Category: HEALTH AND WELLNESS

 

 

  1. Lumbar spinal stenois (LSS)…defined by any narrowing of the spinal canal and/or nerve root canals…In patients with severe LSS, a space reduction of 67% has been found in the spinal canal.”

 

Spinal stenosis is the narrowing of the holes of the spine. The spine has 3 holes in it in the lumbar region. Each hole carries a nerve. It could either be the nerve of the spinal cord down the middle, and larger, hole. It could be the nerve roots out of the holes on the side of the spine. Each hole needs to be big enough so that it doesn’t irritate the nerve that it allows to pass through the hole. Picture a water pipe. If you put too much stuff in the pipe it will clog up. Sometimes there are tissues that can make their way into the holes of the spine to clog the holes. When the hole is clogged, the nerves don’t have as much room to do their job (transmitting signals to and from the brain). Now take that same pipe and come back and look at it over decades. There will be sludge and stuff built up around the pipe. This is essentially creating a smaller diameter on the inside of the pipe. This smaller diameter due to sludge is also creating a smaller hole. This could happen in the spine with severe arthritis or degenerative disc issues in which the hole gets smaller. A visual is much better so maybe this will help. image for spinal stenosis

 

  1. “…estimated the incidence of LSS in Denmark to 272 per one million inhabitants per year”

 

In other words, it is not very common in Denmark.

 

  1. “…it is important to discriminate between LSS and disc generated pain since these conditions have different prognoses and the range of evidence based treatments are different, as well.”

 

The treatment between the two issues, discogenic back pain and stenotic back pain, is very different. A thorough evaluation can start to correlate symptoms with either discogenic pain or non-discogenic pain. Many patients believe that an MRI will be the answer to why they have pain, but unfortunately this isn’t so.

 

  1. “a valid and reliable clinical assessment protocol for identifying LSS would be valuable in terms of choosing relevant treatment and informing the patient about the prognosis as early as possible.”

 

This article was written in 2009. The medical profession has existed for eons. There is still not a valid way to assess a patient in order to determine spinal stenosis. There are biologically plausible ways, meaning that when I assess you, I can make an educated guess from some of the findings in the history and physical, but it is not a valid (proven) way of coming to a conclusion.

 

  1. “The high sensitivity and specificity of MRI suggests this is a good test for ruling in and out the disease.”

 

The MRI does a great job of telling us what is abnormal, but it doesn’t do a great job of telling us if the abnormal finding is causing symptoms. As seen in the link above, there are abnormal findings in a population without symptoms. We have to take the imaging findings and see if they make sense after performing a physical exam.

 

  1. “…history will provide strong clues to the presence of spinal stenosis…more than 65 years of age…prolonged history of low back pain and intermittent radiating symptoms having developed gradually…limited walking capacity…Movements or positions involving flexion e.g. sitting or stooping, will often abolish symptoms…total loss of lumbar extension range is usually found, while flexion most often is well preserved.”

 

The typical patient with lumbar spinal stenosis will notice that the ability to walk has gradually reduced over time and there is a need to sit due to back or leg pain. Sitting will typically turn down or off the symptoms rapidly. This patient will have limited motion into extension (think of looking over your head to see the stars or bending backwards while standing).

 

  1. “…stenosis from zygapophyseal joint hypertrophy, ligament thickening or other degenerative changes, it cannot be expected that physical exercise or manual treatment will create a lasting change in the degree of space reduction in the spinal canal or intervertebral foramina”

 

In the presence of physical changes to the bones, ligaments or loss of disc height, there is nothing that a PT can do to change these back to the way that they were previously. These have been described as wrinkles on the inside. If we look at your face we can start to see how much age you have based on the wrinkles in the face. This is also done on the inside in that some “degenerative” changes are normal. Wrinkles are normal; they are not symptoms of anything sinister. The same can be said for physical changes on the inside. They don’t have to be pain generators. It takes a physical exam to determine how your symptoms respond and whether or not this matches the images on an MRI or X-ray. Even then, we can’t say that movement won’t help, only that we won’t change the physical “inside wrinkles”.

 

  1. “The main purpose of this pilot study is to evaluate the validity and intertester reliability of an algorithm of physical examination tests, in relation to identifying symptomatic lumbar spinal stenosis.”

 

This is good. A pilot study is like a pilot for a t.v. show. This is done to see if additional episodes should be done. This study will conclude if additional studies on this topic should be done.   What it hopes to find is a reliable (consistent) way of determining validity (actually seeing what the test hopes to see) in testing for lumbar spinal stenosis. A test that is both reliable and valid should be able to test for spinal stenosis regardless of who is performing the test and who is measuring the test.

 

  1. “Two patients were classified as “LSS” and five patients “Not LSS”, meaning a 29% prevalence of “LSS” Intertester agreement for overall diagnostic conclusion was 100%”

 

There are so few patients that this study will likely not yield any results that are actionable. The interesting thing is that the examiners agreed 100% of the time. This is not common in the medical field to have 100% agreement on near anything.

 

  1. “…the algorithm in its present form can not be used as a screening test to rule out LSS, although it may be able to diagnose the condition.”

 

There were so few people in the study that it is hard for any clinician to put it to use in the clinic. It may be able to diagnose the condition in that it demonstrated a specificity of 1.0, which is really good.

 

 

Excerpts taken from:

 

Lengsoe L, Lyhne S, Melbye M. An algorithm for clinical identification of spinal stenosis-a pilot study of validity and intertester reliability. International J of MDT. 2009;4(2):21-28.

 

Can’t find the abstract to the study, but it is listed under the author’s CV http://pure.au.dk/portal/en/persons/martin-melbye(ed4ee688-2d9e-4c17-b0b1-44a5b4b59ada)/publications/an-algorithm-for-clinical-identification-of-spinal-stenosis–a-pilot-study-of-validity-and-intertester-reliability(6d714ee0-d910-11de-9e3b-000ea68e967b).html

 

 

 

 

HR 101

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

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

Not all back pain is back pain

“Findings such as disk height loss and disc bulges are common in individuals without low back pain.”
Disc bulges, degenerative joint disease, spinal stenosis, can all be a result of living with gravity. We have gravity acting as a compression force on us almost 16 hours a day. Anytime that there is a problem, we want to blame something or somebody. Low back pain is an enigma at times. We can draw correlations, we can come up with risk factors, we can even tell you how to treat it sometimes, but what we can’t do is tell you is exactly what causes your back pain. 
“Surprisingly, disc protrusions were associated with a lower risk of subsequent back pain. Nerve root contact and central stenosis had the largest hazard ratios on baseline imaging findings, and they were associated with incident back pain in the expected direction but not statistically significant. Self identified depression was the strongest predictor of subsequent back pain, with a greeter hazard ratio than any imaging findings.”
What should be taken from the above statistics is that mental health plays a role in pain. There are a lot of new studies that are associating catastrophizing and external locus of control with increased pain levels. Work by Nadine Foster demonstrates a screen for patients who will have a difficult time improving with therapy alone. New were books, such as the one by Annie O’Connor and Melissa Kolski (two people with whom I’ve studied at our RIC study group), goes into great detail regarding pain science. Big picture, we can not neglect the patient’s emotional well-being when attempting to treat the patient’s physical complaints.
“Our results indicate that depression is a strong predictor of who will subsequently report low back pain than baseline imaging findings.Subjects with self reported depression at baseline were 2.3 times as likely to have back pain compared with those who do not report depression.” 
There is obviously a psychosocial component to low back pain. The question is… Chicken or the egg. Is a person more likely to be depressed because they have back pain that is not improving? Or is that person more likely to have back pain because they are depressed? I don’t think that there are cause and affect articles in the literature at this point, but there is definitely a high correlation between patients who are depressed and patient who continue to report low back pain.
“In our analysis of baseline data, we concluded that central stenosis, nerve root contact, and disc extrusion were the most important imaging findings related to prior low back pain. Our current analysis indicates that central stenosis, disc extrusion, and root contact may also be risk factors for future low back pain.”
In other words, if you have a major deformity you will probably have pain. This doesn’t mean that you will definitely have pain, it just increases your risk of experiencing symptoms.
The moral of the story is that we cannot deny the brain. The brain has the ability to see pain, and some patients are more susceptible to seeing this pain. Don’t get me wrong, a thorough mechanical evaluation should be performed when a patient has pain, but when this patient is not inclined to respond to mechanical therapy, the patient should be referred to someone that can better handle this patient’s pain.Sometimes, that person will be a behavioral therapist, a psychotherapist, or a clinical psychologist. Physical therapists are not always the go to in order to treat a patient’s pain.
Excerpts from:

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

Outline to back pain presentation

žCentralization

žCentralization, although first described by McKenzie14, has been replicated in multiple research studies15,16,17.

žCentralization is the movement of symptoms from an area distal to the spine to a more proximal segment14,18.

žPeripherilization is the movement of symptoms, originating from the spine, from a more proximal and central location to a more distal location14.

žThe centralization phenomenon, when produced in patients, correlates with good outcome9,10,18,19.

žPatients presenting as non-centralizers are six times more likely to require surgical intervention19.

žCentralization is shown to highly correlate with a discogenic lesion20.

žOTHER CONSIDERATIONS

  • Spinal Stenosis= reduction of the surface area of the spinal canal or foramen

–No clinical feature or diagnostic test can confirm that stenosis is the cause of symptoms

–A literature review determined that “all studies favored decompressive surgery for improvement of pain, function and quality of life, as well as in terms of patient satisfaction” compared to conservative care24

  • The advantage of surgery was noted within 3-6 months and remained constant for up to 4 years.
  • Surgery is more cost-effective for this group of patients
  • Appropriate for patients that have not improved with 12 weeks of conservative care.

žEPIDURAL STEROID INJECTIONS

žThere are multiple systematic reviews demonstrating that ESI’s can be effective in the short term and long term for managing back pain for both discogenic pain and stenotic pain21,22

žFollowing an ESI, about 45% of patients then demonstrate centralization and report 90% satisfaction of results after 1 year23

žAny questions?

žreference

1.Garzillo MJD, Garzillo TAF. Review of the Literature: Does Obesity Cause Low Back Pain? JMPT 1994;17(9):601-604.

2.Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary care management for low back pain with the current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378:1560-1571.

3.Walker BF, Williamson OD. Mechanical or inflammatory low back pain. What are the potential signs and symptoms? Manual Therapy 2009;14:314-320.

4.Fritz JM, Cleland JA, Speckman M, et al. Physical Therapy for Acute Low Back Pain: Associations with Subsequent Healthcare Costs. Spine 2008;33(16):1800-1805.

5.Shin G, Mirka G. An in vivo assessment of the low back response to prolonged flexion: Interplay between active and passive tissues. Clin Biomech 2007;22:965-971.

6.Kelsey JL, Githens PB, White AA, et al. An Epidemiologic Study of Lifting and Twisting on the Job and Risk for Acute Prolapsed Lumbar Intervertebral disc. J Orthop Research 1984;2:61-66.

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

8.Natural history of lumbar disc hernia with radicular leg pain: Spontaneous MRI changes of the herniated mass and correlation with clinical outcome. J orthopedic surg 2001;9(1):1-7.

9.Long A, Donelson R, Fung T. Does it Matter Which Exercise? A Randomized Control Trial of Exercise for Low Back Pain. Spine 2004. 29(23):2593-2602.

10.Long A, May S, Fung T. Specific Directional Exercises for Patients with Low Back Pain: A Case Series. Physiotherapy Canada 2008;60:307-317.

ž

  1. Kovacs FM, Urrutia G, Alarcon JD. Surgery Versus Conservative Treatment for Symptomatic Lumbar Spinal Stenosis: A Systematic Review of Randomized Controlled Trials. Spine 2011;36(20):1334-1351.
  2. Urquhart DM, Bell R, Cicuttini FM, et al. Low back pain and disability in community-based women: prevalence and associated factors. Menopause 2009;16(1):24-29.
  3. Konstantinou K, Dunn K. Sciatica: Review of Epidemiological Studies and Prevalence Estimates. Spine 2008;33(22):2464-2472.
  4. McKenzie R, May S. The Lumbar Spine: Mechanical Diagnosis and Therapy. 2nd ed. Waikanae, New Zealand: Spinal Publication Ltd;2003.

15.Delitto A, Cibulka MT, Erhard RE, et al. Evidence for an extension-mobilization category in acute low back syndrome: A prescriptive validation pilot study. Phys Ther 1993;73:216-228.

16.Donelson R, Silva G, Murphy K. The centralizaiotn phenomenon: Its usefulness in evaluationg and treating referred pain. Spine 1990;15:211-215.

17.Donelson R, Grant W, Kamps C, Medcalf R. Pain response to sagittal end-range spinal motion: A multi-centered, prospective randomized trial. Spine 1991;16:S206-212.

  1. Werneke MW, Hart DL, Cutrone G, et al. Association Between Directional Preference and Centralization in Patients with Low Back Pain. JOSPT 2011;41(1): 22-31.
  2. Skytte L, May S, Peterson P. Centralization: its prognostic value in patients with referred symptoms and sciatica. Spine 2005;30(11):293-299
  3. Laslett M, Oberg B, Aprill C, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine Journal 2005;5:370-380.

ž

  1. Manchikanti L, Kaye AD, Manchikanti K, et al. Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review. Anesth Pain Med. 2015;5(1):e23139.
  2. ManchikantiL, Buenaventura RM, Manchikanti K, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012;15(3):E199-245.
  3. van Helvoirt H, Apeldoorn AT, Ostelo RW, et al. Transforaminal Epidural Steroid Injections followed by mechanical diagnosis and therapy to prevent surgery for lumbar disc herniation. Pain Med. 2014;15(7):1100-1108.

ž

If the shoe fits

  • SHODDY FOOTWEAR

Understanding the difference among shoes with regards to function

Vincent Gutierrez, PT, MPT, cert. MDT

  • OBJECTIVES

1.To briefly relate the history of the modern athletic shoe

2.To explain the differences regarding functionality among dress shoes, classic footwear, minimalist footwear and barefoot.

3.To provide general recommendations of footwear for varying populations.

  • The Shoe
  • The worlds oldest shoe is roughly 6,000 years old and was meant for foot protection. Prior to this it is theorized that all activities took place barefoot1.
  • Through the years
  • First athletic shoes
  • Keds Champions: unchanged since 19172,3
  • Modern (Classic) Shoe
  • Designed with the foot anatomy in mind (i.e. motion control)3,4,5
  • Minimalist shoes
  • In the recent years these shoes have noted increased sales and are advertised to mimic barefoot activities.
  • These shoes offer no support and increase the intrinsic/extrinsic strength of the foot musculature
  • WALKING
  • When compared to barefoot, wearing standard walking shoes increases stride length by 6%14.
  • Heel strike is more pronounced with larger stride length and varum stresses at the knee were found (9%).
  • Impact on medial compartment OA.
  • For every 1% increase in stress, there is 6x greater risk of knee OA
  • “Flat flexible footwear are associated with significant reductions in dynamic knee loads during ambulation, compared to supportive, stable shoes with less flexible soles.”15
  • Running
  • (1980) It was advised to buy a shoe with built in support mechanisms for the arch and cushioned heel7
  • The authors make this recommendation based on the gait cycle and apply the same gait cycle to running.
  • Recent running analysis challenges this basis of running as fast walking
  • To understand this lets talk GFR
  • http://links.lww.com/CSMR/A3
  • By incorporating arch supports, there is a reduction in elastic recoil of the spring ligament and posterior tibialis, thereby reducing force output at the foot intrinsic/extrinsic3
  • Running
  • Minimalist shoes are more economical compared to classic running shoes in that the the runner utilizes less energy to run9
  • The weight of the shoe was controlled for by using ankle weights.
  • Neuropathic foot8
  • Most ulcers occur in forefoot
  • Study compares barefoot walking in patients with DM neuropathy and those without neuropathy
  • Results
  • Pt with neuropathy place more stress on the forefoot when barefoot (2x more) than controls
  • Possibly due to hammer toe formation and a lack of distribution among toes
  • Unable to feel increased stresses at the forefoot resulting in injury under met. Heads.
  • Balance
  • 100 older women (mean=82 y/a) examining usual footwear vs. barefoot on balance6
  • 68% required AD
  • 42% wore walking shoes, 17% sandals, 11% moccasin
  • Subjects with poorest balance (BBS) benefitted most from usual footwear
  • Post CVA subjects demonstrate increased gait speeds when using a classic shoe compared to barefoot or slippers11
  • Wearing dress shoes (>.5 inch heel) resulted in 15% worsening of balance testing compared to barefoot and a 12% worsening when changing from standard shoe to dress shoe. The TUG improved in standard shoes compared to barefoot12.
  • Healthy older adults demonstrate increased postural sway when wearing traditional walking shoes compared to barefoot13
  • Authors postulate due to sensory deprivation due to footwear
  • Pediatric population
  • “Influence of footwear on the prevalence of flat foot”
  • Study of 2300 children between 4 and 13 y/a
  • 1555 used footwear and 745 never wore shoes
  • 9% of shodded children presented with flat foot and only 3% of children without footwear presented with flat foot.
  • Closed toed shoes appeared to inhibit arch formation moreso than sandals/slippers.
  • The authors suggest that children should play barefoot or in sandals/slippers.
  • Recommendations
  • Running:
  • Classic Running shoes influence a RFS, which increases impact loading into the LE and runners sustain 2.5x more injuries (LBP, LE pain) when running with a RFS3,9
  • Barefoot running fosters a FFS, which strengthens the muscles of the foot3,10
  • Balance:
  • Those with poor balance are advised to wear shoes6 and avoid higher heeled shoes12
  • Healthy individuals are advised to wear minimalist shoes for static balance
  • Neuropathic foot
  • Therapeutic shoes to reduce plantar pressure at the metatarsal heads
  • Walking
  • s/p CVA should wear classic shoes for improved gait speed.
  • Healthy individuals are advised to wear minimalist/barefoot shoes to decrease risk of knee OA
  • Kids
  • barefoot or minimalist shoes
  • QUESTIONS:
  • What’s the difference between running barefoot and running in standard/classic shoes?
  • What are two benefits and limitations of classic shoes?
  • Did this presentation add to your knowledge base and is there a change in your confidence level when recommending shoes for patients/friends?
  • References

1.Ravilious, K. National Geographic News. June 2010. Available at: http://news.nationalgeographic.com/news/2010/06/100609-worlds-oldest-leather-shoe-armenia-science/. Accessed on July 10, 2013.

2.Keds Shoes Official Site. July 2013. Available at: http://www.keds.com/store/SiteController/keds/ourstorypage. Accessed on July 10, 2013.

3.Altman AR, Davis IS. Barefoot Running: Biomechanics and Implications for Running Injuries. Curr Sports Med Reports. 2012;11(5): 244-250.

4.Griffith I. Choosing Running Shoes: The Evidence Behind the Recommendations. February 2011. Available at: http://sportspodiatryinfo.wordpress.com/2011/02/02/choosing-running-shoes-the-evidence-behind-the-recommendations/. Accessed on July 10, 2013.

5.McPoil TG. Footwear. Phys Ther. 1988;68: 1857-1865.

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

7.Heckman B. Selection of a Running Shoe: If the Shoe Fits-Run. JOSPT. 1980;2(2):65-68.

  1. Mueller MJ, Zou D, Bohnert KL, et al. Plantar Stresses on the Neuropathic Foot During Barefoot Walking. Phys Ther. 2008;88:1375-1384.
  2. Perl DP, Daoud AI, Lieberman DE. Effects of Footwear and Strike Type on Running Economy. Med Sci Sports Exer. 2012;44(7):1335-1343.
  3. Lieberman DE. What We can Learn About Running from Barefoot Running: An Evolutionary Medical Perspective. Exerc Sport Sci Rev. 2012;40(2):63-72.
  4. Ng H, McGinley JL, Jolley D, et al. Effects of footwear on gait and balance in people recovering from stroke. http://ageing.oxfordjournals.org/. Accessed on July 6, 2013.
  5. Arnadottir SA, Mercer VS. Effects of footwear on Measurements of Balance and Gait in Women Between the Ages of 65 and 93 Years. Phys Ther. 2000;80:17-27.
  6. Brenton-Rule A, Bassett S, Walsh A, Rome K. The evaluation of walking footwear on postural stability in healthy older adults: An exploratory study. Clinical Biomechanics. 2011;26:885-887.
  7. Keenan GS, Franz JR, Dicharry J, et al. Lower limb joint kinetics in walking: The role of industry recommended footwear. Gait and Posture. 2011;33:350-355.
  8. Shakoor N, Sengupta M, Foucher K, et al. The effects of Common Footwear on Joint Loading in Osteoarthritis of the knee. Arthritis Care Res. 2010;62(7):917-923.

Directional preference compared to “evidenced based practice”

The Audrey Long article is commonly cited as one of the landmark articles for those of us that treat spines utilizing directional preference and centralization.  As well it should be! The results are unbelievable.  This researcher…I take that back…clinician performing research in the clinic published an article that, up until this time, was only speculation.  How could patients not get better using evidence based practice?  For a long time, the evidence was based on expert opinion and not really research.  I enjoy reading the publications on spine and it is interesting to read the changes in the Clinical Practice Guidelines for Low Back, published in JOSPT over the years.  Prior to the most recent publication, flexion based exercises were the rage and directional preference was only moderately supported.  Thanks to clinicians such as Audrey Long, this type of treatment has gained more support in the practice guidelines.  When I was in PT school (I sound like an old man, and year to year this is true, but not yet) this was a very small talking point in our curriculum.  Students now come out of school with a better awareness, though not a true understanding, of the concept of directional preference.

 

A Critical Appraisal of Directional Preference Exercises Compared to Two Other Exercise Paradigms

 

P: For patients with low back pain, with or without leg pain, demonstrating a directional preference

I: is treatment with a directional preference

C: as compared to treatment in the opposite direction of the directional preference or an evidence based approach

O: more beneficial when compared with subjective outcome measures

 

Reviewer:

Vincent Gutierrez, PT, MPT, cert. MDT

 

Search:

Pedro.org with the keyword terms “directional preference and low back pain”. Nine results were found and the article with the highest score was chosen.

 

Date of Search: February 15,2014

 

Citation:

Long A, Donelson R, Fung T. Does it Matter Which Exercise? A Randomized Control Trial of Exercise for Low Back Pain. Spine 2004;29(23):2593-2602.

 

Summary:

 

Eleven clinics, from five separate countries, participated in the study. Consecutive patients presenting for treatment of LBP, with or without leg pain, were asked to participate in the study. The inclusion criteria is as follows: consecutive patients with low back pain, with or without one neurological sign, age 18-65 years and demonstrating a directional preference. The exclusion criteria is as follows: cauda equina, two or more neurological signs, spinal fractures, post surgical, off work for one year or more due to low back pain, medical causes, uncontrolled medical conditions, pregnancy, inability to read English (except for those from Germany), patients with prior knowledge of, or specific physician referral for, the Mckenzie method, or no directional preference (DP) elicited.

Therapists credentialed or diplomaed in the McKenzie method performed the assessments. The directional preference was noted as either extension, flexion or lateral, but the subjects were shielded from the significance of directional preference. The subjects were then randomized to one of three groups: matched directional preference exercises, opposite directional preference (ODP) exercises, or evidence-based care (EBC). There were no baseline differences among the groups regarding demographics

The subjects attended at least three and no more than six sessions over the course of two weeks. Those in the DP group received exercises that matched the DP and were instructed to avoid all activities that increase intensity or radiation of symptoms. Those in the ODP group received exercises that were opposite to the DP, and the EBC group performed mid-range exerices and stretches for the hips and thighs. The final two groups also were instructed to return to remain active.

 

The outcome measures utilized in the study are as follows: back and leg pain intensity ratings using an 11 point visual analogue scale, the Roland Morris Disability Questionnaire (RMDQ), and medication use.

 

Five hundred three subjects were assessed and 230 demonstrated a DP as follows: 83% extension, 7% flexion and 10% lateral. Twenty-nine dropped out of the study at two weeks, and the remaining 201 were eligible for analysis. There were 36 withdrawals, which indicated that the subjects worsened or had no change in symptoms and were transitioned to alternative care. None of the DP group withdrew, but 16 in the ODP and 20 in the EBC withdrew. All outcome measures improved in the three groups over the course of two weeks, with the DP group demonstrating significant improvement compared to the ODP and EBC.

 

Appraisal:

The authors satisfied eight of the ten questions regarding the Quality Appraisal Checklist. The subjects’ group design was not blinded to those enrolling the subjects and this was a comparison study of varying interventions, which indicates that a true control group was absent.

 

This study will have a direct impact for clinical therapists. Because this study compared three different interventions, opposed to identifying the efficacy of a single intervention compared to a control group, it mimicked clinical practice. The authors compared evidence based care with a directional preference treatment paradigm, which would be similar to a question asked in clinical practice.

 

Conclusion:

Directional preference exercises are superior to performing exercises opposite to the directional preference or “evidence based care”. Patients that demonstrate a directional preference and are treated accordingly perform significantly better in outcomes measured in this study. There appears to be no harm in treating a patient with directional preference exercises, but the same does not hold true for performing exercises opposite of the directional preference or “evidence based care”.

The following is breakdown of the systems involved in “assessing” research articles.

 

  1. Were the subjects randomly assigned into groups?

Yes. The subjects were randomly assigned to one of three groups.

 

  1. Was each subject’s group assignment concealed from the people enrolling individuals in the study?

No. Because the study is a multi-centered study in outpatient practice, it was not acceptable to the authors to have patients drop out of the study due to changing therapists.

 

  1. Did groups have similar characteristics at the start of the study?

Yes. The authors note that there were “no differences among the three treatment groups in any baseline demographic characteristics or outcome measures.”

 

  1. Were subjects masked or blinded to their group assignment?

Yes. Although subjects couldn’t be blinded to the treatment, they were unaware of the specific grouping (i.e. matched vs unmatched vs EBP)

 

  1. Were clinicians and/or outcome assessors blinded to the subjects group assignment?

No and yes. Although the clinicians were not blinded, which is common in practice, the assessors of the outcome measures were blinded. The outcome measures were subjective measurements in order to minimize therapist bias.

 

  1. Did the investigators manage all of the groups in the same way except for the experimental investigation?

No. Because this is an intervention study in patient’s seeking treatment, it was impossible to withhold treatment to establish a true control group. The types of treatment for the opposite direction and EBP groups were vaguely described.

 

  1. Did the investigators apply the study protocol and collect follow-up data on all subjects over a time frame long enough for the outcomes of interest to occur?

No. There was a 12% dropout rate, which was anticipated by the authors when determining the number of patients needed to maintain a power of .90. Thirty-eight patients withdrew from the study, as opposed to dropped out, due to no improvement or worsening of symptoms in the EBP and unmatched group. Two weeks was long enough in order to assess change.

 

  1. Did subject attrition occur over the course of the study?

Yes. Twenty-nine subjects dropped out of the study, with 12 of the 29 dropping out due to no change or worsening of symptoms. Although these participants did not “drop out”, indicating that follow-up information was unattainable, 36 subjects withdrew early due to no change or worsening of symptoms. No subjects from the matched group withdrew. Those that withdrew completed the outcome measures prior to 2 weeks in order to seek alternative care.

One school’s take on educating the future

One school’s take on educating the future.

 

This was a refreshing article regarding the creation of a progression to a doctoring program for a school in Australia. Although this school is a world away from my practice, they face the same situations that we do here in the states. I was impressed with the thoroughness of the article’s message and am excited to see the students that graduate from a program like the one described. I would love to see this type of program offered in the states, as I personally don’t feel that this type of education is being offered. At least I haven’t seen many students that possess these traits in my clinic yet. Those that do, I am uncertain if they were learned in school or through inherent characteristics.

 

  1. “Chronic disease management requires holistic, patient-centered care, with collaborating and respectful teams of interdisciplinary providers (physicians, nurses, pharmacists, and allied health workers).”

 

I see where the authors are going with this, in that they are creating the lead in for the rest of the article. On a side note…I can remember in 6th grade reading/composition learning how to make a house in order to get a point across. You had to start with the roof, which is the overall theme and then build the house down from the roof by adding in the thesis and supporting points. Mrs. Hart..I didn’t forget. With that in mind…that analogy doesn’t apply to this type of writing, as I simply brainstorm and just try to keep up with my thoughts on paper.

 

Back to it. We should be collaborating for all patients, not just chronic illness based patients. All patients should expect the same high level of care, which involves calling other professionals with results if need be. I see way to often the lack of communication when working with patients in the clinic. Luckily, no one has suffered greatly from the lack of communication, but luck shouldn’t be my basis of success.

 

  1. “health care ‘now requires large enterprises, teams of clinicians, high-risk technologies, and knowledge that outstrips any one person’s abilities’”

 

I beg your pardon?! I am very capable mind you…just kidding. No one person can know all of all things. It is important for a PT, or any one for that matter, to know his/her weaknesses and place him/herself in a position to leverage strengths, while hiding weaknesses. For instance, I am very good at orthopedics, which means that if I work in a clinic that sees more than just orthopedic patients (which I currently do), then I have to partner my skills with those of someone that is very good at everything else. Luckily, I have. If I were to ever leave to open up my own practice, I would have to either 1. Work on my weaknesses (I’ve never been a fan of that) or 2. Be so good at treating orthopedic conditions that I can refer those patients that encompass my weakness to a colleague or a friend at another clinic. WHAAA?! Turn away patients…sacrilegious! I wouldn’t want my mother to see me if she had Dandy Walker syndrome…it’s not my specialty.

 

  1. “The Centers for Medicare & Medicaid Services recently implemented bundled payments for hip and knee replacements…the hospital that performs the surgery will be accountable for the costs and quality of related care for the episode of care…The payment structure incentivizes better coordinated care”

 

SIGN ME UP! Accountability paired with incentives to improve patient outcomes. This is a great thing. Some people are scared of this bundled payment thing, as they talk only about loss of profits. I only see rewards for fixing patients quicker, with fewer complications, leading to increased pay.

 

EVERYONE NEEDS TO WAKE UP THOUGH! This is happening. You need to do a better job of choosing your provider. If you ask a friend and learn that the friend got crappy care from their provider…don’t go there! Even if others (namely health care professionals) are trying to push you in that direction, make more informed decisions. Get a second opinion before going there.

 

  1. “The curricula need to engage students to develop the necessary attributes, knowledge and skills in health leadership, policy, advocacy, and research…physical therapy curricula need to be forward thinking and innovative.”

 

AWESOME SAUCE! Now…I’ll believe it when I see it. I totally agree that PT’s need to be better trained when coming out of a Doctorate program, but unfortunately tradition appears to be taught more so than forward thinking…or thinking in general. We have come past the recognition and regurgitation aspect of therapy. We need to do a better job of teaching how to think.

 

The rest of the article went deeper into the curriculum for the program. I highly recommend any and all teachers of health care to read this article. It touched on some very important points and I look forward to practicing alongside those that graduate from a program like the one described in the article.

 

Quotes taken from:

 

Dean CM, Duncan PW. Preparing the Next Generation of Physical Therapists for Transformative Practice and Population Management: Example From Macquarie University. Phys Ther. 2016; 96:272-274

MRI: Medico-Reckon to identify: what you need to know

 

 

MRI: Medico-Reckon to identify: what you need to know.

 

This was a great article. It puts numbers to the faces seen on MRI’s. I like numbers…kind of like Rainman. Numbers comfort me. Enjoy the read. There is some higher level thinking in the below quotes. If you have any questions, leave a post either here or on the movementthinker Facebook page.

 

  1. “Magnetic resonance imaging (MRI) provides clinicians with a noninvasive mechanism for viewing lumbar anatomy in great detail”

 

READ AND RE-READ THE ABOVE STATEMENT.

Question #1 from the above statement: Can an MRI tell me what is causing your pain?

 

Question #2: Can an MRI tell me how to treat you?

 

Question #3. Does the MRI differentiate between abnormal structures that cause pain and abnormal structures that don’t cause pain?

 

The answer to all of the above questions is NO! Everyone seems to think that they need an MRI before they come to therapy…as if I am going to just treat them on a whim without the MRI…or that the MRI will somehow give me a paint by number way of treating the symptoms. This does not exist. The MRI can be helpful in a small percentage of patients that are either seeking or needing surgery, but aside from that it is just something for me to read after I have performed my clinical assessment of the patient and come up with my own conclusion. Now…if my conclusion matches the MRI then awesome! Well…at least for me. If it doesn’t match the MRI…that sucks because now I have to go back and reassess to see which one of us is more right…the PT or the MRI.

 

  1. “For example, large variations in lumbar disc and radicular canal morphology have been identified in both symptomatic and asymptomatic individuals”

 

This means that an MRI is very good at determining what is not normal, as compared to a textbook, but the variations of normal is so wide that the test may not tell us much.

 

  1. “…challenge for examiners in their attempts to differentiate between observations that are “symptom generators” and those that are benign variations”.

 

When a radiologist reads your MRI, they are the ones that are determining what is going on in the pictures, they spend on average of 30 seconds per picture. In 30 seconds, they have to figure out what is abnormal. Then, if they have found something abnormal, they have to determine if it can cause your symptoms. All of this is performed without ever evaluating the most important aspect of the symptoms…YOU! The radiologist never sees you. If you look at the bottom of your report (assuming that you have already had an MRI), you will typically see the phrase “patient would benefit from clinical examination to correlate imaging”. This is the radiologist saying; “Look, I only have the pictures. I can tell you with a degree of certainty what the MRI says…does this fit your symptoms?”

 

  1. Patients were classified according to this table:

 

  1. Primay LBP (low back pain): pain in the back or buttock

 

  1. Posterior thigh referral: pain in one or both back/lateral thighs with or without LBP

 

  1. L1-L3 distribution: pain in the anterior thigh and top of foot

 

  1. L4-5 distribution: pain in the mid and distal anterior thigh, anterior leg and top of the foot.

 

  1. S1-S2 distribution: Pain in the lateral border of the foot and bottom of the foot

 

  1. Bilateral distribution: any combination of the above in both legs instead of one leg.

 

  1. Atypical: none of the above.

 

This is an overall pain pattern distribution. Unfortunately, this is not drilled in PT school. I was about 2-3 years out before I figured this out on my own and then after discovering it, I looked it up. It’s funny…if you don’t know what you don’t know, then you don’t know how to find it. I think that PT’s schools should heavily bias students in this direction for learning. Think of it. If you knew that for every dollar you invested, you would get an 80% return if you simply knew a few tricks…would you learn those tricks?

 

Roughly 80% of the population will have back pain at some point in his/her life. This is either the primary or secondary reason for physician office visits (depending on which research you read) and the one that it competes with is the common cold. Think about that…back pain is about as “common” as the cold.

 

  1. “All images were initially screened for evidence of neoplastic, inflammatory or infectious disorders…”

 

This is all of the very bad stuff that needs to be ruled out if someone is going to look at an MRI. This is stuff that won’t get better with therapy. If you have certain characteristics, your PT may refer you back to your physician in order to rule out the nasty stuff.

 

  1. “…study involved 408 participants…55% had acute pain…50 participants reported a recurrence of previous symptoms within the past 2 months…303 participants reported chronic symptoms of longer duration than 2 months”

 

This sounds about right. Those with back pain may have it go away, but it will come back. Those whose pain doesn’t come back is mostly because…IT NEVER WENT AWAY!

 

  1. “…the most common location of symptoms was in the S1-S2 segmental, followed by the L4-L5 distribution. Bilateral radicular patterns were the least frequent.”

 

This means that a high percentage of patients had symptoms radiating into the foot, from the back. Fewer patients experienced symptoms into both legs. If both legs are causing you pain…at the same time…you are among the few.

 

  1. “The presence of weakness in ore of both lower extremities was reported by 175 participants (42.9%)”

 

If your back symptoms are bad enough, they will start to cause a “power outage”.   For instance, I use a specific analogy in the clinic. If your lamp doesn’t turn on when you flip the switch…what is wrong?   A common answer is that the light bulb is burned out. How many light bulbs will you go through before you realize that the bulb is working fine? When a muscle is weak, it is like the above idea. I can give you strengthening, but I would have to give you about 6 weeks of strengthening exercises in order to determine if “just muscle weakness” is the problem. This is like changing the light bulb daily for 6 weeks. I doubt that you would actually do this. Most people may do this once or twice and then just give up. When I give you strengthening exercises, you will do them for a couple of days and then give up because you won’t see much change.

 

What else could cause the light to not turn on? There could be a fray in the cord. This also happens in the body. If there is a nerve (electrical wire) that is not working appropriately, then the muscle won’t contract…the light bulb won’t turn on. This one becomes a little harder to figure out because we would have to try to find the location of the “fray”.

 

The final thing is the easiest to check for…the lamp isn’t plugged in.

 

It’s funny because I frequently have students. Recently, I had a patient that struggled to go up the stairs. She noted that her leg was weak. Students always want to make a muscle stronger. They are good at that. Unfortunately, her hip muscle wasn’t plugged in. After performing 30 repetitions of repeated extension in lying, her hip strength went from weak to moderately strong. Her ability to ascend stairs was visibly improved and the patient was surprised that her sensation of strength had improved. The student asked “why don’t we learn this in school?” I don’t know. I have the same question.

 

  1. “Disc extrusion was significantly related to the presence of distal lower extremity pain…not significantly related to weakness…not significantly associated with the presence of paresthesias or numbness”

 

What is a disc extrusion? This guy does a great job of explaining it: http://www.bodiempowerment.com/disc-bulge-why-is-my-disc-bulging/

Why reinvent the wheel?

 

  1. “Overall 149 of the participants (37%) had MRI evidence showing some degree of nerve or thecal sac compression…The most common segmental level of compression was L4-L5, followed by L5-S1…There was a significant association between the side of nerve compression and the side of pain…of the 256 patients with no evidence of nerve compression visible on MRI, 151 (58%) indicated unilateral lower extremity symptoms”

 

This means that some patients that have an MRI will show that the disc has caused some sort of nerve compression. When this happens, you will typically have pain on the side of the compressed nerve. On the flip side though, you can have pain on in one leg that is not coming from the nerve. Think like this…nerve compression can cause leg pain, but not all leg pain is caused by nerve compression.

 

  1. “participants who reported weakness had a greater prevalence of nerve compression, and those without weakness had a lower prevalence of nerve compression”

 

Again, the nerve supplies electricity to the light bulb. If the electricity is not getting there because of a problem with either the plug or the cord, then the muscle won’t work.

 

  1. “Roughly 63% of the participants had no evidence of nerve root compression on MRI. Of these, 35% had pain patterns referring distally to the knee”

 

THIS IS HUGE! PT’s in school learn that if you have pain below the knee that there must be some nerve that is compressed. This is not always the case. Any structure that has a nerve going to it can cause pain to radiate in a pattern specific to that nerve. For instance, in the neck we know that if we irritate the nerve in the joint, it could refer pain into the shoulder blade. It doesn’t have to be a “PINCHED NERVE”!

 

  1. “the presence of disc extrusion or ipsilateral, severe nerve compression at one or multiple sites is strongly associated with distal leg pain. Mild to moderate nerve compression, disc degeneration or bulging and spinal stenosis are not significantly associated with specific pain patterns.”

 

I enjoy weightlifting. When I see a snatch done well, it is like poetry. I can’t explain the entire movement in one fell swoop other than to say it is beautiful. When I see someone do this movement, with little experience, we can officially say that: yes you went from point A to point B, but not well.

 

When we see a sever nerve compression or disc extrusion, we can say “YUP I KNOW WHAT THAT IS.” Anything past that is a guess as to what is causing your symptoms, based on the MRI.

 

Quotes taken from the following:

 

Beattie PF, Meyers SP, Stratford P et al. Associations Between Patient Report of Symptoms and Anatomic Impairment Visible on Lumbar Magnetic Resonance Imaging. Spine 2000;25:819-828.

 

 

HOT DOG…GET YOUR HOT DOG! Health care sales

Hot Dog!…Get your hot dog!

 

This article highlights how we, as healthcare professionals, are salespeople. Some points I don’t agree with and others I would take a step further. Enjoy!

 

  1. “Be patient: ‘the purpose of a pitch…is to offer something so compelling that it begins a conversation, brings the other person in as a participant, and eventually arrives at an outcome that appeals to both of you’.”

 

I reminisce about my few marketing experiences that have produced major referrals. In one instance, I (there were three of us, but I did a majority of the talking) was sitting in front of a medical group (around 12 physicians) and just gave my pitch. It was great! Those that know me, know that I can be verbose and a salesperson…especially when it comes to back pain. It just so happens that it was my opportunity to tout our clinics greatness when it comes to treating back pain. I was writing checks that my a$$ couldn’t cash at the time, but in the end it worked out so well that we have more patients than we can handle.

 

  1. “Be present: Be in the moment in your encounter”

 

This holds true for every encounter throughout the day. This doesn’t apply just to “the sell”. My patients can tell when I was up late writing…like tonight. I just don’t have the same sharpness that I normally do. I try to be in the moment as much as possible and do my best to clear my head during the workday by taking a nature walk in the short time I have for swallowing my meal. Do what you have to do to make the person in front of you feel like the only person alive.

 

  1. “Be prepared: Physicians are just like everyone else, and they typically love to discuss things like football, golf, and pop culture.”

 

Look…I disagree with this to my very heart. If I have to learn about how Taylor Swift broke up with her latest boyfriend…(this statement seems to be timeless throughout the years)…in order to have a conversation, then I consider myself a failure. If I can’t make my topic of interest so compelling that I lose the physicians interest, then I need to work on my knowledge or performance of my knowledge. I go a little different direction with be prepared. Know so much about your topic that the other person actually learns something that can be helpful to your audience. If I provide a physician with information that can help his patients…I have physicians now call my personal cell phone for a quick phone consult…then I will have done a good enough job to have that physician’s trust to send me patients.

 

  1. “Ask questions” Referring to personal questions.

 

I don’t look to this as selling, instead this is simply “not being a douche”. I know as much about my referrals as they want me to know. I don’t pry, but I don’t shy away from a “normal” conversation either. Be real…be you…and if you are a douche…act like someone else.

 

  1. “Be cool: …this is a way to show off your bedside manner”

Again see number 4. I thought that this point was redundant.

 

  1. “Be punctual: Which really means, be early.”

 

Again, this goes back to not being a douche. If someone takes the time out of his/her day to meet with you, in order to further your agenda, at least be respectful of his/her time. I’ve heard that in the military if you are 10 minutes early, then you are late…but if you are 15 minutes early, you are on time. Take this to heart.

 

  1. “Be human: Give them a chance to highlight their accomplishments or current work they are doing.”

 

I don’t know how much I agree with this, especially for the first encounter. I would be just as happy to say hello…My name is movementthinker and here’s my card. If there is anything that I can do to assist you with a problem or if you have a patient that has tried everything else…give me 3-5 visits to prove myself. Wow them!

 

  1. “Be awesome: …always point out the things that you have that no one else has”

 

I think that this is a very superficial definition of awesome. Writ a check that you will difficulty cashing! Make statements that you will have trouble backing up. Push yourself to be better by putting pressure on yourself to get better.   You had better live up to the hype though. If you can’t cash the check…don’t bother even having the discussion. As a matter of fact, if you can’t cash the check…go listen to the following:

Entreleadership, Spartan up, PT insiders, the Tim Ferriss podcast.

 

  1. “ Do your homework: Find out where they went to school, where they did their residency, and most importantly what their Starbucks preference is”

 

This is infuriating! Drug reps sell drugs to physicians, but really they are just the closer. The commercials pitched the entire game and the lunches, “business trips” and other perks are acting as the Mariano Rivera of drug sales. I would rather find a good starter and have them pitch the entire game. When I need a closer, I will look into it. Give me a Nolan Ryan over Kid K. I will be advertising…no…selling to the patients. They are the ones that make the health care decisions, because as time moves on…they will be the ones paying out of pocket. I will give value.

 

  1. “The most important ingredient we put into any relationship is not what we say or what we do, but what we are.” Taken from Stephen Covey.

 

I have had many conversations with private practice owners and this seems to be the overarching message. Provide good care, be a good person and allow the patients to see that. The attitude of “if you build it, they will come” no longer applies in healthcare. I take pride in the fact that patient’s refer me friends and families, I will take my attitude towards providing service to whatever avenue life brings.

 

Quotes taken from:

 

Lee A. Top Ten Tips: Selling strategies for the nonsalesperson physical therapist. IMPACT. April 2016: 63-64.

The age old question (for healthcare providers at least)

The age old question

 

How do we get patients in the door? Many therapists, especially the mom and pop clinics, struggle with this question. Some physicians are spoken for by specific companies, which makes getting a referral from the physician difficult. Some insurance companies are making it difficult to see a physical therapist of choice, at least without you paying $$$$ out of pocket. So how do we get patients?

 

  1. “…marketing to physicians-would not provide the expected revenue stream. Instead, a direct-to-consumer marketing strategy was needed and needed fast!”

 

Why does it take so long for PT’s to catch on to this concept? I have heard it all my career; “patient’s need a referral in order to come to therapy, so we should market to physicians.” There’s a great documentary done by a fellow meathead called “Prescription Thugs”. Drug companies realize that if they can sell their drugs to the patients, that the patients will go to their respective physician and ask for the prescription. The question is where do we want to spend our marketing dollars or time? I have seen over and over again, the physical therapists takes coffee to the physician and tries to grab the physicians ear for a couple of minutes. THIS WILL NOT WORK! Think about it. When you go to the physician, how much time do you actually see the doctor? What…5 minutes…maybe 10 max? How much time do you think that the doctor has to offer you…for free? Not much. With that said, there are some companies that have doctors ears. I will let you make the conclusion about how they are able to get into the doctors ears for 5 minutes.

I think that a good t.v. commercial would look like this…dream with me.  A father picking up his child and having a big red throbbing circle radiating from his back.  Black screen. A mother breast-feeding her daughter and a big red throbbing circle radiating from her neck. Black screen. A weekend warrior doing pull-ups with a red circle radiating from the shoulder.  A different weekend warrior playing basketball with the circle from the knee.  Black screen.  DO YOU HAVE ANY OF THESE SYMPTOMS?  Go talk to your doctor and then see movementthinker.org.

My biggest referral source is previous patients. I have so many patients requesting me at this point that I am unable to satisfy the need in a 40-hour work week. There are many private practices that would kill to have this problem. I see this as a major problem though because I stand for very personalized care to each patient and if I can’t get the patient in the door…it’s not very personalized.

 

  1. “1. Clearly define the customer”

 

Who is my customer? Anyone that I come in contact with knows about my blog. Everyone is my customer. This is where you define your elevator pitch. What do you do? I can tell you what I do. I offer specialized care in which I take the puzzle that is your problem and break it down into smaller pieces that you can understand and teach you how to aide in not only fixing yourself, but preventing your problem from returning. I am a teacher, disguised as a physical therapist. My customer is anyone that has a problem…puzzle…that revolves around movement based pain or limitations.

 

  1. “2. answer the question, ‘Why should the consumer come to our clinic specifically and pay cash at our practice”’

 

I will give you value. Within a short number of visits I will teach you about your problem. I will guide you and teach you how to fix your problem. I will educate you on why this may have started and how to keep it from coming back again. I will ensure that you understand the basics of human movement. I will guide you to resources that you can read if you want to learn more than you can in a short number of sessions. I will tell you if therapy will help you. I will tell you if you are more likely to respond to surgery than to therapy.

 

Not only that, but I will do this in a short number of sessions in order to save you money in the process. It would be cheaper for you to pay out of pocket to see me than to go through your insurance company. I will give you value.

 

  1. “3. Determine how to effectively reach that target market”

 

You’re reading the first way that I am answering this question. I just realized that I have reached over 900 “visits” over the previous 4 months. Officially, this blog now reaches more people than I can care for in the clinic. This is my start of marketing myself and my knowledge to others. Whether you choose to come see me or not, you will be better after having read the blog.

 

Quotes from:

 

Clinton SC. OVERCOMING MARKETING OBSTACLES: A cash-based practice perspective. IMPACT. April 2016: 52-56.