Author: Dr. Vince Gutierrez, PT, cert. MDT

“Patients who have lumbar discectomy with predominant leg pain at initial presentation are known to have a better result than patients with primarily low back pain without radiation”
WHAAT!? You mean to tell me that patients with back pain only, don’t do well with a surgical approach? Yougottobekiddingme!
Obviously I joke. We can predict that a certain portion of the population may actually respond better to a surgical approach or other invasive interventions compared to therapy. Patients that have more leg pain than back pain may do better with a surgical approach than those with more back pain than leg pain.

“Of 27 patients who had only leg pain at initial examination, 26 (96%) were found subsequently to have an extruded fragment.”
Leg pain, in the absence of back pain, has a high rate of being an extruded disc fragment. What’s this mean? Picture a half-filled tube of toothpaste. Let’s start with the lid on. If you squeeze the back of the tube, the paste moves towards the front of the tube. This is similar to how a spinal disc reacts to movement. When you compress the back portion, in most healthy discs, the toothpaste consistency portion of the disc moves forward. Now, take the lid off. When you squeeze the tube, the paste comes out. Try to put it back into the tube…good luck. It doesn’t work. When the paste material in the disc comes out through an opening in the disc, this is called an extrusion.
“…33 of 39 (85%) patients with predominantly leg pain had an extruded fragment.”

The statistic to pay attention to is the high percentage of patients that either have all leg pain or mostly leg pain present with an extrusion. This information is learned simply by talking to the patient and paying attention to what the patient is saying. If you hear this pattern, think that there may be a discogenic lesion in the lumbar spine.

“Only 2 of 12 patients presenting with more back pain than leg pain were subsequently found to harbor an extruded fragment”

This sentence sounds ominous. “Harbor an extruded fragment”, sounds like harboring a fugitive. Funny thing…the way a therapist words the education portion with the patient can either be helpful or harmful. Harboring is a negative connotation and may actually increase the patient’s pain if described in this manner. The portion that is most important though is that only 12% of patients with more back pain than leg pain present (harbor) with an extrusion. An extrusion may be less likely found in a patient with more back pain than leg pain. This plays a role in the patient’s rate of improvement over time, so it is very important for all therapists to know this information. Unfortunately, if a PT is not reading the research, this information may never be learned. I only took one course in the previous 10 years that even mentioned this information.

“No difference was observed in the pain severity of patients with an extruded fragment, compared with those with a disc protrusion. Patients with an extruded fragment were more likely to experience a resolution of back pain at the onset of leg pain, than patients with a disc protrusion”

There are some theories about this. Let’s start again with some education. A protrusion is what happens when the toothpaste pushes against the tube, but the lid is still on. This means that the hydrostatic properties (big words) of the disc is still intact. Hydrostatic mechanism is simply stated that when you push on the back of the toothpaste tube, the paste moves to the front and when you push on the front of the tube, it moves to the back (in most cases, but not all cases this happens. There is another study that I may discuss if I can find it at a later date that discusses how older looking discs may respond differently).

One theory for the resolution of back pain is that the posterior longitudinal ligament (posterior = back of spine, longitudinal = up and down, ligament = ligament) no longer has pressure against the ligament when the disc loses the hydrostatic mechanism. The ligament, when irritated under experimental situations, is known to cause back pain to the side of ligament irritation (another study that I will have to find for a later blog). If there is no pressure against the ligament, it may be a factor in not experiencing back pain.

“Pain fibers are present in the outer layers of the annulus and posterior longitudinal ligament and produce severe central low back pain, when stimulated directly or stretched by injection of saline”
Over the years I have read so many studies. I also have a decent memory, so all of the stuff that I typed above I didn’t realize came from this study that I am writing about. I typically read an article and then come back and blog on it at a much later date. This quote says in more sciency terms what I said in the previous paragraph.

“The ability to predict the presence of an extruded fragment is clinically important because these patients have been reported to achieve a better result from discectomy and therefore case selection could be improved by a simple assessment of pain distribution on presentation”

WAIT!!! Not all patients with an extrusion need surgery!!! This is simply a starting point. If the patient presents with this pattern, but also demonstrates centralization of symptoms, the patient is expected for a good outcome.

Moral of the story: you are not your symptoms, but they can assist us in determining how to proceed with care.

Excerpts from:

Pople IK, Griffith HB. Prediction of an Extruded Fragment in Lumbar Disc Patients from Clinical Presentations. Spine. 1994;19(2):156-158.

“Therapists using the McKenzie method classify patients based on repeated end-range trunk movement tests into 1 of 3 main syndromes: derangement, dysfunction and posture.” 
There is a lot here even though they summarized it very succinctly. By the by, one of the authors, Jason Ward, has an awesome podcast called the Mechanical Care Forum that you guys should all check out. He delves into the topics of Mechanical Diagnosis and Therapy mostly, but also has other guests on the show such as Stu McGill, Mulligan (no need for a first name) and others.

 
MDT is a systematic assessment process in order to classify patients into one of three categories. The derangement category has the hallmark sign of centralization and peripheralization. This is being taught in schools with much evidence to support it for good outcomes. RANT: When I was in school this was barely touched upon and MDT was only one of the methods that a person may be exposed to upon graduation. I recently visited Governors State University and was pleased to see that they have added centralization/peripheralization, directional preference and repeated movement exams into the curriculum. The derangement syndrome is classified by rapid change, for better or worse, either symptomatically or mechanically (range of motion, reflex, strength change, sensation changes). The derangement syndrome is the most prevalent syndrome classification in MDT.
 
The second most common syndrome is the dysfunction syndrome. This is further subclassified into two parts: articular dysfunction and contractile dysfunction. Starting with a contractile dysfunction, it is as simple as the name denotes. It is a dysfunction of some of the contractile tissues of the body and is named for the direction of dysfunction. For instance, if there is a “muscle strain” of the shoulder flexors, the patient would demonstrate with pain during contraction of the muscle with pain increasing with increasing load and also pain during the stretch of this muscle. This is a contractile dysfunction into shoulder flexion.
 
One could also have an articular dysfunction, which is a dysfunction of non-contractile tissues. This could be any structure that doesn’t contract, but the joint capsule is one of the structures typically referred to. A deficit in the non-contractile structures should cause a joint to be limited in its range, but not with regards to its strength. The hallmarks of the dysfunction syndrome are both a lack of dramatic change and consistency with regards to the limitation.
 
“The patient may also be categorized ino an “other” category (eg, chronic pain syndrome, surgery, mechanically inconclusive, spinal stenosis, spondylolisthesis, hip, sacroiliac joint dysfunction, and other)if the patient cannot be successfully classified into 1 of the 3 main McKenzie syndromes”
 
I wrote a case series a couple years back that I am working to get published regarding cancer causing back pain. This would be an “other” category. It doesn’t fit one of the 3 presentations and would have to be classified as other and wouldn’t fit into the treatment paradigm for MDT.
 
“Within the McKenzie classification system, evidence supports the prognostic relevance and discriminative utility of 2 pain-pattern classification criteria: centralization and directional preference…Briefly, centralization is characterized by spinal pain and referred spinal symptoms that are progressively abolished in a distal-to-proximal direction in response to therapeutic movement strategies. Directional preference has been defined as a specific movement or posture that decreases the patient’s pain, with or without the pain having changed location, and/or increases the patient’s lumbar range of motion”
 
Where to start? Centralization…there has been much work by Werneke and Hart regarding centralization’s prognostic value for both positive and negative. Also, Skytte 2005ish has an article that reveals that a lack of centralization leads to a 600% increase in the need for invasive procedures. https://www.ncbi.nlm.nih.gov/pubmed/15928538
 
http://www.google.com/search?hl=en&source=hp&biw=&bih=&q=wernecke+centralization&gbv=2&oq=wernecke+centralization&gs_l=heirloom-hp.3…484.4320.0.4535.23.15.0.8.0.0.100.1014.14j1.15.0….0…1ac.1.34.heirloom-hp..9.14.961.viHMXlkcfYc
 
If you don’t know the story behind Mr. Smith, I will tell it to the best of my recollection. Robin McKenzie, the founder of MDT, had a patient come into the clinic in New Zealand in the 1950’s with back pain that radiated into the leg. Mind you, patients at this time were only performing flexion based exercises (knees-to-chest or chest-to-knees) and extension based exercises (back bends or press-ups) were thought to sever the nerves of the spine if one performed the exercises too aggressively. Hence, they were avoided. Walks in Mr. Smith. Robin was a great therapist and thus he was also a very busy therapist. Robin told Mr. Smith to go into the room and lie down on his belly, forgetting that he had the table positioned in such a manner that the head of the bed was elevated. What this means is that when Mr. Smith was on the table, he was in extension. Robin was so busy in the clinic that he was unable to get to Mr. Smith immediately. In essence, Mr. Smith spent a prolonged period of time in extension. His symptoms rapidly abolished in his leg and he only had back pain remaining. Robin saw this and made an attempt to understand the phenomenon. This lead to 50 years of studying pain patterns until the dynamic disc theory was finally being confirmed in the research. Mr. Smith and Robin effectively changed the way that spines are treated and because of this, Robin was ranked the most influential therapists in the 1900’s by the orthopedic section of the APTA.
 
Directional preference was termed by Dr. Ron Donelson, also author of Rapidly Reversible Back Pain (a good read, but at times boring). A person can have a directional preference in the absence of centralization. There may be a change in mechanical responses prior to a report of centralization, also there are studies documenting directional preferences in joints outside of the spine.
 
“…retrospective analysis of a longitudinal, observational cohort was conducted”
 
This is fancy speak, but the words are important. This means that the researchers observed what happened over the course of time (observational longitudinal), but the information is from a time period prior to actually initiating the study (retrospective). The reason why it’s important is because patient consent is not needed for this type of study, since the treatment was unchanged from what a therapist would do compared to an interventional study in which a person is trying to prove or disprove something is effective.
 
“Patients were classified at intake into the subgroups of centralization, noncentralization, or not classified…using a body diagram”
 
Not all patients will centralize at the time of the initial evaluation. If they do centralize and remain centralized, this is a great sign, but some patients may require up to 7 days in order to centralize, as noted by one of the Werneke studies.
 
“Treatment processes were guided by the patient’s symptomatic and mechanical responses to continual assessments of repeated movements, positioning, and/or manual techniques. If centralization or directional preference was observed, treatment was standardized following MDT assessment and treatment methods.”
 
The problem with this system is that it is elusively easy to use. If during the session, we find movements, positions, or postures that make your symptoms worse, we educate you to discontinue or avoid those positions TEMPORARILY. When we see a directional preference or centralization, we tell you to go forth and do those movements that cause good things to happen. That’s it. For someone well trained, we can find a directional preference in most patients. For those that aren’t trained…well…the system may not work, which is a bummer for the patient because it’s not the systems fault.
 
“The primary findings suggest that (1) classifying patients with lumbar impairments at intake by either McKenzie or pain-pattern classification methods my slightly (around 3%) improve explanatory power in robust risk-adjusted rehabilitations models predicting discharge FS outcomes”
 
Classifying a patient demonstrates improved results compared to not classifying patients. Although this may be a small improvement over other factors that could predict outcome, it is still better than not classifying. When you go to see a therapist as a patient, you want to know how they are classifying you. As a student, you want to know how sophisticated the clinical instructors classification system is. A therapist that is performing interventions because of tradition is not using a good classification system.
 
“…therapists with the highest level of McKenzie training (diploma in MDT) achieved significantly better FS (functional) outcomes compared to therapists who did not have a diploma in MDT”
 
This won’t offend me. I don’t have a Diploma in MDT and personally know many therapists that have earned this distinction. It takes time to complete, a lot of money and time off of work/away from family in order to complete the diploma. If one has access to a therapist with this distinction…please go forth and get assessed.
 
Look…there are a lot of therapists that say that they “use McKenzie” in their treatment. Be wary of these therapists. McKenzie is not a treatment intervention, but an assessment process. If the therapist doesn’t have the initials denoting passing a certification exam or diploma exam, he/she is not using MDT at even a competent level.
 
Excerpts taken from:
Werneke MW, Edmond S, Deutscher D, et al. Effect of Adding McKenzie Syndrome, Centralization, Directional Preference, and Psychosocial Classification Variables to a Risk-Adjusted Model Predicting Functional Status Outcomes for Patients with Lumbar Impairments. J Orthop Sports Phys Ther. 2016;46(9):726-741.

“…the new physical therapists may lack the entrepreneurial spirit, skill and knowledge required to build their practice. Despite the size of a practice, time and effort dedicated to educating physical therapists new to the practice on how to develop a following should be implemented.”

I think that this holds true for any company. We should always groom those that work for the company in order to assist them with progressing their career. For instance, when I worked for Sam’s Club, I was consistently put into situations that would allow me to be more and more independent. In private practice, I was consistently left alone in the clinic run the clinic. At the hospital, there has been stagnation. I have no additional responsibilities given to me than I had when I started. This is one of the reasons that I am contemplating starting a new journey. I already have a following, but this does not translate into any more than simply being a practicing clinician. I can offer so much more.

“Send birthday or holiday cards…be active on social media…set reminders to contact patients at certain periods post-discharge…offer gift certificates to local coffee shops as a way to thank past patients who refer friends…offer a 1-year checkup consultation”

All of these are great ways to establish a following. I recently started this blog with the intention of building my brand. I am experimenting with how to reach the largest amount of people with the blog. As I continue through the months, I want to give this a 1-year trial period to see if consistent posts will bring more readers to the blog. I have a feeling that it won’t work, but I am willing to give it a try.

“Volunteer for local nonprofit organizations…provide free screenings, support local sports teams…offer your expertise to vendors.”

Again, all good ways to build a clientele. The best way to build a clientele in my opinion has yet to come up in this article. Provide excellent care that is patient focused. As hard as it is to get a patient in the door in today’s market of super chain PT clinics, hospital-based PT clinics, and Physician Owned PT clinics, it is vital that the private practitioner provide great service that separates him/her from a profit driven corporation. Physical therapy has decreased in profitability over the years (assuming that it is one therapist per one patient), but it continues to make money in the outpatient setting. The only way to make money is to gain the trust of patients by demonstrating that the therapist has the patient’s best interest at heart. I’ve seen all of the above put into action in a small private practice and in the end, it made the patients feel like a dollar sign. The patient’s realized that there was a primary reason for all of the above tactics, and it wasn’t to help the patient get better. This has to be the over riding theme of any marketing tool that we use. When I give community education speeches, I don’t care if the patient comes to me for future treatment. I care that the patient walks out the door with more knowledge than they walked in with. When I take a student, I care that they are better clinicians on the final day that the first day. This is how I have built my reputation in the community and as a clinical instructor.

“Strategically developing relationships with referral sources will lead to patients being directed to specific physical therapists due to their ‘expert’ knowledge and skills”
I question this last statement. I would love to believe that a physician would continue to refer to me when I leave the hospital based setting, but I realize that some people are beholden to others. I can’t blame them, but the system is broken. A patient has the right to go to therapy wherever he/she would like. This has to be the first thing that the patients understand. From here, a recommendation should be made, but the patient needs to know that they have the final say. I have a large patient base and there are many physicians that refer to me, but I tell the patient that they have a choice to see someone closer to home and sometimes I will go so far as to direct them to a therapist closer to home if I don’t feel that I have the special sauce needed for this patient. I have a specialty. I have talents, but if the patient is someone that has the ability to get better with most therapists, then I would rather them not be inconvenienced to drive more than 30 minutes to get to me. This may make for a worse business model, but my primary driver is patient care not the almighty dollar. I have done well for myself financially using this model and hope that it will continue to carry forward in private practice when I choose this model.

If there are any questions, comments, concerns or good jokes, please feel free to post them at my facebook page or comment on this blog.

Excerpts taken from:

Collie M. Innovative Growth: Developing a practice of entrepreneurial physical therapists. IMPACT. Oct 2016:89-90.
 

How does the disc move?
“Clinically, disc herniation is most commonly observed posteriorly or posterior-laterally”

Very rarely does the disc herniated straight backwards (posteriorly). There is a very strong ligament at the back side of the spine that prevents a posterior herniation. The material in the disc will typically make a trough in the disc and go sideways from that point.

“Specifically, when the spine is loaded asymmetrically, the nucleus tracks along a radial fissure formed in the contralateral corner of the disc suggesting that annular delamination is load/direction dependent.”
 When the spine is loaded asymmetrically is similar to bending sideways. Picture the spine as a bunch of books loaded on top of each other with big bars of wet soap in between. When you bend to the right, you would bring the right sided edges of the books closer together (i.e. they would be compressed) and the left side of the books would be gaped open (i.e. they would decompress). If there is a wet bar of soap in the middle, it would move away from the compressed side. This is what the above sentence is saying in a lot of words. There is more to it than this, such as forming a trough, which is similar to the annular fissure.

The disc is composed of two separate parts: the annular rings and the nucleus. The annular rings are a cartilaginous protector of the nucleus. It’s similar to putting Play Do in a sealed freezer bag. When you push on one end of the freezer bag, the play do goes in the opposite direction. This holds true for most discs. There is a study (I have trouble remembering the name, but its by a Japanese author…I’ll try to find it and write a post on it) that demonstrates that as the discs age and dehydrate, they may not always move away from the compressed side, but this is a different story for a different day. Just know that for the most part, most discs operate like this on most days.

“Callaghan and McGill (2001) determined that posterior disc herniations are consistently created with repetitive flexion under modest static compressive forces”

McGill…Oh great guru of spines…has done much research regarding the biomechanics of the spine. Stu, as he likes to be called, is actually very approachable and responsive to e-mails, which is surprising considering how high profile he actually is in the rehab world. Anywho…what they found was that a disc herniation is predictable with specific forces. If one repeatedly bends forward while standing and does this bending from the spine (NO-NO) instead of from the hips.

“Their data suggests that disc herniations are an injury that result from cumulative bending trauma and can initiate after only 5870 cycles of flexion/extension while under a compressive load of only 867N.”

It’s funny that they use the term “only 5870 cycles”. That’s a whole heck of a lot of flexion/extension cycles. This is more of the case of the straw that broke the camel’s back more so than one cycle of flexion/extension. The number that the authors gave for force is equivalent to about 200 pounds. Now take your upper body weight plus any external weight and this is the number of flexion cycles that it would take to cause a herniation.

“Bending the motion segments about an axis oriented 30 (degrees) to the left of the sagittal plane flexion axis resulted in the focused nucleus tracking toward the posterior right side of the disc in 15 of the 16 trials”

What this means is that in a majority of people, bending towards one direction will cause a movement of the disc material in the opposite direction. The are treatment strategies that are based on this exact theory.

“Discovering that the side that the nucleus tracks is dependent upon the direction of bending motion is of use in understanding injury mechanics”
This means that we could reverse engineer the injury if we have a picture of the disc. It also means that we could reverse the injury if the disc is still intact by moving in the opposite direction of the problematic motion. These are theories of course, but this type of theory is used in treatment.

NOTE: This article uses a porcine disc model, which is commonly used in the research to mimic the motion of the human disc.

Excerpts from:

Aultman CD, Scannell J, McGill SM. The direction of progressive herniation in porcine spine motion segments is influenced by the orientation of the bending axis. Clinical Biomechanics. 2005;20:126-129.

“Various authors have argued for and against the effects of several factors on increasing costs (of college education), including growing numbers of institutional administrators, increasing federal regulation, new campus buildings to attract students, rising costs of employee health insurance, costs of intercollegiate sports, and an increasing proportion of professors staying beyond traditional retirement age”
 
Debt has become a crisis not only among PT students, but across the board for students of all disciplines. Dave Ramsey, Author of the Total Money Makeover and other national best sellers, speaks of this problem frequently on his show. He notes that the cost of education has gone up not just because of administrators but also because of an increase in other personnel also, such as secretaries. I was about $80,000 in debt graduating from PT school and this is about half of what some of my current student’s debt load look like. This is scary. I can’t image the burden that these students will have coming out of college, especially if the increase was to go towards more secretaries and administrators throughout the university

“The result is that over the past 3 decades, tuition and fees have increased approximately 210% at 4-year public universities and by approximately 130% at private 4-year nonprofit institutions, while median household income has increased by approximately 2%.”

Something smells fishy here? If the average median salary has only gone up 2%, this is an income issue. Seems that those that have gone into higher education have not done much to increase their overall salaries. Let’s take a for instance. When I quit Sam’s club, I was making about $32,000 per year. This is a lot of money for no education or experience needed to start. I studied to be a teacher and raked up about $35,000 dollars in debt and this is with taking all available credits at a community college paying cash for the first two years. The average starting salary for a teacher in Illinois is about $37,000. Let that sink in, I went to school for 6 years to get an undergraduate degree (insert slow joke here). I worked full time through most of my college years. All of this would have been to make an extra $5K? Enough of that…Let’s go back to school! I accumulated another $50,000 in debt in order to make $62,000. Although I had a big hole to dig out of, I went out and bought a bigger shovel. After 8 years in practice, I am making north of 80,000. This is about a 29% raise over the course of the 8 years, averaging 3-4% raise per year. In that same time, the cost of school has increased at double the rate that my salary is improving. Again, Dave talks about this all of the time on his podcast. This just seems like a large hole for current students to dig out of, as the size of their shovel is proportionately smaller to their debt load than mine (This is one case in which size matters).

“Consequences of high student loan debt are reported to include delays in starting families, buying homes, or saving for retirement. Some evidence suggests that student loan debt influences decisions about where to work or live, with increase importance of salary and cost of living in decision making.”

One theme that I notice in my students is that they have no idea how much total debt they have. I encourage all PT students to pay attention to this number and try not to let it grow out of control. This number may dictate how you practice your craft for your entire career. If you are so focused on your salary, you may neglect mentoring opportunity. You may choose not to spend more money on continuing your education than you have to spend. You may choose to live a cheaper lifestyle in order to abolish your debt. Go check out another new graduates blog posts how he is going about financial independence. https://fifthwheelpt.wordpress.com/

I chose to live with my parents for the first 9 months in practice. This may not be the most attractive, but I was able to bank $25,000 to save for a wedding. I hear students talking about buying new cars and houses and traveling and chuckle to myself before dropping the financial hammer. All college students need to be aware how much their education costs and treat it like any other business transaction, find the best value for the dollar. 

“…the aggregate limit for graduate or professional students is $138,500. Aggregate loan limits for private student loans are $75,000 to $120,000 for undergraduate students and limits for graduate and professional students are higher.”

Shaking in your boots yet!? Think about these numbers! This is a mortgage…AND YOU STILL DON’T HAVE ANYPLACE TO LIVE YET! There are ways of making this blow a little easier to manage and I would advise all PT students to check out http://williambutler.nm.com/ This guy has gone through your education and then some. If you don’t contact him, that’s fine, but at least Google some of the podcasts that he has done so that you are more educated on how your finances will affect your life.

“…since fiscal year 2004-2005 the mean total cost of physical therapist education programs has increased nearly 100% at private institutions (mean fiscal year 2014-2015 = $99.797) and approximately 50% for in-state students at public universities (mean in fiscal year 2014-2015 = $55,997).

Lets make a couple of points about this. First, in the previous 10 years, the cost of becoming a professional has increased about 10% per year. This is huge given that the average raise of a PT (using a N of one) is about 3-4%. The cost of education is outpacing the salaries of PTs.

The next huge example though is to take the total cost of public in-state universities compared to private universities. The difference between the two is about $43,000. This sound doable over the course of 20 years, it’s only about an extra $2,150 dollars per year right??? WRONG! You can add an additional 23,000 dollars on top of that difference. The choice between in-state public compared to private school is $66,000 dollars! That would be enough money to pay for in-state school twice! This money would be very helpful when one gets to retirement age. It’s the equivalent of one year salary for a first year graduate.

The point of the matter is that school choice matters, which is also spoken of on the Dave Ramsey podcast. Dave Ramsey college choice

“Eighty-six percent of doctor of physical therapy (DPT students graduating from one state university program in 2005-2007 financed their education with student loans, and more than 13% had student loans of more than $80,000…physical therapist program graduates 1 to 5 years out of school had an average cumulative student loan debt of approximately $96,000.”
Can you hear me now? This number should scar you so much that your drawers have an odor! We are not dumb people. We have to be smart to even get into PT school. Financially, on the whole though we aren’t that bright. Every PT student should know what an amortization calculator is amortization calculator. Interest can either be a reward as an investment or a punishment as a debt.

“Financial experts recommend that cumulative student loan debt not exceed a graduate’s starting annual salary or that monthly student loan payments not exceed 10% of monthly salary…on average, in 2013 physical therapist up to 10 years post graduation did not make more than $80,000.”

Lots in this statement. First, a new graduate demanding more than $80,000 better be able to bring in the business. As a therapist, I have spent 5 years building my brand. My brand travels wherever I go. I had to work hard to create a reputation in the community and based on the blog across the world. As of today’s writing, it has been seen in 37 different countries.

It makes sense that the average therapist is not making more than $80,000 dollars because the average therapist is not going to follow these basic principles: leave the cave, kill something and drag it home. 
 Excerpt taken from: 

Jette DU. Physical Therapist Student Loan Debt. Phys Ther.2016;96(11):1685-1688

“Org charts are critical to efficient business operation, and form the foundation for growth through clear delineation of responsibilities and reporting assignments.” 

An org (organization) chart is similar to a flowsheet that directs the companies hierarchy. For instance, when I worked at Sam’s club I knew my role. As a cart guy, I was at the bottom of the barrel. No one was below me and I had a huge organization of people above me. As I moved up to cashier, at least the cart guy was below me in the organizational chart, but there was still the cashier supervisor, front end manager and general manager above me. As I continued to advance in the company, there were more people under me than above me. Without a working knowledge of he hierarchy, I would never know who is senior and who is not in the company.

Taking this to a hospital- based setting, a staff therapist answers directly to a shift manager or site manager. The only person below them are PTA’s and physio techs (if the company has any). There are only so many positions available in a hospital-based setting, so in order to move up the org chart, usually one person has to quit or retire.

In a small private practice based clinic, it may only be you and the owner. In this case, you definitely aren’t moving up the org chart. Not moving up doesn’t necessarily mean that you are stuck at your current salary, but it means that you may be stuck at a specific set of minimal requirements. Obviously, you could always do more, but you will never be mandated to do more.

“An org char is your road map. It’s a top-down and bottom-up char that provides each member of your organization a direct reporting relationship to someone else within your company

I hope that I explained it well in the above example, but if not…here’s another go. One person should directly report to one person. If that person is unavailable, then that person should report to the one person above the initial superior. As you move up the chart, there will be fewer people to answer to. For instance, at Sam’s club there were about 40 people that worked on the front portion of the store (cashier, carts, door etc). These people all answered to the COS (check-out supervisor). The COSs all reported to the Front End Manager and the Front End Manager reported to the GM. One person reports directly to one above them until you get to the top of the organization and there is no one left to report to. This is an example of an org chart

“Start at the top. Somebody-possibly you-is ultimately responsible for the entire company…Continue down the organization until all leadership roles are identified”

Everyone must know who they report to. It doesn’t make sense for a supervising therapist to look for approval from a volunteer. This reminds me of a line from Saving Private Ryan

Captain Miller: “I don’t gripe to you, Reiben. I’m a captain. There’s a chain of command. Gripes go up, not down. Always up. You gripe to me, I gripe to my superior officer, so on, so on, and so on. I don’t gripe to you. I don’t gripe in front of you.”

This is another example of an org chart.

“Respect the ‘one boss rule’”

Essentially, there should be no confusion about who a person reports to. A person should never have to decide who is his/her superior. If this has to be a guess, then the organizational chart is not very specific.

“Publish, Publish, Publish. You’ve got a beautiful org char, but it is only as good as those who rely on it.”

Doing all of the work to create an org chart is only beneficial if that information gets passed to all of the employees. There should not be any confusion regarding the organization. If there is confusion, then the staff employees need to speak to the top supervisor in order to educate them. A supervisors/manager’s job is not to supervise/manage, but to serve those that they manage in order for the employees to perform their job duties to the best of their abilities.

Excerpts taken from:

Quatre T. FIVE-MINUTE FIX: Mastering the Org Chart. IMPACT. Oct 2016:16-19.

“We must now have 12% to 15% of our weekly visits as new patient visit… There is an increased financial responsibility being placed on our patients to higher co-pays and adaptable, less resulting in fewer visits per week causing the potential for greater noncompliance with their prescribed plan of care.”
I guess I never really thought about this. When I was in private practice if we had 10 patients per week for me and for new evals, then we knew that we would remain busy for the next four weeks. With patients coming in for fewer and fewer visits, the rest of the week needs to still be filled with patients otherwise they will be therapist sitting around feeling their pumps. This means that we have to get more patients in the door for new evaluation. I don’t know if I agree with the fact that a patient coming into therapy for fewer days per week will lead to a lack of compliance, because compliance or better yet therapeutic alliance is more related to the communication that takes place between the therapist and clinician while the patient is in front of the therapist. I have many patients that I’ve been very compliant and active with her home exercise program even though I may only see them once every other week.
“If your therapist are not 85% efficient according to their schedule, maximizing their productivity per visited , and getting raving feedback in writing from both her patient in your referral sources, then you have found a good place to start.”
Again, it has to be said that productivity is not a bad word. Businesses need to keep their doors open. The only way that they can keep their doors open is to make money. The only way to make money, is to have your time settled with activities that actually make money. This is the definition of productivity. How much money are you making per hour for the company. When you consider that the average cost per session is $70 and the reimbursement from Medicare ranges from $9200, there is not a large margin when you are treating Medicare patients. So if your therapist is not busy making money all day long, this is a good place to start. The people who generate income must be generating income. Know the people on the team must be excellent. Period when I want their communication skills have to be excellent, their clinical skills have to be excellent, and their ability to work within a team must be excellent. Obviously, not every therapist is at that point yet. If I work for a team that has therapist that aren’t at this level, then I hope that this team is doing its best to coach everyone up to that level.
Gallagher BJ. Scheduling the next visit: Ensure your patients follow through with treatment with one simple task. Impact. Sept 2016. 33-36.

“Between 2000 and 2011, the number of ED visits in the United States rose by 26%, and this trend is expected to continue with implementation of the affordable care act.… Nearly 30% of hospital-based EDs have closed since 1990”
Essentially, this means that more and more people are using the emergency department, but staff sizes aren’t increasing as much as they should be according to the increase in usage. With the addition of the affordable care act, more people are insured. Although this sounds good, the reimbursement rate for providing the same service from last year has gone down this year.
Rant: this just chaps my ass. How many different businesses will allow the customer to pay less next year than they did this year? I would love it if the price of milk kept dropping year-over-year unfortunately for healthcare providers the value of saving lives has gone down year to year.

“…nearly half of all ED visits can be classified as semiurgent (35%) or nonurgent (8%).”

This means that the “emergency department” is no longer used for emergencies. This takes resources away from those that are urgent in order to treat those that are not as urgent. The article speaks of using ED physicians to treat sprains and strains, which could be treated by a primary care physician’s office.

“With increasing numbers of patients seeking care in EDs for nonurgent musculoskeletal conditions, physical therapists have the knowledge and skills required to play an increased role in the primary care of patients and to help mitigate overcrowding and improve time efficiency in the current ED environment”

This was a mouthful. The authors are making the assumption that the types of patients presenting to the emergency department will not change. This means that almost half of the patients coming into the ED do not actually need “emergency” services. Because of this, PT’s can play a major role in assessing and treating musculoskeletal conditions. Doing so would take the resources (emergency physicians) and allow these services to be directed towards the patients that need this service specifically. This would reduce wait times in the ED. Having been to the ED at times with my daughter (one of the prices of being a new parent), I totally agree that wait times can be a deterrent to going to the ED. For some problems though, we can’t wait.  

“This practice (physical therapists in the ED) was first described in the United States in 2000 and was identified as an ‘emerging practice’ by the American Physical Therapy Association.”

My specific hospital started using PT’s in the ED and I am proud to say that I was part of the catalyst for starting this program. We go up to the ED in order to assess spinal pain and balance/vestibular conditions. I find that our opinion is valued as a consultation by the ED physicians, but I have no objective data to back up that belief.

“Physical therapists function as secondary practitioners and require referrals from medical doctors to examine and treat patients”

This is true to an extent. PT’s in this state I practice require a referral in order to treat a patient, but not to evaluate a patient. This is not true for every state, as each state has its own practice act.  

“Physical therapist practice in the IUMH (Indiana University Methodist Hospital) ED began in 2002 with one full-time physical therapist…evaluate more than 2,000 patients annually”

In the hospital from the study, the article notes that the total number of hours of PT’s working in the ED has increased over time. This is not the case yet in our hospital, as the therapists are essentially “on-call” in the ED from their respective locations in the hospital. For instance, I work in the outpatient setting, but when there is need for a spine evaluation, I get called to go upstairs when needed/able.

“The reason for dissatisfaction reported in both cases (both from staff physicians) was that the ED physical therapist was not available at the time the physician sought to refer a patient”

This is the only reason for being dissatisfied?! This is a great sign for the future of PT’s in the ED.

“…the following 3 items were rated as most valuable in both 2004 and 2011: (1) provide specific instructions regarding the proper and safe use of assistive devices; (2) provide interventions that are an alternative to pain medication; (3) educate patients regarding injury prevention, safety, and body mechanics with daily activities.”

We look at gait training and think that it is easy. We are trained very well to do this and should take ownership over performing gait training and gait analysis. As PT’s, especially outpatient PT’s, gait training with an AD is something that should be done before a patient gets to outpatient, but this is a part of our profession. We should not allow other professions to own this. In taking ownership, this needs to be done for all patients that need the assistive device, regardless of setting.

Pain management seems to be pushed hard in the media now, as there is an opioid epidemic. As therapists, we can educate on the hurt vs harm mentality. Patients need to understand the difference. Unfortunately, pain can cause patients to become fearful. This places the patient into a cycle in which any activity that causes pain should be avoided. This will only prolong the cycle of pain.  

I don’t believe that there is any other profession that can assess body mechanics with as much depth as PT. 
The end result of the article is that physicians are pleased with PTs in the ED and note that PTs are the most qualified to assess body mechanics, gait training, and return to work. The chief gripe was lack of availability of PTs when requested. This is another avenue for hospitals to increase revenue, as this is considered an outpatient visit. 
Fruth SJ, Wiley S. Physician Impressions of Physical Therapist Practice in the Emergency Department: Descriptive Comparative Analysis Over Time. Phys Ther. 2016;96:1333-13341