Get PT 2nd

“out of 137 patients, 100 had been recommended for spinal fusion. After evaluation, the group advised 58 of those patients to pursue a non operative plan of care”
There’s a slogan going around social media saying “GETPT1ST” I don’t know if I completely agree with the saying, but I can’t disagree with that either. The saying could just as well be get PT second. At some point a second opinion has to come in to play for a patient’s dysfunctions or pain. That second opinion, in my belief, has to come from someone without a financial stake in the surgery. This could be a physiatrist, PT, or a separate surgeon, which was done in the study cited. 
The take home point is that 58% of those recommended for spinal fusion were recommended to seek a separate form of care, thus advised to avoid the surgery initially. What this means for the patients is that a second opinion should always be sought out, because the person advising a plan of care is advising it from their perspective. I’d love to say that everyone has the patient’s best interest in mind, but I can’t. In that case, the patient must become more educated and advocate for him/herself. For instance, a surgeon does surgery, a physical therapist does physical therapy and a physiatrist does physiatry. We see problems from different lenses and therefore will advise different plans of care for varying presentations. Some patients need surgery and some don’t. Some patients need physical therapy and some don’t. We can’t say PT first because PT is not magic and can’t fix everyone’s issues. 
“As clinicians, we bring our own biases into the treatment plan for patients”
Want to decrease unnecessary surgeries? Have a multidisciplinary team do evaluations, researchers say. PT in Motion. April 2017:46. 

Results based care

Results based care

 

I’m going to get away from typing out all of the quotes, which is what I have been doing for the previous year, for the sake of time. I have opinions that can be expressed without the need for the direct quotes. I’ll still link to the article so one can go back to read it if interested.

 

Health care is changing. We are moving from a fee-for-service type of setting to pay-for-performance setting. Some of us are thinking “about damn time!”

 

Fee for service indicates that a person gets paid for doing things to do. For instance, if I keep you for 90 minutes and do a bunch of stuff with you, then I would get paid much more than if I only spent 45 minutes with you. Now, if I see you for 90 minutes and see you 3 times per week for 4 weeks, then I would make a lot more money from the patient than if I saw for 45 minutes 1-2x per week. There is absolutely no incentive to get a patient better quickly. Do the patient’s realize this? I hope that this article goes viral so that the patient’s have a better opportunity to read this information. Some health care providers would hate for this to happen and other are thinking “HELL YEAH!”

 

Pay for performance: Some of the ways that this is being done is that a certain dollar amount is allocated for a specific diagnosis and this amount is paid regardless of how often or how many times I see the patient. I now have a huge incentive to get you better fast and to make you as independent as possible so that you no longer need to seek treatment for the same issue. If the patient can get better faster, then there is more money to be made in healthcare because we are not treating out of fear, but instead out of ambition. Some companies are afraid to discharge a patient because there may not be another patient taking that spot anytime soon. I’ve worked in these situations multiple times before, so I am not talking out of my A$$. Treating out of ambition allows the therapist to apply the evidence as best fits for the patient in front of us in order to get that patient better faster. No offense, but I want my patients to get better and leave. Hopefully, to never come back for the same thing again. I was listening to an episode of Mechanical Care Forum in which the therapist (Mark Miller) was describing an embarrassing moment in which Mark had a patient returning to therapy for the same complaint that the patient was there previously. He was proud because he thought the patient was coming back because he did such a good job the first time and the patient was satisfied with the treatment, but Robin Mckenzie, one of the most influential PT’s of the last century, noted that if the patient was actually better and if Mark did his job then the patient would know how to address the situation without seeking help again. I want to treat with the hope that the patient will only come back because they have a separate issue that needs a consultation for treatment. This is the ambition that I am talking about.

 

The article speaks of staying up to date on the literature, regularly attending continuing education classes, learning new approaches, tracking outcomes and adjusting treatment according to the patient. I would love to say that 100% of PT’s are performing all of the above in the list, but I can’t. There are countless articles speaking to the reasons that PT’s give for not staying up to date with the research, which indicates that there are some aren’t doing their professional or social duty. I take this stuff seriously. It’s Easter and I am typing about the stuff I just read. It sucks to take time away from work in order to find the articles, read them and then try to put the information out on the World Wide Web for patients and other therapists to read and criticize. I’d love to relax with my beverage of choice and just not think about it, but my patients and society, as a whole deserves better from my profession and me.

 

Anyway, Medicare is moving more towards a pay for performance method of healthcare and their goals are pretty aggressive. Medicare will have up to 50% of patients on this type of fee schedule by 2018 and for those that are still fee-for service, medicate will tie the payment to outcome measures in 90% of the cases by 2018.

 

I’m doing my part to educate, educate and overeducate the patient in order to get the patient on board with treatment. If I can get the patient to play an active role in the treatment, then I know that I have a better chance of getting that patient better.

Themes taken from:

Jannenga H. Tracking for success: Why outcome measures are essential to your practice. IMPACT. Jan 2017:53.

Build you and your brand

Build you and your brand.

 

“…your brand not only communicates who you are and what you value, but also elicits a response from those you are trying to reach.”

 

How many brands can we think of off the top of our head. I think Coke and think of polar bears and Christmas. I think Apple and think of technology so easy a 3 year old can use it, which lessens my fear of breaking it. I think Google and think the greatest search engine in the world. Our lives are surrounded by brands. Some we notice, but the great ones are just a part of our day.

 

“…branding process is about painting a positive picture that will stir an emotional response from your target market.”

 

I don’t know if I necessarily agree with this. Some brands are based on loyalty to the initial need that they made easier. For instance, I didn’t really use the internet before the age of 20, but now closer to 40 I am on it frequently because it is so portable and convenient thanks to the Iphone. Thanks to Amazon, I don’t have to drive to the baby store at night in order to purchase more bottles. Thanks to Facebook, I now have thousands of friends that I never have to see. I don’t know if the brand has to elicit an emotion as much as it has to fill a need.

 

“…a brand is a promise that is conveyed through a ‘combination of logo, words, type font, design, colors, personality, price, service, etc’”.

 

I am looking at the top 500 brands across the world and looking at the logos. There is a consistent pattern that I see with red, yellow and blue. I don’t think of colors when I think of logos, but obviously those much smarter at marketing have figured out that these colors give a response. After seeing this pattern, I decided to look up color schemes for logos and this cool infographic was the first link. I hadn’t thought this much about color, mostly because my wife says that I live in a black and whit world. Oh well.

 

“As a way to broaden your perspective, take a moment to objectively evaluate the other physical therapy clinics in your area and see if you can identify what they are promising”

 

Your brand gives the patient promise. Some clinics have the name of the owner on the front. This tells me that I am guaranteed to see the owner when I come in, but if I don’t see the owner I may not be as satisfied with my experience. Others name themselves after the feelings that they are trying to convey to the patients. The name carries weight when seen from an outside perspective.

 

“Once you are clear about your practice values and what you are offering your community, you can start to develop the visual look and feel of your brand…logo should be unique but also relevant…convey both who you are and what you have to offer.”

 

After reading this article, I scrolled through about 500 logos on Google images (again the only search engine that I use) and this logo was the best that I saw. It clearly states what the company does. It takes a person from a continuum of care from a non-walker to a runner.

 

“As you begin to express your brand, I can’t stress enough the importance of being invested in your community.”

 

This one is the most important for me. I believe that if I get in front of enough people that I will be able to sell my services. This goes back to some of the views from the Gary Vee show. He notes that giving away services can come across as a hack move, but it still gets people to buy. I can remember working for Sam’s club and on the wall would be a huge cardboard check of all of the money that the store has donated to the local charities. It makes the employees proud to know that they had a hand in providing support to the local charities. I am not sure if anyone ever shopped at the store because of it, but it made me feel good that I was able to give to those causes. I’ve volunteered at local races, though I haven’t gotten a single patient from those races. I rarely volunteer at those races anymore. I spend most of my time in the community doing patient education regarding back pain, blood pressure checks and the importance of staying active. These lectures bring in patients. This is how I stay invested in my community nowadays.

 

 

 

EXCERPTS FROM:

Stamp K. Painting a Positive Picture: How to craft an effective brand for your private practice. IMPACT. January 2017: 37-38.

Barefoot influence on arch height

Barefoot influence on arch height

 

“Our aims were to establish the prevalence of flat foot in a population of schoolchildren in rural India and to determine whether this prevalence varied between shod and unshod children”

 

First, it is hard to translate this research over to an American population. Just because it is the prevalence in India, doesn’t mean that it will be the prevalence in other countries. Until I have other research though…this is all I have to work with.

 

Unshod means not wearing shoes. Therefore, shod means wearing shoes.

 

“…2300 children between the ages of four and 13…static footprints of both feet were obtained from all 2300 children”

 

This encompasses a large age span from the time prior to arch formation to post arch formation. I remember learning in school that the arch starts to take shape around the age of 8, but this may just be a tradition that has carried through the ages of PT students. Anyway, this is a large sample size to look at.

 

“The footprints were classified as normal, high-arched or flat. Some form of footwear was worn by 1555 children and 745 never used shoes.”

 

It’s still hard to believe that there were this many children that hadn’t used shoes. The children in the study were between the ages of 4 and 13. We sometimes take for granted all of the “needs” that we have here in the states. Anyway, here is a link to give an idea of what the arches would look like on a static footprint. One way to think of it is to get your foot wet and go walk on a wood floor or deck. You would have an imprint of your foot as follows: picture of arch height.

 

“…1551 were considered to have normal arches in both feet, 595 had a high arch in one or both feet and 154 had unilateral or bilateral flat foot. The prevalence of flat foot progressively decreased with increasing age.”

 

This last statement is what is taught in PT school. There are so many facts that are taught in PT school, but we don’t learn the research behind the facts. A majority of children go on to develop normal arch height. There needs to be a further breakdown of the children that go on to develop an “abnormal arch height”.

 

“There was a significantly higher prevalence in children who wore shoes (8.6%) than among the unshod (2.8%)”

 

There is a large difference between the two populations of children, but we also have to consider the small sample size of 154 children. I would love to see this study take it one step further and search for all children in a larger radius with flat feet and see if the same types of prevalence rates are present. If this is the case, then we can start to make some assumptions regarding footwear affecting arch height. There are so many other variables that are not accounted for that could also play a role in arch formation, so this study has to be taken with a grain of salt. It does though make a statement that kids wearing shoes may not develop a normal arch compared to those not wearing shoes. It literally states: “…shoe-wearing predisposes to flat foot”.

 

“It seems that closed-toe shoes inhibit the development of the arch of the foot more than do slippers or sandals. This may because intrinsic muscle activity is necessary to keep slippers from falling off.”

 

This is a good theory, but would have to be proven. As a PT, we tend to recommend against sandal or flip flops because of the same reason: we have to work differently to keep the shoes from falling off. There is something called the windlass mechanism that can be altered when wearing shoes that can easily fall off. Again, more research is needed in order to figure out which party is right.

 

Excerpts taken from:

 

Rao UD, Joseph B. The Influence of Footwear On the Prevalence Of Flat Foot. J Bone Joint Surg [Br]. 1992;74-B:525-527.

 

Link to article

 

 

 

 

OPEN MOUTH…INSERT (BARE)FOOT

Open mouth…insert (bare)foot

 

  1. “Around one in three older people falls each year with one third of over 65s and half of of over 80s falling each year.”

 

Falling sucks. People get hurt when they fall. Most older adults can’t withstand the impact of a fall and get seriously hurt. There is research demonstrating that people older than 80 that sustain a fractured hip have a higher prevalence of death. One way that we can keep people from dying is to keep people from hitting the floor. There are many ways to do this and the article below will emphasize how footwear plays a role.

 

  1. “The shoe features which have been shown to influence balance performance include heel height, heel collar height, and sole thickness and hardness.”

 

I am going to take the low hanging fruit first. The density of the foam that is on the bottom of the shoe will play a role in how a person balances. Think about standing on a bed and how unstable it is. Now, think about standing on a waterbed…a little more unstable. The less stable the bottom of the shoe the decreased stability you will have when on your feet. There were shoes at one time that were advertised to “improve your balance”, needless to say it didn’t work out so well. When we place more cushioning under our feet, we lose a little of our stability because we are decreasing the role that one of our three senses, proprioception, systems have in maintaining balance.

 

When we increase the height of the heel, a few things happen. First, we place more weight over the front of the foot and decrease the weight bearing over the back of the foot. This changes the base of support during walking, as the person will have an earlier heel off (when the heel leaves the ground) and a quicker heel strike. This is one reason, in my opinion, that a person wearing heels doesn’t take a large stride. Doing so would impair the balance because the base of support would be very narrow during portions of the gait cycle.

 

Another thing that happens when a person adds a heel is that the person becomes a little taller. There is a good t.v. episode about this on Seinfeld. Raising your height will make balancing a little more difficulty because the center of gravity has gone a little higher. Think of it this way, when you are on an unstable surface, what’s the easiest way to keep your balance…squat slightly to lower your base of support. This is why wrestlers are so well balanced during the match because the squat down when they are being pushed and pulled.

 

The heel collar height is a little harder for me to rationalize. The higher the collar, the less mobility the ankle will have. The lower the collar, the less external stability will be provided to the ankle. I could make a case for both.

 

“Lord and Bashford evaluated balance in 30 older women when barefoot, wearing low heeled walking shoes, wearing high-heeled shoes and wearing their own shoes. The worst balance performance was seen when subjects wore high heels.”

Is this surprising? I included the quote because the author’s name was Lord…just kidding. Story time:

 

I tell all of my patients that I would not have them do anything that I either haven’t done or am willing to try. I had a patient once whose main goal was to be able to walk in heels. Needless to say, she called me out on the carpet for trying to teach how to walk in high heels based on book knowledge and not on actual experience. She went out and bought me a pair of heels. I wore the heels the entire treatment session. I got some catcalls from coworkers during the session. The best part of the story is the following. After the session I through the heels in the back seat of the car. That night I gave my wife’s mom a ride in the car. She looked into the back seat and must have seen the heels. She didn’t mention anything in the car…possibly because she mostly speaks polish and didn’t want to start a conversation that she wouldn’t be able to understand, but she told my wife when I got home. BOY DID I GET AN EARFUL! After I explained myself and it is still a funny story that I get to live to tell.

 

“The aim of this study was to examine the effects of usual footwear (versus going barefoot) on balance in frail older women attending a geriatric day hospital”

 

Remember what I said about the different portions of the shoe? If a person is barefoot, the center of gravity is lower, there is no cushion and there is decreased ankle stability. Two of the three may favor barefoot walking. I thought for sure that barefoot would be the answer…Read more to see how wrong I was.

 

“Berg Balance Scale was used to assess balance…under two conditions in this study: shoes on and shoes off. The order of testing with shoes on and off was counterbalanced so that 50% of patients were tested ‘shoes on’ first and 50% ‘shoes off’ first so as to avoid an order effect when testing”

 

First, you can see my report on the Berg Balance Scale from many years ago. I’m sure that the research has changed slightly, but the basics will still hold true. It’s important that the authors of the study changed the order of performing the testing for different patients in order to get a good idea of how patients perform. For instance, in high school no one liked the dreaded POP QUIZ! But when the teacher did a review for a test and gave a “wink wink”, you knew that the question would show up on the test. This is the same concept. If the participant already knows what’s on the test (seeing as they do the test twice), we would expect the second score to be slightly, is not significantly, elevated from the first score.

 

“One hundred elderly females were assessed with a mean age of 82…most were living in the community, required a mobility aid and had had a fall in the previous year.”

 

This is good information. A study can only be generalized to the population that the study was performed. For instance, the results of this study can not be generalized to a barefoot running group or a military group. It sounds obvious, but you’d be surprised how many “professionals” read an abstract (summary) of an article and start applying the “research” immediately in practice.

 

“There was a significant improvement in the mean BBS score of 2.5 when shoes were on”

 

I was wrong. I expected barefoot to win hands-down. This is because I have read a lot of research on barefoot walking and running. I came in biased and was WRONG! There I said it…mark this date. Moving on. Come back next week when I have a better chance of being right again.

 

Horgan NF, Crehan F, Bartlett E. The effects of usual footwear on balance amongst elderly women attending a day hospital. Age and Ageing. 2009;38:62-67.

 

 

Link to article

 

 

Is Your Therapist an Expert?

Experts…at least on paper.

 

I was very impressed with the Jensen article. I appreciate the historical analysis of experts. To believe that an expert simply knew more and was able to solve problems better than anyone else is disheartening. I work with others that are certified in MDT and though we go about treatment strategies in similar fashions, we compete against each other with paper patients. One strategy that we use to refine our skills in a group setting is a version of 20 questions. One therapist will create a case study and each therapist is attempting to ask the fewest questions in the history section in order to create a hypothesis to solve the patient’s puzzle. Though there are varying degrees of experience in this group, the therapists that consistently attend the study group are typically able to solve the case puzzle within 3-5 questions, whereas others may take 10-20 to create a hypothesis. I agree with the statement that experts are able to recall meaningful, selective knowledge. I can appreciate the next generation, which describes recall of patterns. This is extremely important for orthopedics. Patterns take much time to learn, but once a pattern is consistently witnessed, the therapist can be confident in the treatment approach.

I find the “necessity of self-monitoring through self assessment” to be extremely important in my practice. The saying “if all you have is a hammer, then everything looks like a nail” comes to mind. There are many therapists that force extension because it is the most common pattern, although the patient may not be an extension responder. I have had to step back many times to reassess my rationale for a treatment approach in order to ensure that I am not just following a preconceived bias.

 

The fact that the therapists were videotaped is interesting. There is one point in the paper when the therapist changed demeanor from clinical to personal while doing soft tissue mobilization prior to traction. I wonder if the therapist was taught this somewhere along the educational spectrum or if this is inherent. This skill has to do with “reading” reading the patient. I am reading a book called Telling Lies by Paul Ekman in order to better understand body language. This therapist either learned or inherently knew to change the approach at that time. To me, this is interesting.

I subscribe to the paragraph on page 34, “The expert therapists in this study shared…”. This is a central component to MDt. At no point do we utilize the word compliance, but instead emphasize therapeutic alliance. In other words, a team approach to fix the patient, with the patient’s preferences, judgments, and decisions having as much importance as the clinician’s knowledge of the problem.

Bill Curtis, PT, cert. MDT lectured to our class about MDT and at the time I had a hard time believing that spine symptoms could be fixed in days. I called, pardon the language, bullsh_t. I spoke to Bill after the lecture and because he did not have any research to back his claims, I had a hard time believing him. That was the greatest thing to have happened to me as a therapist, because he challenged me to do a clinical with him. I learned more in the 8 weeks as to how to fix people than I ever did in school. At that time I knew that I had to work with him in order to continue learning the secrets to solving the puzzles. I see some of my colleagues struggling with spines, and think that I would’ve been in the same boat if I didn’t seek out a mentor with more experience and abilities than I had at the time.

I like the statement that the OC made “you made a lot of mistakes”. I actually feel bad for some of the early patients that I treated. It’s one of those situations that if I knew then what I know now. Some of those patient’s wouldn’t have needed 15-16 visits in order to be back to 100%.

 

I thought that it was common sense that listening to patients is vital for proper classification and treatment. Apparently I was wrong. This is a skill that has to be learned and practiced in order to master. When working with PT students, I ask them to follow along and just write down on the form the information and we compare forms after the evaluation. Initially, the students miss so much relevant information, but by the end of the clinical are able to catch all relevant information and information that may not be as relevant to the case as much as relevant to the patient.

 

It is interesting that therapists are classifying patients, although they do not classify formally. Anthony Delitto stated in one of his papers that a clinician will attempt to classify all the patients. The NC stated that he/she “form opinions pretty quickly about certain patterns” and the OC stated “I constantly try to make sense to see how certain clinical pictures behave”. At this point, they are initiating a rudimentary classification process. Also a strong theme in this paper is therapeutic alliance. It comes up many times in the article.

I like that the experts used little equipment and gave few exercises. I tell patients that I can give them a book of exercises to do at home or I can give them one or two that will fix their complaints, which I also learned from Bill.

 

All therapists “set high standards and were driven to stay current in their specialty area”. As much as I agree with this statement, this statement also disheartens me. As professionals, I would expect this mentality from all of my colleagues, not just “experts”.

 

I love this article and am not speaking to all of the points of the article, just those that I find interesting or of differing viewpoints than those taught in school.

The comment on page 41, “If expertise in physical therapy is some combination of knowledge…can clinical practice and education be designed in a manner to address these multiple dimensions of professional competence?” I think that the first question to be asked is does everyone desire to be an expert. The desire to be an example and set an example for other PT’s to follow has to come before attempting to teach the skill set of an expert, in my opinion.

 

Another great question posed was “Why do some therapists continue to develop into expert clinicians, while others lapse into mediocrity?” Can this be detected during the interview process for PT schools? This question is very thought provoking in that it may be possible to create a profession of experts if we choose the right students.

 

Again, I loved the article and found certain elements as basic, such as caring and compassion being cornerstones of experts, while I believe that the other concepts, indirectly described in the article, are intriguing.

 

 

Excerpts and opinions based on the following article:

Jensen GM, Gwyer J, Shepard KF. Expert practice in physical therapy. Phys Ther. 2000;80(1):28-43.

 If you are in need of physical therapy or would like to talk to a therapist about the benefits of PT, I am more than happy to accommodate. 

FUNCTIONAL THERAPY AND REHABILITATION

now part of the Goodlife family

903 N 129th Infantry Dr

Suite 500

8154832440 

Do you run loudly?

Shhhhhh…quiet. Tread lightly and land softly. May your joints forever feel young.

  1. “Several of these programs instruct participants to land softly in an attempt to teach proper landing technique and reduce impact forces. Mandelbaum et al reported an 88% decrease in anterior cruciate ligament injuries in 1041 female subjects using soft landing cues”

Are you thinking what I’m thinking? Seinfeld? Mandelbaum seriously?! This was the family of old guys in the hospital with Jerry that kept hurting themselves trying to lift the t.v. I thought it was funny.

What the above is saying is that the sound of your landing can directly indicate your injury risk. Don’t go jumping off buildings to test this theory! I won’t be held liable.

 

  1. “13% decrease in peak vGRF during a drop-landing task when 80 adult recreational athletes were instructed to listen to the sound of their landing…reduced by 24% in a stud in which 12 female recreational athletes were asked to land softly…”

What this means is that the softer you land the quieter you land. vGRF is vertical Ground Force Reaction (some people really hate it when I mix up the letters, but oh well…You know who you are!). This is it this way. For every action, there is an equal and opposite reactions. This means that if you land with a heavy load, the ground pushes back up at you with an equal load. If you absorb some of the load with your joints by bending, then the ground doesn’t push back as hard. Think of dropping a stick vertically from a specific height. The stick will actually bounce a little after it hits the ground, because the ground pushes back. Now do the same experiment with a wet noodle and you will get a totally different result. This may not be an exact science, but at least it makes sense to me. When you land quietly (wet noodle), you don’t get the jarring force from the ground as when you land loudly.

  1. “Initially, the participants were instructed to perform drop landings (with no instruction) to obtain a baseline, normal sound amplitude of landing…then instructed to …create a quieter or louder sound from this normal landing condition”

For those of you that perform high-intensity exercise of varying modes under time domains-based exercises, (I am unsure that if I use the word crossfit that I may be sued like those before me) such as box jumps, that this study will apply to you.

  1. “quiet-landing instruction results in significantly greater joint excursion at the ankle and knee when compared to a normal landing sound instruction”

Essentially, the quieter that you try to land, the more that you perform a squatting based movement on the land. The stiffer you land, the louder you are. The louder you are, the more force (think jarring) that your joints have to endure.

MORAL: Be quiet! Tread lightly!

Excerpts taken from: Wernli K, NG L, Phan X, et al. The Relationship Between Landing Sound, Vertical Ground REaction Force, and Kinematics of the Lower Limb During Drop Landings in Healthy Men. J Orthop Sports Phys Ther. 2016;46(3):1945-199.

If you would like a running assessment or are experiencing pain during running, come see me at:

Functional Therapy and Rehabilitation

(Now part of the Goodlife family)

903 N 129th Infantry Dr

Joliet IL

8154832440