PTs – Page 9 – Dr. Vince Gutierrez, PT

key to unlocking pain

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

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

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

I: is treatment with a directional preference

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

O: more beneficial when compared with subjective outcome measures

Reviewer:

Vincent Gutierrez, PT, MPT, cert. MDT

Search:

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

Date of Search: February 15,2014

Citation:

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

Summary:

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

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

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

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

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

Appraisal:

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

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

Conclusion:

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

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

Were the subjects randomly assigned into groups?

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

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

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

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

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

Were subjects masked or blinded to their group assignment?

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

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

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

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

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

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

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

Did subject attrition occur over the course of the study?

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

Slump test: what’s it mean?

This is a common test performed in the clinic. The article goes into great detail (again not written about here because I don’t really have an opinion about the technique) of how to perform the test. I highly recommend reading the article for all health care practitioners that care for patients with spinal pain.

“neuropathic pain (NeP) as “pain caused by a lesion or disease of the somatosensory system”

This is a great start to what will be a good read. If I were to say this to most PT students that come into my clinic, I would get the “Bambi in the head light look”. The fastest way to say this is that neuropathic pain is a pain that may be coming from a structure that is innervated (has nerves). This doesn’t really tell me anything though.

the presence of NeP has been linked with poor recovery, along with higher health care costs and lower quality of life.”

This makes sense to me. If you have pain, that is coming from somewhere, you are more likely to require more treatment than someone that has pain coming from nowhere and are less likely to enjoy your life than someone that is pain-free.

“The diagnosis of NeP typically consists of a thorough history and an extensive neurosensory examination to identify both positive (exaggerated responses to stimuation, such as allodynia) and negative (various sensory and motor losses) signs…usually performed by a specialist, requires a lot of time to complete, and in many regions involves a long waiting period for the consultation”

As a Doctor of Physical Therapy, I happen to be said specialist. This type of patient typically takes longer to evaluate than someone that only consists of weakness or deconditioning. There is much more to look at. I don’t know if I would say that it involves a long waiting period for the consultation. I think that this has more to do with a person’s type of insurance regarding wait time. For instance, if you are willing to pay out of pocket for the assessment, and pay what the “chargemaster” (an inflated charge board that no one ever really pays…unless they can’t afford insurance) states, then I am sure that I can fit you in for a $400-600 evaluation tomorrow. (We don’t actually make that much for an evaluation, but insurance companies would love you to believe that we do).

“The straight leg raise (SLR) test is the most commonly used neurodynamic test for the lower extremity. The slump test is another…”

The SLR test is easy to perform and most physicians are aware of its implication in discogenic pain. I include it when I am trying to make a point to physicians and insurance companies regarding a possible pain generator. I prefer to use the slump test because it is easier for me to test when I already have the patient sitting in the chair testing lower extremity strength (testing nerve electrical power). If I have a positive slump test, then I will typically perform a SLR test in order to “paint a better picture” of the patient to the insurance company.

“the SLR test demonstrated 100% specificity in patients clinically diagnosed with NeP.”

I don’t expect the lay person to understand this because this is such a difficult concept for most physical therapy students to understand. Basically, if you have a positive test, then your symptoms may be coming from the nerve. If you have a negative test, then we can effectively rule out nervous tissue pain.

“Key components of the clinical exam included pain (location, behavior, quality), motor function (strength/weakness, reflexes), sensory function (mechanical/thermal sensation), autonomic function (sweating, hypotension), and the SLR test”

You’d be surprised (or may you wouldn’t if this also describes you) regarding how many patients are surprised that a PT would take their blood pressure. I read a statistic years back regarding the following: 50% of patients seen in an outpatient clinic have undocumented hypertension. I can’t tell you how many times I have had to stop a session to call a doctor to inform them of a patient’s hypertension. I had one patient argue with me years ago that he wasn’t there for blood pressure issues, but to have his pain fixed. Unfortunately, his BP was higher than the maximal allowable threshold for exercise and I sent him back to the doctor. (Mind you, my current state is not a direct access state, which means that the patient had to be referred by someone prior to coming to therapy). The patient was apologetic the next session when the doctor told him what the numbers could mean regarding DEATH! That’s right…I save lives. Just kidding, but not really. If you see a therapist, your blood pressure should be checked at least on the first visit. If it is not, question the intentions/ignorance of the therapist. Could be oversight on the therapist’s part. I used to be that therapist.

Also, your sensation and strength should be tested in certain circumstances. Again, just ask your therapist why/why not the above testing was/wasn’t completed. There should be a good rationale for the answer. We love to teach…at least I do.

The authors of the article did an excellent job of describing positioning for testing, so if you are in health care and would use the slump test, it is a good refresher. Highly recommend it.

“…designated as positive if the following conditions were met: (1) pain or sensations were reduced with neck extension, and (2) there was a right-to-left difference in pain distribution or there was a difference between right and left knee extension.”

This is something that most PT students, and I must surmise that new professionals miss while in the clinic. This is the small details of the test. Is there a loss of knee extension on one knee? The only way to know is to have someone teach it to the student or for the student to go out on his/her own to learn it. What profession are you in? In your profession, who is the best in your workplace? What separates that person from anyone else in the workplace? Usually it is initiative, persistence, self-learning, confidence, experience, etc. This same thing can be said for the PT profession. We aren’t all born with these characteristics; they are honed over years of working and studying. If all we do is work, then we may gain experience, but the experience may be that of missed details.

“From these data, a difference of 10 degrees or more was used to indicate a positive slump test component.”

Again, small details. Many students are not looking at the angle change in the slump test and although 10 degrees is small when eye-balled, it can be huge when it is the difference between being able to stretch out and push the gas pedal with or without pain.

“very little can be interpreted when the slump test is positive but the pain does not extend below the knee.”

Students need to know this stuff! We learn in school that if it produces pain, that the test is positive, especially if the pain is reduced when the patient is then asked to look up. This means little in terms of telling us important information.

“The sequential combination of the 2 tests provided an effective means of ruling out those without NeP and ruling in a large proportion of those with NeP.”

This is important for students and PT’s to understand. If the patient has no pain production with the slump test, then “nerve pain” can effectively be ruled out due to the small rate of false negatives. When a patient has pain below the knee, then “nerve pain” can be ruled in.

This was an excellent article going more in depth than anything we learn in school. I have been using this test for years and have slowly incorporated the information into practice over the years, but I now know that there is a good reason to look at the knee extension change. When studying the McKenzie Method (MDT), we are taught to look at the angle changes when performing these “dural tension” based tests. It is informal when taught in the course, but here is the formal information.

Quotes taken from:

Urban LM. Macneil BJ. Diagnostic Accuracy of the Slump Test for Identifying Neuropathic Pain in the Lower Limb. J Orthop Sports Phys Ther. 2015;45(8):596-603.

Traction: useful or not?

I use traction sparingly. It is a last resort if the patient is going to have a surgery. If I have tried everything in my power and knowledge to help a patient, and the patient continues to not improve, then traction it is. It is my Hail Mary.

“Physical therapists may choose from myriad intervention options for LBP, but the effectivenss of many of these options is questionable”

Do you feel good about coming to therapy yet? An awesome question to ask your therapists is; “What does the research say about xyz?” or better yet “Does the research support xyz for my condition?”

It’s funny, in school we all learn that ultrasound brings more blood flow to an area…SO FRIGGIN WHAT? Does that blood flow actually fix me? Not really, but it brings more blood flow! That’s an expensive transportation of blood. Do you know what else brings more blood flow…Hickies. That brings more blood flow. Ask your therapists to suck on your skin for a while to see if that will also bring more blood flow. It will probably cost you a little more for that service though…I digress. There is not much, if any, CURRENT research that supports the use of ultrasound for back pain. If your therapist tells you that ultrasound will help, ask how? If they tell you the blood flow thing…ask them to pucker up.

“Authorities have recommended traction for conditions including protruding Intervertebral discs, spinal muscle spasm, and general pain and stiffness”

This is what I learned when I was in school. Seems archaic that we were taking general recommendations from “authorities” to try to fix the second largest complaint to the common cold. At least research has advanced from the opinion of authorities.

“several systematic reviews and clinical guidelines conclude that the effectiveness of traction is limited…little evidence to recommend traction…clinically important benefits of lumbar traction were demonstrated for neither acute nor chronic back LBP…traction should not be used…41% of the physical therapists in the UK used traction”

Boy can those statements be any stronger. Traction should not be used because it is not very effective for low back pain (LBP). Now if you want to use traction because it makes you feel better, then go ahead. Sugar pills work for some people also. (Not trying to come across as sarcastic, but I’m sure it sounds that way). If you have preference for a specific intervention, then that intervention may be likely to help you. I have a patient that believes that ultrasound of the back muscles helps. No matter how much education I have provided, I’d be better off talking to the wall. Needless to say, we have a great conversation during the ultrasound, while the patient is propped up on his elbows and lying on his belly. For those that know, these positions can help/fix up to 65% of back pain patients.

“Our findings suggest that a majority of APTA Orthopaedic Section members use traction…In contrast, approximately one third of respondents indicated that they would use tractions for patients in a manner that is contrary to that classification”

There is a clinical prediction rule in the derivation (creation) phase that indicates a certain type of patient may benefit from traction. This is less than 10% of the patients in the clinic. This rule has not been replicated yet, so it is more like an educated guess at this point. Other research has reported the above, in which traction has no added benefit to an exercise program. Also, exercise increases blood flow (see above). The sad part is that about 1 in 3 therapists are using traction contrary to how it should be used. Have you seen that therapist? They are typically the ones applying hot packs, Hickies and massage.

“employing soft tissue mobilization or massage was identified by approximately 65% of our respondents as a supplement to traction. Given limited evidence for the effectiveness of massage for treating LBP…the extent to which physical therapists in the United States use soft tissue mobilizations/massage in managing LBP may be concerning”

WOW! I was totally talking out of my a$$ in the above paragraph, but my a$$ is also supported by research. Who knew?

“there is a growing body of evidence that higher levels of professional preparation influence clinical decision making and, potentially, patient outcomes”

Look there has been a backlash in our profession for what is called “alphabet soup” after our names. This means that some therapists have gone on for “extra” training and certifications. This is important. Unfortunately, our profession has deemed it inappropriate to put down all of the certifications after our name. The only way to know what your therapist knows is to ask. I personally have the initials:

DPT (Doctor of Physical Therapy), cert. MDT (certified in Mechanical Diagnosis and Therapy). None of the above initials were given to me…I earned them.

Thanks for reading this. If I go overboard at times and offend you, there are other blogs to read. Have a good night.

Quotes taken from:

Madson TJ, Hollman JH. Lumbar Traction for Managing Low Back Pain: A survey of Physical Therapists in the United States. J Orthop Phys Ther. 2015;45(8):586-595.

Ivory tower of PT

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

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

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

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

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

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

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

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

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

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

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

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

Quotes taken from:

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

Soft sell to patients

“Your clients do not know what you know”

Man…this statement says a lot! We are highly educated (some more than others of course) and our patients come into the session with varying levels of education regarding either their health or the specific ailment. The part that irks me though is when the patient DOES know more than my students. We dedicate so much time to teaching our patients that I am frustrated if my patient now knows more than the student working with the patient.

Don’t be offended, but I am going to talk to you like an 8 year old, until you’ve earned the right for me to talk to you like a teenager. I will talk to you like a teenager until you’ve earned the right to be spoken to like a college student and so on and so forth. I have to ensure that you know what I am trying to teach you. If that means that I have to dumb it down a little at first…so be it. Senor Sosnowski once said that a smart person can always climb down the ladder of intelligence, but an ignorant person can’t just climb up the ladder. They have to put the work in order to get to a level of intelligence on this topic. I will be the first to say that I suck at a lot of things…physical therapy just isn’t one of them.

“simply calls for a direct and simple correlation that is made between your intervention and the positive outcome achieved by your patient.”

I expect people to improve. With patients that I don’t expect to improve, I am over educating that patient on day one. This is few and far between though. I expect patients to improve and in the end, I will never act the hero, but more like the facilitator. When you understand that you are “in charge” of your symptoms, then I become your cheerleader. (I’ve worn heels, but won’t go so far as to wear the skirt…one day I’ll tell the story of the heels).

QUOTES TAKEN FROM:

Quatre T. Why they buy: Because You Have connected the Dots. IMPACT June 2016:11.

Comparing McKenzie to a cognitive behavioral treatment strategy

Got back pain?

This is a study that compares two different treatment approaches head to head. Bout damn time that we are looking at two approaches and comparing them in a study. We (health care researchers) typically compare one treatment against no treatment. This is good and all, but then we believe that all treatments work and work equally. These are the types of studies that need to come out, so that as a health care provider, I am providing the best treatment to help your problem.

“A recent UK survey estimated the (1-month period) prevalence of spinal pain to be 29%”

This means that during any one month period about 1 in 3.5 people are experiencing back pain, over on the other side of the pond. Think about that! If you have one person on each side of you, one of you will have back pain during the month.

“The lifetime prevalence of these conditions is also high—it is estimated that »70-85% of the population will experience some spinal pain during their lifetime”

Again, 8 out of 10 people will have back pain during their lifetime. This is starting to sound grim. Pain is not normal. What are we doing to ourselves? Why do we keep having back pain at such an alarming rate? I have my opinions, based on some research, but it hasn’t been fully substantiated yet. I will pull out the research at a later date of course.

“In 1998, the cost of lower back pain alone to the UK National Health Service was estimated at 1 billion (pounds), with over 200 million (pounds) being spent on physiotherapy”

So…what’s this got to do with us? That’s the UK. The numbers aren’t too far off of what we are spending on back pain. See the link from a previous post in which I discuss monetary figures.

https://movementthinker.org/2016/03/17/a-little-bit-of-crazy/

“guidelines state that in the first instance patients should be encouraged to remain active, with the prescription of anti-inflammatory drug and/or analgesia where required.”

There is an opiod epidemic spreading world wide. I realize that opiods and anti-inflammatories are a long ways away from each other, but to think that back pain will be fixed with medication only is dreaming. NSAID’s are not always the answer either. http://www.aafp.org/afp/2002/0401/p1319.html

Robin Mckenzie states in his textbook (paraphrased): a mechanical problem needs a mechanical answer and a chemical problem needs a chemical solution. The first question has to be: is the pain mechanical or chemical?

To remain active is the same advice that I could get from my dad. You’ve heard the advice countless times I’m sure…especially if you’ve ever been hit by the ball while standing in the batter’s box…”walk it off”. Hell, my dad was a laborer. He didn’t go to medical school, but gives the same advice. I pay for better than that. I can get the advice for free back in Elwood.

“Physiotherapy treatments aimed at alleviating the physical causes of back and neck pain include: advice, exercise programmes, massage, mobilization and manipulation”

Some big takeaways from this sentence are what was left out of the sentence. At no point did the authors talk about ULTRASOUND!, ELECTRICAL STIMULATION!, TRACTION!, VAX-D (sp)! CUPPING! or any of the other passive fads that make clinics money for doing thoughtless work. Look…if the above (in capital letters) makes up a part of your treatment, you have to question your practitioner as to why and what are the expectations of the intervention. I know what my expectations are…lining the owners pocket with greenbacks.

“a new type of intervention for treating back and neck pain has recently been developed, triggered by growing awareness that psychosocial factors play an important role in musculoskeletal complaints. These behavioural interventions have different compositions depending on the specific theory underpinning the approach.”

To think that the “biopsychosocial” approach is new is a fallacy. It is a newer concept to put a name to it, but even those that simply have “mechanical” training understand that in order to use “mechanical” training, we have to get through the psychosocial constructs of each patient.

“elucidating whether a treatment offers good value for money in terms of cost vs benefit must also be considered”

This is an interesting topic that is finally coming to the forefront in healthcare. I’m going to go to the extremes to make a point. Let’s say that you have a heart problem and a surgery that costs 100,000$ will keep you alive for decades, but a surgery that only costs $1,000 can keep you alive for a year. Which would you take? Costs vs benefits become very apparent in this scenario. This article will scale the topic down to back pain.

“The trial compared two physiotherapists delivered interventions for musculoskeletal back and neck pain, which aimed to promote return to normal activities…Solution Finding Approach, was a brief physiotherapy intervention based on cognitive behavioral principles…a patient-centred view and, in this context, aims to help patients identify reasons for their pain and to provide solutions and long-term management strategies”

This essentially says: this approach consists of few physical therapy visits in order to help you figure out why you have pain and to provide solutions to long term management of your pain.

Remember this because it is important for the next section.

“The second approach was the more traditional biomechanical approach used by physiotherapists, the McKenzie approach, which involves classification of patient’s spinal condition and the prescription of specific therapeutic exercises.”

This one states the following: The therapist will help you figure out why you have pain, through a classification system, and issue solutions (exercises) in order to provide long term management of your pain.

Sounds fishy…I don’t know if I like either method since they both sound so similar. Those that know me, know that I am biased. I am certified in the McKenzie method, formally known as Mechanical Diagnosis and Therapy.

MeKenzie approach…has been clearly documented…commonly used by physiotherapists…conducted a biomechanical assessment using repeated movements of the spine and, based on these findings, prescribed specific exercises for the patients to work on repeatedly themselves…relies on active compliance with the exercises and advice.”

MDT (McKenzie method) was created a long time ago. I know the history like the back of my hand, but it seems like too much to type out here. Look up his biography, “Against the Tide” to read how this man revolutionized the way spines and now extremities are treated…by those that have studied the method. In a time in which not many believed him, and many went so far as to ridicule his methods, it took almost 50 years to confirm his thoughts through science.

Anyway, we use repeated, sustained, resisted and speed based positioning in order to elicit a change in symptoms. Manual techniques can also be used to elicit a change. Once we see a change that is documented with having good results…we stop there and send you home with the exercise, position or movement.

“All the physiotherapists delivering the McKenzie approach were experienced in this method and had undertaken McKenzie Institute training (courses A-D).”

This is important. Scott Herbowy, one of the highly trained professors of the method, published a study in the recent years regarding the training and outcomes of those using the methods. It seems realistic to believe that someone that has taken courses A-D would have the same reliability and outcomes as someone that has taken the same courses and passed a competency exam. This is not true though. Those that have not yet passed the test appear to be inconsistent in classifying patients using MDt. See the study below to learn more:

http://www.ncbi.nlm.nih.gov/pubmed/24253786

“…both the McKenize and Solution Finding approaches lead to improvements in patient outcomes over time, with no significant differences between the two treatments.”

Both treatment ideas provide similar improvements over time. This indicates that just in terms of improvements, it doesn’t matter which method is used (albeit neither group of therapists were highly trained in using the intervention attempting to be studies). I liken this to asking an auto mechanic to work on a Boing Jumbo Jet. Yes…the mechanic understands engines, but there’s a difference in specialties.

“The McKenzie treatment required on average, one extra subsequent visit to the physiotherapist”

This means that seeing a therapist semi-trained in MDT will cost you an extra $100 dollars compared to seeing someone semi-trained in the Solution Finding Approach. Is this a bad thing? We will see.

“the Solution Finding Approach is slightly cheaper than the McKenzie approach but confers marginally lower benefit”

Dave Ramsey has a free radio show about finances. One of his taglines is “the advice is worth what you pay for.” Obviously he’s kidding, but we all know that the better stuff in life isn’t free. When it comes to your health, how much more are you willing to pay? Are you willing to pay “slightly” more?

“The policy maker needs to decide whether she or he is willing to invest additional health care resources funding the McKenzie approach”

Look, you need to find someone that has this certification or diploma training if you have back pain. Countries are debating whether or not more money should be put into training therapists in this method. Some of us have paid for the training out of pocket in order to become better therapists, with the end goal of providing great care to patients.

“the additional cost associated with the McKenzie treatment is worth paying, given the additional benefit it provides”

NEED I EXPAND ON THIS SENTENCE? This benefit is from people that aren’t even “minimally competent” to provide this service. Imagine how much more benefit or less cost that you would have from someone that is competent in using the method.

This study was performed in the UK. There is no reason for me to believe that back pain differs that significantly from those experiencing back pain in the US. I have to correlate that those seeing a McKenzie Credentialled therapist will see even better results or spend less money over the long haul than that those seeing someone using cognitive behavioral therapy.

Quotes taken from: Manca A, Dumville JC, Torgerson DJ, Moffett JAK, et al. Randomized trial of two physiotherapy interventions for primary care back and neck pain patients: cost-effectiveness analysis. Rheumatology 2007;46:1495-1501.

MRI’s fact vs fiction

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

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

READ AND RE-READ THE ABOVE STATEMENT.

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

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

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

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

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

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

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

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

Patients were classified according to this table:

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

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

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

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

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

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

Atypical: none of the above.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Why reinvent the wheel?

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

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

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

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

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

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

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

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

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

Quotes taken from the following:

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

Have you sold your services?

Hot Dog!…Get your hot dog!

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

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

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

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

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

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

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

“Ask questions” Referring to personal questions.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Quotes taken from:

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

Patients through the door

The age old question

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

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

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

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

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

“1. Clearly define the customer”

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

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

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

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

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

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

Quotes from:

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

Not all are altruistic

I want to congratulate this student for getting published before graduation. This is a great feat and kudos to you. Now the student makes great points, but I doubt that this student is at the bottom of his class. Not all can be amazing students. Someone has to be the student that brings the average down. Nothing wrong with that, but unfortunately, anyone lower than the highest-grade earner will be that student. Someone wrote this article on the “awesome-side” of the bell curve. I retort using the “not so awesome side” of the bell curve examples.

“There is a way to meet these goals (increased productivity demands), a simple and safe way that bypasses the “high-risk, high-reward” decisions that practice owners face when on the brink of future growth of their company: Add a student into your clinic”

This is coming from a student!? Look, I love taking students. I am a credentialed clinical instructor (this means that I have taken a course to learn how to work with students). I completely disagree with the above statement. From a business perspective, we should not be using students as free labor in order to pad our profits. These students are paying for the right to be in the clinic. Our primary objective as clinical instructors is to produce the best therapists that our ability allows. If I treat a student as a therapist, then I am doing the student a disservice by asking them to do the work that I usually do, and then going off to do more work in order to increase the companies bottom dollar. There has to be a line drawn in the sand regarding business ethics.

“I have experienced good clinics, bad clinics, and great clinics; and I have noticed certain characteristics that tend to separate one from another”

I’m sorry, but as a student, the sample size is very small. To say that one has seen great clinics is a far reach since, in my opinion, they are few and far between. It is rare to be in a clinic in which the bottom dollar is secondary to patient outcomes. This will be changing in the future, but not anytime soon. For additional information, please see: http://www.mechanicalcareforum.com/podcast/97)

“…students can be your safe haven for boosting morale”

I haven’t seen this as much in my career. There are those “go getters”, but this is just as rare as finding a “great clinic”. When looking at the bell curve of PT classes, there are only so few on the awesome side of the bell curve. Mostly, students coming out of PT school are average in my experience. Every once in a while, we get the student that has the potential to change the profession, but again…few and far between.

“…having a student in their second or third year of physical therapy school who can take half or one-fourth of your caseload can save you time to work on documentation while maintaining clinic productivity standards”

This is where the shit hits the fan. Most students coming out of school have not mastered biomechanics. If a student can’t step in and do my job, including my clinical rationale, then I should not be using this student to bolster “my productivity” because the student will not be giving “my quality”. Some therapists come out of school and after 3 years are no more than overpaid personal trainers. Again, this doesn’t apply to all, but to believe that a PT student can come out of school and do my job with my experience leads me to believe that I am overpaid. In 8 years of practice and having well over 50 students, I have only had two that could possibly take my job. Again, these two were rock stars. They have the potential to change the profession. All other students needed to be built into clinicians. This does the opposite of improving my productivity because I am now spending time that would have been spent on paperwork in order to teach the future of our profession. I have had very few failures, but also very few rock stars. The rest start as average and become clinicians as the weeks progress.

“Another benefit of having a student is that they can keep you up to date with the latest evidence”

Again, this is another fallacy. There are clinicians out there that don’t know how to research. I believe that Jensen (many will cite this article about PT’s that don’t research) states it clearly that the longer you are out of school, the less likely you are to perform research. That doesn’t mean that the newer grads coming out of school are much better at interpreting research beyond an abstract. I have encountered many abstract readers, but few students that can break down the article to actually tell me if it will affect my clinical outcomes. As you can see though, I also am spending time making myself better by reading the “latest evidence”.

“What better way to create a legacy than to help students practice with the same methods that helped you prosper?”

It took the author many pages of writing to get to the heart of why many of us take students. I am looking to create amazing clinicians that feel confident in their abilities. My goal is that for any student that goes through me to become a Doctor…Doctor…Doctor of Physical Therapy, will earn that title. If a student has me as a CI, it will be a rough clinical, but I guarantee that the student will be much better off for it. This is why I do what I do!

Quotes taken from:

Sinacore A. SIMPLIFY! How adding a student can amplify growth. IMPACT. April 2016:40-46.

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