“Chess is one of the few arts where composition takes place simultaneously with performance.” - Garry Kasparov
There has been a resurgence in interest in Chess of late, specifically because of the highly acclaimed Netflix miniseries The Queen’s Gambit. This has led me to thinking about chess, physical therapy and advancing excellence in the clinic during the current healthcare environment.
A gambit, in chess, is sacrificing a lower-level piece (a pawn) for a greater advantage later in the game. It is risky, calculated and can only be done with planning, insight, and experience. Novice chess players routinely lose their queen by mistakes made in the opening or mid-game of chess, making the endgame a foregone conclusion.
There are many similarities between achieving excellence in chess and physical therapy. There are three aspects of interaction — the opening (initial evaluation), middle (subsequent visits) and end game (discharge), all of which must be executed with forethought and can only develop as a result of how the person you are engaging with responds, “composition takes place simultaneously with performance.”
Chess has many styles of play, just like PT has multiple ways to render treatment. Standard play with 40 moves in 2 hours (45 min to an hour patient visit model), rapid chess which has a 15 minute clock time per player (30 minutes per patient model) and blitz chess in which each player has 3 minutes (I would equate this 15 minute per patient visit model). In listening to Malcolm Gladwell’s Revisionist History Podcast I learned about Hikaru Nakamura and his ability to play rapid and blitz chess, and Magnus Carlsen who currently is the highest ranked Bullet, Blitz and Rapid player in the world. These achievements do not come overnight, but through practice, skill building and reasoning to recognize patterns so that you don’t make midgame mistakes that lead to an inevitable loss. Also, some players excel with a rapid and blitz style while others thrive in the standard chess style.
Currently PT appears to be playing a Rapid and Blitz version of rehabilitation. We are experiencing increased pressures to see more patients in a shorter period of time. What are the PT gambits? How do we as a profession accommodate to the shifting sands of healthcare? What are we sacrificing with a rapid or blitz version of PT? How are we ensuring we are connecting with our patients, recognizing patterns and planning for the endgame?
Sheila Nicholson mentions in her book, The Physical Therapist’s Business Practice and Legal Guide, a case (Wyckoff vs Jujamcyn Theaters, Inc) where a patient with an undiagnosed cervical fracture was rendered a plan of care and treated by a physical therapist for one week. Was this a case of Blitz PT or the fact that the therapist was ignorant of the Canadian Cervical Spine Rule? There isn’t an indication that the PT was sued in the case, but nonetheless this direct access practitioner missed the same diagnosis as the physician.
Pattern recognition, heuristics and a high level of skill (doing the little things well) are all components of best clinical practice and adapting to a faster movement of healthcare delivery. This takes work, dedication and a passion for elevating the profession. NAIOMT over the past 30 years has blended the science and art of physical therapy where we are “simultaneously composing” and collaborating with our patients. The satisfaction comes in the PT Endgame, the elevation of our patient’s quality of movement and helping them live their highest potential.
Stress tests of the cervical spine are essential for the safe rendering of manual therapy, and clustering the tests ensures greater reliability. In the rush of day-to-day practice, these tests are sometimes not performed or if they are they are not clustered. The video below shows an example of a compromised alar ligament stress test. A recent article in JMMT reports that "when using the three clinical tests (for the alar ligament) as a cluster with a threshold of more than two positive test results, the sensitivity and specificity amounted to 85.7% and 100%, respectively" 1.
1. Diagnostic accuracy and validity of three manual examination tests to identify alar ligament lesions: results of a blinded case-control study
JOURNAL OF MANUAL & MANIPULATIVE THERAPY
2019, VOL. 27, NO. 2, 83–91