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“Fear can be useful”

As you can see, I’m in the middle of reading the book from Blake Mycoskie, founder of TOMS shoes.

I have never really had to work hard for anything. At least I don’t consider what I did hard work. I was comfortable. I had goals, but knew that they could be achieved with just a little bit of time and a continuation on the trajectory of life that I was on. BOY WAS I WRONG!

Things changed dramatically after our second child. Let’s paint a picture.

My awesome wife is a PTA and wants to go back to become a Doctor of Physical Therapy. We had our tentative plans on place for her to apply (and of course get accepted) into one of the two programs in the country that allow for this transition. We, meaning she, was pregnant at the time and were expecting to love after the baby was born.

Life happens and sometimes there are situations that you can’t predict or prepare for in life.

Our second daughter was born with Down Syndrome. We weren’t aware of it until the next day, as we were parents enjoying the birth of a child. Our lives changed that day. I can speak from my perspective.

I became afraid.

I wondered how will I support this child through adulthood?

I see and try to prepare for worst case scenario at all times?

Will my child be able to take care of herself?

Will my child be able to hold a job?

Will my child be able to live alone?

All of these questions have to be faced by parents with a special needs child. I don’t like to wait for things to happen in life, but like to prepare and over prepare.

I was afraid that I would fail my child and therefore fail my family, my wife and my children. That fear lit a fire under my ass that I have never had before. There is more focus now than I’ve ever had previously.

Here’s the sad part…it’s not hard to shoot to the upper echelon of our profession. Since my daughter’s birth, I worked and worked on creating myself as a brand. This was to prepare for a move that had to happen. I now need to create a legacy for my family. I was comfortable at my previous job, but it wouldn’t have provided the amount of financial stability that I needed to possibly support a child through retirement. I had to make a move.

I worked on building a brand and within 1 year was named among the top 40 influencers in our field by Updoc media. I started mentoring PT students and other PTs throughout the country. I started a Facebook show called People you should know. I doing more volunteer work now than I had in the previous years.

I thought that I was “busy” before Natalia was born, but now I’m no longer busy…I’m productive. I opened a clinic in Joliet with the purpose of trying to give back to the entire city. It’s been said that if you want to make a million dollars, you have to help a million people. My mission has been set to help as many people as I can because I know that this is the only way to face my fear of failing my family.

If you found this to be inspiring, informative, or entertaining…share it so others can read and learn from my experience.

Thanks.

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Story

“Having a story may be the most important part of your new venture…”

We all have a story. I actually have spent a good amount of my time recently learning about other people’s, group’s and mission’s story on my FB page People you should know. My story started a long time ago, but I won’t bore you with the details. The one part of the story that is most important is that I always look for the next opportunity to succeed. At Sam’s club, I was named employee of the year in 2013 and quit soon thereafter because I had reached my ceiling. There was no other Hill to climb or challenge to face. I know that it sounds like a small feat, but I worked hard to reach that status. Unfortunately, the journey was worth more than the victory, because my journey seemed complete.

My PT career has taken a similar trajectory. I started in a clinic, that I was excited to work at, in order to learn as much as I could. After 2 years, I lost that zest because I was more like a robot than a sponge. I wasn’t learning…growing…as much as I was simply going through the motions of treating patients. It sounds horrible, I know, but I was pretty good at using the McKenzie Method back in those days. If you’re familiar with Mariano Rivera, you know that he had one pitch. It was an unhittable pitch for a long period of time. He built a career on throwing his “cut fastball”. I spent more than two years honing my craft as a McKenzie based PT, but after 2 years I felt like the game wasn’t any fun anymore. I remember taking the trash out after 18 months on the job and thinking that I was “bored” with my job and could treat patients with back pain while dreaming.

Not soon after, I left that job and took a hefty pay cut in the process (you’ll start to see a pattern that I didn’t see until recently). I switched to a hospital-based outpatient department. Mind you, for two years I saw nothing but patients in pain with a generic diagnosis of: low back pain, neck pain, shoulder pain, knee pain, hip pain so on and so forth. I don’t mean to demean the patient’s pain, but c’mon “low back pain”?! Is t that what the patient told the doctor at the beginning of the session. The doctor then turns around and gives the patient a referral to PT stating back pain. (Venting a little).

At the hospital, I encountered something that I hadn’t encountered in the two previous years…a protocol! A protocol is similar to the old book “paint by number”. There is. O significant thought that goes into treating these patients post-surgically because we are bound to treat the patient by following the directions given. I had the hardest time treating patients post-surgically because I spent the previous 2-3 years with constant algorithms floating through my head. Think John Nash from “A Beautiful Mind”. I may be exaggerating, but that’s what it feels like at times. For those two years I was playing a chess match with the patient’s symptoms and pain. I was always playing 5 moves ahead with an answer for every patient move. (A patient move is considered his/her response to a previous exercise or intervention. For instance, a patient can only always respond one of three ways: better, worse, same). I had a response for each of these answers and just worked through this chess match with each patient. My biggest fear was “paint by number” because the patient would come in and…game was already over because I couldn’t make any moves.

I digress.

I matured while working at the hospital. I learned to be a team player instead of playing clean-up or closer. I learned that when horses pull in the same direction that they can pull harder than they could as individuals. Unfortunately, I also learned something else about me…I hate when the game is over. I continue to search for ways to grow and be better day-day. I reached the end of my limit at the hospital because the opportunities to play and grow were no longer available.

This is where my story starts again. This time, this time, the game is much bigger. The chess board has expanded. The moves I can make are multi-variable. I liken my current position in the profession like playing a continuous chess match in which the boards are suspended above each other like floating plates. When one piece gets taken it gets placed on the board above the previous board. The game ends when all of the pieces make it to the top board and only one piece remains. There is no tipping pieces. There is no quitting. Only moves and reactions. This is the equivalent to the biggest algorithm I have ever got to play inside. I can make on”wrong” moves, only temporary losses.

Life is pressure, but the game is fun.

Goodnight all.

Thanks for reading some of the late night ramblings.

Btw, the quote was from Blake Mycoski in “Start Something That Matters”.

Admit weaknesses

“You don’t always need to talk with experts;sometimes the consumer, who just might be a friend or an acquaintance, is your best consultant.”

Blake Mycoskie

This is more apparent now than it has ever been.  As a practicing clinician for over 10 years, the patient’s/consumer’s/acquaintance’s input mattered, but it played a small role in how I would change.  Not to belittle the advice, but I was getting great outcomes in patient care and was just making great strides clinically over the past decade.  My patients had little to offer in terms of things to change.

Fast forward to now and I am a clinic director taking on the same struggles that other new businesses face.  Not many new patients are walking through the door.  I will always be my biggest critic, but at this point, the words of wisdom given to me by patients and family members is worth gold.

“You have no visibility from the street.”

“No one knows that you are here.”

“You need to get out more to the older communities.”

“You should advertise in the local newspaper.”

“You should give more talks to churches.”

“You should go to neighborhood associations and speak”

All of these are great pieces of advice.  Some are more doable than others because advertising takes money.  Fortunately, since I have time on my hands, I am reaching out to different organizations for speaking opportunities.

Listen to your ideal client because they know how to reach more people like him/her.

 

Be the change

“Be the change you want to see in the world”

Mahatma Gandhi

This quote gets thrown around, but how often do we stop to analyze it?

What is the change that I want to see?

1. I want all PTs to have easier access to research.

2. I want the public to be more aware of the difference between good PT and bad PT services.

3. I want the public to know that a. PTs exist b. how PT is covered by insurance related to out of pocket costs c. and how PTs can help with physical issues.

4. I want PTs and students to be humbled and ask for help when needed and offer help when able.

Hello 2018, I got some lofty wants.

How have I started to accomplish these goals

1. Writing a blog and putting out videos describing the research that I am reading on a daily basis.

2. Giving community lectures educating the public regarding what to expect from a physical therapist. Educating the public on the core values and how some practices may demonstrate the practices. Unfortunately, I also highlight how some may not practice according to our profession’s core values.

I also started posting reviews of some of the neighboring clinics on social media when these clinics aren’t practicing in an ethical fashion.

3. Again, the blog and community lectures serve to educate the public of our existence and during these lectures I typically explain Medicare Part B regulations and coverages so that the potential patient can feel more comfortable about their responsibility financially.

4. To help others in areas of my strengths I do one-one conversations on FB, via telephone and in person. I readily ask for help when I am stuck and believe that I have a team of Avengers that I can reach out to at all times of the day.

How will you be the change in 2018?

 

Archilochus

“We do not rise to the level of our expectations. We fall to the level of our training”

This quote is taken from the Tim Ferriss book Tools of Titans.

In PT, we all believe that we will change the world. We have visions of grandeur in which we take patients from wheelchair to playing field. Preventing surgeries, curing world health problems and wearing a red cape with a big “S” on our chest…okay maybe not all of us have these dreams.

In the end though, our patients are doomed to fail if they see a PT that has not lived up to his/her professional duties of continuing education. In Illinois, we are required to obtain 40 hours of continuing education every 2 years.

Let’s think about this number. It’s been said that one needs about 10,000 hours to master a topic. That’s a lot of years if one takes the minimum amount of hours. At that pace, one can never become a master of anything other than a long commute.

When choosing a therapist, there has to be more thought put into it than your next vacation. You are spending your hard earned money…or the insurance company’s money…don’t you want to know that the person treating you is actually good at what they do?

Have they taught classes? Have they studied independently? Are they giving back to the community?

HELL, let’s start at the basics…do they pay attention to you when you’re in the clinic? Not in a three ring circus kind of way, in which they are just managing the acts that come in and send the patient from machine to machine, but are they paying attention to YOU?

I’d love to think that everyone in this profession of PT is operating up to his/her expectations, but deep down I know that we operate at or below our training. Not all PTs have the same knowledge.

https://movementthinker.org/2017/10/17/not-knowing-versus-not-learning/

Having spent time in the profession, I can state that I’ve seen the top 5% of the profession, and they are awesome. Unfortunately, it’s only the top 5%. The rest go nameless like worker bees to support a queen. There are very few queens in this industry and if you do a quick search, you can find those companies that make the most, are worth the most, are publicly traded etc.

We just want to help people. That’s the number one answer I hear from students entering the field, unfortunately not everyone continues to practice in this mentality once out of PT school.

We need to live up to our expectations more and improve our training to reach those expectations.

Salute!

“No one owes you anything”

This quote is from an excerpt of a conversation with Amelia Boone from “Tools for Titans”.

Growing up with 5 brothers and a sister, I learned that I wasn’t owed anything and that I had to work to get anything. My brothers were great baseball players and my sister had a mean tennis serve. I wasn’t built to be an athlete. At least that’s what I told myself.

In my neighborhood, college wasn’t an expectation or even an option unless one was a master of sport. Our area wasn’t known for producing scholars.

This would be my path. My parents sacrificed in order to send me to a private high school, where it would be hard to fit in because my upbringing wasn’t the “Leave it to Beaver” type. I had more in common with JJ Walker than Wally Cleaver.

I was descent at sports, but I knew I couldn’t play. I saw sports as a gateway to failure. I saw too often how excelling at something could lead one down a broken road. I chose not to play.

I instead joined the honors group at Providence. It was a small group of about 30 of us. One of the coaches said we weren’t “that smart, just knew how to cheat better”. He was partly correct, we knew how to cooperate to win.

What’s all this have to do with physical therapy?

In the end no one owes you anything. Having finished PT school, it was time to rest on my laurels and collect a paycheck. It was time to treat every patient that walked through my door the same as anyone before him/her. It was time to take the easy road…because I earned it.

Anyone who knows me, knows that I am blowing smoke.

I still follow this saying that I’m owed nothing and bust my tail to continue to learn and produce. I treat each patient as a new patient, even if it’s a presentation I’ve seen hundreds of times before, because it’s possible that there will be something with this presentation that will help me with the next hundred.

I never get to “cash it in” because I haven’t made it yet.

I have a pattern in life and it’s very apparent. My mom brought it to my attention about 15 years ago. The pattern is that once I’ve climbed the mountain and made it to the top…I pivot. The juice is always worth the squeeze, even when there is no juice.

There’s always something to learn, something to accomplish and another mountain to climb. I only wish that everyone could live a live never feeling like they were owed anything.

Salute!

Hey! If you enjoyed this post, so may your friends…SHARE IT!

Thanks.

The underdog story

The Underdog Story

How many of you stood in line to collect government cheese? That used to be a joke I would hear from those that were part of the “have” culture, but being raised in the “have not” culture made the line for government cheese a reality. The cheese was a brick of cheddar cheese.  Picture the industrial size that you would buy from Sam’s club or Costco, but it wasn’t near as good.  We had to use the old wire cutter in order to slice it.  We would race home and start cutting the cheese (not like that) with the wire cutter and the kids in the neighborhood would be full.  I never told my dad this story because he would’ve been upset with us taking handouts.

That’s were I grew up.  Our playground was a parking lot.  Our games of choice were whiffle ball and if you hit the taped up ball over the roof of the corner tavern, it was a home run.  We played tag in a blocks radius, which takes me to my next story.

I was always the heavy one.  I can remember going to Sears as a kid and heading straight to the Husky section.  That’s right…we had a section named just for us big kids.  Men’s, women’s, kid’s…husky.  Yeah, that wouldn’t fly today.

Being the “big kid”, I was always “it” when playing tag.  I wasn’t as fast as my more athletic brothers and would only be able to tag them if they let me.

One day while playing tag, I was chasing my brother and out of nowhere a car hit me and ran me over.  It could have been the end of me.  I should have been up in the clouds playing a harp.  Luckily, I was the big kid and my doctor reminded me of this when I was finally taken to the doctor after the accident.

He said (in a Chinese voice): “If you weren’t so fat, you could have been seriously hurt”

Looking back now, it’s a funny story, but it wasn’t then.

When my dad got home he only had one phrase for me; “did you learn anything”.  Mind you I’m 5 at the time! My dad is a Vietnam Veteran.  Tough to the core, but a heart of gold.  Whatever didn’t kill us would make us stronger and there had to be a learning lesson in there somewhere.

Needless to say, I had to overcome a lot of challenges growing up in an area where the anticipated outcomes were jail or cemetery.

This is what makes the story so great.  I overcame! I believe that anyone can overcome with the right mind set.

To other PT’s the title of doctor is one that can be spoken of only quietly in dark corners.  I am proud of it.  I am more so proud to have been named among the greats this year.  Updoc media named me among the top 40 influential physical therapists of 2017.

I’ve come a long way from the husky kid collecting government cheese.

Thanks to the guys at Updoc and thanks for reading.

https://updocmedia.com/2017-top-40-influencers/

HOW PT CAN HELP WITH FMS

HOW CAN PT HELP WITH FIBROMYALGIA?

I was recently asked in an open forum how PT can help fibromyalgia.  I hope the summary of this article sheds light on how important of a role PT’s play in this ailment.

“…Fibromyalgia syndrome (FMS) as a syndrome characterized by chronic widespread pain and tenderness in at least 11 of 18 predefined tender points”

First, when something is characterized as a “syndrome” it means that there is a cluster of symptoms that are common amongst people, but there is no definite test in order to prove that it is the cause of symptoms.

This makes FMS difficult to treat and understand because we don’t have a specific test in which to try to “fix” the underlying cause.

This article will go into what we know about FMS and what is hypothesized about FMS to further the patient’s knowledge of how PT can help.

“…prevalence rates between 0.5% to 6%”

This means that in the general population we will see this diagnosis between 5 in 1,000 and 6 in 100.  Depending on the setting that a PT works in, the prevalence rate may be much higher.  I can say personally that this is either the primary diagnosis or a secondary diagnosis in about 25% of my current caseload.

“…high comorbidity with other disorders, particularly chronic fatigue syndrome and mental disorders, including depression and anxiety disorder”

FMS is not frequently a diagnosis on its own. The patient with FMS may also have other issues such as chronic fatigue, which is not the same as FMS.  The person may also have a psychological issue, which may play a role in FMS.

“FMS is not only a chronic pain syndrome but also consists of a whole range of symptoms referring to effort intolerance and stress intolerance, as well as hypersensitivity for pain and other sensory stimuli”

Fibromyalgia goes well beyond pain only.  The patient with FMS is not frequently able to tolerate a great deal of activity without worsening of symptoms.  This is a major role for the PT to educate the patient regarding when it is safe to push harder and when the patient may need to back off activity in order to allow the system (read that as body as a whole) to calm down. A good book for this topic is “A World of Hurt” by Annie O’Connor and Melissa Kolski.

Hypersensitivity is a key finding in FMS and this will be spoken about later in the article.

“The precise etiology and pathogenesis of FMS remain undefined, and there is no definite cure”

When I read this, it sounds doom and gloom, but if you read it more like a science person instead of as a layperson it makes sense.  If we don’t know the cause of a specific action, then we can’t possibly know how to stop the action or prevent it in the first place.

“It is not our intention to advocate that physical therapists are able to manage a complex disorder such as fibromyalgia on their own”

Because there are multiple components to the syndrome (remember the psychological issues spoken of earlier), this is not a problem that can be handled by one professional without help from others.  As PT’s, we can play a role in managing this process, but that’s it…we play a role.

“Fibromyalgia syndrome is characterized by sensitization of the central nervous system, which explains the majority of, if not all, symptoms…Once central sensitization is established, little nociceptive input is required to maintain it…an increased responsiveness to a variety of peripheral stimuli, including mechanical pressure, chemical substances, light, sound, cold, heat, and electrical stimuli…results in a large decreased load tolerance of the senses and the neuromuscular system.”

When your nerves are more sensitive, then the sensations that you feel such as pain, heat, pressure, etc may be felt quicker and more intense than those without this syndrome.  This is the concept of little nociceptive input (pain input) is required to maintain sensitivity.  For instance, when someone has a lower threshold for pain (not an ego thing) then smaller deviations will cause pain.  I have treated patients that claimed to have increased pain from being touched by a feather! It is real and the patient’s experience of pain cannot be denied.

“…pain facilitation and pain inhibition is influenced by cognitions, emotions, and behaviors such as catastrophizing, hypervigilance, avoidance behavior and somatization”

This is a great article because the authors did a great job of attempting to summarize FMS in a concise manner. Pain is an experience.  It doesn’t mean that a tissue is injured, as pain can be felt in the absence of injury.  A person can also have a severe injury and not have pain.  A person’s emotional state can override the pain response. For instance, I experienced a major injury to my face in which my nose was pulled from my face during a weightlifting movement.  I had no pain until I actually saw the injury in a mirror.  The injury was unchanged from the minutes of standing at the bar until I went into the locker room and saw the injury.  What changed was my mental state.  I started worrying about severe damage, financial concerns, loss of work etc.  All of these are the same worries that everyone else has when they experience a pain that is not explained (this is the definition of catastrophizing).

Avoidance behavior means that a person will stop performing activities because of fear of making symptoms worse. Finally, somatization indicates that a person experiences symptoms in the absence of a test that can show anything is actually causing the pain.

Avoiding activity and catastrophizing actually causes a change in the nervous system in that it may sensitize the spinal cord.

“…abnormal functioning of the stress system seems to occur mostly in the aftermath of a long period of overburdening by physical and emotional stressors and to be precipitated by an additional trigger in the form of an acute physical or emotional event.”

Now you, as the reader, can see why PT’s can’t solve this puzzle alone.  There are so many variables that play a role in this syndrome that more than one professional needs to be involved in the care.

“…many patients with FMS have maladaptive illness beliefs, cognition, and behaviors that preclude successful rehabilitation.”

The primary intervention that takes place in therapy, almost regardless of the diagnosis, is education.  When a patient understands their own beliefs and how they may play a role in hindering progress, we have actually reached a milestone.  This is very much based in education.  If we can educate the patient enough regarding pain and more importantly how to respond to pain and its meaning, then we can progress towards other interventions.  If we can’t teach the patient or come to a mutual understanding regarding pain and how it is thought to work, then progress will be difficult.  As stated in the following portion of the article; “Poor understanding of pain may lead to the acquisition of maladaptive attitudes and behavior in relation to pain”. This means that the number one treatment that PT’s can offer to patients with FMS, and any other pain disorder for that matter, is education.

“…more adequate pain beliefs lead to increased confidence, which, in turn, leads to increased activity levels. An education course directed at improving self-efficacy for the management of the pain disorder ameliorated symptom severity and improved physical function”

We have to break the cycle of pain.  This may be achieved by breaking any part of the cycle.  The thought is that if we can increase a person’s activity level, or tolerance, that we could improve or decrease how sensitive the nerves are to outside stimuli.  This would allow a person to slowly tolerate more and more activity with less pain over time.  This is considered graded exposure.

“Evidence in support of activity management alone for those with FMS is currently unavailable. However, it is generally included in cognitive behavioral therapy.”

The thought is that if we can reduce the stress (think physical, emotional and otherwise) that a person is experiencing, that we would be able to reduce flare-ups.  This is a good thought, but hasn’t been proven.  What we know is that we need to increase activity levels because there are many good benefits from an active lifestyle such as decreased risk of mortality, increased lifespan, and improved quality of life.

“Limited evidence supports that use of spinal manipulation and moderate evidence supports the use of massage therapy in patients with FMS”

There are many in the field of PT, including the American Physical Therapy Association, has stated that the passive use of physical therapy should be questioned if it is the primary treatment.  Passive therapy is treatment done TO the patient instead of done BY the patient.  This “passive therapy” also fosters the dependence of the patient on the therapist.

When a patient is dependent on a therapist for improvement, the winner is always the therapist and his/her bank account.  In the end, we want to empower the patient to take control of his/her pain status and start to experiment with activity in order to establish a baseline activity that can be performed without flare-ups.

“Strong evidence supports aerobic exercise, and moderate evidence supports muscle strength training for the management of FMS”

This is an easy statement to make, but many patients tell me that “they couldn’t tolerate any exercise”. This is where the therapist-patient team (therapeutic alliance) really comes into play.  It is the therapist’s job to listen to the patient in order to provide treatment strategies that will improve the patient’s fitness levels, WITHOUT flaring-up symptoms.

“Physical exercise is troublesome for many patients with FMS due to activity-induced pain, especially for patients with severe disabilities”

This statement sums up the challenge of physical therapy and the challenge for the physical therapist.  A patient with FMS cannot be issued a check-list of exercises to perform in the clinic.  There has to be a relationship of trust between the therapist and the patient.  When a patient comes into the clinic, he/she trusts that the therapist is issuing interventions with the patient’s end-goal in mind.  If, at any time, the patient feels that the therapist is not providing GREAT care, then the patient needs to leave and find a therapist that treats them as a person and not a number! This is important and will come up again towards the end of the article.

“Nonspecific factors such as the patient’s emotional processing of the encounter with the health care professional, the quality of the therapeutic alliance, and the patient’s treatment preferences may be important in predicting therapeutic outcomes.”

THIS IS HUGE! The emotional processing of the encounter….Read that again….How the patient perceives being treated during the session plays a role in the outcomes. When we know that there is an emotional component to FMS, it is our responsibility to ensure that we accommodate this by trying to provide the best experience as possible. This starts from the initial phone call and progresses through the initial visit.  This perception starts prior to the patient coming into the clinic.  The patient needs to be heard and feel important in order to get the best results. I would say that this should hold true to all patients and not just for those with chronic pain or FMS.

Thanks for reading and I hope it was helpful.

Excerpts taken from:

Nijs J, Mannerkorpi K, Descheemaeker F, et al. Primary Care Physical Therapy in People with Fibromyalgia: Opportunities and Boundaries Within a Monodisciplinary Setting. Phys Ther. 2010;90(12):1815-1822.

Not all patients get the same treatment for pain because not all therapists have the same knowledge

“Exponential increases in magnetic resonance imaging (MRI) scanning to identify these damaged structures (believed to be causing low back pain) have led to escalating rates of spinal fusions and disc replacements.”

There is a trend towards increased surgery rates in the US for low back pain.  We see upwards of a 777% increase in spine surgery for low back pain.  The sad part is that the your chance of having surgery is more dependent on your geographic location than other variables.  It has been said that if you are trying to avoid a surgery that you should also avoid an MRI…which takes us to the next fact.

“…evidence that abnormal MRI findings are prevalent in asymptomatic populations and are poor predictors of future LBP (low back pain) and disability”

In other words, if you go looking for a problem…you’re likely to find one.  The “problem” on the MRI may not actually be causing your symptoms though, as we see “problems” with people that have no symptoms.  To put it another way, if a “herniated disc” was always a cause of pain, then everyone with a herniated disc will have pain.  We know that this isn’t true.  This indicates that the structure/tissue that is a “problem” on the MRI may not be causing any problems at all during your day.

“…providing a patient with a pathoanatomical diagnosis can result in increased fear and iatrogenic disability”

Lots of big words there, so let’s work through this together.

Patho: bad

Anatomical: body parts

Therefore: pathoanatomical = bad body parts

This is typically what you hear when you have imaging (MRI, X-ray, CT scan) performed.  Herniated disc, degenerative joint, arthritis, stenosis. All of these words mean that something abnormal was seen on the image.

Iatro: means relating to medical treatment

Genic: means coming from

This means that the “iatrogenic disability” could be disability coming from medical treatment.

I know what you’re asking: “How can the medical interaction with a doctor/therapist/medical professional be causing the disability?”

This is a great question that the authors of the article will go into in a short while. More to come.

“It is increasingly clear that persistent and disabling LBP is not an accurate measure of local tissue pathology or damage alone…it is best seen as a protective mechanism produced by the neuro-immune-endocrine systems in response to the individual’s perceived level of danger, threat or disruption to homeostasis.”

WHAAAT?!

This means that the tissue that was previously damaged may not be the culprit for prolonged pain.  For instance, your body can have a protective mechanism produced by the brain when it feels threatened.  The brain is powerful in creating change. For instance, watch this video to see how quickly it can start to change.

“…pain and behavioral responses may fluctuate based on a person’s perception of threat, levels of attention to pain, mood, contextual social stressors, sleep, and activity levels.”

If you feel threatened, your pain levels may increase.  Removing threat through distraction has been shown to be helpful in multiple studies.  Tetris seems to be one of the most studied games.  Also, math is more painful to some than others.  In the clinic, I have used math as a distraction and watched how pain rapidly resolves and some patients are able to perform movements that they wouldn’t consider performing if they weren’t distracted.  There is some thoughts that the more often we ask you about pain…the worse it actually gets because we force the patient to emphasize the feelings of pain compared to their current function.  Finally, we know that a lack of sleep can cause a myriad of problems from difficulty concentrating to an increase in pain due to increased nerve sensitivity.  These are all factors that play a role when a patient comes to the clinic experiencing pain.

“This contemporary understanding demands a shift away from providing a simplistic structural and/or biomechanical diagnosis and treatment for LBP…enables the patient to become a partner in a therapeutic journey”

For some patients, we can correlate a “problem” on the MRI with their symptoms, but in a subgroup of patients, we are unable to do this.  For that subgroup, we need to look past the pathoanatomical model and therapeutic alliance (the teamwork between the therapist and patient) becomes very important in order to empower the patient with regards to symptom response and education.

“Growing evidence suggests that current practice is discordant with contemporary evidence, and is in fact often exacerbating the problem.”

We may not need to abandon the patho model completely, but we as practitioners need to have more than just the patho model.  In order to prevent iatrogenic pain beliefs, we need to grow our skills in order to better help you…the patient.  If you are going to therapy and are not seeing relief within 6 visits and don’t feel that your therapist has a strong understanding of your pain…seek a second opinion. Not all Medical Doctors are the same, and the same can be said for physical therapists.

Excerpts taken from

O’Sullivan P, Caneiro JP, O’Keefe M, O’Sullivan K. Viewpoint: Unraveling the complexity of low back pain. J Orthop Sports Phys Ther. 2016;46(11):932-937.

 

 

Not knowing versus not learning

“Ignorance: a limited understanding of all the relevant physical laws and conditions that apply to any given problem or circumstance”

I don’t think that this is much of a problem in the physical therapy profession for the basic concepts of the profession.  The issue of ignorance comes into play when we start discussing current evidence.  A new graduate’s primary responsibility is to pass the boards ( a national test in order to determine basic competency in order to practice as a PT).  Unfortunately, the boards are based off the books used during the physical therapy program and the books are based from research that is at least 5 years old or older.  This means that the students are being tested on material that is greater than 5 years old.  Current published research may not make its way into an educational programs curriculum due to time constraints.  In this fashion, the students may be ignorant to current research or niche research.

“Ineptitude: meaning that knowledge exists, but an individual or group fails to apply that knowledge correctly in a particular circumstance. “

This is common.  We know that therapists are not staying current with published research.  Time and access are two barriers to staying up to date on the research.  Just a quick example.  I dedicate 10 minutes per day to reading.  Even 10 minutes per day is hard to fit in with all the other hats that I must wear such as: business partner (http://www.goodliferehab.com/) , father, husband, running a separate Facebook page that interviews influencers and performing community lectures.  There is only so much time in the day and I can understand how some therapists will have a difficult time fitting learning into their day.  Barriers to obtaining current research can be the cost of a subscription to get the journal articles.  For instance, I pay over $1,000/year just to have access to research.  This is a big chunk of money when you consider all the other life activities that aren’t free.  Pair this with the fact that the “average” salary for PT is 80,000 ish and that students have well over $100,000 in debt.

, that $1,000/year over the lifetime of a career becomes expensive!

“For instance, through numerous scientific breakthroughs, there has been a repudiation of ‘folk’ treatments in our profession-such as hot packs or ultrasound for heat therapy-in favor of treatments based on scientific evidence.”

Going to PT should not resemble going to a spa! If you are going to PT and getting electrodes placed on you…getting hot packs placed on you…getting rubbed with gel while someone is moving a wand on your skin…or getting a rubdown…THAT IS NOT PHYSICAL THERAPY! On the flip side, PT should not resemble personal training! Going to your therapist and getting a list of exercises for you to perform independently while your therapist is chatting with others…IS NOT PHYSICAL THERAPY! The closes profession that I can equate therapy to is that of a teacher-student (and not always is the therapist the teacher!).  This healthcare relationship should be a personal relationship that takes place in a private setting allowing for open communication between the therapist and patient.  The patient should walk out of each session with more knowledge than they walked in with. The patient should understand why interventions are performed…or better yet why some aren’t performed.  We need to get away from the tradition of PT and move towards what the evidence tells us.

“However, despite the excellent EBP (current evidence) resources now available, ineptitude remains a major 21st century challenge in medical and rehabilitation care”

I have a dare for all of you reading this.  When you go see your next healthcare practitioner I want you to ask a simple question: “How much education do you get every 2 years?” In PT, we are required to get a minimal amount of continuing education to maintain our license.  DO YOU WANT TO BE TREATED BY SOMEONE THAT IS ONLY GETTING THE MINIMAL AMOUNT OF EDUCATION OR SOMEONE THAT IS DEVOTING TIME TO FURTHER THEIR KNOWLEDGE OUTSIDE OF THE MINIMAL STANDARDS FROM EACH STATE!

“…3 types of influence that have been shown to relate to the rate of spread of an innovation: (1) perceptions of the innovation, (2) characteristics of those who adopt the innovation or fail to do so, and (3) contextual factors”

The following will discuss how these all relate.

“First, the perceived benefit of the proposed innovation relative to its cost is the most powerful influence.”

For instance, a hot pack may not give much benefit, but it is cheap and relatively safe.  You will see this frequently in a PT clinic that sees a high volume of patients because of its relative ease of use and safety…assuming the therapist is asking you how you’re doing and checking a few things before, during and after.

Cold laser treatment is slower to take off in our profession because it is an out of pocket intervention…which means that your insurance company won’t pay for it regardless of whether it works.  This intervention is slower to be used in the clinic because it may be cost prohibitive for some patients.

“Second, rapidity of change is directly related to how compatible the innovation is to values, beliefs, and history.”

There are some “treatments” that become popular during years of summer Olympics.  In 2012, a specific brand of tape was seen on many of the “big name” volleyball players.  The thought was that it “kept things more supported”.  There is no research that conclusively states anything near this type of statement…but there is a lot of research that says the opposite.  We still see it used in clinics today…which is okay, if the rationale for using it is what is intended from our current knowledge base.  For instance, we know that it reduces pain and allows for increased ROM…sometimes.  If the patients are educated in this regard and not that it “keeps things in place” …go for it.  It seems like 2016 was the year of the octopus.  If you looked at one of the “world’s most famous swimmers”, it looked like he wrestled with an octopus underwater.  This technique has been around for centuries.  Some therapists are starting to do it because patients are asking for it.

“Third, the complexity of an innovation affects the rate of its adoption, and, as expected, simple innovations spread faster than complicated ones.”

Ultrasound, electrical stimulation, and traction are all very easy to perform…since the machine does most, if not all, of the work.  These were quickly adopted into our profession and are hard to convince some clinicians to stop using…regardless of what the evidence states.

More complicated interventions such as “critical thinking” are harder to adopt.  For instance, when assessing a patient with back pain or vestibular issues, there is a plethora of research showing that if we can classify it that we have a better outcome.  Classifying the problem requires (1) knowledge, (2) assessment, (3) application, which is a lot harder than just pushing a button on a machine.

Some of the personality types are as follows: 1. Innovators, 2. Early adopters, 3. Early majority 4. Late majority, 5. Laggards

A lot of these are self-explanatory, but it trends from those that jump onto something quickly to those that just hate change.

“Organizations that foster social exchange among its members are likely to see faster adoption of innovations as compared with institutions and organizations that foster habits of isolation and tradition.”

Essentially, workplaces that allow for communication will allow for change faster than workplaces that keep everyone separate.  This has to do with changing a culture.  A business that has a fluid culture (one that is easily adjusted), is more apt to change than one that has a strict culture.

“Publishing our work in journals is essential-but publication of research is not, by itself, sufficient if our goal is to change clinical practice. People follow the lead of other people they know and trust when they decide whether to take up an innovation and change the way they practice!”

This is huge! Any profession is a small world and PT is no different.  To push the profession forward, we must depend on more than just published research.  There are many influencers in our sphere such as Dr. Ben Fung, Dr. Jarod Hall, the team from PT on ICE, the team from Evidence in Motion, Dr. Richard Severin, and myself (I’m always trying to sneak my way into this group of titans).  By seeing others lead the way, it is much easier to follow.  Only the innovators and early adopters will feel comfortable at the front of the pack.

As a patient and therapist, you may want to assess your therapists/mentor and determine which of the 5 personality types he/she has.

 

Thanks for reading.  Please leave a comment on my FB page letting me know what you think.

EXCERPTS TAKEN FROM:

Jette AM. Editorial: Overcoming Ignorance and Ineptitude in 21st Century Rehabilitation. Phys Ther. 2017;97:497-498.

 

link to abstract