Allan Besselink

"Eric - that must have been an intriguing comparison. Two albums with some incredibly strong social commentary! How old were you when you wrote it? Thanks for sharing the video - I don't think I have ever seen it before. A classic!!" - Allan Besselink

"Most coaches that I have worked with over the years did not have an "injury management plan" - unless you count "time off" as a "plan". The best plan is for the training plan to not injure them in the first place!" - Allan Besselink

""The best coaches with the best runners suffer non-traumatic running injuries" - interesting point. Given that >70% of running injuries are training-related, then "the best coaches" are promoting an environment for injury. I don't think that makes them the best coaches! Sadly, we have come to accept this as "the norm", even in the face of good scientific evidence to the contrary." - Allan Besselink

"I think there is a relatively stable formula - assuming that the athlete continues to monitor appropriate and inappropriate responses to training. Building recovery days into the training on the front end is critical. However, there are many athletes that will a) not have a methodical plan, and b) will ignore the warning signs as they go with adjusting accordingly!" - Allan Besselink

"Bruce, I would suggest that "over-training" should really be considered "under-recovery". But that is a whole 'nother topic ..." - Allan Besselink

"I think that there always a variety of contributors. As long as we can be aware of them, and utilize strategies that address them appropriately, then we can build an optimal training plan - and not a sub-optimal "appease the beast within" plan." - Allan Besselink

"Definitely! Many clinicians seem to forget that an intervention is an opportunity for data collection as well. Baseline, intervention, assess response!" - Allan Besselink

"Janelle - thanks so much for your comments. I appreciate you providing us with your personal experiences. You brought up some interesting points. re: the issue of "respect" - even when I graduated as a PT, respect wasn't bestowed upon me. I had to earn it in the clinic. In the first facility that I worked in, I had the most recent PT degree by at least 5 - 8 years, so I had the "latest and greatest" - yet I still had to earn respect. Sadly, I think that many graduates assume that a DPT entitles them to respect because of their degree. It hasn't been that way, nor should it. When a non-DPT takes issue with it "moving the profession in the wrong direction" (as I have written here), many DPTs take it personally. The issue I have is with where we put our trust, the reasoning behind it, and the evidence of whether or not it is moving the profession forward. That is called "learning from experience"! Unfortunately, I have witnessed two degree transitions in my career (three, if you count..." - Allan Besselink

"Thanks, Julia. Low back pain is one of the biggest contributors to health care expenditures. As I mentioned in Part III, solutions exist - we just have to choose to utilize them!" - Allan Besselink

"Holly - thanks for sharing your thoughts!" - Allan Besselink

"There are two issues at stake - the reimbursement dilemma, and the ability to give a patient with low back pain a specific pathoanatomical diagnosis (and then, give it a code). Reimbursement and claims review could be a totally separate post on its own!" - Allan Besselink

"It concerns me that it was taught as a "hybrid" and that there was little time spent on the MDT diagnosis. If you don't have the mechanical diagnosis, then you are selecting treatment arbitrarily - which seems rather pointless and defeats the purpose. Was it taught be a faculty member (or adjunct) with any higher-level training in MDT - or training in MDT whatsoever?" - Allan Besselink

"Thanks! I will definitely have to find the Radney Foster song you mentioned." - Allan Besselink

"Thanks for your comments, Scott. Welcome!" - Allan Besselink

"Thanks, Scott!" - Allan Besselink

"Christie - great post (and certainly not too long!). Your first couple of paragraphs summarize the problem nicely. In the world of running injuries, if 70% can be attributed to training error alone, then I would suggest we have far too many inexcusable "missed opportunities" - simple solutions or otherwise." - Allan Besselink

"Ryan - good points. Clinicians straddle this topic in some interesting ways. On one hand, we discuss the importance of "evidence-based" approaches; on the other, we promptly ignore or disregard when the evidence doesn't jive with our beliefs. Does that become an ethical issue?" - Allan Besselink

"Cook C, Learman K, Showalter C, Kabbaz V, O'Halloran B. Early use of thrust manipulation versus non-thrust manipulation: A randomized clinical trial. Man Ther 2012 Oct 2. pii: S1356-689X(12)00189-0. doi: 10.1016/j.math.2012.08.005. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pu... Just curious ... if you are a chiropractor, then why would you say that "I don't think manipulative therapists are going anywhere"?" - Allan Besselink

"James - just saw this post, so apparently our comments are crossing each other somewhere over Africa :-) With regards to standing x-rays, digital measurements, etc - as I mentioned, I would be hard-pressed to remember a patient that has ever had one of these assessments performed. That may in fact be a US issue - which would not surprise me. Is manipulative therapy a "waste of money"? A tough question. However, here is a thought. I will preface this by saying that I am not saying right or wrong, simply "to consider" ... I believe that Chad Cook has a study to be published (or has recently been published) regarding the outcomes of mobilization vs manipulation. Finding? Same outcome. Manipulation is no better than mobilization - or mobilization is as good as manipulation. With that said, if a patient can perform a self-mobilization, then what is the value-added benefit to the patient of a manipulation performed by the clinician? This is something that was proposed by McKenzie many years..." - Allan Besselink

"A few references to begin the discussion: Chiropractic concepts of the short leg: a critical review. http://www.ncbi.nlm.nih.gov/pu... "A major tenant of some chiropractic therapies involves the use of measurement of "functional" short leg. Though procedures for making such measurement are in the public domain, there is no proof within the literature that such exists. here have been done reliability studies attempting to show repeatability of measurement. Results have been mixed at best." Leg length inequality. http://www.ncbi.nlm.nih.gov/pu... "Much controversy exists with some of the clinical orthopedic methods and the visual "quick" leg check. Because there is such a vast range in estimates of reliability, few if any definitive conclusions can be made regarding these methods. Given this, it is evident that more research is needed before the use of certain orthopedic and visual checks are considered reliable and valid". Comparison of leg length inequality measurement methods as..." - Allan Besselink

"Sadly, the reality of running injuries is simple - it is a multi-billion dollar enterprise in the US alone. That is unacceptable given the current state of the sports sciences literature. With that said, are there a lot of clinicians making decisions based on monetary gain? Absolutely - and we both know it. I am sure we could both provide examples of countless "treatments" that have no scientific plausibility. How's that for "monetary gain"? You have injected a lot of superlative statements - "never indicated", "useless", "never requires surgical intervention". I don't know why, because that wasn't the point of the article. Of course, each patient has a context. I haven't suggested or even inferred to throw away that context. Clinician accountability is of issue here. I don't call that "taking a swipe at others integrity" - I call that "asking clinicians to be accountable to patients" - plain and simple. Patients need to be better consumers and more aware of the potential pitfalls of..." - Allan Besselink

"James - again, you have specifically misquoted me. You made mention that I had "plucked a figure of 99.9% of clinicians not using imaging for evaluating LLD". And again, the context of the statement is rather important. Most patients that are told that they have a LLD have not had imaging studies to confirm it. They are told they have a LLD based on unreliable palpation-based assessment performed by a clinician. When they come to see me and mention having been told they have a LLD, I always ask them if this was established via imaging studies. Over 25 years of clinical practice, and more than my share of orthopedic cases, I would be hard-pressed to think of one case in which the patient said that yes, it was confirmed via imaging. So with that said, I did not say that 99.9% of clinicians aren't doing it - I said that patients presenting with the "diagnosis" of LLD have not had imaging. There is a vast difference between your words and the original words and context. The issues related..." - Allan Besselink

"Although I am glad to hear that the issue of autonomy is being promoted in the educational programs, I have to wonder - how was it not being done so before? As you said, the military has been doing it for decades, as have many other countries. With regards to DA and the patient - I think that patients need to be given the truth. The harsh reality is that patients cannot access a physical therapist directly and in an unrestricted fashion in the majority of states. The data to support DA has existed for 20+ years, and there are plenty of global examples. Sadly, the data has been (and continues to be) ignored. When patients decide that they will no longer tolerate this, and they demand (from their legislators) to have the right to access a provider - any provider they choose, whenever they choose - then something will happen. But that will require a lot of truth-telling along the way." - Allan Besselink

"James - no, actually, I did not state that we "throw all therapeutic efforts out the window" nor did I infer that. I didn't say that specific exercise isn't important. I think that as clinicians, we need to NOT micromanage conditions, especially when the scientific literature doesn't support it. Relevance and context are critical - which, I would suggest, are integral to a good clinician's clinical reasoning. Unfortunately, the vast majority of patients continue to be told that their running problems are related to a number of issues that, frankly, have little to no relationship to the onset of their problem. Speaking of research - while you speak of my only mentioning the "70% related to training", you nonchalantly ignored the issue of assessment (reliability/validity). In your words, "A good clinician ... understands the strengths of different types of examinations". How about we look at the reliability and validity of the typical examination procedures? Perhaps you would like to..." - Allan Besselink

"James - thanks for your comments. Before I throw in a few thoughts, could you please clarify your last sentence re: research?" - Allan Besselink

"Jeffrey: Thanks for the feedback. I totally agree with you - and I think those fears are all warranted. No conspiracy theory there - especially if you look back and examine the transitions from Bachelors to Masters and then Masters to Doctorate. I think that our profession - including the APTA and the educators - need to make an effort to present the profession not as a "doctoring profession" but as a "movement expert profession". Then, let the market place take care of the rest - and we both know that quality, outcomes and cost (assuming patient access) will drive the market sufficiently in the long term, regardless of degree. That is why I proposed "Vision Now". We should put our efforts into developing true autonomy (which begins with professional self image), providing patients with better access to appropriate care, and promoting the value of PT in health care reform - as a unified group of PTs, not a diverse group of degrees. The Three Musketeers had it right :-)" - Allan Besselink

"Christie - very well stated! What I have always found intriguing is that a broad range of clinicians - PT, chiropractors, physicians, and others - continue to perpetuate the myths of asymmetry, malalignment, and the like in the face of good scientific evidence to the contrary. Worse yet, nobody seems to care or notice." - Allan Besselink

"Nick - you can treat an asymmetry forever ... no? As I always say, "follow the money trail" ..." - Allan Besselink

"LoMoPT - congratulations on starting your own clinic. Exciting times await! It is great to know that there are a growing number of clinicians that support the manifesto. A link on your site would be tremendous!" - Allan Besselink

"Thanks, Nick. Any time that you lose someone who has had an important role in your world, it always makes you reflect. This week has definitely been a week of reflection - and a reminder to be present, in the moment, to appreciate the beauty of those special people in our world." - Allan Besselink