firm belief from my personal and clinical experience the importance of going back to the basics and learning them well can indeed accelerate one’s growth.  When one gets stuck or if a treatment is not working, one can always back-track or self-reflect on where one went amiss in the thinking process and adjust the treatment, thus, learn from it.  Perhaps that’s one of the reasons I subscribe to Dr. Shirley Sahrmann’s emphasis on performing a structured exam, so that one can piece the data collected and makes sense of the SOURCE and CAUSE of a musculoskeletal pain problem.   Tagging on Vladimir Janda’s influence in my clinical career, the functional exam accelerated my understanding and appreciation of “regional interdependence” and looking at a patient as a “whole” and how we need to promote treatment or exercise strategies to target the central nervous system to make long lasting changes.
  3. Movement patterns can be changed but it does take conscious and countless repetitions of deliberate practice for motor engrams to form and take hold.  My coaches (like Mr Miyagi in Karate Kid) understood that principle – if you recall the movie, young Daniel was made to perform countless chores e.g painting fences, waxing cars, while concentrating on the quality of the movement.  He was frustrated and angry because he thought that Mr Miyagi was just exploiting him.  Just as he was about to quit, Mr Miyagi showed him the relevance of those menial tasks when he attacked Daniel, and Daniel instinctively and reflexively defended himself because of the motor engrams formed from the supposedly repeated menial tasks that was he was given by Mr Miyagi.  Only then, did young Daniel understand the reason for the countless hours of the mundane and repetitive chores.

In short, in all of our ambition and drive to better ourselves, we often seek the quickest way to become the most efficient, the most effective in order to get the quickest results.  However, let’s not forget all the lessons, beauty, and insight gained from taking the long way home.  I leave you with portions of a quote that captures my sentiments about the importance of not shortchanging the journey.

“As you journey through life, choose your destinations well, but do not hurry there. You will arrive soon enough. Wander the back roads and forgotten paths, keeping your destination in your heart like the fixed point of a compass. Seek out new voices, strange sights, and ideas foreign to your own. Such things are riches for the soul. And if upon arrival you find that your destination is not exactly as you dreamed of, do not be disappointed. Think of all you would have missed but for the journey there, and know that the true worth of your travels lies not in where you come to be at the journey’s end, but in who you come to be along the way.”      Unknown

Blogpost written by Clare Frank

Friday, May 2, 2014

Schroth Method for Scoliosis Management

In February of this year, I traveled to Barcelona, Spain, to attend the Schroth C1 certification course through the Barcelona Scoliosis Physical Therapy School, (BSPTS).
My journey with scoliosis actually started a year and a half prior, in 2011, when my mentor and colleague needed a guest lecturer to pinch hit for an entry level PT program.  I welcomed the opportunity as I had recently learned that I had mild scoliosis myself, and scoliosis was always a clinical presentation that baffled me in school and in my clinical practice. 

In my preparation for that initial lecture, I quickly came across the Schroth method.  I was intrigued from the start, and knew I wanted to learn more.  What struck me was the emphasis on exercise correction specific to the individual’s asymmetry and in 3D, as well as the integration of the corrections into everyday posture and ADLs.

Katharina Schroth
The Schroth method is based on the work of Katharina Schroth, born in Dresden Germany in 1894.  She was diagnosed with scoliosis as an adolescent, underwent brace treatment, and eventually began to develop a method to achieve postural correction on herself. 

            She used the idea of a balloon to envision flattened areas of her ribcage to fill out, and expanded areas to contract.  Mirrors were an integral part of her work, to change her perception of her own posture.  Originally trained in business, Katharina Schroth eventually went back to school to study physiotherapy so that she may begin to treat other patients. 
The method has grown and expanded and is now taught in Germany, Spain, as well as the US, and is expanding to other parts of the world. 

The Schroth- based method as taught by the BSPTS, can be defined as a conservative method aimed at “cognitive, sensory-motor and kinesthetic training to teach the patient to improve his/her scoliosis in 3D posture” and to incorporate this correction into all ADLs.

Muscle cylinder exercise on floor

The 10-day course was taught by Dr. Manuel Rigo, originally trained in the specialties of allergy and clinical immunology, but eventually transitioning to scoliosis, the population he has been managing for the last 30 years.  He is world renowned in the conservative management of scoliosis, and has been teaching the Schroth method since 1989.  Dr. Rigo has a very hands-on approach, working side by side with the physiotherapists who work with him at the Institut Elena Salvá to participate in the exercise instruction and progression.  He fabricates his own braces using the principles of Chêneau and his braces are made in accordance with the Schroth principles of correction.  Dr. Rigo is a brilliant man who is clearly passionate about his craft, yet humble and with a willingness to admit that there is so much still unknown about the etiology and progression of idiopathic scoliosis.

The course was truly an enriching experience for me.  Dr. Rigo launched the course on day 1 with the statement that from that time forward, we were considered family to him.  It is interesting how correct he was, as naturally, spending 10 days of intensive study in a small group away from the additional stresses of family and personal life will create a unique connection among the participants. 
BSPTS C1 Certification Class, February, 2014

We were a group of 12 from 8 different countries (South Africa, Greece, Israel, Bulgaria, Norway, UK, Australia, and the US).  Our experiences with scoliosis leading up to the course were varied as well as our general physiotherapy backgrounds.  I so enjoyed getting to know each person and learn from my classmates and the rich knowledge each brought to the journey we took together.

On the final night, we ate together at Dr. Rigo’s home with his wife, Gloria Quera-Salva, as we indulged in his homemade paella. Delicious!! I can still taste it!

Dr. Rigo's homemade paella

 Major take home messages from the course:
1. The patient with scoliosis has a body schema in the brain that re-enforces the scoliotic posture.  This posture is “correct” for that person.  One of the goals of Schroth treatment is to change the scoliotic body schema in the brain with the postural correction.  Ideally, over time, the correct posture becomes more automaticized and the corrected body schema becomes more dominant in the brain. The problem is not just isolated muscle imbalances but a faulty cortical representation of a particular posture or movement pattern that has become dominant in the individual’s repertoire of movement at some point in life.

2. The 1st principle of correction: Spinal elongation from a stable pelvis in all three planes.  Elongation allows for postural correction in the sagittal, frontal, and transverse plane.

3. The use of body blocks to envision the scoliotic posture is key to the method. It helps classify patients and provides a way to visualize three dimensional nature of the particular individual’s curvature.  From studying the body blocks, appropriate exercises can be developed

3C Classification

Body blocks to visualize 3C Classification
4. Much remains unknown about the etiology and progression of scoliosis. Generalizations can be made, but we must always consider the individual we are managing apart from statistics

5. “Do not create a patient.”, in the words of Dr. Rigo. The clients that we serve with scoliosis are healthy children and adolescents who have an asymmetry in their spine.  Scoliosis does not equal handicap or disability. 

On the last day of the course at one of the breaks, Dr. Rigo came out of his office with a magazine cut out of a women wearing a gorgeous hat with an asymmetry to it’s shape.  He said, “This is how we should view scoliosis.  This hat is asymmetrical, but it is beautiful.”

Thank you to the BSPTS for such an enriching experience! 

Thank you to the many individuals who have given me the courage and support to venture out of my comfort zone and open myself to new experiences!

Kelly Grimes, DPT, OCS