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Category: PTs

Part I: TBCS revision

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Part I: TBCS revision

“In order to optimize the treatment effect, patients with LBP should be classified into homogeneous subgroups and matched to a specific treatment. Subgroup-matched treatment approaches have ben shown to result in improved outcomes compared with nonmatched alternative methods.”

There is more information coming out over time that demonstrates certain patients do well with specific treatments related to that particular patient.

Looking at the broad scale, there are many people with LBP across the world.  Not everyone with LBP has similar symptoms or will respond to the same treatment.

For instance, if your pain gets worse with repeated or prolonged bending, prolonged sitting an standing slouched, your treatment will look differently than someone that gets better with the aforementioned activities.

This is what is meant by subgrouping patients into groups.  We take the patient’s presentation and history and match that to an intervention that tends to work well for that group.

One such method of subgrouping can be found here.

This article will highlight a different approach to subgrouping, the Treatment-Based Classification System. This is a post that I previously wrote on this system.

“There are 4 primary LBP classification systems that attempt to match treatments to subgroups of patients using a clinically driven decision-making process: 1. the mechanical diagnosis and therapy classification model described by McKenzie, 2. the movement system impairment syndromes model described by Sahrmann, 3. the mechanism-based classification system described by O’Sullivan and 4. the treatment-based classification system described by Delitto et al.”

I won’t hide from my deficiencies.  I am well versed in the MDT system and fairly well versed in the treatment based classification system.  I am not well versed in the MIS or the MBC.  I will limit my advice to that which I am knowledgeable.

Yet, these systems-without exceptions- have 4 main shortcomings:

  1. No single system is comprehensive enough in considering the various clinical presentations of patients with LBP or how to account for changes in the patient’s status during an episode of care.
  2. Each system has some elements that are difficult to implement clinically because they require expert understanding in order to be utilizied efficiently.
  3. None of these classification systems consider the possibility that some patients with LBP do not require any medical or rehabilitation intervention and are amendable for self-care management.
  4. The degree to which the psychosocial factors are considered varies greatly among these systems, which runs contrary to the clinical practice guidelines established by the American Physical Therapy Association (APTA) that advocate using the biopsychosocial model as a basis for classification.”

I will address these points regarding my knowledge of MDT and TBC.  I will not address the MIS or the MBC due to my lack of knowledge regarding these systems.

1. No single system is comprehensive enough or accounts for changes in status during an episode of care.

First, I can’t fully agree with this statement.  Yes, there is no system to date that can account for every patient that walks through the door.  This is true.  This is why a therapist must be well versed in multiple systems.  For instance, MDT is a system that doesn’t take into account non-movement based pain presentations.  When paired with an approach that takes this patient presentation into account, it makes for a great pairing.

The TBC does not account for change during the patient’s episode of care.  Once a patient is classified and the intervention is applied, there is no algorithm for further improvement or progression.

This is not true though for MDT.  For instance, a patient can be classified into one of three categories.  The first two categories have built in progressions, regressions and modifications to movement.  The third category is a category that doesn’t require much intervention aside from advice.

With the first category, derangement (another way to say this would be rapidly changing) there is a clear progression.  Let’s start with the term derangement.  No one likes this term to be used for patients.  It’s a long running joke that we should never tell patients that they have a derangement. Words do matter and the patient’s perception of this term may be just as important as our expectations for the patient.

Now, moving on to the important part of the post.  When a person is classified as a der…I mean a rapidly changing presentation, here is what the progression looks like in the clinic:

  1. Reduce the der…Dangit! I almost did it again.  Make the symptoms better quickly.
  2. Make sure that the patient can maintain the reduction in symptoms.
  3. Return to the functional activities that the patient would normally do during the day without reproducing symptoms
  4. Teach how to prevent the symptoms from returning

That seems like a fairly simple strategy when bringing patients through a program in PT, but unfortunately this simple construct is lost on a lot of professionals.

 

Why you ask?

 

Thanks for asking.

 

Because unfortunately, there is no profit in getting people better.  Shhhh….You didn’t hear it from me.

 

Regarding the second category of Mechanical Diagnosis and Therapy: Dysfunctional tissues, it also comes with a game plan that is easier to follow than the first, but not as fun to implement.

Also, the name dysfunction is another term that I have gotten away from in the clinic.  Again, patients don’t want to be deranged or dysfunctional, although if given the choice, I would much rather have a derangement.  They want to know is it going to improve and if yes, what’s the timeline.

These issues are like hamstring or achilles problems…they tend to get better if left alone until….WHAM! You goin for a quick sprint to keep your child from running out of the door at the grocery store.  OR you run down the stairs because you are feeling froggy.

It let’s you know….DUFUS! YOU NEVER CORRECTED THIS PROBLEM!

This tissue issue (say that 5 times fast!) needs to be loaded to the point of pain and then allowed to recover before it is loaded again.

Like one of my mentors Annie O’Connor says in her courses “No pain… No gain…No guts…No glory”

This example is rarely used in therapy, but this is one case in which this example is fitting.  Ideally, this tissue is loaded consistently.  I have seen research that states the achilles tendon should be loaded about 1200X/week.  That’s a whole hell of a lot of repetitions.

As a matter of fact, if you would like to read more about this, you can find a previous article that I commented at this link.

  1. “Each system has some elements that are difficult to implement clinically because they require expert understanding in order to be utilized efficiently.”

I would wholeheartedly agree with this statement.  There is research that demonstrates good reliability when MDT is applied by those that have taken, and passed, the credentialing exam.  It has been shown multiple times, but here is one of the more current articles.

The systems are not easy to use, nor should they be easy to utilize.  It irritates me to no end when I hear about a therapist “using the McKenzie exercises” even though he/she has no idea regarding the wrongness of the statement.  Open mouth…insert foot.

There has to be something sacrificed in order to learn a method or system.  Time, money, life…these are all things that I sacrificed in order to get to where I am at in my career, which much to learn remaining.

 

“None of these classification systems consider the possibility that some patients with LBP do not require any medical or rehabilitation intervention and are amendable for self-care management.”

Again, can I disagree with these statements.  At one of the MDT conferences (they blend together), Nadine Foster presented on the STarTBack screening tool.  MDT is advancing to keep up with the research.

Those that keep up with the research or attend MDT-based conference, understands that not all patients require follow-up, or even an evaluation!  Some patients do get better with time.

To follow-up with this, there is still one classification that I didn’t describe yet. This is the postural syndrome. In this syndrome, the patient has no signs or symptoms of a problem…unless he/she maintains one position for too long.  Once the patient moves from that position…the symptoms disappear.  It’s like Wizzo (it’s a Chicago thing).  I bet you didn’t know that you were going to get a history lesson.

“The degree to which the psychosocial factors are considered varies greatly among these systems, which runs contrary to the clinical practice guidelines established by the American Physical Therapy Association (APTA) that advocate using the biopsychosocial model as a basis for classification.”

I agree with this, in that MDT or the TBCS doesn’t appear to utilize psychosocial factors in classifying patients.  There is another classification that appears to be paired well with MDT.  Check out this podcast with Annie describing this system.

This will be continued in the next article that goes more into depth on TBCS.

If you would like to read the article highlighted above, you can find it at this link.

Thanks for reading.  For those that gained a little knowledge from this article…please share so others can learn about classification of low back pain.

 

 

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The influence of patient choice

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on The influence of patient choice

“Approximately $85 billion are spent annually on spine-oriented conditions, and an additional $10 to $20 billion are attributed to economic losses in productivity…Per-patient costs have increased by 49% from 1997 to 2006.”

Spine related issues cost our country about $1 Trillion over the course of a decade. Seeing as how we are dealing with a pandemic, people now have a better understanding what $1T can do for the country.

It can give each person thousands in financial relief. It can give small businesses hundreds of thousands in relief.

The number seems arbitrary until you actually see what a Trillion dollar bailout looks like.

If we can reduce the impact of back pain on society, we could keep this money in the economy because there wouldn’t be lost productivity, out of pocket spending and other expenses that come with back pain.

Healthcare would forever be changed if we can reduce the economic impact of back pain, as it is the most prevalent issue seen in outpatient clinics, many emergency departments and most primary care physician offices.

There would be so much opportunity to actually focus on maintaining a healthy population instead of trying to solve a pain/disability problem.

“despite the rising costs, there has been no real improvement in terms of disability or reduction in the proportions of individuals who report back or neck pain.”

This is a little bit of a controversial fact for me. Our ability to treat back pain through classification has improved over the years. For instance, a recent study on downstream costs shows that when using MDT there is fewer follow-up visits and extensive diagnostics required.

I don’t think that we will ever stop people from experiencing pain, back pain or any other locations. People experience pain. This is a fact. Pain can be a good sign to keep us from doing things that create pain in the first place. The problem, in my opinion, is when we allow pain to prevent us from doing things that are considered a normal part of life.

For example, most experience pain when touching a hot stove. This can be used as a warning signal that hot stoves are dangerous.

Unfortunately, many experience pain when bending forward. The same logic applies and some believe that they are actually creating harm when bending forward, so it’s avoided altogether.

This is where I believe a good PT can be worth his/her weight in gold. Teaching a patient to return back to normal activities that the patient previously believed to be dangerous could increase the patients quality and possibly quantity of life.

I now want to address the rising costs of treating pain. The next unfortunate issue is that I personally know practitioners that are so out of touch with current research that they continue to treat patients as if it is 1980. We wonder why, as a whole, we are no better at treating patients.

Why do you think this happens?

One reason is that healthcare is a business.

There’s a ton of conspiracy theorists out there that believe the government is hiding the cure for cancer so that the businesses that treat cancer can continue to make money. For some reason this same conspiracy hasn’t made its way down to back pain.

I’m not sure if you saw the amount of money spent on back pain, but if not then go back up to the top of the post.

There’s big money in back pain.

Why should providers want to get you better faster?

In all honesty, I think the providers want you to get better faster. The providers don’t typically make much less if you get better faster.

The business on the other hand stands to lose a lot of money if the patient gets better at a faster rate.

I’ll speak specifically to physical therapy and use real numbers.

On average a clinic with 2 PT sees about 10 new patients per week. Let’s just say that 8 of the 10 are for some version of spine pain.

This would mean that on average we are seeing 400 new cases of spine related pain in a two person clinic per year.

On average, the reimbursement per treatment session in IL is $95-$100 per session.

If the business asks (more like demands) that a PT keeps the patient for 13 sessions, where’s the therapist with less supervisory demands sees the patient for 8 visits, there is a major difference in the overall income for the clinic.

Clinic 1:

400 (new patients) x 13 (visits)= 5,200 visits

At $95/visit

5,200(visits) x $95(per visit)= $494K

Clinic 2:

400(new patients) x 8(visits)=3,200 visits

At $95/visit

3,200(visits) x $95(per visit)=$304K

Are you starting to understand the problem?

The clinic that requires PTs to see a patient for a specific number of visits stands to generate an extra $190K. This is an example for a two therapist clinic.

Multiply that by the hundreds of thousands of PTs in the country treating back pain and you see how the costs are artificially inflated.

Until insurance companies cut back on what is reimbursed, we will not see a change in practice. What we are seeing insurance companies do is a step in the right direction, bu I personally believe that they are doing it incorrectly.

Right now the insurance companies are giving us typically 8-12 visits that are to be used over the course of 6-8 weeks.

What I would like to see is an insurance company give us a stipend of a few thousands of dollars to care for that one patient over the course of the year. Meaning any problem that occurs with that particular patient is our responsibility to rehab. We become accountable for that patients health.

We are seeing this with some Medicare Advantage Plans, and it seems to be effective at countering the rising costs of healthcare.

Until a drastic change in how we get reimbursed happens, we will continue to see the numbers rise like they have.

I just don’t think that the changes that have happened, restricting the number of visits, is enough to make companies take responsibility for actually helping patients.

“The estimated proportion of persons with back or neck problems to self-report physical functioning limitations increased from 20.7% to 24.7% from 1997 to 2005, suggesting that current care models may be insufficient.”

I have personally seen patients reporting increased disability with time.

Part of what has to be considered is “how many of these individuals reporting disability also have secondary gain issues?”

Meaning, how many people reporting increased disability are actually receiving disability payments?

Secondary gain issues would have to be considered a limiting factor when reporting these numbers.

The next aspect to be considered is the affective component of the impairment. Meaning, how many people are experiencing increased disability due to the environment they spend their time and the situations they surround themselves.

It’s like the opposite of herd immunity. I’ve been part of many FB groups specifically designed for support, but the groups offer anything but support. These groups offer misrepresentation of diagnoses and prognoses. Many people looking for support and assurance are met with information about lifelong disability, surgical options and nocebo language.

There’s more to disability than pain.

A persons belief about pain has an impact on disability. We know this.

We really need to look at changing the narrative about back pain.

“Clinical practice guidelines for primary care management of spinal conditions generally suggest initial management strategies of self-care and nonsteroidal anti-inflammatory medications. Referral to specialist, including physical therapist or for diagnostic imaging is only encouraged for those who failed to respond after period of watchful waiting.”

This is part of the problem. Instead of stratifying the patient based on risk factors for developing persistent pain, which I’ve written about one tool previously, they are treating all back pains similarly.

Some patients will get better on their own without any treatment.

Others would benefit from early treatment.

The medical system has to do a better job of separating these groups in order to maximize outcomes and reduce disability numbers.

“recommended best practices based on such clinical practice guidelines are to avoid bedrest, to use opioid medications for a limited time, and to obtain magnetic resonance imaging only for specific presentation of radicular symptoms.”

This seems very basic.

Unfortunately, these aren’t necessarily followed. I have many patients, over my career that are opioid dependent. There is research showing that long term opioid usage can actually increase a person’s sensitivity to pain. Think about that, medication that initially makes a person unable to sense pain, over time makes a person feel more pain (either frequency or intensity).

I believe that the idea that imaging should be minimized until needed has be adopted more so than the short term usage of opioids.

I rarely see patients coming into the clinic for an evaluation that received an MRI prior to physical therapy. Part of this has to do with insurance companies not approving MRIs until conservative care has been attempted. This has to be commended.

Now we just need our profession to stop looking at patients like an ATM and start to see each case as one that could go to surgery if we don’t make progress.

We have to see the months that the patient would be unable to work and function. We have to employ empathy.

The state of the profession currently sees patients as widgets to be accounted for in productivity measures.

Again, this needs to change in order for us to have an impact on the disabling mentality that is growing with regards to back pain.

“… alternative care models offering direct access (The ability to seek and receive the examination, valuation, and intervention by physical therapist without requiring physician referral for legal or insurance coverage) to physical therapy have suggested fewer days of care and lower costs.”

Looking purely at costs, direct access has the potential to save insurance companies and patients money. This savings would come at the expense of the physicians, hospital systems and emergency departments.

But how you ask?

As it stands, patients would require a referral in most states to be evaluated and treated in a physical therapy environment for longer than 4 weeks. Because of this, a patient would need to go to a physician in order to receive a referral for physical therapy. Each time the patient sees the physician, the costs is about $80.

If PTs has direct access, which in my mind doesn’t just include the ability to be assessed and treated by a physical therapist, but also consists of having that particular patient’s insurance pay for the assessment and treatment, then we would have fewer trips to the emergency department, quick care or physician.

This would save money immediately for the healthcare system and saves the patient time. Instead of waiting to get into a physician and then waiting to see the PT, the patient could walk into the PT office and be assessed within 24-48 hours.

“The majority of the 447 patients included in the analysis chose traditional medical referral (61.7%).”

This is interesting for me to navigate. The group that chose to go the route of direct access ended up saving about $1,500 in total cost of care. This number is misleading though because it didn’t take into account the amount of money that the patient actually paid out of pocket.

For instance, in a 90%/10% coverage plan, the patient would have only paid an extra $150 out of pocket (assuming the deductible was met). That’s a large difference from the patient paying an extra $750 if the patient has an insurance that pays 50%.

Because this $1,500 can vary patient to patient, I’m not sure if it is a good metric to use because it really tells us how much money we are saving the insurance company, instead of telling us how much money we are saving the patient.

I understand the argument that if we save the insurance company money, then we would save the patient money on a lower premium, but I just don’t believe that we will make enough of a dent in healthcare costs to ever drop premiums. It is a business after all and the scenario I more likely see is the business pocketing a larger profit for the money we save them.

This brings us to the next topic : why would patients choose to go to see a physician first before going to PT as a direct access visit?

I think that this would make a good quantitative study to determine what are the factors that correlate with seeing a physician first for back pain prior to seeing a PT.

The other questions to be asked are what would make one choose a chiropractic physician, naprapathic doctor, accupuncturist, massage therapist or physical therapist for specific ailments?

In the end, we know that we have the potential to save the patient money if the patient chooses a direct access (walk into the clinic off of the street) when compared to seeing a physician prior to receiving a referral for physical therapy. Because a majority of patients in this particular study still chose the physician first, there must be other issues in play as to why patients aren’t choosing direct access OR the patients aren’t aware that we could actually save them money.

Link to article

A novel case study

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on A novel case study

I was just speaking about this case to one of the PTs that works with me this week, and felt it a good learning opportunity to post to the inter webs.

78 year old male was referred to me from another PT. The patient underwent 6 weeks of PT with another therapist also certified in MDT.

I helped train that PT and she felt that the patient should be referred to me to see if there was anything missed during the appointments.

The patient had an extrusion at L3, affecting quad strength. He also had a loss of light touch sensation at the anterior thigh.

His only complaint was pain that would wake him up at 2 AM, which was very intense. He would take a Norco and walk for 30-45 minutes to reduce his pain. He could sleep until 6 or 7 AM, which is when the excruciating pain would return. Again, he would take a Norco and walk. The pain would go away and not return the rest of the day until 2AM. He was very active with Tai Chi and Kung Fu over 10 hrs per week.

His only complaint was pain in the middle of the night.

I couldn’t provoke his pain during the evaluation.

He had already been through 6 weeks of PT without change, so I was only trying to figure out his sleep issue.

I had a working hypothesis

1. Overnight, the disc imbibes fluid and increases in size.

2. It was possible that the change in fluid content was increasing his pain since the pain went away when he was up walking during the night

3. If I could prevent the disc from taking on fluid, his pain might shut off

That was my only thought pattern that made sense for his symptoms.

I had him sleep in a recliner and to call me in 2 days with the result.

He was painfree in the recliner and did not wake at all.

Because he already had 6 weeks with an MDT trained clinician, I didn’t feel that bringing him into the clinic was going to be productive, so I followed by phone.

After two weeks, which is how long it is expected to see results if given the right direction and load, he was able to return to bed without waking.

This patient returned to therapy for a different issue a year later and we had a conversation about his back (he was seeing a different therapist). His strength recovered and he didn’t require surgery.

Moral of the story:

1. Sometimes you have to think outside of the box

2. Don’t let the image dictate treatment

3. Only treat the patient if we can improve their lot in life

4. Always develop a relationship with the patient you are treating.

Hip impingement? Is there a place for PT?

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Hip impingement? Is there a place for PT?

“surgical rates for correction of FAI have escalated, despite limited evidence to support a cause – and – affect relationship between FAI and hip pain.”

It is said that there is an 18X increase in procedures over the decade Studied.

The fact that this surgery has increased at such a dramatic rate may be a result of who the patient sees for the problem.

Physical Therapists do physical therapy.

Surgeons do surgery.

Pain management do management of pain through chemical means.

Chiropractors do chiropractic medicine.

Acupuncturists do acupuncture.

It’s a very easy equation to figure out. Who you see to manage your symptoms will dictate what is done for your symptoms.

“… The evidence from these studies is mostly level four (low level), the reported results are short term, and at least one studies suggest a notably lower level of sport activity at three years surgery. Currently, there are no high – quality randomized studies examining the effectiveness of surgery for FAI”

This makes it difficult to make a broad statement due to the lack of controlled research. For instance, a sham surgery (a surgery in which the patient is cut, but nothing else is done) compared to an actual surgery would start to give us information on the value of the surgery.

Looks like the study is in the process of being Completed.

I personally like case studies and case reports because sometimes a “classic study”, such as a randomized controlled study, may not capture the characteristics of the patient in front of the health care professional.

“75% of surgeons believe that FAI surgery prevent future osteoarthritis, although 62% of the surgeons were either unsure of or did not believe there was an optimal debridement of SAI lesions to prevent future osteoarthritis”

A belief plus 5 dollars will buy a coffee at Starbucks.

Not a fan of these types of studies because it demonstrates the bias of the profession. The shocking statistic is the reverse. The fact that 25% of surgeons don’t believe that surgery prevents future OA is cool. Unfortunately, we don’t know the education level, outside of the fact that the people polled were surgeons, of each person in the poll. For instance, if it’s the best of the bell curve that believe surgery has no effect on OA, then I may side with that opinion. We just have to think critically when reading these numbers.

“… The fact that 34% of both pediatric and adult patients diagnosed with FBI stated that they I knew they wanted FAI surgery (21% not willing to try conservative therapy for six months) suggest that orthopedic/sports patient has a propensity for overconfidence in surgery as the gold standard treatment.”

We are all salespeople for our profession.

Don’t believe me…just check out how many people are selling PTs education on Sales tactics and marketing.

It seems that surgeons are doing a great job of sales in that 1 in 3 believe that surgery is the answer.

As PTs, many of us are learning how our language affects the patient, both positive and negative.

It would be easy for me to convince a patient that they are weak and need us, but I don’t know if that is doing more of a service or disservice st that point.

“We think we could all benefit from learning from our past, when, despite similar increased endorsement of surgical intervention (746% increase in shoulder arthroscopy for impingement over a ten-year span), surgical patients fared no better than those treated conservatively.”

Yup.

Another way to say conservative = non surgical.

I’m going to leave this final quote from the article as the final statement. 👇

“Stop accepting morphology as pathology”

Link to the article

Life purpose and changes

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Life purpose and changes

“If you want to change the world, you have to enroll others in your plans and vision.”

Adam Robinson

About 2 years ago I started a blog. It was just for fun and the premise behind the blog is this “the only knowledge wasted is the knowledge not shared”. I saw this quote on a t-shirt; a blog was born.

My goal is to provide high quality content to readers through this blog in order to assist them with making decisions regarding choosing a health care practitioner. The secondary goal is to educate physical therapists at least up to the point of at patients. It sounds cynical that I believe that some patients have more knowledge than the PT, but I also believe that the patient has more to lose and more at stake than the PT.

The PT only has a paycheck at stake, maybe a reputation. The patient has life limitations and issues that may prevent them from truly experiencing life. That way more at stake than the PT has on the line. In this fashion, I have seen patients becoming smarter over the years through forums, FB groups, reading blogs and watching videos.

The reason why I say high quality content is because there are a lot of lies and misinformation on the World Wide Web (internet). Healthcare professionals prey on the weak and ignorant to take their money using scare tactics and unrealistic hype.

I ain’t got nothing to sell you other than making you a better human through work. Nothing ventured, nothing gained.

I have increasing demands on my time with a family, managing multiple clinics, treating patients and community involvement.

My posts will become fewer and fewer as I try to fit them into my life instead of fitting my life around my work.

Love your life or change it

Dr. Vince Gutierrez, PT

It’s like the Gamler by Kenny Rogers

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on It’s like the Gamler by Kenny Rogers

“If you must play, decide on three things at the start: the rules of the game, the stakes, and the quitting time.”

Chinese proverb.

This is a lesson that learned later in life. I entered into an agreement under one pretense (set of rules) and after entering the agreement and quitting my job, the rules changed. At that point, I had to ride out the decision that I had made to quit and try to make the best of it.

I wasn’t fully aware of the rules; they changed during the game.

After making the decision to leave my current job, in order to open a clinic with a friend near where I created my following, it was decided that the clinic would be 35 miles away! This was a major blow because now I was starting completely fresh and had no following (although a few patients chose to make that drive). I was able to get in front of over 1,000 pairs of eyes in person and 160,000 pairs of eyes through social media and newspapers.

Unfortunately, I still didn’t know all of the rules until well into the game and at that point my wife and I realized that I couldn’t win the game and we started to discuss quitting time.

Luckily for me, I busted my ass to build my following in this new area. A local business wanted both my skills and my work ethic. The fact that I was able to bring new faces to the clinic was a bonus.

The clinic needed another PT within a few months and through hustle and blessings, I was also able to build a following among PTs, so finding another PT that wanted to work with me wasn’t difficult.

I am now making more money working fewer hours and learning more about the business of health care than I had during the previous 12 years of my career.

I had to learn the lesson the hard way.

Whenever you are entering into an agreement, both sides need to understand the rules of the game, the risks and rewards and when to call it quits.

“You got to know when hold em; know when to fold em; know when to walk away; know when to run.”

Rehabilitation after a shoulder replacement: What’s the norm?

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Rehabilitation after a shoulder replacement: What’s the norm?

“There is growing belief among orthopaedic providers that how much formal physical rehabilitation a patient receives is influenced by the patient’s insurance and its willingness to pay for various postoperative therapies.”

This makes sense. Many patients aren’t aware of how much their insurance will cover regarding physical therapy. For example, Medicare will cover 80% of physical therapy after the deductible is met. The deductible is $183. In our state, average coverage of physical therapy is about $90/session. This means that the patient would be responsible for 20% of the $90, or $18/session. This makes the assumption that the patient does not have a secondary insurance that may cover the 20% that Medicare doesn’t cover.

Medicare will cover all PT that is considered medically necessary and cases that go above $3,000 are subject to a manual medical review. This would be about 33 visits per year. Speak to your PT about this in order to verify this information. Each clinic charges a little differently than others and these are the averages in my experience.

Unfortunately, many people that have Medicare as their primary insurance do not understand the physical therapy benefits associated with this insurance.

“A recent study challenged the need for formal physical rehabilitation after anatomic total shoulder arthroplasty (TSA), finding that a home-based, physician-guided therapy program provided similar results with lower costs.”

If a patient can get better without going to PT, we should all be in support of this.

This study tracked patients with Human, which included 20.9 million people. This is a huge sample size. This information was compared with a 5% sampling file of patients utilizing traditional Medicare. The study collected data for a long period of time, from 2010-2015 and the patients had to undergo a TSA or RSA (reverse shoulder arthroplasty). Rehablitation visits were tracked for 6 months after surgery, by tracking charges that are traditionally utilized in rehabilitation. Any date that a specific charge was utilized was counted as 1 visit.

The grouping was paired as follows: 0 visits of rehabilitation, 1-5 visits of rehabilitation, 6-10 visits of rehabilitation, 11-15 visits of rehabilitation, 16-20 visits of rehabilitation, 21-25 visits of rehabilitation, 26-30 visits of rehabilitation and greater than 30 visits.

“The study included 16,507 patients”

This was a huge number of patients. This strengthens the reach of the research. The more patients that are included in a research study, the stronger the statement can be made (regardless of the statement) at the end of the study.

“In general, the Humana cohort had higher overall physical rehabilitation utilization than did the Medicare population across all factors.”

Patients with Medicare are not treated in physical therapy as much as non-Medicare patients.

“The Humana and Medicare populations had a similar percentage of patients with 0 visits.”

“The Humana population had a higher percentage of patients in all visit categories above 1 to 5 visits”

“…with the Midwest having significantly less physical rehabilitation utilization, which is best demonstrated by 69% of patients in the Midwest undergoing only 5 or fewer physical rehabilitation visits, compared to only 54% of patients in the Northeast and 53% of patients in the West.”

This is the anomaly that I would like to know more regarding. Why do patients in the Midwest choose to not utilize PT? This could be poor education of patients regarding the importance of PT. It could also be that PT’s in the Midwest are following more of a HEP based protocol and only having patients return to update the HEP.

“the possibility of patient-directed rehabilitation at home having equivalent outcomes to formal office-based physical rehabilitation was brought to the forefront after Mulieri et al demonstrated equivalent outcomes after TSA when comparing the 2 therapy programs.”

This is a study that I will attempt to get in the next couple of weeks. If a patient does not need PT services in order to improve function, then Boo Hoo for our profession, but we have to do what is best and right by the patient. Should this study demonstrate that PT’s aren’t able to provide additional value beyond not performing therapy, then patient’s should not seek out PT.

I’d like to believe that we have a place in the rehabilitation process post TSA, but I also don’t think that our place is one of > 20 visits.

Excerpts taken from:

Wagner ER, Solberg M, Higgins LD. The Utilization of Formal Physical Therapy After Shoulder Arthroplasty. J Orthop Sports Phys Ther. 2018;48(11):856-863.

 

One piece of equipment that may benefit your rehab process after a shoulder surgery is the following:

https://amzn.to/2BHMpX7

I find that over the door pulleys are easy to use and quick to install.

 

Plantar Fasciitis and Ultrasound: questionable at best

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Plantar Fasciitis and Ultrasound: questionable at best

“The plantarfascia is a thick, nonelastic, multilayered connective tissue crossing the plantar part of the foot. Plantar fasciitis is the main cause of pain in the plantar surface of the heel.”

The plantarfascia is located at the bottom of the foot, between the heel and the toes.   It is very thick and a tough band.

A part of physical therapy school includes dissecting the human body.  Some people find this disgusting, but it is actually an honor.  We were told that only 5% of college students will ever be able to dissect the human.  The bottom of the foot is very intricate. There are multiple layers of muscles, but the plantar fascia is a very taut band that requires a scalpel in order to tear.  In other words, it is very strong tissue.

“In the United States, more than 2 million people are treated for plantar fasciitis every year…the most common signs for identifying plantar fasciitis are pain and tenderness in the medial …heel bone, as well as an increase in pain when taking first steps in the morning and pain in prolonged weight bearing.”

First, plantar fasciitis is mostly diagnosed through a patient’s history.

Second, there are a lot of people with plantar fasciitis that seek out treatment.

This leads us to the next statement from the article

“…researchers have not determined the most effective combination of treatments due to the dearth of high quality research in this area.”

Feel good about this condition yet? So many treatment options are available, but few with solid research to back them up.

If you are interested in learning more, check out this  Link

“One of the most widely used electrical devices among physical therapists in Israel and worldwide is therapeutic ultrasound…Yet there is insufficient high quality scientific evidence to support the clinical use of therapeutic ultrasound in treating musculoskeletal problems.”

I find it funny that PT’s should know this information and yet they act opposite of what the evidence indicates.  There are running jokes that using ultrasound may be just as effective turned off as when turned on.

If your PT continues to utilize ultrasound, ask why?

Sometimes the answer may simply be: it is easy, it can be charged and it will do no harm.

Treatment:

Both groups were given stretches for the Achilles/calf and the plantar fascia.  One group was issued ultrasound at a higher intensity in order to create a thermal effect and the other group was given ultrasound that was low intensity and not postulated to have any physiological effect, as the intensity was low and the depth of treatment was considered more superficial.

There was no significant difference in the number of treatments per group.

Result: There was no additive effect of ultrasound on the treatment of plantar fasciitis for pain, function or quality of life.

There are reasons to use ultrasound from a business perspective, but the more and more that I read research I find fewer reasons to perform the intervention medically.

Reference:

Yigal K, Haidukov M, Berland OM et al. Additive Effect of Therapeutic Ultrasound in the Treatment of Plantar Fasciitis: A Randomized Controlled Trial. J Orthop Sports Phys. 2018;48(11):847-855.

ACL rehab

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on ACL rehab

“At 13 months post ACLR (Anterior Cruciate Ligament Reconstruction), individuals exhibited average knee extensor moments that were 17% smaller in the surgical limb during a bilateral squat against body-weight resistance”

ACL injuries tend to be noted in some non-contact sports such as soccer and basketball. Contact sports, such as football, also have ACL tears noted during contact, such as a tackle that makes the knee buckle inwards.

The patient with an ACL tear will typically opt for surgery if he/she plans on returning to some type of sporting activity. There is a debate as to whether or not to have the surgery if there will be no return to sporting activity.

After the ACL surgery, the research above notes that patients are less likely to use the surgical side during a squatting activity (think getting up from the toilet) and will push more with the non-surgical side.

This makes sense to me. After the surgery, the patient is in a locked long leg brace and is unable to move fluidly on the affected leg. The patient will not spend as much time on the surgical leg because of this and will transfer the weight to the non-surgical side. It becomes a learned habit to transfer the weight to the non-surgical side, but this is just my opinion.

 

“The persistence of under-loading is concerning, as asymmetrical limb loading during landing tasks has been linked to increased risk for anterior cruciate ligament (ACL) reinjury”

This is important! If we never get the patient to load the leg in order to improve strength and motor control (ability move in the way that the brain dictates), then the patient is at a higher risk of future injuries.

Let me clarify: if you squat and allow your legs to go wet noodle during the squat, it will look like a knocked-kneed version of a squat. This is not inherently horrible, but when asking the body to absorb a large load in this positon, when not trained to absorb this load, may lead to an injury. It all comes down to progressively loading specific positions in order to learn how to hold this position.

This is a major component of Olympic weightling compared to powerlifting. In the performance of the snatch (the most explosive movement in sports), maintaining proper position is extremely important for completing the lift. In powerlifting, the position may be able to be off a little and the athlete can overcome the small error in position.

With regards to ACL rehabilitation, it is important that we ensure that the patient is able to have enough strength to maintain positions without the load (bodyweight jumps, external weight, etc) dictating positional changes.

 

“…the bilateral multijoint nature of a squat allows for compensations that can shift the task demands to the nonsurgical limb (interlimb compensation) or to adjacent joints within the surgical limb (intralimb compensation) to reduce knee extensor moments.”

The bodyweight squat can be performed differently and switches the load from either the hip to the knee.

If you watch someone squat (recommended for all people that will attempt to squat), the person should both watch the knee and the hip. If you look at opening and closing, this will be much easier.

  1. Watch the knee to see how much the knee “closes” or how much the angle changes from the calf to the hamstring
  2. Watch the hip to see how much the hip “closes” or how much the angle changes from the trunk to the thigh

Which joint moves more?

This will help the reader to understand whether the knee joint muscles or hip joint muscles will be the dominant movers during the squat. Those that have knee issues will tend to move the hip joint muscles more than knee joint muscles.

I’ll make a video on this at a later date.

 

“…individuals 1 month post ACLR performed bilateral sit-to-stand tasks with a 38% reduction in vertical ground reaction forces (vGRFs) in the surgical limb”

This very simply means that the person is pushing less with the surgical leg than the non-surgical leg.

This means that the surgical leg is taking less force through it and will not be able to generate the same amount of power. Also, it is typical to see the patient weight shifting towards the non-surgical leg.

“reduced knee extensor moments have been found along with increased hip extensor moments…may rely on interlimb compensations to unload the knee during early rehabilitation but adopt intralimb compensations as they progress through rehabilitation.”

This goes back to the differences in a powerlifting based squat and an Olympic weightlifting based squat. The more upright the torso, the more that the knee takes a load and the less upright the torso, the more the back and hips will take the load.

I am having this exact conversation with a patient currently following an ACLR, attempting to get the patient to increase the load on the knee.

“During early rehabilitation, strategies for restoring symmetrical weight bearing during bilateral tasks should be emphasized and reinforced even during submaximal tasks…efforts should be made to continue to focus on sagittal plane knee loading and avoid compensation with the hip extensors.”

I tend to use a mirror for visual feedback in order to allow the patient to see the weight shift between the legs. This tends to fix the problems for weight shifting. We then progress to doing the squatting motion away from a mirror in order to build in positional awareness without the need for visual cues.

In order to improve the knee to hip ratio regarding which joint moves more, the cues will switch from sitting back on a chair (similar to a box squat which is hip hinge emphasizd) to emphasizing sitting between the feet (similar to an overhead squat) which is more knee joint driven.

If you don’t have a PT that understands how to squat, this may be a difficult movement to restore with physical therapy alone.

It may be prudent to ask your PT to describe a squat prior to starting therapy in order to ensure that your therapist has at least a baseline knowledge of squatting.

If the therapist doesn’t start describing multiple techniques for squatting based on body shape, then the therapist may not be well versed in the movement.

If you have any questions about squatting or ACLR rehabilitation…comment below.

Article: https://www.jospt.org/doi/abs/10.2519/jospt.2018.7977

 

You can find me at Primarycarejoliet.com and wherever you subscribe to podcasts at A physio’s perspective: movementthinker.

Second opinion

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Second opinion

How many people will choose to get a second opinion before going in for a major surgery?

I would hope 💯%!

I had an awesome conversation about 10 years ago when I was visiting Canada. There was a guy that traveled to Canada in order to get an opinion regarding back surgery. He was from San Diego. That’s a pretty far trip to see if he needs back surgery.

I asked him why travel that far for an opinion and he said that he wanted to reduce any bias on the doctor’s part regarding whether he was a candidate. For instance, the doctor in Canada would not be performing the surgery and it was unlikely that the doctor giving the opinion would be able to benefit from recommending surgery, since the patient would have surgery in California.

He avoided going for the opinion in California because the hospital system would profit from the surgery. The surgeon may have an arrangement with the hospital to ensure that the hospital gets a percentage of the money. We know that the hospital will make money during a surgery. Many people stand to profit from a surgery and the patient would do well to get an opinion from someone that doesn’t stand to benefit.

This brings me to my rant for now. 👇

Why don’t patients get a second opinion regarding physical therapy?

1. It’s not a huge expense

Physical therapy, on average will cost the insurance company about $1200 per episode of care. If the patient is paying 20% for the coinsurance, then it will only cost the patient $240/episode. This works out to about $50/week.

That’s relatively inexpensive compared to a large surgery. The question is: why not spend an extra $25 to see if a second therapist agrees with the first? If there is a disagreement in how treatment should be performed, then the cost may not be the chief factor.

This leads us to 👇

2. All therapists do the same thing

Not all PTs are trained the same! Don’t let a non-PT (such as surgeon or family doctor) tell you that it’s all alike.

Not all surgeons have the same reputation and skills. Not all PTs have the same reputation and skills. The only way that you, as a patient, will know about other’s skills and reputation is to ask and try.

If you are absolutely in love with your PT or MD, then so be it. Sing from the rooftops so that the reputation gets built. If you’re not…try someone different.

Sometimes the grass IS greener.

3. Convenience

I get it. A drive around the corner is much easier than a drive for an hour. It makes sense.

If we believe that not all therapists have the same training or passion for treating a specific issue, then we must also believe that these therapists are worth the drive.

Follow this example:

1. Patient A decided to go to a therapist close to home or work (we know that regarding gyms most people won’t drive more than 15 minutes from work/home). The therapy session costs the patient $240 out of pocket and the insurance pays $1000.

Let’s also say that the patient is being seen for low back pain or sciatica, since this is the number one reason to seek PT. The patient is seen in a clinic in which the therapist is there to punch a clock and see as many patients as possible because that’s how 💰 is made.

The patient doesn’t get much better and then returns to the doctor for a series of shots (more money and time). The shots are a 50/50 chance of working.

Half of the patients will then still have pain and now be shuffled to the next step, either pain management or surgical consult.

2. Patient B spent a little time to search for the therapist in a 20 mile area that best treats low back pain or sciatica. The patient makes an extra 20 minute drive. The therapist decides that the patient would ben for from 8 visits of PT over 6 weeks and the patient gets better because the therapist enjoys the job and works well with patients having this diagnosis.

The patient made a little more of an effort up front, but saved 💵 and ⏳ by choosing the right therapist instead of moving further along in the medical system.

Want a second opinion, send me a message.