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HR 101

“We must recognize that each one of our employees comes to us with a unique personality and a backlog of experiences that will influence the way they work.”

My experience at Sam’s Club plays a large role in my choices as a physical therapist. Sam Walton was still alive during my first years working for the company. There were some major rules that we had to follow as employees of Sam’s Club. The first rule is the 10 foot rule. This means that any time that I come within 10 feet of a Sam’s Club member I must make eye contact and acknowledge that person. It seems so simple to just give a hello, but we all know that customer service is lacking in many companies. Customer service is the reason we are doing what we are doing. Without the customer we have no income. In healthcare, we can substitute the word customer with the word patient. Without the patient I have no income. I need to ensure that that patient is well taken care of, and that starts just by acknowledging that the patient is a person. Other things that I learned from Sam’s Club is that hard work is rewarded. I was given many merit raises during my first three years at the store. In 2003 I was the best employee out of the 200 employees. This is not subjective on my part, but I was awarded with the employee of the year award. At that time I knew I had to quit. This is another thing that I learned about myself while working at Sam’s Club. I have a drive to improve and to consistently and constantly get better. Once I have reached the top of a certain position, then it is time for me to try new things and strive to be the best.

“… More than 30,000 physical therapy jobs that will go unfilled in 2016, it is difficult to understand why a practice owner wouldn’t make the effort to appropriately care for their therapist.”

It is easier to take care of the good people that you have working for you than to find a good person In the sea of applicants to a business.

“Daniel Pink, In his wonderful book, Drive: the surprising truth about what motivates us, point out that people want to believe they are contributing to something meaningful.”

When I worked for Sam’s Club, we had a core group of people that we would go to bat for. We worked hard in order to make up for any shortcomings of the people that were around us. When everybody is pulling in the same direction, great things can be done. I believe that. At the time I worked at Sam’s Club we were doing great things. I currently work with a group of people at small community-based hospital in which we all have our niches. We are all really good at our specific specialties and it is fun to be a part of this team. We don’t have the newest equipment, but we are all share a passion for patient care. It is demonstrated in both our outcomes and our patient satisfaction. We are playing our part in the changes that are occurring in healthcare, which emphasize patient outcomes and improving overall health status.

“Creating strong company values, and a clear mission statement, are necessary to motivate and engage staff. Period. More than 70% of all employees were disengaged at work. Disengaged employees tend to create drama… And subtly communicate their unhappiness to patients.”

This correlates with the old saying idle time will provide for the devils handiwork. If we have something to do and are passionate about doing that activity, we will provide customer service. We have to be engaged more with our patients than with our cell phones or Facebook.

” Pink suggest that most people are innately motivated by autonomy. Essentially his philosophy is that we should hire good people and let them do their job.”

I love this quote! The problem though is that not all companies hire good people. When you surround yourself with people who are going the extra mile, they push you to go the extra mile. I would much rather play on a team with scrappers, then play on a team with a bunch of superstars. My job is to make my teammate better and their job is to make me better, in the end the patients get better because of the team.

“Too often we repetitively train, and retrain, an employee who is falling short rather than letting them go in order to preserve the overall atmosphere within the clinic. As difficult as it is to terminate an employee, we must put the needs of the whole clinic above the negative behavior of one person.”

This couldn’t be said any more clearer. Politics unfortunately cloud judgment. Legalities cloud judgment. Dave Ramsey has said it many times over if I wouldn’t re-hire that person, then that person should no longer work here.
Excerpts from:

Stamp K. HR 101: The art of managing people. IMPACT. Aug 2016:29-30.

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HR 101

“We must recognize that each one of our employees comes to us with a unique personality and a backlog of experiences that will influence the way they work.”
My experience at Sam’s Club plays a large role in my choices as a physical therapist. Sam Walton was still alive during my first years working for the company. There were some major rules that we had to follow as employees of Sam’s Club. The first rule is the 10 foot rule. This means that any time that I come within 10 feet of a Sam’s Club member I must make eye contact an acknowledge that person. It seems so simple to just give a hello, but we all know that customer service is lacking in many companies. Customer service is the reason we are doing what we are doing. Without the customer we have no income. In healthcare, we can substitute the word customer with the word patient. Without the patient I have no income. I need to ensure that that patient is well taken care of, and that starts just by acknowledging that the patient is a person. Other things that I learned from Sam’s Club is that hard work is rewarded. I was given many merit raises during my first three years at the store. In 2003 I was the best employee out of the 200 employees. This is not subjective on my part, but I was awarded with the employee of the year award. At that time I knew I had to quit. This is another thing that I learned about myself while working at Sam’s Club. I have a drive to improve and to consistently and constantly get better. Once I have reached the top of a certain position, then it is time for me to try new things and strive to be the best. 
“… More than 30,000 physical therapy jobs that will go unfilled in 2016, it is difficult to understand why a practice owner wouldn’t make the effort to appropriately care for their therapist.”
It is easier to take care of the good people that you have working for you than to find a good person In the sea of applicants to a business.  
“Daniel Pink, In his wonderful book, Drive: the surprising truth about what motivates us, point out that people want to believe they are contributing to something meaningful.”
When I worked for Sam’s Club, we had a core group of people that we would go to bat for. We worked hard in order to make up for any shortcomings of the people that were around us. When everybody is pulling in the same direction, great things can be done. I believe that. At the time I worked at Sam’s Club we were doing great things. I currently work with a group of people at small community-based hospital in which we all have our niches. We are all really good at our specific specialties and it is fun to be a part of this team. We don’t have the newest equipment, but we are all share a passion for patient care. It is demonstrated in both our outcomes and our patient satisfaction. We are playing our part in the changes that are occurring in healthcare, which emphasize patient outcomes and improving overall health status.
“Creating strong company values, and a clear mission statement, are necessary to motivate and engage staff. Period. More than 70% of all employees were disengaged at work. Disengaged employees tend to create drama… And subtly communicate their unhappiness to patients.”
This correlates with the old saying idle time will provide for the devils handiwork. If we have something to do and are passionate about doing that activity, we will provide customer service. We have to be engaged more with our patients van with our cell phones or Facebook. 
” Pink suggest that most people are innately motivated by autonomy. Essentially his philosophy is that we should hire good people and let them do their job.”
I love this quote! The problem though is that not all companies hire good people. When you surround yourself with people who are going the extra mile, they push you to go the extra mile. I would much rather play on a team with scrappers, then play on a team with a bunch of superstars. My job is to make my teammate better in their job is to make me better, in the end the patients get better because of the team.
“Too often we repetitively train, and retrain, an employee who is falling short rather than letting them go in order to preserve the overall atmosphere within the clinic. As difficult as it is to terminate an employee, we must put the needs of the whole clinic above the negative behavior of one person.”
This couldn’t be said any more clearer. Politics unfortunately cloud judgment. Legalities cloud judgment. Dave Ramsey has said it many times over if I wouldn’t re-hire that person, then that person should no longer work here.
Excerpts from:

Stamp K. HR 101: The art of managing people. IMPACT. Aug 2016:29-30. 

Core stabilization compared to McKenzie method treatment

 

  1. “The condition has been identified as the leading contributor to ‘years of life lived with disability’ in the world including the United States.”

 

Big surprise, we are talking about back pain again. I see a majority of my schedule as back pain for the previous 8 years. There is no loss of people with back pain. This is an epidemic. The only reason it is not treated in such high regard has cancer, AIDS, Zika, and others is because it’s not deadly and does not cause major deformities. Because back pain is so common, it’s treated with little urgency such as the common cold.

  1. “In Australia, LBP is estimating to reduce gross domestic product by $3.2 billion annually and is the leading cause of early medical retirement for older working people.”

Think about that! You go to school and you load up on student loan debt. After school, you get a job paying much less than you think you’re worth. Then you get sidelined by low back pain and are forced to retire well before you’re ready. It doesn’t have to be this way! Not all low back pain is the same, and when you figure out what type of back pain you have it becomes a lot easier to prevent recurrent issues of back pain.

  1. “Directional preference classification is characterized by a reduction in distal pain and/or observation of the centralization phenomenon with the application of repeated or sustained end-range loading strategies to the spine that remain better after assessment. Centralization is defined as a progressive change in pain from a more distal location to a more proximal location that remains better after applying repeated or sustained end-range movement to the spine… hallmark characteristic of the McKenzie derangement classification.”

There is no doubt that a directional preference correlates with great outcomes. There is no doubt that centralization correlates with great outcomes. The thing that needs to happen is that therapists need to be trained to see these during the initial evaluation. A majority of patients demonstrate a classification utilizing the McKenzie method, based on the research of Stephen May. The derangement classification is the largest classification syndrome based off of Stephen May’s previous research, but there are other syndromes. Typically, it’s the derangement syndrome that the research attempts to study. I see very few articles on the other two syndromes in the mainstream research journals.

  1. “There is some evidence that improvement in size and recruitment of the muscles of the spine, including the transverse abdominis, is associated with improved function in the short-term when patients with low back pain receive motor control exercises compared to general exercise or spinal manipulation. However, increases in transvere abdominis and lumbar multifidus thickness using real time ultrasound have also been observed immediately and one week following spinal manipulation in people with low back pain, suggesting that increases in transverse abdominal recruitment may not be specific to motor control exercises.”

OK, a muscles ability to contract is not dependent on its size. A muscle’s ability to contract is based off of that muscle’s ability to receive the nervous system input from the central nervous system. Should there be something that allows for better neural activity, we expect to see an increase in muscle contraction and possibly an increase in muscle size. This is important because we may not have to train a muscle in the traditional sense in order to making muscle contract better.

  1. “The McKenzie method was prescribed according to the principles described by McKenzie and May… Delivered by two therapists who had obtained the level of credentialed therapist from the McKenzie Institute International… Mechanical therapy, including patient and therapist generated forces utilizing repeated or sustained and range loading strategies in loaded or unloaded postures, according to the patient’s directional preference..that guided by symptom response. The aim was to reduce, centralize, and abolish peripheral symptoms… Once symptoms centralize, any movement loss was then treated with repeated and range movements in the direction of movement loss… Received a copy of treat your own back to supplement treatment and self-management.”

The patients included in the study were all patients of the derangement syndrome. When assessing a patient utilizing the McKenzie method, we are attempting to classify the patient into one of three syndromes. This has a high reliability when performed by therapists that are highly trained. The hallmarks of the derangement syndrome is centralization, this occurs when symptoms move from a segment far away from the spine towards the spine. The symptoms in the furthest position from the spine have to decrease or abolish. This is accompanied by the directional preference. A directional preference is as stated, when we move you in a specific direction…your body prefers that. Your body tells us it prefers that direction by centralizing symptoms, improving range of motion, improve strength, or improving other neurological tests such as reflexes and dural tension testing. One can also have a directional preference in the absence of centralization, as extremities also demonstrate directional preferences.

  1. “Initially, promotion of independent contraction of the deep stabilizing muscles, such as the TrA and multifidus, was facilitated by pelvic floor contraction…Objectively, skill mastery of TrA recruitment was measured by palpation and visual assessment for a reduction of overactivity of the superficial trunk muscles…practice daily…attend the physical therapy clinic twice a week for the first 4 weeks and once per week for the remaining 4 weeks”

This is beat into students during PT school…understanding the impact of performing TrA contractions on low back pain. The problem with this theory is that the research is scant on cause and effect. We know that patients with low back pain have smaller multifidi and TrA muscles, but we can’t say “chicken or the egg” yet. We also can’t say if the back pain caused the smaller muscle or if the muscle was smaller and then it caused back pain. More research needs to take place. The topic of centralization and directional preference was briefly touched upon while I was in PT school and the topic of TrA was hammered into us. Now it appears that centralization and directional preference are being taught more in PT schools based on the students that I get as a clinical instructor.

  1. “Participants allocated to the McKenzie method group attended an average of 5.4 +- 2.5 treatment sessions over an average of 38.6+-18.8 treatment days, while participants in the motor control group attended an average of 6.5+-2.7 treatment sessions over 47.3+-22.7 treatment days”

This doesn’t look like a huge difference, but this indicates that those being treated by a MDT credentialed therapist, one less session was required. Think about this again. Each session is performed at a cost to insurance companies (read Medicare) of about $100. At this point, each patient would save $100 to insurance companies when seen by a credentialed MDT therapist. This, over the long term, has dramatic effects on the total cost of spending in the US.

  1. “…no statistically significant effect for treatment group for muscle thickness…at an 8-week follow-up in a population of people reporting chronic LBP classified with a directional preference. Global perceived improvement was the only secondary outcome that demonstrated a significant between-group difference, which favored the McKenzie method”

Let me say this slowly. Using a directional preference based exercise provides the same result as actually training a specific muscle in terms of muscle size! This is huge! We all are taught that to make a muscle bigger (hypertrophy) requires up to 6 weeks of performing an exercise in order to specifically improve a muscles size. This indicates that a muscle’s size can increase without any direct exercises to improve a muscle’s size.

The final piece of this is that those treated with MDT based principles actually felt better than those receiving motor control exercises (read this as core stabilization).

You walk into any clinic in America (aside from those that are doing MDT) and you will see bridges, bird-dogs, pull your belly into your spine exercises, and of course the traditional hot pack and e-stim. These types of treatments may not be the best. Ask your therapist how your back pain is classified. If they can’t give you a straight, honest, and well reasoned answer…FIND A NEW THERAPIST!

  1. I am bolding this, because it is important to read straight from the article. There will be no explanation needed.

Results from our study suggest that in patients with a directional preference, receiving exercises matched to their directional preference is likely to produce a greater sense of improvement than receiving motor control exercises.”

Excerpts taken from:

Halliday MH, Pappas E, Hancock MJ, et al. A Randomized Controlled Trial Comparing the McKenzie Method to Motor Control Exercises in People with Chronic Low Back Pain and a Directional Preference. J Orthop Sports Phys Ther.2016;46(7):514-522.

Evidence Based Medicine

“Evidence  based”  practice  or  medicine  appears  to  be  the  phrase  of  the   current  generation  of  health  care  professionals.    A  general  search  utilizing  Ovidsp   resulted  in  over  200  journal  articles  with  the  phrase  “evidence  base”  in  the  title.     Although  the  basis  of  evidence  based  medicine  was  first  established  in  the  1970’s,   the  evidence  has  grown  exponentially  in  the  previous  twenty  years1,2.    Evidence   based  medicine  is  the  “use  of  current  best  evidence  in  making  decisions  about  the   care  of  individual  patients3.”       As  professionals,  but  more  specifically  as  APTA  members,  we  can  agree  that   the  utilization  of  evidence  is  important  for  our  profession4.    There  are  a  plethora  of   articles  establishing  evidence  for  various  types  of  medicine,  but  it  is  important  to   understand  that  evidence  based  practice  also  presents  with  limitations.    For   example,  Jette  et  al4  reports  that  physical  therapists  have  a  positive  attitude  towards   evidence  based  practice.    A  limitation  of  this  study  is  that  the  survey  was  issued  only   to  APTA  members.    It  may  be  argued  that  those  that  have  joined  their  respective   professional  organization  are  more  proactive  than  those  that  have  not  joined.    This   study  surveyed  motivated  therapists,  which  may  have  led  to  the  positive  attitude   regarding  evidence.    Another  limitation  related  to  positive  results  is  “publication   bias”,  which  indicates  that  research  with  negative  results  is  less  likely  to  be   published1.    Because  not  all  research  is  published,  specifically  negative  research,  the   audience  (physical  therapists)  is  inundated  with  positive  outcomes,  which  may  bias   the  reader  that  the  intervention  is  statistically  effective  in  treating  patients.       It  has  been  established  that  randomized  controlled  trials  (RCT)  are  the  gold   standard  for  providing  the  best  evidence  for  interventions5.    It  is  the  physical   therapist  responsibility  to  thoroughly  assess  the  RCT  in  order  to  determine  if  it  is   applicable  to  the  population  treated  clinically2.    Maher  et  al1  concluded  that   individual’s  ability  to  critically  assess  an  article  is  a  limitation,  as  not  all  therapists   critique  an  article’s  validity  to  the  population  treated.    Another  limitation  to   evidence  based  practice  noted  by  Maher  et  al1  is  FUTON  bias  (full  text  on  the  net),   which  means  that  therapists  are  more  likely  to  quote  and  utilize  only  the  articles   which  are  available  in  full  text.    I  am  guilty  of  this  bias,  as  I  do  not  find  that  utilizing   an  abstract  is  valid  for  patient  care  if  I  cannot  assess  the  methodology  of  the  study.       Additionally,  conflicts  of  interest  serve  as  a  limitation  to  evidence  based   practice6.  Croft  et  al6  states  that  professional  groups  that  have  an  interest  may   promote  a  specific  intervention.    Because  of  this  financial  conflict  of  interest  the  use   of  evidence-­‐based  practice  may  be  used  as  a  marketing  tool  for  individual   professions.       To  answer  the  question:  Do  I  think  that  evidence-­‐based  practice  will  require   a  change  in  the  profession?  Based  on  Jette  et  al4,  I  do  not  believe  a  change  is   required.    Time  will  eventually  dispense  of  the  therapists  that  are  uncomfortable   with  research,  lack  the  database  knowledge,  or  are  unable  to  critically  appraise   research.    According  to  the  article,  younger  therapists  are  more  inclined  to  be   researched  based  practitioners,  as  they  are  more  confident  and  able  to  critically   appraise  the  research  out  of  school.    Based  on  Vision  2020,  it  is  hard  to  believe  that  a   change  needs  to  take  place  in  order  for  our  profession  to  become  more  research   based.

 

References:

1. Maher  CG,  Sherrington  C,  Elkins  M,  et  al.  Challenges  for  Evidence-­‐Based   Physical  Therapy:  Accessing  and  Interpreting  High-­‐Quality  Evidence  on   Therapy.  Phys  Ther.  2004;84(7):644-­‐654.

2. Vaccaro  AR,  Fisher  CG.  Evidence  and  Impact:  Should  these  articles  Change   the  Practice  of  Spine  Care?  An  Evidence  Based  Medicine  Process  [Published   Ahead  of  Print].  DOI:  10.1097/BRS.0b013e3181d4ea37.  Accessed  on  January   25,  2012.

3. Sackett  DL,  Rosenberg  WMC,  Muir  Gray  JA,  et  al.  Evidence-­‐based  medicine:   what  it  is  and  what  it  isn’t.  MBJ.  1996;312:71-­‐72.

4. Jette  DU,  Bacon  K,  Batty  C,  et  al.  Evidence-­‐Based  Practice:  Beliefs,  Attitudes,   Knowledge,  Behaviors  of  Physical  Therapists.    Phys  Ther.  2003;83(9):786-­‐ 805.

5. National  Health  and  Medical  Research  Council.  How  to  Use  the  Evidence:   Assessment  and  Application  of  Scientific  Evidence.  Canberra,  Australia  Capital   Territory,  Australia:  Biotext;2000.

6. Croft  P,  Malmivaara  A,  Van  Tulder  M.  The  Pros  and  Cons  of  Evidence-­‐Based   Medicine.  Spine.  2011;36(17);1121-­‐1125.

Mission Statement

My personal mission statement is as follows: As a professional, I will provide a thorough assessment of your clinical presentation and symptoms in order to determine both the provocative and relieving positions and movements. The assessment process and ensuing treatment will be based on current and relevant evidence. Furthermore, I will educate the patients regarding their symptoms and their likelihood of improving with either skilled therapy, an independent exercise program, spontaneous recovery or if the patient should be referred to a separate specialist to possibly provide a more rapid resolution of symptoms. Respecting the patient’s limited resources is important and I will provide an accurate overview of the prognosis within 7 visits, again based on current research. My goal is to empower the patient in order to take charge of both the symptomatic resolution and return to full function with as little dependence on the therapist as possible. Personally, I strive to be an example for family and friends. My goal is to demonstrate that success is not a byproduct of situations, but a series of choices and actions. I will mentor those, in any way possible, that are having difficulty with the choices and actions for success. I will continue to honor my family’s “blue-collar” roots by working to excel at my chosen career and life situations.   I choose to be a leader of example, and not words, all the while reducing negativity in my life.

I began working towards the professional aspect of the mission statement while still in physical therapy school. By choosing an internship that emphasized patient care and empowering the patient, instead of the internship that was either closest to home or where I knew that I would have the easiest road to graduation, I took the first step towards learning how to utilize the evidence to teach patients how to reduce their symptoms. I continued this process by completing Mechanical Diagnosis and Therapy courses A-D and passing the credentialing exam. I will continue to pursue my clinical education through CEU’s on MDT and my goal is to obtain the status of Diplomat of MDT. Returning back to school for the t-DPT was a major decision for me, as resources (i.e. time and money) are limited. My choice was between saving money for the Dip MDT course (about 15,000 dollars) and continuing on with the Fellowship of American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) (about 5,000 dollars), as these courses are paired through the MDT curriculum or returning to school to work towards a Doctorate of Physical Therapy degree. I initially planned on saving for the Dip MDT and FAAOMPT, but life changes forced me to re-evaluate my situation. The decision then changed to return for the tDPT, as my employer paid for a portion of the DPT program. My goal for applying to and finishing the Dip MDT and FAAOMPT is 10 years. This is how long I anticipate that it will take to finish paying student loans and save for both programs, based on the current rate of payment.

I don’t know if I will ever accomplish what I set forth in the mission statement, but I do know that it will be a forever struggle to maintain this standard that I set for myself.

 

 

centralization and the correlation to discogenic pain

Critical Appraisal for a Reference-Standard Validity Study

 

P: For patients with chronic low back pain, with varying levels of distress,

I: can the centralization phenomenon

C: as compared to discography results

O: provide diagnostic power for discogenic pain

 

Reviewer:

Vincent Gutierrez, PT, MPT, cert. MDT

 

Search:

Ovidsp with keyword terms “low back pain and centralization and specificity and sensitivity”.   44 citations were found between the years 2004 and 2014.

 

Date of Search: January 21,2014

Re-evaluation date: January 25, 2014

 

Citation:

Laslett M, Oberg B, Aprill C, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine Journal 2005;5:370-380.

 

Summary:

This validation study has two purposes. The first is to investigate the predictive value of the centralization phenomenon (CP) in relation to provocation discography, which is the only reference standard available for discogenic pain. The second is to investigate the role of distress and disability with regards to the predictive value of the centralization phenomenon in relation to provocation discography.

 

The inclusion criteria were patients with persistent low back pain (LBP), with or without lower extremity (LE) symptoms, whom were referred to a private radiology practice. Patients were excluded for the following reasons: a normal magnetic resonance imaging (MRI) assessment, severe degeneration associated with spondylolisthesis, and if the discography was contraindicated or a referral ruled out discography. The patients that were included were assessed consecutively.

 

Prior to the evaluation by a physical therapist, the patient completed a visual analog scale (VAS) for pain and the Roland-Morris Disability Questionnaire (RMDQ). The Zung Depression Index (ZDI), Modified Somatic Perception Questionnaire (MSPQ) and the Distress Risk Assessment Method (DRAM) were also completed prior to the physical therapy (PT) evaluation. The evaluation was performed prior to the discography and the physician performing the discography was blinded to the therapist’s results. The therapist was blinded to the results of the subjective outcome measures.

 

The physical evaluation consisted of a McKenzie evaluation. The exam required 30-60 minutes and also included sacro-iliac joint (SIJ) provocation tests. Centralization or peripheralization was noted and at this point the examination was terminated.

 

Discography was performed using standard technique and the patient was required to report pain in at least one disc, without pain at an adjacent disc in order to receive a positive test result.

 

One hundred eighteen patients participated in the PT evaluation and discography. One hundred seven patients were included in the initial analysis. Of the 107 patients, 69 received a full PT evaluation, 21 received a partial evaluation and 17 did not receive an evaluation. Of the above, the physical therapist offered an opinion regarding CP for 83 patients.

 

Appraisal:

The authors utilized the only reference standard studied, provocation discography, in order to determine if CP is predictive of discogenic pain. The physician was blinded to the physical therapists’ evaluation and the physical therapist was blinded to the patients subjective outcome measures. Not all patients received both the PT evaluation and discography.

 

The confidence interval was 95%. For non-distressed patients, the following statistical measures were calculated: sensitivity of 37%, specificity of 100%, positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were incalculable due to a specificity of 100%. For distressed patients, the following statistical measures were calculated: sensitivity of 45%, specificity of 89%, LR+ of 4.1, and LR- of 0.61. For not severely disabled patients, the following statistical measures were calculated: sensitivity of 35%, specificity of 100%, LR+ and LR- are incalculable due to 100% specificity. For severely disabled persons, the following statistical measures were calculated: sensitivity of 46%, specificity of 80%, LR+ of 3.2 and LR- of 0.63

 

Conclusion:

Performing a McKenzie evaluation in order to determine the presence of CP is a good test for determining a positive discography, especially in patients without severe disability or distress. The presence of CP improves the pre-test probability to post-test probability of positive discography from 39% to greater than 75% in patients with severe disability or distress. CP is a strong predictor of positive discography in patients without severe distress or disability.

Why be a mentor?

I have some passions in the profession of physical therapy and the first is to provide the best care to my patients.  The second is to create therapists that will provide the best care to patients, as they indirectly represent me.  I do my best to ensure that PT students that go through me develop the reasoning ability to understand ethical and unethical environments that will challenge their ability to provide that best care to patients.  This profession is very much driven by the almighty dollar and I understand why some students make specific decisions as to which job to take, but as long as that student has weighted the “pro’s” and “cons” of taking a job, I know that I did what was right in teaching my students.  Some students unfortunately never develop that ability to reason past the $$$.  

 

The Oxford dictionary defines mentor as “an experienced and trusted advisor” and “an experienced person in a company, college, or school who trains and counsels new employees or students.” 1 There are published studies that oppose this definition, which will be discussed in detail further in the paper. Other professionals have specific definitions of mentor as follows: “ Mentor is an individual with noted experience and position within the Military Nurse Corps who possesses a genuine interest in guiding the professional and personal development of a less experienced Nurse Corps officer.”2 As a physical therapist, mentoring is a topic of importance for the author.   I started my career as a teacher of biology, secondary education, with the intent to mold current students into future leaders. Because of circumstances, that dream was never to become a reality and I chose a different career path. My first year of clinical practice, I was asked by GSU to be a clinical instructor because of personal characteristics. Holmes3 states that novice clinicians placed in a mentoring role may have difficulty with individual personal development. My boss/mentor at the time believed that I possessed the qualities to overcome this added adversity and after serving as a clinical instructor for the first student, I found that my initial dream could become a reality in this new field. The stresses of mentoring during the initial years

Christiansen et al5 notes that there are two processes for mentor selection: assignment by an institution or selection by the protégé. Others disagree with this statement, in that preceptors are assigned, but mentors are chosen8. It is advised to choose a team of mentors in order to advise on multiple issues, with each mentor having a specialty6. In the end, one should choose a mentor “who exemplifies traits and skills that you want to adopt”6.

As a mentor, it is rewarding to observe students and clinicians that choose me as a mentor when these individuals apply the information garnered from the relationship in order to treat a patient whom previously the clinician would not have the knowledge or experience to treat. This is consistent with Wainwright et al4, in which the following is stated: 1. clinical decision-making is advanced through clinical education, 2. positive mentoring enhances clinical practice skills, 3. Experienced clinicians inevitably become mentors to novice clinicians. Christiansen et al5 and Holmes et al3 also relate mentoring to the advancement of clinical skills.

Attributes and roles of a mentor are widely published in the research as demonstrated in the following table:

Characteristics Roles
Experienced4,8 Coach6,10
Content knowledge5,6 Advisor1,6,9
Communication skills5,8,9 Counselor1,6,10
Personal integrity5,6 Confidant6
Self-reflection5
Systems-based learning5
Willingness to teach5
Intellectual humility5
Internal locus of control5
Empathy8
Caring8
Unbiased6,9
Committed6
Maintains confidentiality6
Patience6

 

As stated previously, a mentor is an advisor…who counsels new employees or students1. Christiansen et al5 states, “Mentoring is not supervising, advising, career counseling, shadowing or coaching. Mentoring is workplace learning and must occur within that environment.” Although the previous statement relays that a mentor must work in the same environment as the mentee, Liu and Ansbacher6 state that long-distance mentoring can be successful through e-mail, phone conferencing or meeting at annual conferences. Based on the aforementioned articles, the act of mentoring appears subjective in nature, as varying authors have different opinions on both the definition and act of mentoring.

Mentoring requires dedication to the process, which includes substantial investments of time, energy, and resources-physical, emotional and intellectual.”3

As a clinical instructor and mentor to other Mechanical Diagnosis and Therapy (MDT) trained therapists, this statement is accurate. When I was a new professional (< 5 years of experience), I was consistently studying the concepts of MDT, hierarchy of knowledge principles and coursework for clinical instructors. This studying was not without cost. I sacrificed time from family, friends and life experiences in order to work towards that initial dream. Being a mentor also poses a challenge of finding a mentor4. The mentors that I chose are from around the country, and I am only able to meet with them at large spine conferences. As a clinical instructor, I am aware of the bias that is inherent when a relationship is created and established with a mentee and try not to provide preferential treatment for my students7.

The American Physical Therapy Association (APTA) does not define a mentor, but establishes the roles for the mentor and protégé as follows11:

MENTOR

  1. Acclimate the early-career protégé into the culture and the value of PT12
  2. Help the ECP understand the core values of PT and the role of each PT and PTA to support the practice mission of PT
  3. Be open to working as a mentor
  4. Create a collegial atmosphere that provides responsiveness and respect for the ECP
  5. Seek training and education to further skills in mentoring

PROTÉGÉ

  1. Identify knowledge and skill gaps
  2. Establish career goals for life-long learning, both short and long term.
  3. Identify specific experiential opportunities
  4. Identify potential mentors, both junior and senior, who have compatible interests.

During the literature review for this paper, there was only one article that formalized a mentor program. Burritt et al13 studied the outcomes of removing experienced nurses from clinical practice in order to work as a mentor for novice nurses. “The prevalence of stage 2 or greater nosocomial pressure ulcers improved by 38%, which was significantly lower in the post implementation phase. A 47% reduction in the number of adverse events that comprise the composite measure of failure to rescue was also noted to be significant.” Tactics such as this may also influence retention rates of nurses8.

CONCLUSION

To conclude, Holmes et al3 sums it up in a concise statement, “Rejoice in the successes of your mentee, these triumphs can only enhance your own standing.” The author personally chooses to be a mentor for those with less experience, in order to assist those with the characteristics needed to become a successful mentor. My dream of creating future leaders is now reality as my protégés are now becoming mentors.

Bibliography

  1. Mentor. In Oxford dictionary online. Retrieved from http://www.oxforddictionaries.com/us/definition/american_english/mentor.
  2. Blankenbaker SE. Mentor Training in a Military Nurse Corps. Journal for Nurses in Staff Development. 2005;21(3):120-125.
  3. Holmes DR, Hodgson PK, Simari RD, Nishimura RA. Mentoring: Making the Transition from Mentee to Mentor. Circulation. 2010;121:336-34.
  4. Wainwright SF, Shehpard F, Harman LB, Stephens J. Factors That Influence the Clinical Decidion Making of Novice and Experienced Physical Therapists. PTJ. 2011;91:87-101.
  5. Christensen N, Gerber P, Jensen G, et al. (2014). American Board of Physical Therapy Residency and Fellowship Education: Mentoring Resource Manual. Accessed from: www.abptrfe.org
  6. Liu JR, Ansbacher R. Assembling the Optimal Mentor Team. Obstetrical and Gynecological Survey. 2008;63(4)

7.Coulson CC, Kunselman AR, Cain J, Legro RS. Graduate Education: The Mentor Effect in Student Evaluation. Obstet Gynecol. 2000;95:619-622.

  1. Martin CA. Across the Generations: It takes a village to raise a nurse. Nursing Critical Care. 2007;2(3):45-49.
  2. Ansbacher R. A Guest Editorial: The Mentor-Mentee Relationship. Obstetrical and Gynecological Survey. 2003;58(8):505-506.
  3. Hurst SM, Kplin-Baucum S. Innovative Solution Mentor Program: Evaluation, Change and Challenges. Dimens Crit Care Nurs. 2005;24(6):273-274.
  4. American Physical Therapy Association. (2012). Best Practice for Mentoring Early-Career Proteges: HOD P06-12-16-05. Retrieved from: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Professional_Development/BestPracticesMentoringEarlyCareerProteges.pdf.
  5. Gardner EA, Schmidt CK. Implementing a Leadership Course and Mentor Model for Students in the National Student Nurses’ Association. Nurse Educator. 2007;32(4):178-182.
  6. Burritt J, Wallace P, Steckel C, Hunter A. Achieving Quality and Fiscal Outcomes in Patient Care: The Clinical Mentor Care Delivery Model. JONA. 207;37(12):558-563.

Not all back pain has a definitive cause

“Findings such as disk height loss and disc bulges are coming in individuals without low back pain.”

Disc bulges, degenerative joint disease, spinal stenosis, do you all a result of living in this world. We have gravity acting a force on us almost 16 hours a day. Anytime that there is a problem, we want to blame something or somebody. Low back pain is an enigma at times. we can draw correlations, we can come up with risk factors, we can even tell you how to treat it sometimes, but what we can’t do is tell you exactly what causes your back pain.

“Surprisingly, disc protrusions were associated with a lower risk of subsequent back pain. Nerve root contact and central stenosis had the largest hazard ratios on baseline imaging findings, and they were associated with incident back pain in the expected direction but not statistically significant. Self identified Depression was the strongest predictor of subsequent back pain, with a greeter hazard ratio than any imaging findings.”

What should be taken from the above statistics is that mental health plays a role in pain. There are a lot of new studies that are associating catastrophizing and external locus of control with increased pain levels. Work by Nadine Foster demonstrates screen for patients who will have a difficult time improving with therapy alone. New were books, such as the one by Annie O’Connor and Melissa Kolski (two people with whom I’ve studied at our RIC), goes into great detail regarding pain science. Big picture, we can not neglect the patient’s emotional well-being when attempting to treat the patients physical complaints.

“Our results indicate that depression is a strong predictor of who will subsequently reports low back pain then baseline imaging findings.Subjects with self reported depression at baseline were 2.3 times is likely to have back pain compared with those who do not report depression.”

There is obviously a psycho social component to low back pain. The question is… Chicken or the egg. Is a person more likely to be depressed because they have back pain that is not improving? Or is that person more likely to have back pain because they are depressed? I don’t think that there are cause and affect articles in the literature at this point, but there is definitely a high correlation between patients who are depressed and patient who continue to report low back pain.

“In our analysis of baseline data, we concluded that central stenosis, nerve root contact, and disc extrusion were the most important imaging findings related to prior low back pain. Our current analysis indicates that central stenosis, disc extrusion, and route contact may also be risk factors for future low back pain.”

In other words, if you have a major deformity you will probably have pain. This doesn’t mean that you will definitely have pain, it just increases your risk of experiencing symptoms.

The moral of the story is that we cannot deny the brain. The brain has the ability to see pain, and some patients are more susceptible to seeing this pain. Don’t get me wrong, a thorough mechanical evaluation should be performed when a patient has pain, but when this patient is not inclined to respond to mechanical therapy, the patient should be referred to someone that can better handle this patient’s pain.Sometimes, that person will be a behavioral therapist, a psychotherapist, or a clinical psychologist. Physical therapists are not always the go to in order to treat a patient’s pain.
Excerpts from:

Jarvik JG, Haegerty PJ, Boyko EJ. Three-Year Incidence of Low Back Pain in an Initially Asymptomatic Cohort. Spine. 2005;30(13):1541-1548.

Our we worth it?

“First, we must actually prove the value of our services, ourselves, and our profession. And we must do so objectively – with outcomes data. ”
I agree to a certain extent, that we need to prove our value with outcome data. Patients, so need to be educated on what this data actually means. We are slowly transitioning to a point in which patients are paying for a majority of their healthcare when compared to insurance companies. Co-pays are rising. Outcome data needs to be measured, but explained to patients in a way in which it makes sense. We do need to prove our value, but proving our value to patients will be completely different than proving our value to insurance companies.
“That that that tracking patient outcomes… The demand for this type of data collection has amplified in the last few months…”
The demand for this type of data is increasing from insurance companies. Do you think insurance companies are demanding this data in order to increase our pay? I highly doubt it. They’re demanding the data to determine whether or not therapy in actually valuable. I, as the therapist, sometimes question the value of physical therapy. Not all therapists practice alike, so is there one best practice? As a profession, we have clinical practice guidelines. Not all therapists are utilizing clinical practice guidelines. Can we weed out those therapists that are not using the guidelines, or can we coach up these therapist to ensure that they are practicing in a way that is supported by the evidence.
“… The federal government is not wasting any time and it’s quest to reduce healthcare spending that ”
We all know that our country is broke! if we ran our household in the same manner that our government runs the country, we would all be filing for bankruptcy. The government is trying to find ways to reduce costs. Healthcare appears to be one way in which to reduce costs. I am not saying I totally disagree, because as a country we spend a great deal of money on healthcare, but do not get the results commensurate with the spending. We have to find a way in which to incentivize good care to ensure that patients are no longer getting sick at the same rate they’re getting sick currently.
“So, in all likelihood, most – if not all – payments will be linked to value within the next few years quote
This same line has been stated year-to-year for at least the last six years. At some point I am waiting for the boy to stop crying wolf. I welcome the day when pay-for-performance actually takes place. Therapy consists more than simply ultrasound,hot pack, electrical stimulation, and massage. The best evidence we have is regarding exercise. It’s sad because not all therapist coming out of schools are proficient at analyzing, providing, and creating exercises in order to address the limitations seen during the initial valuation. I spend a great deal of time with the students that I have teaching them how to create and how to analyze movement patterns. They do not learn this very well in school.
“… There is a big difference between merely recording numbers and generating meaningful, actionable insights, because when you do the latter, you can achieve three really important things: ”
As a profession, we need to start by “merely recording numbers”. I started as a therapist in 2007, and during those first few years recording numbers was not happening. We have come a long way in utilizing functional outcome measures, but this is because insurance companies have forced our hand in order for us to receive payment. I do not believe that our profession would have policed itself into using outcome measures.
Excerpts from:
Jannenga H. IS PT VALUABLE? ONLY OUTCOMES DATA WILL TELL. IMPACT. June 2016: 46-51

Brother my Brother

Today’s blog is very different from any of those written before. This is an insight into my life, into my thought process, into my experiences, into those things that made me who I am. I started this blog to teach people about healthcare, but there is so many more things that people can learn from my experiences. I dictate today’s blog on my way to the cemetery. It’s a little bit more emotional than anything that I would typically write.
Life is precious. My brother is a fucking idiot, in 2008 he overdosed. He never really saw anything outside of Joliet Illinois. I want to live until I die. There is too much to see and too much to live for in this life. After eight years, I still think of everything that he missed out on. He missed out on having a family. My family is the greatest thing that ever happened to me. I would be my fathers son, I would be content to stay at home and work hard and live my life in that fashion. My wife loves to travel and loves try new things. If it wasn’t for her I would’ve never traveled to Europe, I may have never made to Alaska. If it wasn’t for my daughter, I wouldn’t slow down and slide down the big slide. I probably wouldn’t go to another waterpark, I probably wouldn’t climb in the tunnels at Odyssey fun world. My brother missed out on a lot, when I go visit cemetery it just my heart.. Life is precious. For those going through difficult times, Know that life is precious. There are people that love you and people that will miss you if you’re gone. I miss my brother frequently. Life goes on, and life will go on without you. I hate to say that because it sounds harsh but it will. I am happy, and unfortunately he’s not here to see that.

At what age does dreams die? I don’t know that answer. At what age do we throw in the towel? At what age do we give up? I don’t know what was going through my brothers head those last days And it kills me eight years later.
In memory of Michael Anderson. I miss you brother