🦀 PT Crab Issue 83 - Be on Point Tip. All the time Phife.

Welcome this this week's roundup of physicla therapy clinical research, awesomely brief. Two articles below, while our supporters got four. They got what you got, plus one systematic review of walking for LBP another that details how you should clean your clinic more often. Please.

Also this week, welcome to new subscribers Ryan P., Katie S., Emma V. (from Alaska, where my family is from!), Cara A. and more. Hullo!

With that, let’s dive in!

Be on point Tip. All the time Phife.

The Gist - We’re getting back into the mind of Chad E. Cook this week as he combines with Jason Beneciuk and Steven George to talk procedural drift and treatment fidelity. This viewpoint piece breaks down how practitioners’ interventions lose their way in implementing the best evidence in a process called procedural drift. CPGs are amazing, they say, but since they don’t often come with specifics on interventions, PTs can drift away from best practices as they go through the course of care. Their examples were low levels of resistance in strength training, poorly calibrated patient education, and poor reinforcement of patient homework during CBT.

Fidelity in research is easy, in practice, it’s tough. We’re busy. I don’t have to tell you that. And Cook and the boys understand. That’s why they have some solutions. They recommend “checklists and manuals when providing complex interventions such as behavioral or exercise-based care.” To all those worried about this becoming cookbook PT, they have some helpful tips about how to avoid that too. They have many other recommendations in this easy to read, open access piece, so I highly recommend you check it out. High quality evidence only helps our practice if we use it in a high quality way.

Paper? Here it is. Enjoy!

You Don’t Need ACL Surgery to RTS. But it helps.

The Gist - This paper from the American Journal of Sports Medicine dug deep into some personal data from 56 ACL surgeries and 45 ACL non-operative managements to see what happened when these folks returned to sport. They did long term follow-ups (I’d say long long term myself) at 9 years for the reconstructed group and 11(!) years for the non-recons. Overall, they saw that pretty much everyone kept playing sports (4% drop-off in the recon and 7% in the non) but many adapted their participation or sport choice in their returns from injury. The non-recons adapted a bit more than the recons too, with only 14% returning to competitive pivoting sports while 43% of the recons did.

Unsurprisingly to you seasoned rehabbers out there, five of the 56 recon patients (that’s about 9% jsyk) ruptured their contralateral ACLs and 1 ruptured their graft. In both groups RTS correlated significantly with quad and hamstring strength, with coefficients of r = 0.65 and 0.72 respectively.

Tell Me More - Now is where I sound some alarm bells on this study. It was basically two case series combined into one so they could be compared. Almost all the ACLs were surgered by one surgeon and/or treated by one PT. At best, this study provides general information about these two pathways toward rehab. We already know from elsewhere that only 49% of patients return to preinjury sport levels after ACL reconstruction (and only Adrian Peterson returns to being Adrian Peterson) so the researchers wanted to see how things played out in their own practices. Based on their data, it’s still better to get an ACL repaired than not if you want to return to high level sport but maybe think twice if you’re not a pivoter or if you’re recreational. But again, this isn’t systematic data, it’s just interesting.

And if you find it interesting Here’s the whole paper.

And that’s our week. The bibliography is below. Share with colleagues and friends please, that’s how PT Crab grows! The only way it grows in fact. Thanks!

Here’s this week’s bibliography:

• Cook, C. E., Beneciuk, J. M., & George, S. Z. (2022). Procedural Drift: An Underappreciated Element of Clinical Treatment Fidelity. JOSPT Cases, 52(2), 63–66. https://doi.org/10.2519/jospt.2022.10961
• Keays, S. L., Mellifont, D. B., Keays, A. C., Stuelcken, M. C., Lovell, D. I., & Sayers, M. G. L. (2022). Long-term Return to Sports After Anterior Cruciate Ligament Injury: Reconstruction vs No Reconstruction—A Comparison of 2 Case Series. The American Journal of Sports Medicine, 03635465211073152. https://doi.org/10.1177/03635465211073152