Don't Be Afraid to Sweat
2 minute read
Maghan is a physical therapist from a small town in Indiana who works in rehabilitation clinics that treat patients with injuries to their nervous system, such as stroke or spinal cord injury. Maghan had been a physical therapist for 18 years and would describe her practice as "…very neurodevelopmental treatment (NDT) focused. My treatment sessions focused on promoting normal movement patterns after stroke and included progressively mastering easier skills (like sitting) before harder tasks (like walking)." Maghan was eager to expose herself to new evidence, and decided to sign up for a course on gait rehabilitation.
Through the 3-day course, Maghan reflected on her clinical practice and on how it compared with the evidence presented. She states, "We learned that a key parameter in improving gait-related outcomes was intensity. Specifically, intensity as measured by heart rate. We also learned that practicing walking without perfect kinematics could result in improvements in sitting or balance abilities, or something they called reverse transfer effect. In the end, the patient's kinematics looked better without practicing normal walking." Maghan had some concerns about the adoption of intensive walking practice. "I was taught that you could reinforce abnormal motor behaviors by having patients move quickly. The notion that ‘perfect practice makes perfect' was the foundation to my entire practice. This, however, was in stark contrast to the data presented." Maghan left the course with both excitement and hesitation for the new challenge of changing her practice.
Maghan knew that she had to exert a lot of effort to change her clinical practice, but she was willing to take on the challenge for herself, her colleagues, and her patients. She decided to institute standardized outcome assessments and see for herself if her patients would improve. "There were many bumps in the road. I realized that we needed a few pieces of additional equipment to provide the amount and intensity of walking practice that was shown to be effective. I had staff that were concerned about taking time away from balance or transfer practice to devote to walking. This concern was quickly eliminated when the outcome measures that we instituted were showing that patients were improving in their balance and transfers, without their explicit practice! I found that it was hard at times. In order to have some of my patients work hard, I had to sweat too!"
Maghan experienced firsthand some of the commonly reported barriers to delivering intensive practice, but persisted with developing implementation tools, advocating for equipment, and educating her colleagues. "Delivering a gait intervention at the appropriate targeted intensity was definitely a learning curve. I am still learning to this day. I found that my patients were starting to sweat when intensively walking! Continuously monitoring heart rate has been key to ensure that my patients are reaching and maintaining the targeted intensity zones, as some of my patients were higher or lower than I had thought."
Recognizing that we need to adjust our clinical practice and embarking on the steps to change requires self-reflection, patience, and a lot of effort—some of it may require you to sweat! Emerging evidence can challenge long-standing beliefs and require physical therapists to learn new skills and think outside the box. Part of learning new skills and exploring new ways of treating can be uncomfortable territory, particularly if we have practiced one way for many years. However, engaging in the practice of continual self-improvement and the responsibility of making sound professional judgements lie at the core of what it means to be a physical therapist, as evident in our Code of Ethics.
It is estimated that it takes upwards of 17 years for a piece of evidence to be translated to the clinical environment. This lack of translation is likely multifactorial and presents serious ethical issues for the health care provider, insurers, and patients alike. More than a decade has passed since the discovery of the importance of repetitive, task-specific, and high-intensity gait training in the maximization of walking ability in individuals with neurologic diagnoses. However, practice patterns largely remain unchanged.
We, as physical therapists, should be devoted to continued professional development and to be accountable for making sound professional judgments informed by evidence. We have to sweat if we expect our patients to; anything less is unethical.
To hear more about including tools and resources accessible to assist students in the implementation of these recommendations into clinical practice, join us at our session "Intensity Matters: Maximizing Walking Recovery in Individuals With Neurologic Conditions" at APTA's 2019 National Student Conclave.
Join us October 31 - November 2, 2019 at APTA's National Student Conclave — the only conference for students, by students. For the best rates register by September 25, 2019.
Carey Holleran, PT, MPT, DHS, is a board-certified clinical specialist in neurologic physical therapy and assistant professor of physical therapy and neurology in the Program in Physical Therapy at Washington University in St Louis.