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Community

Some of us really want to do good things for our community.

What is better than spreading joy?

The first time Inout on the nose I had thoughts of Patch Adams. It brought a smile immediately.

Why not spread that feeling?

The best part was that the proceeds went to help childhood poverty.

#rednoseday

Thanks to Rosattis , First Presbyterian Church of Joliet, Joliet Area Historical Museum, Spanish Community Center, Alzadas for taking the time for a photo.

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Ways to mitigate burnout

“Burnout…is a syndrome of depersonalization, emotional exhaustion, and a sense of low personal accomplishment leading to decreased effectiveness at work…primarily affected those in ‘helping’ professions”

Hey!…  Hey!…  You!… PT’s!…Are you listening?!….

Does this sound like someone you know?

“The high prevalence of burnout among physicians results in lowss of engagement and commitment…5 out of every 10 physicians affected by burnout”

Loss of engagement and commitment with patients.  Hmmm? How many therapists do you know that are “punching the clock”?

I have a problem with a lack of engagement.  It just isn’t something that I tend to do often and I have a short attention span.  Maybe not as short as the new average of 9 seconds, but pretty darn short.  I just shift the engagement to something different.

A therapist that isn’t engaged with the patient is problematic.  Patients are coming to us for our professional opinion and placing trust in us to help them along their journey of pain or functional restoration.  To have loss of engagement places that trust at risk.

Not only is trust lost between the patient and the physical therapist, but also between the patient and the profession of physical therapy.

Remember young Jedi, YOU REPRESENT THE FORCE (by force I mean the PT workforce).  Your burnout makes me look bad.  Not that it’s all about me, but really…it’s all about me.

50% of physicians are affected by burnout?!

I haven’t seen any studies on prevalence in our profession, but I hope it’s not that high.

“Many factors contribute to burnout, including high workloads; an inefficient environment; problems with work-life integration; lack of flexibility, autonomy, and control; and loss of meaning in work.”

I’ve seen research showing that treating 20 patients per day may lead to burnout.  I don’t know if it’s the 20 patients or the notes that come along with the 20 patients, but….20 patients!!! REALLY?

At my busiest time, I was only seeing about 15 per day.  This may be why I have yet to experience burnout from treating patients.

An inefficient environment.  I have experienced this multiple times.  Sometimes people and companies are just set in their ways and don’t see a good enough reason to change.

Problems with work-life integration: this is what I am struggling with right now.  Is the juice worth the squeeze?  This is a phrase that I am thinking of more and more currently.  When I think of how many hours that I am away from my kids and wife, I have to think (or my wife makes me think) about where do I want to be in life 5 years from now.  Managing a clinic takes a ton of time.  If you have never tried to build a “brand”, it takes a lot of time and work in order to get a personal brand out to the community.

Autonomy and control: I haven’t personally experienced a loss of control in the clinic,  but I hear from PT’s all over the country that their boos/manager/director almost dictates the care in order to create a “comprehensive care plan”. Now this sounds all good and nice and all, but in the end the question has to be asked…Why? Why does the boss want a comprehensive plan?

The reason is no different than any other business and it has to do with money.  Clinics make more money by doing multiple different treatments than providing one treatment that may have the best outcomes.  It’s sad…but I hear it frequently.

“Physicians who suffer from burnout are impaired and they and their organizations are at risk of having higher rates of medical errors, less professionalism, lower patient satisfaction, and lower productivity, as well as more turnover and suicidal ideation”

Does burnout sound good?

Not like the burnout that I would do on my BMX bike as a kid or in my F-150 as a teenager.

Burnout leads to major issues at a personal and corporate level.  I wonder though if the companies care about burnout.  Turnover happens in physical therapy.  Although it costs money to train a new therapist, it may not matter since many companies see a PT as a widget instead of as an autonomous practitioner.  If one therapist can easily be swapped out for another, is burnout an issue at the corporate level?

Rhetorical questions of course.

“Organizations that make investments in leadership development experience substantially higher returns than those that do not.”

This is a great quote. Invest in your people, more so than seeing your people as an investment.

For instance, when you put money into an IRA, it sits there and you hope it grows (at least matches the 10% historical APR). You are passive in this role. Hopefully money makes money. This is what typically happens in a company. The employee is expected to go out and grow individually, which benefits the company, although the company may not take part in that individual investment.

I would like to see it more as owning a home. This is an investment also. It averages about a 2% gain per year, but the individual living in the home has to actively care for the investment in order for it to keep growing. I would love for more businesses to see employees as an investment for which they should foster care. High tides raise all ships. When the employee is successful both on an individual and business sense, everyone wins.

“Clinician engagement is empirically linked to more effective organizations, with outcomes including lower turnover rates, superior clinical outcomes, better patient experience, and superior financial performance”

Does this sound like a positive experience for clinicians and patients alike?

If the clinician is engaged in not only treating patients but also regarding the health of the business everyone wins.

Some therapists don’t see themselves as business people, which is a shame because if we don’t get the patient in the door, then we can’t help that person. We have to feel confident in attracting our customer (someone with functional complaints that may or may not relate to pain), educating our customer, selling to our customer and then accepting their money. Sales doesn’t have to be a bad thing. I have been reading Rabbi Daniel Lapin and have learned that money is just as much a show of appreciation and gratitude as it is a financial transaction.

“Physicians experience highest levels of engagement when they have a degree of control over their work environment. Engage Physicians tend to receive higher patient satisfaction ratings.”

This is an indication of autonomous practice. When a clinician gets to dictate care, instead of having care dictated to the clinician, then everyone wins again.

“Combating physician burnout is a twofold process that involves 1. mitigating the structural and functional drivers of burnout and 2. bolstering individual resiliency.”

This is the Mayo Model to try to reduce burnout in physicians. This appears useful for many other health professionals also.

Quick Link to the article here

Prone lying

I hear it frequently…this is an exercise?!

Sure, if it fulfills the purpose of making one more mobile, more resilient and more awesome!

This position is called prone lying and just means that you are lying face down.

For people with back pain, this has been referred to as the rescue position.

This position can be highly effective in reducing back or leg pain in 49-64% of people with symptoms.

Is it for everyone?

No..of course not. There is not a single exercise that is beneficial for 100% of the population that has pain, but there are patterns.

If your pain worsens with sitting, bending or twisting then this may be beneficial.

If your symptoms worsen withstanding or walking, this position may not work well for your symptoms.

Some things to note:

1. If you get into this position and your symptoms move further away from your spine…no good and you should stop and seek a full evaluation

2. If your symptoms move closer to your spine, you should pick up the book “Treat Your Own Back”.

Healthcare fraud and abuse

“During Fiscal Year (FY) 2017, the Federal Government won or negotiated over $2.4B in health care fraud judgments and settlements…$2.6B was returned to the Federal Government or paid to private persons.”

Put this into perspective.  If you were born today and started counting one…two…three…four, you would get to 2B right around retirement age.  This is of course assuming that you don’t sleep.

That’s a lot of money!

What’s important is to read that the money was returned to the government or paid to private persons.  This means that the Government is at least paying this much out to health care providers in order to recover the money at a later date.

There is a saying in health care…”it’s not about how much you make, but how much you keep that matters”.

“In FY 2017, the Department of Justice (DOJ) opened 967 new criminal health care fraud investigations…filed criminal charges in 439 cases.”

Again, I’d love to say that health care is a field full of altruistic people, we we know that some people suck!  They just suck. They take advantage of people.  They may have been bullied as a child and feel the need to get payback.  They may have been the bullies and just continue to try to take advantage of others.  It doesn’t matter the why, but they can’t be trusted to do the right thing when placed in a situation in which personal gain is an option.

“HHS-OIG also excluded 3,244 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs.”

When a health care provider attempts to defraud a federally funded program, the health care provider can be excluded from seeing any patients that participate in these programs.  For instance, if I were to be a shady individual and overbill or bill for services that I didn’t actually provide, the government can then say that I am no longer allowed to see these patients.  The government could also enter into a corporate integrity agreement with the person or company and allow them to see patients, but the company would have to prove that steps are being taken in order to minimize abusing the system.

“Under the joint direction of the Attorney General and the Secretary, the Program’s (Health Care Fraud and Abuse Control Program) goals are:

  1. To coordinate federal, state and local law enforcement efforts relating to health care fraud and abuse with respect to health plans;
  2. To conduct investigations, audits, inspections, and evaluations relating to the delivery of and payment for health care in the United States;
  3. To facilitate enforcement of all applicable remedies for such fraud; and
  4. To provide education and guidance regarding complying with current health care law. “

Imagine that you have the full force of the Federal Government tracking you as a health care professional.  How confident are you that you are doing everything correctly? We are responsible for complying with health care laws and regulations.

It’s unfortunate, but there are many therapists that still struggle with how to bill appropriately and will just take the word of another health care provider instead of looking up the rules and regulations.

“Relators’ Payments: $262,095,000…are funds awarded to private persons who file suits on behalf of the Federal Government under the qui tam (whistleblower) provisions of the False Clams Act”

In my opinion, this is where it gets interesting.  If anyone sees an injustice of abuse or fraud and reports it to the government, the government may pay that person(s) a percentage of what is recovered from the abusing person or company.

About 10% of what was recovered was paid out to individuals and groups that reported this fraud.

Someone is hitting the lottery by doing the right thing and reporting on those that are taking advantage of the system or are ignorant of the rules of the system.

“The return on investment (ROI) of the HCFAC program over the last three years is $4.20 returned for every $1.00 expended.”

If you are the federal government, “would you put more or less money into trying to recover more money from those committing fraud or abuse?”

I don’t see these recovery attempts to slow down over the years.

“Health Care Fraud Prevention and Enforcement Action Team (HEAT)…The Medicare Fraud Strike Force teams are a key component of Heat.  The mission of Heat is:

  1. To marshal significant resources across government to prevent waste, fraud, and abuse in the Medicare and Medicaid  programs and crack down on the fraud perpetrators who are abusing the system and costing us all billions of dollars.
  2. To reduce health care costs and improve the quality of care by riding the system of perpetrators who are preying on Medicare and Medicaid beneficiaries.
  3. To highlight best practices by providers and public sector employees who are dedicated to ending waste, fraud, and abuse in Medicare.
  4. To build upon existing partnerships between DOJ and HHS, such as our Medicare Fraud Strike force Teams, to reduce fraud and recover taxpayer dollars. “

If you are in healthcare…are you listening?!

Does this sound personal?

This is to crack down on perpetrators costing us billions of Dollars.

“DOJ and HHS have expanded data sharing and improved information sharing procedures in order to get critical data and information into the hands of law enforcement to track patterns of fraud an database and increase efficiency in investigating and prosecuting complex health care fraud cases…enables the DOJ and HHS to efficiently identify and target the worst actors in the system.”

As a therapist, you should be shaking in your boots…if you are breaking the rules.  When the DOJ gets involved, it gets serious.

If you aren’t sure if you are one of the “worst actors in the system” you should check out the statistics.

Scary statistics for some

“In January and February 2017, 4 defendants pled guilty…conspiracy to commit health care fraud and conspiracy to commit money laundering…submit false claims to Medicare and Medicaid for among other things, fraudulent physical and occupational therapy services…patients received medically unnecessary services that were later falsely billed to Medicare and Medicaid…totaling over $55 million were submitted to Medicare and Medicaid in connection with the scheme”

This may be more than most people can perceive regarding fraud, but it doesn’t always start this way.  I’ve heard that it starts with overcharging by a couple of minutes and when a person doesn’t get caught, then the billing becomes more and more unethical.  Before you know it, the person is billing for thousands of dollars of services that weren’t actually performed.

“In March 2017, an owner of several physical and occupational therapy clinics in the Central District of California was sentenced to 5 years and 3 months in prison after pleading guilty to health care fraud conspiracy…ordered to pay more than $2.4 million in restitution to Medicare…instructed therapists and others to bill Medicare for physical and occupational therapy services that were medically unnecessary and not provided”

This is unfortunately all to common.  I received calls just in the past year from PT;s in Minneapolis, Houston, NYC, and San Diego describing similar situations.  This is happening all across the country, but very few people are saying anything about it.  It is much easier to ask opinions of others that have no vested interest in the topic than it is to actually call the compliance officer for the company or call the office of inspector general.

“In July 2017…a 2-count indictment against 5 high-billing medical professionals who worked at a network of Brooklyn-area clinics where patients were paid illegal kickbacks in return for subjecting themselves to purported physical and occupational therapy, diagnostic testing and other medical services.”

Kickbacks are illegal.  Kickbacks come in many forms.  Money is the easy one, but there are others.  I’ve heard of free sports tickets, free trips to medical conferences, paying patients to show up for sessions, waiving co-pays for all patients in order to keep them in the clinic, etc. etc. etc.

If you are a patient, this is illegal and needs to be reported.  If you are a therapist, this is illegal and needs to be reported.

“In October 2016, the owner and medical director of Christian Home Health Agency in New Orleans were sentenced to 8 years and 6 years in prison, respectively, after being convicted of health care fraud for billing Medicare for home health services that were not medically necessary or were not provided.”

People go to prison.  Some worry about whether they will be shunned by their job, so they don’t report the wrongs noted in the clinic.  Some people worry about whether they will lose their job, so they don’t report it.  People are going to prison.  Jobs come and go, but time served isn’t something that one can just walk away from.  Walk away from a negative situation while you still have time…or you may find yourself doing time.

To see the report in whole click here

To learn more click here.

Burnout in Canadian physios

This post may be the most important post that I have done in the past year.  This topic has piqued my interest since a person on a PT FaceBook page wrote about regretting becoming a PT.

My passion for this profession has grown in the 11 years since starting the profession.  I never…ever…thought that I would be able to impact people from all over the world with my content, but it is happening.  I never thought that I would be voted among the most influential therapists, but it is happening.  I laughed the first time that someone told me that they follow my content, but it is happening more and more.

This profession is awesome…if you let it be.  This profession can be very destructive to those in the profession…if you let it be.

Today’s post will cover burnout and will take quotes from the paper “Burnout Among Alberta Physiotherapists”.

“Burnout is defines as ‘…a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with people in some capacity.'”

Is this the healthcare practitioner that you want as a patient?

Is this the healthcare practitioner that you signed up to be when you graduated from PT school?

No?  Well then what are you going to do about it?

If you don’t make a change in your life situation, then life situations won’t change around you.

I have more zeal for my profession now than I did 10 years ago, 5 years ago and even 2 months ago.  I am meeting new people on social media and engaging in meaningful conversations with the “big dawgs” of the profession.  You know what…so can you!  You just have to take that first step from behind the keyboard or phone and just reach out.  Everyone that I have interacted with, from across the world, has been very awesome to talk to and at no point did I ever feel like I was a burden or a vampire on their energy or time.

These relationships help to prevent emotional exhaustion for me.

I love people! Really, I do…most of the time at least.  I don’t understand the depersonalization portion of burnout, because we signed up for working with people.  This is an inherent part of the job.

Reduced personal accomplishment….hmmm…what do I say about this?

This is inherent.  I don’t understand how an external force can allow for reduced personal accomplishment.  Each day we have choices to make.  One choice could be to stay in the situation that you are in, but another could be to just make a different decision.  I have worked with many people that weren’t satisfied with their job or their career, but when asking them why don’t do something different, the answer was always the same…I can’t afford to.

When the money becomes to good to leave, there is a problem.  When the money over rides personal accomplishment and satisfaction, there is a problem.  The problem is that the person may no longer recognize the person looking back at him in the mirror.  I’ve made 6 figures in this profession.  I took a major pay cut and essentially started over.  I have to work multiple jobs in order to try to accomplish a goal of being my own boss and creating an army of PT’s that have similar goals and wants in the profession.  I will try to keep this dream alive as long as possible.  This is what I am trying to accomplish.

“The concept of work engagement is also relevant and is considered the opposite of burnout. Individuals may demonstrate a high degree of burnout if they report high levels of emotional exhaustion and depersonalization and low levels of personal achievement.”

here is so much that I struggle with in these papers.  I come from a blue collar family.  My dad served as a Medic in the 101st Airborne during the Vietnam War.  When he returned home, he went to work as a laborer putting in water and sewer lines.  He nearly died multiple times at his job and he showed up he next day.  He had multiple broken bones from accidents and he showed up the next day.  Work ethic seems to be a lost trait.  For years, I just put my head down and worked.  I made my first boss look good.  I made my second boss look good.  At not time did I ever worry about making myself look good.  I always assumed that if I made the organization look good that I would reap the benefits.

I had to leave my last job because there was too much of a gap between the highest producer and the lowest producer not only in terms of productivity, but also in terms of patient satisfaction and outcomes.  That’s when I realized that I could no longer continue to work for the same company and decided it was time to put my work ethic to use for my family and my community.

This is work engagement.  When I realized that I needed to shift places of employment, I really learned about professional engagement.  In the year of deciding to leave the comfort of a fairly high paying hospital, I since became one of the most influential people of 2017, simply by putting my head down and working.  I am hosting my first CEU course in the next month and I have found a way to piece together enough hours through other opportunities to cover the lost income from leaving the high paying cushy job.  I will continue to put my head down and work.   I feel like I am accomplishing more at this point in my career than I did during the previous decade.

“Research has demonstrated that burnout and work engagement are negatively correlated”

This is not earth shattering information, but serves to demonstrate that loving your job and actively engaging your work can combat depersonalization and emotional exhaustion.  My previous cushy job had me working from 9:30-6 M-F without any forced weekends or need for overtime.  I was paid higher than the median salary, but I realized that the company as a whole was full of donkeys.  This is a Dave Ramsey reference.  Don’t get me wrong, my immediate team had some thoroughbreds, but they were definitely outnumbered by… you guessed it!

I saw myself climbing the ladder at this location and when I got near the top rung, there was no place left to grab onto.  Some of the people that had the position that I was gunning for had no intention of retiring.  At that point, I knew that if I stayed it would only have been for the $$$$$.

“37.3% of survey respondents were estimated to demonstrate a high degree of burnout based on thier EE (emotional exhaustion) subscale sore.”

Overall, the scores for burnout were average to low, but there were some aspects of the survey that demonstrated high burnout levels.  Being emotionally exhausted is a topic that was recently discussed in a FB post.  One PT posted that he was emotionally drained from the treatment of patients.  This is an issue and should throw up a flag for some employers.  When looking at work engagement and burnout being negatively correlated, there is research that states that high burnout rates may lead to compromised care.  Hopefully, this is actually a concern, but in reality I’ve learned that many corporate based therapy clinics care more about the Benjamins than patient outcomes.

“Respondents 61 years of age and older reported statistically significantly lower mean EE (emotional exhaustion) scores than respondents in other age categories…there was a decreasing trend in depersonalization scores with increasing experience”

There is a light at the end of the tunnel…and it’s not an oncoming train! If you can make it in this field for at least 30 years, then you will no longer let it get to you.  (I’m trying to make a funny).  Why should we have to wait until almost retirement age before we experience less emotional exhaustion and depersonalization.  I have personally seen this in practice, but from my experience, it is due to the therapist just not caring as much.  It’s like some of them have started counting down the days to retirement.  I’ve seen therapists that are more focused on the upcoming vacation than they are on the patient in the present.  They anticipate the vacation for weeks and then leave for a week or two and when they return they talk about it for two months until they start to anticipate the next vacation.  Work is just a way to pass the time while waiting for vacation.  Nothing wrong with that if it’s your style, but that’s not the Doctor that I want treating me!

We have to do better, otherwise the newbies in the profession won’t last until they can reach the age in which they can stop caring about the stresses of the profession.

There were some flow sheets from the paper that I will put in at the end.  I highly recommend reading this paper as a whole if you are interested in burnout.

“The most commonly reported symptoms of burnout related to fatigue and exhaustion”

It’s not uncommon to hear that therapists are staying after hours to complete documentation.  If you are a patient and you have read this far…kudos to you.  After your visit with a PT, the note may take anywhere from 5 minutes to 30 minutes to complete.  If the therapist is spending 100% of the time with you, then the note will have to be completed after you leave.  If the therapist is seeing 12 patients per day, then there could be as much as 2-3 hours of paperwork left at the end of the day.  In many places, this time is unpaid since it is part of the salary.  If it is paid, then it may count against the therapist because the time is “unproductive”, which means that the company is not making any money although they are paying a therapist to work for that time period.  This is a no-win for the therapist…unless they are over 61 years-old, of course.

“Respondents identified many perceived work-related causes of burnout including work overload, unrealistic expectations, lack of recognition from management and client demands.”

Ours is a profession that is consistently ranked in the top 10 professions in the country.  Why would there be people feeling burned out?

We get into this profession with dreams of helping people and fixing the world.  Those dreams are quickly crushed when corporate greed takes precedence over patient care.  It’s not uncommon to see a therapist trying to manage the circus of “treating” (I use that term loosely here) multiple patients at once.  I have talked to therapist that take pride in “treating” 30 patients per day.  I don’t know how much “treatment” actually gets accomplished when there are three patients in the clinic at the same time.  They actually wear it like a  badge of honor.  sometimes these therapists don’t understand that specific insurance companies require that a patient be treated one-on-one.  This means that the therapist is legally required to only charge the patient for the time that the therapist is actually working with the patient.  We are not allowed to charge insurance companies for having a technician (usually a high school or college that wants to be a therapist).

Patients: If you are unsure if the person treating you should be treating you, simply ask if the person has a license

Therapists: if you are allowing technicians to treat patients…why? Does it benefit you, corporate PT or the patient? If you can answer the patient, I follow with one more question…Is there ever a time in which you believe that the patient is in better hands with an unlicensed professional than with you?

Unrealistic expectations? Never!

I’ve seen therapist that are expected to do their paperwork at home for 2-3 hours per night.  I used to be one of those therapists.  You essentially are working 60 hour weeks for 40 hour pay.

If a patient is doing well and is ready for discharge, good luck with that.  There is pressure from some supervisors to keep patients longer than they need to be in therapy.  This too is illegal, but I hear about it on a monthly basis from therapists all over the country.

Client demands! The client is the boss.  There are very few demands from the client that we shouldn’t attempt to accommodate. The chief demand is accessibility.  Patients want access to therapists essentially around the clock.  This is to be expected in a social driven by social media and access to news/information and advice.

“…burnout prevention…maintaining a healthy lifestyle, and the importance of social relationships.  Within the work environment, flexible hours, career change, positive workplace relationships and continuing education were perceived to help prevent burnout”

All you new grads………

Re-read that paragraph!

Get out there an move! Be an example that your patients can follow.  It will not only give you more authority with your patients, but it may save you from burning out in the long term.

Flexible hours are a plus, but the positive workplace relationships is what kept me in a position for 10 years.  I was able to work with the thoroughbreds for a majority of my career.  I started at that location taking a pay cut from the previous job because I was impressed with some of the people with whom I would be working side-by-side.

Recommendations for employers:

identify burnout early

improve communitcation

address flexible work hours

provide recognition

provide professional development

These are paraphrased from the article and I find some of them overkill.  Zig Ziglar repeatedly stated that people would quit jobs because they were underappreciated.  I have never felt this way in my over a decade long career.  I have always been the work horse in the company, whichever company I worked for, and have never felt unappreciated.

Work hours are important for family and life balance, but goals have to be determined.  If work-life balance is the chief goal, then the flexible hours are extremely beneficial.  If work and learning your craft is important then so be it and make your choice from there.

This is by far and away the most important post that I have done in the previous 2 years of posting.

I hope that all those that read this learn from this and don’t allow themselves to get eaten up by this profession and fall to the wayside due to burnout.

Excerpts from:

Bainbridge L, Davidson K, Loranger L. Burnout Among Alberta Physiotherapists: A White Paper. Physiotherapy Alberta. 2017:

The importance of sleep

“Humans spend roughly a third of their lives sleeping.”

Some people say that there will be time for sleeping when we die.  Unfortunately, by having this attitude, one may get to test it sooner rather than later.  There is no shame in sleeping.  Some wear it as a badge of honor that only 4 hours of sleeping is needed, but as you’ll see later this is not a good idea.  Here’s a list of power people that sleep less than the 6-8 hours per night recommended.

“…it has been recommended to consider sleep as another vital sign, as sleep can give insight into the functioning and health of the body.”

There have been multiple suggested vital signs such as pain, walking speed and now sleep.  I am not saying that sleep isn’t important, but to call it a vital sign may be over-rated.

“…between 50 and 70 million adults in the US experience chronic sleep disturbances, and 62% experience a sleep problem several nights a week.”

Sleep is vital, but maybe not a “vital sign”.  If you are having a problem with sleep, this could be a sign of something more serious, if not it could lead to something more serious.

For instance, my daughter has Down Syndrome.  This is a genetic mutation of the 23rd chromosome, which leads to multiple physical changes.  One of the changes is a larger than average tongue and smaller air passages.  This is in combination with low muscular tone.  The incidence of sleep apnea in kids with Down Syndrome is 50-100%.  One of the side effects of sleep apnea is right sided heart failure, pulmonary hypertension, and delayed growth.  These are some serious effects of a lack of sleep.  I can speak for my daughter, but she will undergo a sleep study around the age of 3-4.  I have some patients that have sleep issues and this is what I hear about doing a sleep study:

“It will be too inconvenient”

“I don’t want to know the results”

“I don’t want to have anyone watch me sleep”

In the grand scheme of things, I will not let ego override my daughter’s long term health.  I don’t understand this belief system, but will always try to educate the patients in order to ensure that my patient’s health is as good I know that it has the potential to be.

“Costs associated with insomnia, which is the most prevalent sleep disorder, are over $100 billion per year due to health care costs, accidents, and decreased work.”

Difficulty falling asleep or staying asleep is termed insomnia.  Think of how much money we spend in health care related costs.  Add musculoskeletal pain costs to isomnia costs and the total is 340 billion.

If you could save $100,000/year, it would take you 3,400,000 years to save 340 billion dollars. If you could save $10,000 every single day, then it would only take you 93,151 years to save 340 billion.

As you can see, if we can start to improve national health, then we have the potential to save more money than I could count to in a lifetime.

“…proposed that knowledge about sleep and skills to screen sleep disorders and to promote quality sleep are important components for physical therapists to promote health and wellness.”

I’ll be honest.  We don’t learn much about sleep in school.  At least we didn’t 10 years ago.  It’s hard to say if this has changed much in the previous decade, as I don’t hear many new graduates talking about sleep.  Everything that I learned about sleep and health has come from a few podcasts from people like:

  1. Dr. Kirk Parsley
  2. Tim Ferriss
  3. Dave Asprey

It’s great that there is more research being published in the field of PT regarding sleep, but this is a population health issue and needs to be addressed by all health care professionals.

“Of the 43% who reported that they do not routinely assess their patient’s sleep habits or sleep quality, the most frequently reported reason was: ‘I do not know how to assess sleep habits or sleep quality.'”

I am not surprised by this number…actually I am.  I am shocked that it is not higher.  I am shocked that half of all therapists are actually assessing sleep habits or sleep quality.  I think that most of us, in orthopedics ask whether or not sleep is disturbed, but I don’t know if this qualifies for asking about quality and sleep habits.  Actually, I hope it doesn’t because this is a basic question that doesn’t assess much other than sleep or no sleep due to pain.

I ask my patients about urinating during the night, how many hours of sleep is achieved during the night, what the environment (room) is like regarding electronic devices and lights.

This is stuff that I had to learn on my own and wasn’t even mentioned in a Doctorate program.

“sleep is critical for immune function, tissue healing, pain modulation, cardiovascular health, cognitive function and learning and memory.”

We already talked about heart health and sleep quality in the personal story of my daughter.

There is some published research regarding a lack of sleep and an increase in Substance P.

Dr. Kirk Parsley speaks frequently of the effects of a lack of sleep on cognition.

“Without adequate sleep, people can experience increased pain perception, loss of function and reduced quality of life, depression, increased anxiety, attention deficits, information processing disruption, impaired memory and reduced ability to learn new motor skills, and are at an increased risk for accidents, injuries and falls.”

I don’t think that too many people will argue about the importance of sleep.  We absolutely need it, but some can go days without sleep.  Albeit, there will be some side effects.

“People with sleep disturbances report increased sensitivity to pain, but also those experiencing high pain intensity have reported significantly less total sleep time, delayed sleep onset, increased nighttime wakening, and decreased sleep efficiency.”

As a therapist, this part plays an important role in my care.  I would estimate that about 90% of my patients are coming to me for some sort of pain complaint.  Sometimes this pain can keep the patient awake.  Knowing the role of Substance P regarding pain and sleep, I ask 100% of my patients about sleep.  If sleep is disturbed, then I know that I have to attempt to understand the problems with sleep.  If the problems go beyond sleep hygiene, then the patient is referred out to a doctor that specializes in sleep studies.

“providing interventions to improve sleep may impact pain and thus improve outcomes”

This is why it is so important for PT’s to ask about sleep!  It may affect our outcomes!

We are all (I’m an optimist) trying to get patients better and we have to look at all of the variables that we can manipulate in order to achieve this goal.

“understanding the important relationship between sleep and pain could profoundly influence the treatment interventions targeted toward changing the patient’s experience of pain”

Just by improving sleep, we may be able to decrease a patient’s pain experience and improve function as a result.

“long duration of sleep (>8-9 h per night) was associated with an increased mortality due to cardiovascular disease and increased risk of developing coronary heart disease…short sleep duration (<5-6 h per night) was associated with an increased risk of developing or dying from coronary heart disease and weakly associated with developing other cardiovascular diseases.”

This is the paradox of sleep.  Get too little and no bueno, but get too much and equally no bueno.  Looks like 6-8 hours per night appears to be the right amount.  Reading this paragraph makes me think of the three bears.

“Sleep apnea…increases the risk of developing cardiovascular disease…heart failure and stroke…breathing stops temporarily, which decreases the level of oxygen in the body alerting the brain to excite certain receptors.”

Fight or flight? When a person stops breathing, the body becomes excitable and stresses out.  This stress can raise BP, increase heart rate and cause other neurological responses.

“About 75% of people with depression experience symptoms of insomnia…almost 20% of those with insomnia have clinically significant depression and anxiety.”

This is a quick question that we can ask when someone notes that they have anxiety or depression, which is typically asked on a history intake form.

“sleep may play an important role to the development of Alzheimer’s disease”

This has to do with neurofibrillar tangles in the brain.  This is another topic of concern for me and my family.

We are doing a lot of studying in order to understand the ramifications of Down Syndrome and there is a high likelihood of developing Alzheimer’s disease.

We put some coconut oil in her cereal and oatmeal.

“…sleep hygiene has been associated with improved sleep quality in college students and in patients with low back pain…reduce pain and fatigue in people with fibromyalgia”

Sleep hygiene is ensuring that the environment and other factors surrounding the act of sleep are ideal for sleeping.

 

Sleep hygiene education

  1. “Go to sleep and wake up at the same time every day and exposure to bright natural light is helpful to set your natural biological clock”
    1. some people will use blue lights in the AM to try to help with waking or to prevent the “winter blues”
  2. Use your bed only for sleep and sex. Do not eat, work, or watch TV in bed.
    1. Getting a little graphic, but the bed needs to be a place meant for things done horizontal.
  3. Develop a relaxing bedtime routine
  4. Avoid moderate to vigorous activity at least 2-3 hours before bedtime
  5. Avoid caffeinated foods and drinks at least 4 hours before bedtime
  6. Refrain from drinking alcohol or smoking at least 3-4 hours before bedtime.  It can cause you to wake up during the night and smoking can act as a stimulant
  7. Do not take un-prescribed or over the counter sleeping pills
  8. Avoid daytime napping so that you are tired at night and can fall asleep easily.
    1. Some people advocate for polyphasic sleep
  9. Make your sleeping environment comfortable and relaxing. Avoid light, wear earplugs and use a mask if needed
  10. Avoid eating a large meal or spicy food 2-3 hours before going to bed
  11. Talk to your doctor or health professional if you still have trouble sleeping.

Thanks for reading.

You can find me at movementthinker on Itunes and if you have questions can also send me a message at Goodliferehab.com.

Excerpts taken from:

Siengsukon CF, Al-dughmi M, Stevens S. Sleep Health Promotion: Practical Information for Physical Therapists. Phys Ther. 2017;97:826-836.

Power cleans

This is a higher level exercise in order to increase power output and increase strength specific to this type of movement. There may be carry-over to jumping or lifting objects to shoulder height.

This exercise works many of the muscles of the body with an emphasis on the posterior chain.

You’ll see my heels leave the ground, which works the calf muscles. The knees go from bent to straightened, which work the quadriceps. The hip moves from closed to open, which works the glutes/hamstrings. The muscles of the back work to maintain positions and keep the spine from slouching. The arm and shoulder muscles work to pull the weight and hold the weight on the shoulders.

You can see that as the weight gets heavier that the technique breaks down. This is similar to everyday scenarios. For instance, if you have the strength to stand up from a chair without your arms over 10 times, we could work on technique, but if you can’t do one then your body will try to find the most convenient way to make it happen…even if the technique is not the best.

Any questions comment below.